PAGENO="0001" 20 t5 1 "(g) The Secretary shall report to Congress no later 2 than May 15 of each year- 3 "(1) the number and identity of all medically 4 underserved populations in each of the States in the 5 calendar year preceding the year in which the report 6 is made and the number of medically underserved popu- 7 lations which the Secretary estimates will be designated 8 under subsection (b) in the calendar year in which the 9 report is made; 10 "(2) the number of applications filed in such pre- 11 ceding calendar year for assignment of Corps personnel 12 under this section and the action taken on each such 13 application; 14 "(3) the number and types of Corps personnel 15 assigned in such preceding year to provide health serv- 16 ices for medically underserved populations, the number 17 and types of additional Corps personnel which the Secre- 18 tary estimates will be assigned to provide such services 19 in the calendar year in which the report is submitted, 20 and the need (if any) for additional personnel for the 21 Corps; 22 "(4) the recruitment efforts engaged in for the 23 Corps in such preceding year, including the programs 24 carried out under subsection (f) (1) and the number PAGENO="0002" 21 1(3 1 of qualified persons who applied for service in the Corps 2 in each professional category; 3 "(5) the total number of patients seen and patient 4 visits recorded during such preceding year in each area 5 where Corps personnel were assigned; 6 "(6) the number of health personnel electing to 7 remain after termination of their service in the Corps to 8 provide health services to medically underserved popula- 9 tions and the number of such personnel wiio do not make 10 such election and the reasons for their departure; 11 , "(7) the results of evaluations made under sub- 12 section (c) (2) (B) (ii) , `and determinations made under 13 subsection (c) (2) (B) (iii), during such preceding 14 year; and `15 "(8) the amount (A) charged during such pre- 16 ceding year for health services by Corps personnel, 17 (B) collected in such year by entities in accordance with 18 arrangements `under `subsection (e) (1), and (0) paid 19 to the Secretary in such year under such arrangements. 20 ` "(h) (1) There is established a council to be known `as 21 `the National Advisory Council on the National Health 22 Service Corps (hereinafter in thi's `section referred to as the 23 "Council'). The Council shall' be composed `of fifteen members 24 appointed `by the Secretary as follow'~: 25 "(A) Four members shall be appointed from the 38-698 0 - 74 - 3 (Pt. 1) PAGENO="0003" CONTENTS (The same table of contents appears in parts 1 and 2) Hearings held on- Page PART 1 May 20, 1974 1 May 21, 1974 353 May 22, 1974 823 PART 2 May 23, 1974 May 28, 1974 1043 May 29, 1974 1203 May 30, 1974 1455 June 27, 1974 1529 Text of- H.R. 11539 2 H.R. 11587 2 H.R. 13174 H.R. 13469 6 H.R. 14196 31 H.R. 14357 40 H.R. 14721 H.R. 14722 191 H.R. 14930 208 H.R. 14931 229 H.R. 15051 232 H.R. 15112 232 H.R. 15128 232 H.R. 15177 232 H.R. 15211 232 H.R. 15225 232 H.R. 15519 31 Report of- Civil Service Commission on hR. 11539 and HR. 11587 249 Health, Education, and Welfare Department on HR. 11539 and HR. 11587 249 Health, Education, and Welfare Department on hR. 14930 and H.R. 14931 251 Office of Management and Budget, Executive Office of the President, on H.R. 11539 and HR. 11587 251 Office of Management and Budget, Executive Office of the President, on H.R. 14930 257 Office of Management and Budget, Executive Office of the President, on HR. 14931 257 Statement of- Aaron, Phil It., speaker of the house, $tudent American Medical Association 1403 Abdnor, Hon. James, a Representative in Congress from the State of South Dakota 825 Allison, Jack, medical student, University of North Carolina School of Medicine 1483 Altman, Dr. Stuart H., Deputy Assistant Secretary (Health, Planning, and Analysis), Department of Health, Education, and Welfare~ 286 Amenta, Charles A., Jr., I).D.S., executive director, American Associa- tion of Dental Auxiliaries 1138 Baerg, Dr. Richard, dean and acting president, New York College of Podiatric Medicine 962 Bailey, Dr. H. D., president, American Association of Colleges of Podiatric Medicine 962 Bates, Dr. James, president, Pennsylvania College of Podiatric Medicine 962 (III) PAGENO="0004" Iv Statement of-Continued Page Bennett, Roger, long-range planner, Health Science Center, Univer- sity of Washington 1476 Besch, Dr. Everett D., Association of American Veterinary Medical Colleges and the American Veterinary Medical Association 936 Blakeney, Hazie E., Ed. D., professor and chairman, career develop- ment, University of Maryland School of Nursing, and chairman, Commission on Nursing, American Nurses' Association 1071, 1075 Blatti, George, past president, Student American Medical Assoeiation 1403 Bliven, Charles W., executive secretary, American Association of Colleges of Pharmacy 995 Bowsher, Prentice, staff member, Association of American Medical Colleges 873 Breslow, I)r. Lester, president, Association of Schools of Public Health 1043 Bulger, Roger, M.D., acting president, Institute of Medicine, National Academy of Sciences 258 Bunker, Dr. John P., professor of anesthesia, Stanford Medical School, and visiting professor, Department of Preventive Medicine, Harvard Medical School, Boston, Mass 642, 691 Bush, Mrs. Ann S., executive director, Coordinating Council for Education in Health Sciences for San Diego and Imperial Counties, Calif 1483, 1484 Buzzell, Harold 0., Acting Director, Health Services Administration, Department of Health, Education, and Welfare 286 Carson, Russell, M.D., president, American Association of Clinical Urologists 1433 Citters, Robert L. Van, M.D., dean, University of Washington School of Medicine 1476 Cohen, Edward, assistant chancellor, health professions education, Department of Higher Education, State of New Jersey 1030 Coleman, Francis C., M.D., chairman, Council on Health Manpower, American Medical Association 1507 Cooper, E. Leon, M.D., acting executive director, National Medical Association, Washington, D.C 380,629 Cooper, John A. D., M.D., president, Association of American Medical Colleges 873, 1530, 1590 Cooper, Dr. Theodore, Deputy Assistant Secretary (Health), Depart- ment of Health, Education, and Welfare 286 Cotton, Raymond, Association of Schools of Public Health 1043 Day, Dr. Robert, dean, University of Washington School of Public Health 1043 Decker, Dr. Winston, assistant executive vice president, American Veterinary Medical Association 936 Denholm, Hon. Frank E., a Representative in Congress from the State of South Dakota 823 de Vise, Pierre, College of Urban Sciences, University of Illinois at Chicago Circle 380 Dewey, Donald R., Ph.D., professor of geography, DePaul University, Chicago, Ill 380,415 Dion, Joseph P., supervisory auditor, Los Angeles regional office, General Accounting Office 1208 Dorsev, Dr. Joseph L., medical director, Harvard Community Health Plan, Boston, Mass 642, 680 Edwards, Dr. Charles C., Assistant Secretary for Health, Department of Health, Education, and Welfare 286 Endicott, Dr. Kenneth M., Administrator, Health Resources Adminis- tration, Department of Health, Education, and Welfare 286 Esch, Hon. Marvin L., a Representative in Congress from the State of Michigan 1203 Etze, Frank D., supervisory auditor, Manpower and Auditor Division, General Accounting Office 1208 Filerman, Dr. Gary L., executive director, Association of University Programs in Health Administration 1182 Foley, Ms. Mary E., president, National Student Nurses' Associa- tion 1071, 1092 PAGENO="0005" V Statement of-Continued Page Fuller, Allene, family nurse practitioner, Haywood- Moncure Health Center, North Carolina 1446, 1473 Gehrig,~Leo J., M. I).,vice president, American HospitalAssociatiom. 1097, 1530 Gewirtz, Mrs. Nancy, administrator, The Monroe Health Center, West Virginia 1286, 1393 Ginley, Dr. TOrn, secretary, council on dental education, American Dental Association 1109 Griffith, 1)r. John R., president, Association of University Programs in Health Administration 1182 Hanft, Mrs. Ruth S., senior research associate, Institute of Medicine, National Academy of Sciences 258, 259 Hanlon, C. Rollins, M.D., president, Council of Medical Specialty Societies 1530, 1597 Harrison, Bernard P., director, Division of Medical Practice, American Medical Association 1507 Heil, Robert, executive director, American Association of Colleges of Podiatric Medicine 962 Henig, Morton E., associate director, Manpower and Welfare Division, General Accounting Office 1208 Henjyoji, Howard, M.D., N.H.S.C., Chicot Memorial Hospital, Lake Village, Ark 1386, 1400 Hines, J)r. Martin, American Veterinary Medical Association ~36 Holden, William 1)., M.D., member, executive committee, American Board of Medical Specialties 1530 Holleran, Ms. Constance, deputy executive director, American Nurses' Association 1071 Hopping, Richard L., 0.1)., American Optometric Association and Association of Schools and Colleges of Optometry 947 Huffington, H. L., M.D., chairman, Commission on Legislation and Public Policy, American Academy of Family Physicians 919 Jaeger, 1)r. Jon, chairman, I)epartment of Health Administration, 1)uke University Medical School 1182 Kindig, David A., MI)., codirector, Institute for Health Team Development, Montefiore Hospital and Medical Center 1386 Kridel, George, immediate past president, Student American Medical Association 1403 Kunkel, Dr. Paul, chairman, council Ion legislation, American Dental Association 1109 Lattirner, John K., M.D., American Association of Clinical Urologists 1433 Lawrence, I)avid McK., Ml)., chairman, National Council of Medex Programs, and assistant professor, I)epartment of Health Services, School of Public Health, University of \Vashington 1455 Lee, Philip R., MI)., professor of social medicine and director, health policy program, School of Medicine, University of California, San Francisco Lein, John N., M.I)., associate dean, University of \Vashington School of Medicine 1476 Lewis, Eloise R., RN., Ed. I)., dean, School of Nursing, University of North Carolina at Greensboro, on behalf of the National League for Nursing 1071 Lin, Sam, Ph. 1)., Student American Medical Association 1403 Lowin, Aaron, Ph. 1)., 1)irector, Health Manpower I)ivision, Inter- Study, Minneapolis, Minn 724 McCartney, 1)onald M., CONSAI) Resarch Corp., Pittsburgh, Pa~ 1321 McCart, Ms. Elaine, family nurse associate, Stonington, Maine~ 1466, 1470 McCool, 1)r. Barbara, assistant professor, program in hospital and health services administi ation, Northwestern University 1182 McGhan, l)r. \Villiam F., executive secretary, Student American Pharmaceutical Association 1024 McNevin, Anthony J., director, governmental affairs, American Association of Colleges of Osteopathic Medicine 834 Madison, Donald L., Ml)., Associate Professor of Medical Care Or- ganization, School of Medicine, and Associate Professor of Health Administration, School of Public Health, University of North Caro- lina at Chapel Hill 380, 620 Magen, Myron S., D.O., American Association of Colleges of Osteo- pathic Medicine 834 PAGENO="0006" VI Statement of-Continued Page Martin, I)r Edward, Director, National Health Service Corps, De- partment of Health, Education, and Welfare 286 Mayer, Eugene S., MI)., assistant professor of medicine and deputy director, Area Health Education Centers program, University of ~orth Carolina School of Medicine, Chapel Hill, N.C 1483, 1491 Mullen, Fitzhugh, M.D., N.lI.S.C., La Clinica de la Gente, Santa Fe, N. Mex 1386, 1397 Myers, Morton A., Assistant I)irector, General Accounting Office. 1208 Norris, J. Ted, president, Student American Medical Association__ 1403 Oliver, Robert \V., secretary-treasurer, Federation of Associations of Schools of the Health Professions and executive director, American Association of Colleges of Osteopathic Medicine 827, 834 Pahl, Charles \V., assistant director, Legislative Department, American Medical Association 1507 Parry, Stanley, executive director, Health Services Education Council, San Jose, Calif 1483 Payne, John, associate director, North Carolina Area Health Educa- tion Centers program 1483 Price, James G., MI)., president, American Academy of Family Physicians 919 Redig, 1)r. l)ale, American Dental Association 1109 Rothberg, 1)r. June, dean and professor, Adelphi University School of Nursing, and l)resident, American Association of Colleges of Nursing 1071, 1084 Rubin, 1)r. Abe, president, Ohio College of Podiatric Medicine 962 Rube, C. H. Williani, Ml)., director, 1)ivision of Medical Education, American Medical Association 1507, 1512, 1530 Samuel, Frank E., Jr., Deputy Assistant Secretary for Health Legis- lation, 1)epartment of Health, Education, and Welfare 286 Sauer, Larry, director, legislation division, American Hospital Asso- ciation 1097 Schondelmeyer, Stephen \V., president, Student American Pharma- ceutical Association 1024 Schwarz, M. Roy, MI)., associate dean, University of Washington School of Medicine 1476 Skinner, William J., legislative and legal counsel, American Association of Colleges of Pharmacy 995 Sodeman, William A., M. I)., l)ast chairman, Council of Medical Edu- cation, American Medical Association 1530, 1536 Swain, Arthur, nursing coordinator, Albuquerque, N. Mex 1466 Thompson, 1)avid M. I)., American Hospital Association 1530, 1534 Tosteson, I)aniel, M. I)., chairman, Association of American Medical Colleges executive council 873 \Veaver, Warren E., Ph. 1)., chairman, executive committee, American Association of Colleges of Pharmacy 995 \\eber, Gerald I., Ph. 1)., acting associate professor, childhood and government project, School of Law, University of California, Berkeley, Calif 642 Weiss, Robert J., M. I)., associate director, Center for Community health and Medical Care, Harvard Medical School, Boston, Mass__ 724 Wiggins, lion. Charles H., a Representative in Congress from the State of California 935 Williamson, Thomas. ~enior attorney, General Accounting Office_ - - - 1208 \arnarnoto, l)ennis, 0.1)., director, department of Federal educa- cational affairs, Amcric.tn Optometric Association 947 Additional material supplied for the record by- American Academy of Family Physicians, Academy position on fund- ing of family practice residency programs 925 American Association of Clinical I rologists, article, "Where Does American Urology Stand in the 1970s" by John K. Lattimer, M. Ii., from the Journal of Urology, I)ecember 1973 1444 American Association of Colleges of Nursing: Attachments to statement of L)r. June Rothherg: Adelphi-Molloy Nurses, article from the Deiphian, April 24, 1974 1091 Nurse's Interest Centers on Family Health, article from Long Island Press, May 20, 1973 1090 PAGENO="0007" VII Additional material supplied for the record by-Continued Page American Association of Colleges of Osteopathic Medicine, Critical commentary on IOM report "Costs of Education in the Health Professions" 842 American Association of Colleges of Pharmacy, booklet: Pharmacy Education Responds to Changing Health Care Needs 1009 American Association of Colleges of Podiatric Medicine, Podiatric Medicine: Function and Education, reprint from Journal of Podiatric Education, March 1973 974 American Association of Community and Junior Colleges, statement 1622 American Dental Association, extramural clinical experience for dental students 1136 American I)ental Hygienists' Association, statement 1625 American Hospital Association: AHA program policy to discourage overpopulated residencies_ - - 1619 Number of graduate hospital administrators in the United States_ 1107 American Medical Association: I)istribution of Physicians by Medical Specialty, report adopted by AMA House of I)elegates, June 1973 1583 Letter dated June 19, 1974, from James H. Sammons, M.l)., executive vice president-designate, to Chairman Rogers, con- cerning support for continued Federal assistance to schools of public health and public health training 1527 Report on Physician Manpower and Medical Education, adopted 1w AMA House of Delegates, June 1971 1540 American Nurses' Association, views on capitation based on gradua- tions 1097 American Optometric Association, letter dated June 13, 1974, from Richard W. Averill, director, Washington office, to Chairman Rogers 1647 American Physical Therapy Association, Royce P. Noland, executive director, statement 1630 American Psychiatric Association, statement 1632 American Public Health Association, letter dated June 10, 1974, from Lorin E. Kerr, M.S.P.H., president, to Chairman Rogers 1648 American Society for Medical Technology, letter dated May 21, 1974, from Annamarie Barros, president, to Chairman Rogers 1650 American Society of Allied Health Professions, statement 1632 American Veterinary Medical Association: A crisis in veterinary education 945 Comments on the TOM study on costs of education in the health professions-veterinary medicine 947 Association for Hospital Medical Education, letter dated August 26, 1974, with attached statement, from Robert B. Carbeck, i\1.1)., to Chairman Rogers 1651 Association of American Medical Colleges: Graduates of foreign medical schools in the United States-A challenge to medical education 909 Use of capitation funds 893 Association of Schools of Public I lealth: Attachments to prepared statement Appendix No. 1-Recomniended substitute for sec. 787 of HR. 14721 1053 Appendix No. 2-Recommended substitute for sec. 788 of HR. 1472L 1053 Appendix No. 3-Employment service: positions available and wanted, from American Journal of Public Health, June 1974 1053 Appendix No. 4-Listing of names, deans, and addresses of schools of public health in the United States, Canada, and Puerto Rico 1063 Full-time equivalent students 1068 Letter dated May 21, 1974, froimi C . Arden Miller, MI)., president-elect, American Public health Association, to l)r. Breslow, endorsing testiniomi before su1)comnmnittee~ - - 1064 PAGENO="0008" VIII Additional material supplied for the record by-Continued Association of Schools of Public Health-Continued Attachments to prepared statement-Continued Page Physicians in the field of public health 1069 Table 1-Enrollment and graduates, U.S. schools of public health, 19.58-72 1052 Table 2-Estimated distribution by emplcvment in 1972 of public health graduates from 1962 to 1972 1052 Tuition charges by schools of public health for 1973-74 academic year 1066 Ass ciat ion of University Programs in Health Administration: Letter dated June 3, 1974. froni (;ary Filerman, Ph.D., executive director, to Chairman Rogers, providing additional information relative to co~t of health administration education and previous experience with project grants .. 1198 I'roject grants for graduate programs in hospital and health ad- ministration, fiscal years 1971-76 1194 Bunker, l)r. John P.. profes~or of anesthesia, Stanford Medical School and visiting professor, Department of Preventive medicine, Harvard Medical School, Boston, Mass. Surgical Manpower-A Comparison of Operations and Surgeons in the United States and in 1ngland and Wales 698 The Physician-Patient as an Informed Consumer of Surgical Services 712 Case Western Reserve University, School of Medicine, letter dated \iay 16, 1974, from Frederick C. Robbins, MI)., Dean, to Hon. Charles A. Vanik, a Representative in Congress from the State of Ohio 1654 Coiiim~ssioned Officers Association of the U.S. Public Health Service, ~tateiiient - - 1654 CONSA!) Research Corp., Pittsburgh, Pa., Final report-An evalua- tion (if the effectiveness if loan forgiveness as an incentive for health practitioners to locate in m(dicallv underserved areas 1329 Cooper, John A. 1)., M.D.. president, Association of American Meoical Colleges: Appendix to statement 1595 List of schools which offer early entrance into a career of family pract:ce 1611 List f schooU which offer either required or elective experience in fanulv medicine 1611 List of schools with either departments or divisions of family medicine 160) 1)enholiii, Hon. Frank E., a Representative in Congress from the State of South 1)akota, statement (if Karl H. Wagner, M. 1)., vice president for Health Affairs and dean, University of South Dakota School of Medicine 824 de \ ise, Pierre, College of Urban Sciences, University of Illinois at Chicago Circle: llealth Planning in Illinois, article from Illinois Regional Medical Program. Fall 1971 issue 395 Phv~ician \Iigration fr ni Iiiland to Coastal States: Antipodal l.xaniples of Illinois and California, reprint from Journal of Medical Education, February 1973 383 The Changing Supply f Physicians in California, Illinois, New York, and Ohio: Redistribution of Physicians Since 1960 and Projections to 1990, working paper, April 1974 401 Dewey. 1)onald 14.. Ph. D.: ~1ore \[oney, More l)octors, Less Care: Metropolitan Chicago's Changing 1)istrihution of Physicians, Hospitals, and Popula- lion, 1930 to 1970, study by Pierre de Vise and Donald I)ewe 594 Survey and Analysis of the Changing Age 1)istrihution of Private Practice Physicians in Metropolitan Chicago by Office Loca- tion, 1930, 1960, and 1970 610 Where the I)ocrors Have Cone, research paper 417 PAGENO="0009" Ix Additional ni:terial submitted for the reci rd hv-Contimiued Page Esch, lIon. Marvin L., a Representative in Congress from the State of Michigan: Exchange of correspondence with Caspar \V. \\eiiiberger, See- rotary of Health, Education, and Welfare re failure of I)epart- merit to iniplement scholarship pI~igr'ani under Emergency Health Personnel Act of 1972 1204 ~tatenent of I)avid Lipsitz and I)avid Hendrick~, University of Michigan Medical School students 1206 Federation (if American Hospitals. letter dated i\Iav Ii, 1974, from Michael I). Bromberg, director, national offices, to Chairnian Rogers 1655 General Accounting Office, CS., Report to Congress by the Comptroller General "C( ingressional Objectives of Federal Li ions a rid Scholar- ships to health Professions Students Not Being AIet_ 1216 Georgetown University Medical Center, letter dated May 30, 1974, front Matthew F. McNultv. Jr., Sc. I)., executive vice president for medical center affairs, to Chairman Rogers_ 1656 Georgetown University, Schools (if Medicine and l)entistry, state- ment. 1635 Health, Education, and Welfare, l)epartment of, National Flealth Service Corps contract.s-flscal years 1974, and 1973 346 Institute of Medicine, National Academy of Sciences: Chart I . Breakdown of activities for a representative week at 82 schools 266 Letter dated June 19, 1974, from Roger Bulger, Al. 1)., tci Chair- man Rogers, enclosing I ~vi i staff papers ana1~zing Capitation support to be provided tinder the administration hills and distribution of income, by source, for medical schools in the IOM sample 274 Table I . Number of schools sampled in estimating costs of health professional education, 1972-73 -- - 266 Table 2. Distribution (if faculty time in health professional schools by activity and profession, 1972-73. 267 Table 3. Compenents of average annual educatiin costs per student bvprofession, 1972-73 267 Table 4 erage and range of annual education costs per student b profession, 1972-73 . 268 Table S erage and range of inst ructional faculty/student ratiosliv profession, 1972-7~L. 268 Table (1 Average arid range of annual net education expenditures per student by profession, 1972-73 268 Table 7 erage annual net educat bin expendi t tires or student bvprofession, 1972-73 .. 269 Tal ile S. Capitation at current out horization levels and at dif- ferent levels of average annual nit educ:it ill expenditures, 1972-73 - 269 Kindig, David A., M. 1)., codirector, Institute for lli'alth Team Dc- veloonment, Montefiore 11 ospital and Health (`enter, specific pro- piisedlegislativechangesinJJJ~ 14721 . .. ... . 1392 Lat tuner, J ((un K., Al. I) .,A men can As'~cicia t ion 4 (liii cal Cr `Ii igDI s Lee, Philip H.. Al. I ).. professor if social medicine and (lirecter. heaP Ii p~1icy program, Univer~mtv if California School if Medicine, San Fr:incisco: Cotnimients en the Health AIamit)o\ver Training Act of 1 ¶174--11. II. 14721 365 Siimnniarv of testimony and reconiniendations - - - 364 Si mnimarv of the foreign nmedm cal graduate sit ito ii iii in the I `nit ed States~..~ 368 Lowin, Aaron, Ph. 1)., director, health Manpower I )ivisi ri, Inter- Study, Minneapi'ilis, Alinn., supporting documnints to tO~"i1fli'fly - - - 729 Madis in, 1 )onal d L., Al. I )., associate professor f oe(li cal care i ir- ganizatii)n, School of Medicine, atid associate ii ofe~seraf health adniiuistratioi'i. School i~f Puihe Health, itivirsity f North Car ilina at Chapel II 1, article fri mc 11 ealI h Set vices Repi irts, October 1973: Recruiting Physicians for Rural Practice 624 PAGENO="0010" x Additional material submitted for the record by-Continued Page Maharishi International University, Ian MacPherson Brown, di- rectorof resource development, statement 1638 Marvin, Langdon Parker, Jr., trainee in emergency medical services, statement 1647 Mayer, Eugene S., MI)., assistant professor of medicine and deputy director, Area Health Education Centers program, University of North Carolina School of Medicine: Letter dated June 7, 1974, to Chairman Rogers, supplying pro- jection of retention rates for medical students trained in North Carolina 1500 Map showing counties served by the North Carolina Area Health Education Centers program, May 30, 1974 1494 Medical education program/Morehouse College, Atlanta, Ga., statement 1644 National Association of Chain Drug Stores, Inc., letter dated June 6, 1974, from Robert J. Bolger, president, to Chairman Rogers 1664 National League for Nursing: Letter dated June 17, 1974, from Dr. Eloise R. Lewis to W. E. Williamson, clerk, Committee on Interstate and Foreign Corn- rnerce, supplying data on shortage of nurses in North Carolina_ 1096 Supplemental statement 1074 Oliver, Robert W., secretary-treasurer, Federation of Associations of Schools of the Health Professions: Member organizations of the Federation 829 Recommendations of the Federation for legislation in behalf of training health manpower 829 Parry, Stanley, executive director, Health Services Education Council, San Jose, Calif., appendixes to statement 1488 Simonds, Scott K., Dr. P.H., professor of health education, University of Michigan School of Public Health, letter dated August 16, 1974, with attached paper, to lion. William R. Roy, a Representative in Congress from the State of Kansas 1657 State University College at Brockport, State University of New York, letters dated May 29, 1974, from Darwin Palmiere, dean, faculty of human Services, and Doris Geiss, Ed. D., chairwoman, nursing department, to Chairman Moss 1665, 1667 University Associates, Inc., letter dated June 25, 1974, from Luther L. Terry, M.D., Surgeon General, retired, U.S. Public Health Service, to Chairman Rogers 1668 \\eber, Gerald I., Ph. D., acting associate professor, childhood and government l)rcject, School of Law, University of California, Berkeley, Calif.: Essay on the Distribution of Physicians Amongst Specialties 646 Wegner, Karl H., M.D., vice president for health affairs, and dean, University of South Dakota School of Medicine at Vermillion, mailgram to Hon. James Abdnor, a Representative in Congress from the State of South 1)akota 1669 Weiss, Robert J., M.D., associate director, Center for Community Health and Medical Care, Harvard Medical School, Boston, Mass., paper-Some Good Features of the British National Health Service, by Paul B. Beeson, M.1)., Nuffield professor of clinical medicine, University of Oxford 815 ORGANIZATIONS REPRESENTED AT THE HEARINGS American Academy of Family Physicians: hluffington, H. L., M.D., chairman, Commission on Legislation and Public Policy. Price, James G., M.D., president. American Association of Clinical Urologists: Carson, Russell, MI)., Fort Lauderdale, Fla., president. Lattimer, John K., chairman, Department of Urology, Columbia University College of Physicians and Surgeons. PAGENO="0011" XI ORGANIZATIONS REPRESENTED AT THE HEARINGS-Continued American Association of Colleges of Osteopathic Medicine: McNevin, Anthony J., director, governmental affairs. Magen, Myron S., D.O. Oliver, Robert W., executive director. American Association of Colleges of Nursing, Dr. June Rothherg, president. American Association of Colleges of Pharmacy: Bliven, Charles W., executive secretary. Skinner, William J., legislative and legal counsel. \Veaver, Warren E., Ph. I)., chairman, executive committee. American Association of Colleges of Podiatric \Iediciiie: Baerg, I)r. Richard, dean and acting president, New York College of Podiatric Medicine. Bailey, Dr. II. I)., president. Bates, Dr. James, president, Pennsylvania College of Podiatric Medicine. Heil, Robert, executive director. Rubin, I)r. Abe, president, Ohio College of Podiatric Medicine. ~merican Association of Dental Auxiliaries, Charles A. Amenta, Jr., D.D.S., executive director. American Association of Dental Schools, Dr. 1)ale Redig, dean, University of the Pacific School of I)entistry. American Board of Medical Specialties, William I). liolden, M.D., member executive committee. American Dental Association: Ginley, Dr. Tom, secretary, council on dental education. Kunkel, l)r. Paul, chairman, council on legislation. Redig, Dr. T)ale, dean, University of the Pacific School of Dentistry. American Hospital Association: Gehrig, Leo J., M.D., vice president. Sauer, Larry, director, legislation division. Thompson, I)avid, M.D. American Medical Association: Colemen, Francis C., M.D., chairman, council on health manpower. Harrison, Bernard P., directoi', division of medical practice. Pahi, Charles W., assistant director, legislative department. Ruhe, C. II. \Villiani, MI)., director, division of medical education. Sodeman, William A., M.D., past chairman, council on medical education. American Nurses' Association: Blakeney, Hazle E., Ed. 1)., chairman, commission on nursing. Holleran, Ms. Constance, deputy executive director. American Optometric Association: Hopping, Richard L., O.D. Yamamoto, l)ennis, O.D., director, department of Feder: 1 educational affairs. American Veterinary Medical Association: Besch, 1)r. Everett I). Decker, I)r. Winston, assistant executive vice president. limes, Dr. Martin. Association of Aiiierican Medical Colleges: Bowsher, Prentice, staff member. Cooper, John A. I)., ~\1. D., president. Tosteson, I)ai~iel, M.D., chairman, executive council. Association of American Veterinary Medical Colleges, I)r. Everett 1). Besch, Association of Schools and Colleges of Optometry, Richard L. Hopping, 0. 1). Association of Schools of Public Health: Breslow, Dr. Lester, president. Cotton, Raymond. Day, Dr. Robert, dean, University of Washington School of Public Health. Association of University Programs in Health Administration: Filerman, Dr. Liary L., executive director. Griffith, Dr. John R., president. Jaeger, l)r. Jon, chairman, Department of Health Administration, Duke University Medical School. McCool, Dr. Barbara, assistant professor, program in hospital and health services administration, Northwestern University. CONSAD Research Corp., Pittsburgh, Pa., Donald M. McCartney. Coordinating Council for Education in Health Sciences for San Diego and Im- perial Counties, Calif., Mrs. Ann S. Bush, executive director. PAGENO="0012" XII ORGANIZATIONS REPRESENTED AT THE HEARINGS-Continued Federation of Associations of Schoels of the Health Professions, Robert W. Oliver' secret arv-treasurer. Health, Education, and \Velfare, I )epartnient of: Altman, 1)r. Stuart Ii ., L)eputv Assistant Secretary (Health, Planning, and Analysis) Buzzeli, Harold 0 Acting I)irector, Health Services Administration. Cooper. l)r. Theodore, 1)eputv Assistant Secretary (Health). Edwards, I)r. Charles C Assistant Secretary for Health. E:idicott, l)r. Kenneth M., Administrator, Health Resources Administration. \Iarti~i, l)r. Edward, l)irector, National Health Service Corps. Samuel, Frank F., Jr., I)eputv Assistant Secretary for Health Legislation. Institute of Medicine, National Academy (if Sciences: B:~icer. Roger. MI) acting president. iRaft, Mrs. Ruth S., senior research associate. N: tinal League for Nursing, Eloise R. Lewis, R. N., Ed. I)., dean, School of N ur~in a, niversity of North Carolina at Greensboro. National St udents Nurses Association, Ms. Mary F. foley, president. New Jersey, State of, Edward Cohen, assistant chancellor, health professions education. I )epartment of higher Education. North Carolina Area Flealth Education Centers program, John Payne, associate direct Cr San Jose. Calif.. health Services Education Council, Stanley Parry, executive direct r. Student American \Iedical Association: Aarn, Phil H., ~peaker of the house. Blat ti, (;eorg , past president Kridel, Russell, immediate past president. Liri, Sam, Ph. l)., Norris. ,j. Ted, president. Student American Pharmaceutical Association: Mc Ghan, I )r. William F., executive secretary. Schondelniever, Stephen \V., president. i.S. General Accounting Office 1)in. Joseph P.. supervisory auditor, Los Angeles regional office. Faze, Frank I)., supervi~orv auditor, Manpower and Auditor Division. Henig, Morton E Associate Director, Manpower and `Welfare Division. Myers, \lorton A .,A~sistant Director. Williamson, Tie mas, senior attorney. University of California, School of Medicine, Philip R. Lee, M.D.. professor of soCial medicine and director, health policy program. University of North Carolina School of Medicine Area Health Education Centers program. Eugene S. Mayer, M. I)., deputy director. Uni~'ersit~' tif \Vashington Bennett, Roger, long-range planner, Health Science Center. Citters, Robert L., Van, Ml).. dean, School of Medicine. Lein, John N., M.D., associate dean, School of Medicine. Schwarz, M. R y, M. L)., associate dean, School of Medicine. PAGENO="0013" HEALTH MANPOWER AND NURSE TRAINING-1974 MONDAY, MAY 20, 1974 Ho1IsF~ OF REPRESENTA'FIVES. ~ITncoMMI'r'rEI: ON PUBLI(' HEALTh AND FNVIRONMENT. (~oh1~rI'r'rI~E ON INTERSTATE ANI) FOREIGN COMMERCE. ~Ti~i~h ;ngto'i~~. D.C. lhe sul)(Olllmttec met at P a.n~ . puisiiant to notice. in room Rayburn House Office Building. Hon. Paul G. Rogers. chairman, ~)1~eSic1iIlg. Mr. ROGERS. The subcommittee will come to order. please. This morning the subcommittee begins 2 weeks of hearings on pro- 1)osecl revisions to the health manpower and nurse training authori- ties. whose funding ~IO%~is~o15 expire omi ,June 30. 1974. I)uriin~ this period we wi1 I lieai testimony from representatives of the T)epartment of Health. Education, and Welfare, panels of health experts who will discuss 1)roblerns of 1)1Y5ic1a11 SlIpply, (uS- tribution. and the status of forei~n medical graduates. as well as rep- tesentatives of the various health professions affected by the bills I)efore us. Became we will not hear HE\V Witllesses until this afternoon. I wIll reserve my full statement until that time. The Health Manpower Act of 1971 and the Nurse Training Act of 1971 for the first time used a ~capitation" approach of providing assistance to health professions schools whereby schools were to re- (dye institutional sul)poIt bi~sed on student enrollment. Because of a lack of data on the true costs of health education, the 1911 law requested tile Institute of Medicine to i)rOvide estimates of the education costs per student in each of the health professions. The Institute of Medicine reSJ)onded in January 1974 through pub- lication of a thorough alici ext remel competent stud entitled ~`Costs of Education iii the Health Professions." IThe texts of H.R. 11539. IT.R. 11587. H.R. 13174, H.R. 13469, HR. 14196, HR. 14357, H.R. 14721. 1I.R. 14722. FT.R. 14930, H.R. 14931, H.R. 15051, HR. 15112. H.R. 15128. ILR. 15177, H.R. 15211. H.R. 15225, and H.R. 15519, together with departmental reports thereon, follow:] (1) PAGENO="0014" 9 [H.R. 11539, 93d Cong., 1st sess., introduced by Mr. Staggers (for himself and Mr. Devine) on November 15, 1973, and H.R. 11587, 93d Cong., 1st sess., introdi'ced by Mr. Hastings on November 27, 1973, are identical as follows:] A BILL Ta improve and extend tile Public Health and National health service (orp~ schloraslliJ) training program. 1 Bc it c1,a(tul b!/ f/ic Senate and These of J?eprescnta- 2 flees of f/ic Un ite(l States of America in Con qrcss assembled, 3 That this Act may lie cited as the `TuLLe ll~a.Ith and Na- 4 nal health ~e rvicc Corps Scholarship Training Program S Aniencimeuts of 1973''. 0 SEe. 2. (a ) Section 225 (a ) of the Puhlie Health Service 7 Act is amended Lv stiikiiig out "other units of the Service" S and inserting in lieu thereof "such other uniformed or civilian 9 Federal health service as the Secretary may determine is 10 appropriate'. PAGENO="0015" 3 1 (U) Sectioii 225 (li ) (3) of such Act is aiuciidcd by 2 t rikiiìg out `iie eligible fi )r, or Ia ild, au appoiui tii i(lit a~ a 3 ~ officer in the Regular or Reserve (~ ups of the 4 Service or' ali(l niserting `or in such other uniformed or 5 civilian Federal health service a.s the Secretary may deter- 6 mine is appropriate' all er the \Vor(1 ``Corps''. 7 ( c) Section 225 (1)) (4) 1 such Act is amiieiided 1 iv S striking ut `in the (oiauni~siouicd ( alps of ti e Service or* 9 and iiisei*t ing or iii 511(11 oilier uiiifoniied or civilia ii Federal 10 health service as the Secretary may detcnnine is appropriate" ii after the word "Corps". 12 (d) Section 225 (e) of such Act is auuiendcd (1) Lv 13 amending the first clause of the first sentence to read "A 14 p~~rson participating ill the program shall be obligated fol- I a lowing completion of academic training to serve as a civilian 16 imieiiiber of the National health Service Corps or in such 17 other uniformed or civilian Federal health service as the I S Kecreta iv may dcl ermine is appn pria te,'' ; (2) Lv striking 19 out the second sentence : aiid (3) by auiieiidiiig the last seli- 21) teuice Lv inserting `~Federal health" before the word 21 ``facility'', by placing a period after the word "facility'', and 22 Lv striking out ``of the Service or oilier facility f the Na- 2~ tional health Service Corps.'' 24 (e) Section 225 (i ) is amended to read as follows PAGENO="0016" 4 3 1 "(1) There are authorized to be appropriated such sums 2 as may he necessary to carry out the program." SEC. 3. This Act shall be effective with respect to appro- ~ priations for fiscal years ending after June 30, 1973. PAGENO="0017" 93o CONGRESS 2D SESSION H. R. 1 3 1 74 IN THE HOUSE OF REPRESENTATIVES FEBRUARY 28, 1974 Mr. ROGERS introduced the following bill; which was referred to the Com- mittee on Interstate and Foreign Commerce A BILL To amend the Public health Service Act to extend to commis- sioned officers of the Service the benefits and immunities of the Soldiers' and Sailors' Civil Relief Act of 1940, as amended. 1 Be it enacted by the Senate and Honse of Represent a- 2 tives of the United States of America in Congress assembled, 3 That section 212 of the Public health Service Act is 4 amended by adding after subsectioll (d) the following new 5 subsection 6 " (e) Active service of commissioned officers of the 7 Service shall be deemed to be active military service in the 8 Armed Forces of the United States for the purposes of all 9 rights, privileges, immunities. a.nd benefits now or hereafter 10 provided under the Soldiers' and Sailors' Civil Relief Act U of 1940, as amended (50 App. U.S.C. 501 ct seq.) .". 38-698 0 - 74 - 2 (Pt. 1) PAGENO="0018" 6 93D CONGRESS T T .- 2D SESSION K 1 3469 IN THE HOLSE OF REPRESENTATIVES MARCH 13, 1974 Mr. ROGERS (for himself. Mr. STAGGERS. Mr. KyRos, Mr. PR~YER, Mr. SYMING- TON, Mr. Roy, Mr. NELSEN. Mr. CARTER. Mr. HASTINGS, Mr. HEINZ. and Mr. HfDxur) introduced the following bill; which was referred to the Committee on Interstate and Foreign Commerce A BILL 1 o amend the Public Health Service Act to revise the National health Service Corps program and the Public Health and National Health Service Corps Scholarship Training Program. 1 Be it enacted by 1/ic Senate and House of Representa- 2 tires of the United States of America in Congress assembled, 3 SECTION 1. This Act may be cited as the "National 4 health Service Corps Amendment of 1974". 5 SEc. 2. (a) Section 329 of the Public Health Service 6 Act is amended to read as follows: 7 "NATIONAL hEALTH SERVICE CORPS S `~Si~c. 329. (a) There is established, within the Service, 9 the National Health Service Corps (hereinafter in this see- PAGENO="0019" 1 tion referred to as the `Corps') which shall consist of those 2 officers of the Regular md Reserve Corps of the Service and 3 sueli other personnel as the, Secretary may designate and 4 which shall 1e utilized by the Secretary under this section ~ to improve the delivery of health services to medically Un- 6 derserved populations. 7 " (b) (1) The Secretary shall designate the medically S underserved populations in the States. For 1)111'Poses of this 9 section, a~ medically underserved population is the popula- 10 thai of an urban or rural area (which does not have to con- 11 form to the geographical boundaries of a political subdivision 12 and which should be a rational area for the delivery of health 13 services) which the Secretary determines has a critical 14 health manpower shoit~ige or a pOI)ullatiOn group determined 1~5 by the Secretary to have sucil a shortage ; and the term 16 `State' ineludes Guam, American Samoa, and the Trust Ter- 17 ritorv of the Pacific Islands. In designating medically under- iS served popu1atioi~s, the Secretary shall take into account 19 (A) the recommendations of the entities responsible for the 20 developnient of the plans referred to in section 314 (b) 21 which cover all or any part of the ~ireas in which populations 22 under consideration for designation reside, and (B) in the case 23 of any such area for which no such entity is responsible for 24 developing such a plan. the recommendations of the agency ~ of the State (or States) in which such area is located which PAGENO="0020" 8 3 1 administers or supervises the administration of a State plan 2 approved under section 314 (a) 3 (2) Any person may apply to the Secretary (in such 4 manuel as he may pn'scrile) for the designation of a popu- 5 lotion as a medically underserved l)01)111at10n. In considering 6 an application under this paragraj)h, the Secretary shall 7 take jute account the 6 dlowing in addition to criteria utilized S by him in making a designation under paragraph (1) 9 (A) Batios of available health manpower to the 10 population for which the application is made. 11 ~` (B) Indicators of the population's access to health 12 services. 13 " (C) Indicators of health status of the population. 14 " (D) Indicators of such population's need and de- 15 mand for health services. 16 (3) The Secretary shall (A) provide assistance to 17 persons seeking assignment of Corps personnel to provide 18 under this section health services for niedicallv imderserved 19 populations. cud (B) conduct such information programs 20 in areas in which such populations reside as may he neces- 21 sarv to inform the public and priva~e health entities serving 22 those areas of the assistance available to such populations 23 by virtue of their designation under this section as medically 24 underserved. 25 "(c) (I) (A) The Secretary may assign personnel of the PAGENO="0021" 9 4 1 Corps to provide, under regulations prescribed by the Secre- 2 tary, health services for a medically underserved population 3 if- 4 "(i) the State health agency of each State in 5 which such population is located or the local public 6 health agency or any other public or nonprofit private 7 health entity serving such population makes application S to the Secretary for such assignment, and 9 "(ii) the (I) local government of the area in 10 which such population resides, and (II) any State and 1 1 district medical or dental society for such area or any 12 other appropriate health society (as the case may be), 13 for such area certify to the Secretary that such assign- 14 ment of Corps personnel is needed for such population. 15 "(B) The Secretary may not approve an application 16 under paragraph (1) (A) (i) for an assignment unless the 17 applicant agrees to enter into an arrangement with the 18 Secretary in accordance with subsection (e) (1) and has 19 afforded- 20 "(i) the entity responsible for the development of 21 the plans referred to in section 314 (b) which covers 22 all or any part of the area in which the population 23 for which the application is submitted resides, and 24 "(ii) if there is a part of such area for which no 25 such entity is responsible for developing such plans, the 26 agency of the State in which such part is located which PAGENO="0022" 10 5 1 adimnisters or supervises the administration of a State 2 plan approved under section 314 (a) 3 all opportunity to review tile application and Slil)mlt its 4 comments to the Secretary respecting the need for and 5 proposed rise of manpower requested in the application. 6 In considering such an apphicatioii, the Secretary shall take 7 into consideration the need of the population for which tile 8 application was sul;niitted for the health services which 9 may he provided under this section; the willingness of the 10 popitlation and rue appropriate govermnental agencies or 11 health entities serving it to assist and cooperate with the 12 Corps in providing (fle(tive health services to the population; 13 and recommendations from medical, dental, or other health 14 societies or from nlediral personnel ~erviiig the population. 15 (C) If with resl)ect to aiiv proposed assignment of 16 Corps peisonnel for a medically uuidcrserved population the 17 requiremeiits of clauses ( i ) and (ii) of subparagraph (A 18 are met except for the cei'tifiuation by a State and district 19 iiiedieal or dental society or lv any other appropriate health 20 society required iiv clause (ii) (II) and if the Secretary 21 finds from all the facts presented that such certification has 22 clearly been arbitrarily and capriciously withheld, the See- 23 retary may, after consultation with appropriate medical, 24 dental, or other health societies, waive the application of the 23 certification requirement to such proposed assignment. PAGENO="0023" 11 1 ``(2) (A) Iii approving an ap~licatio1I snhiintted under 2 paragraph (1) for the assignnient of Corps 1)~15o11fle1 to 3 P~o~jde health services for a medically uiiderscrved popu- 4 lation, the Secretary may approve time assiglinielit of Corps 5 P~1~~fl1~' for such 1)opulatioll (Turing a peiiocl (referred to 6 in this paragraph as tile `assistance period') which may not~ 7 exceed four years from the (late of tile first assigiiment of 8 Corps pel'somlmiel for such po~)u1ation after the date of time 9 approval of tile application. ~ assignment of individual 10 Corps personnel may be made for a period ending after time 11 expiration of the applicable approved assistance period. 12 " (B) lpon expiration of an approved assistance period 13 for a medically underserved population. no new assignment 14 of Corps persomiel miiav be mimade for such popnlat ion unless 15 an application is subniitted iii accordance \vitli panigrapli 16 (1) for such assignnient. rfl1 Secmctam iuia 10 )t approve 17 such miii application unless- 18 " (i) the api)hcation and certification requirements 19 of paragraph (1) are met; 20 "(ii) the Secretary has conducted an evaluation 21 of the continued need for health manpower of the popu- 22 lation for which the application is submitted, of the 23 ~itilization of the manpower by such population, of the 24 growth of the health care practice of the Corps personnel 25 assigned for such population, and of community support 26 for the assignment; and PAGENO="0024" 12 7 1 "(iii) the Secretary has determined that~ such 2 population has made continued efforts to secure its 3 own health manpower, that there has been sound fiscal 4 nianageinent of the health care pract ice of the Corps 5 personnel assigned for such population, including efficient 6 collection of fee-for-service, third-party, and other funds 7 available to such population, and that there has been 8 appropriate and efficient utilization of such Corps 9 personnel. 10 ~` (3) Corps personnel shall lie assigned to provide 11 health services for a medieally underserved population on the 12 basis of the extent of the population's need for health services 13 and without regard to the ability of the members of the 14 population to pay for health services. 15 (4) In making an assigiiiiienl of Corps personnel the 16 Secretary shall seek to match characteristics of the assignee 17 (aiid his spouse (if any) ) and of the population to which iS such assignee may 1)0 assigned in order to increase the hikeli- 19 hood of the assignee remaining to serve the population upon 20 completion of his assignment period, The Secretary shall be- 21 fore the expiration of the last nine months of the assignment 22 period of a member of the Corps. review such member's 23 assignment and the situation in the area to which he was 24 assigned for the purpose of determining the advisability of 2u extending the period of such member's assignment. 26 "(5) The Secretary shall provide technical assistance PAGENO="0025" 13 8 1 to all medically underserved populations to which are not 2 assigned Corps personnel to assist in the recruitment of 3 health manpower. The Secretary shall also give such popula- 4 tions current information respecting public and private pro- 5 grams which may assist in securing health manpower for 6 them. 7 "(d) (1) In providing health services for a medically 8 underserved population under this section, Corps personnel 9 shall utilize the techniques, facilities, and organizational 10 forms most appropriate for the area in which the population 11 resides a.nd shall, to the maximum extent feasible, provide 12 such services (A) to all members of the population regard- 13 less of their ability to pay for the services, and (B) in con- 14 nection with (i) direct health services programs carried out 15 by the Service; (ii) any direct health services program car- 16 ned out in whole or in part with Federal financial assisth~nce; 17 or (iii) any other health Services activity which is in further- 18 ance of the purposes of this section. 19 "(2) (A) Notwithstanding any other provision of law, 20 the Secretary (i) may, to the extemit feasible, make such 21 arrangements as lie determines necessary to enable Corps 22 personnel in providing health services for a medically 23 underserved population to utilize the health facilities of the 24 area in which the population resides, and (ii) may make 25 such arrangements as be determines are necessary for the PAGENO="0026" 14 9 1 use of equipment and supplies of the Service and for the 2 lease or acquisition of other equipment and supplies, arid 3 may secure the temporary services of nurses and allied 4 health professionals. 5 "(B) If such area is being served (as determined under 6 regulations of the Secretary) by a hospital or other health 7 care delivery facility of the Service, the Secretary shall, 8 in addition to such other arrangements as the Secretary may 9 make under subparagraph (A), arrange for the utilization 10 of such hospital or facility by Corps personnel in providing 11 health services for the population, but only to the extent 12 that such utilization will not impair the delivery of health 13 services and treatment through such hospital or facility to 14 persons who are entitled to health services and treatment 15 through such hospital or facility. If there are no health 16 facilities in or serving such area, the Secretary may arrange 17 to have Corps personnel provide health services in the 18 nearest health facilities of the Service or the Secretary may 19 lease or otherwise provide facilities in such area for the 20 provision of health services. 21 "(3) The Secretary may make one grant to any apphi- 22 cant with an approved application under subsection (e) to 23 aszsist it in meeting the costs of establishing medical practice 24 management ~v~tems for Corps personnel, acquiring equip- 25 ment for their use in providing health services, and estab- 11.R. 13469-2 PAGENO="0027" 13 10 1 lishiiig appropriate continuing education programs and 2 opportuiiities for them. No grant may be made under this 3 paragraph unless an application is submitted therefor and 4 approved by the Secretary. The amount of any grant shall 5 be determined by the Secretary, except that no grant may 6 be made for more than $25,000. 7 "(4) Upon the expiration of the assignment of Corps 8 personnel to provide health services for a medically under- 9 served population, the~ Secretary (notwithstanding any other 10 provision of law) may sell to the entity which submitted 11 the last application approved under subsection (c) for the 12 assignment of Corps personnel for such population equipment 13 of the United States utilized by such personnel in providing 14 health services. Sales made under this paragraph shall be 13 made for the fair market value of the equipment sold (as 16 deterniined by the Secretary). 17 "(e) (1) The Secretary shall require as a condition to 18 the approval of an application under subsection (c) that the 19 entity which submitted the application enter into an appro- 20 priate arrangement with the Secretary under which- 21 "(A) the entity shaH he re~ponsible~ for charging 22 in accordance with paragraph (2) for health services by 23 the Corps personnel to he assigned; 24 "(B) the entity shall take such action as may be 25 reasonable for the collection of payments for such health PAGENO="0028" 16 11 services, including if a Federal agency, an agency of a 2 State or local government., or other third party would be 3 responsil)le for all or part of the cost of such health services if it had not been provided by Corps personnel nuder this section, the collection, on a fee-for-service or 6 other basis, from such agency or third party the portion of such cost for which it would be so responsible (and in determiiiing the amount of such cost. which such agency or third party would be responsible, the health 10 services provided by Corps personnel shall be considered as being provided liv private practitioners) ; and 12 "(C) the entity shall pay to the United States the 13 lesser of- 14 "(i) the amount collected by the entity in 15 accordance with subparagraph (B) in each calendar quarter (or other period as may be specified in 17 the agreement), or 18 "(ii) the sum of (I) the pay (including the 19 amounts paid in accordance with subsection (f) 20 and allowances for the Corps personnel for such 21 quarter (or other period), and (II) an amount 22 which bears the same ratio to the aniount of any 23 grant made to the entity under subsection (d) (3) 24 as the number of days in such quarter (or other PAGENO="0029" 17 12 1 period) bears to the number of days in the assign- 2 ment period for such personnel. 3 Any amount of the amount collected by an entity in accord- ~ ance with subparagraph (B) which the entity is entitled to 5 retain under subparagraph (C) shall be used by the entity 6 to expand or improve the provision of health services to ~ the population for which the entity submitted an application 8 under subsection (c) or to recruit and retain health man- ~ power to provide health services for such population. Funds 10 received by the Secretary under such an arrangement shall ~ be deposited in the Treasury as miscellaneous receipts and 12 shall be disregarded in determining the amounts of appro- 13 priations to be requested under subsection (i), and the 14 amounts to be made available from appropriations made 15 under such subsection to carry out this section. 16 "(2) Any person who receives health services provided 17 by Corps personnel under this section shall be charged for 18 such services on a fee-for-service or other basis at a rate 19 approved by the Secretary, pursuant to regulations, to re- 20 cover the value of such services; except that if such person 21 is determined under regulations of the Secretary to be 22 unable to pay such charge, the Secretary shall provide for 23 the furnishing of such services a.t a reduced rate or without 24 charge. 25 "(f) (1) The Secretary shall conduct at medical and PAGENO="0030" 18 13 1 nursing schools and other Schools of the health professions 2 and training centers for the allied health professions, recruit- 3 ing programs for the Corps. Such programs shall include the 4 wide dissemination of written information on the Corps and 5 visits to such schools by personnel of the Corps. 6 "(2) The Secretary may reimburse applicants for posi- 7 tions iii the Corps for actual expenses incurred in traveling 8 to and from their place of residence to an area in which 9 they would be assigned for the purpose of evaluating such 10 area. with regard to being assigned in such area.. The Secre- 11 tary shall not reimburse an applicant for more than one 12 such trip. 13 "(3) Commissioned officers and other personnel of the 14 Corps assigned to provide health services for medically 15 underserved populations shall not be included in determin- 16 ing whether any limitation on the number of personnel 17 which may be employed by the Department of Health, 18 Education, and Welfare has been exceeded. 19 "(4) The Secretary shall, under regulations prescribed 20 by him, adjust the monthly rate of pay of each physician 21 and dentist member of the Corps who is directly engaged in 22 the delivery of health services to a medically underserved 23 population as follows: 24 "(1) During the first thirty-six months in which 25 such a member is so engaged in the delivery of health PAGENO="0031" 19 14 1 services, his monthly rak of pay shall be increased by 2 an amount (not to exceed $1,000) which when added 3 to the member's regular monthly rate of pay and allow- 4 ances will provide a monthly income competitive with 5 the average monthly income from an established practice 6. of a member of such member's profession with equiva- 7 lent training. 8 "(B) During the period beginning upon the expi- 9 ration of the thirty-six months referred to in subpara- 10 graph (A) and ending with the month in which the 11 member's regular monthly rate of pay and allowances is 12 equal to or exceeds the monthly income he received for 13 the last of such thirty-six months, the member shall re- 14 ceive in addition to his regular rate of pay and allowances 15 an amount which when added to such regular rate equals 16 the monthly income he received for such last month. 17 In the case of a member of the Corps who is directly 18 engaged in the provision of health services to a medicaliy 19 underserved population in accordance with a service obli- 20 gation incurred under section 225, the provisions of this 21 paragraph shall apply to such member upon satisfactory 22 completion of such service obligation and the first thirty-six 23 months of his being so engaged in the delivery of health 24 care shall, for purposes of this paragraph, be deemed to 25 begin upon such satisfactory completion. U PAGENO="0032" 17 1 general public to represent the colisumers of health care, 2 at least two of whom shall be members of a-medically 3 underserved population for which Corps personnel are 4 providing health services under this section. 5 "(B) Three members shall be appointed from the 6 medical, dental, and other health professions and health 7 teaching professions. S "(C) Three members shall be appointed from State 9 health or health planning agencies. 10 "(D) Three members shall be appointed from the 11 Service, at least two of whom shall be members of the 12 Corps directly engaged in the provision of health serv- 13 ices for a medically underserved population. 14 "(E) One member shall be appointed from the 15 National Advisory Council on Comprehensive Health 16 Planning. 17 "(F) One member shall be appointed from /tie 18 National Advisory Council on Regional Medical Pro- 19 grams. 20 The Coumicil shall consult with, advise, and make recoin- 21 mendations to, the Secretary with respect to his respons~ 22 hilities in carrying out this section. and shall review and 23 approve regulations promulgated by the Secretary under 24 this section and section 225. 25 " (2) Memnhei's of the Council shall be appointed for a PAGENO="0033" 23 18 1 term of three years and shall not be removed, except for 2 cause. Members may be reappointed to the Council. 3 " (3) Appointed members of the Council, while attend- 4 ing meetings or conferences thereof or otherwise serving 5 on the business of the Council, shall be entitled to receive 6 for each day (including traveltiine) in which they are so 7 serving the daily equivalent of the annual rate of basic pay 8 in effect for grade GS-18 of the General Schedule, and ~ while so serving away from their homes or regular places of 10 business they may be allowed travel expenses, including per ii diem in lieu of subsistence, as authorized by section 5703 (h) 12 of title 5 of the United States Code for persons in the Gov- 13 ernment service employed intermittently. 14 "(1) (1) To carry out the piii~oses of this section, there 15 are authorized to be appropriated $25,000,000 for the fiscal 16 year ending June 30, 1974; $30,000,000 for the fiscal year 17 ending June 30, 1975; $35,000,000 for the fiscal year end- 18 ing June 30, 1976; and 840,000,000 for the fiscal year end- 19 ing 30, 1977. 20 "(2) An appropriation Act which appropriates funds 21 under paragraph (1) of this subsection for the fiscal year 22 ending June 30, 1975, may also appropriate for the next 23 fiscal year the funds that are authorized to he appropriated 24 under such paragTaph for such next fiscal year; hut 110 funds 25 may be made available therefrom for obligation under this PAGENO="0034" 24 19 1 section before the fiscal year for which such funds are author- 2 ized to be appropriated.". 3 (b) (1) The Secretary of Health, Education, and Wel- 4 fare shall report. to Congress (1) not later than September 5 1, 1974, the criteria used by him in designating medically 6 underserved populations for purposes of section 329 of the 7 Public health Service Act, and (2) not later than January S 1, 1975, the identity and number of medically underserved 9 populations in each State meeting such criteria. 10 (2) The Secretary of Health, Education, and Welfare ii shall conduct or contract for studies of methods of assigning 12 under section 329 of the Public Health Service Act National 13 Health Service Corps personnel to medically underserved 14 populations and of providing health care to such popnlations. 15 Such st~idies shall be for the purpose of identifying (A) the 16 characteristics of health manpower who a~re more likely to 17 remain in practice in areas in which medically underserved 18 populations are located, (B) the characteristics of areas 19 which have been able to retain health manpower, (C) the 20 appropriate conditions for assignment of independent nurse 21 practitioners and physician's assistants~ in areas in which 22 medically underserved populations are located, and (D) the 23 effect that primary care residency training in such areas has 24 on the health care provided in such areas and on the de- PAGENO="0035" 25 20 1 cisions of physicians who received such training respecting 2 the areas in which to locate their practice. 3 (c) (1) The amendment made by subsection (a) which 4 changed the name of the advisory council established under 5 section 329 of the Public Health Service Act shall not be 6 construed as requiring the establishment of a new advisory 7 council under that section; and the amendment made by 8 such subsection with respect to the composition of such 9 advisory council shall apply with respect. to appointments 10 made to the advisory council after the date of the enactment 11 of this Act. 12 (2) Section 741 (f) (1) (C) of the Public health Serv- 13 ice Act is amended by inserting "in which is located a. 14 medically underserved population" after "in a State". 15 SEc. 2. Section 225 of the Public Health Service Act 16 is amended to read as follows: 17 "PTJBLIC HEALTH AND NATIONAL HEALTh SERVICE 18 coups SCHOLARSHIP TRAINING PROGRAM 19 "SEC. 225. (a) The Secretary shall establish the Public 20 Health and National Health Service Corps Scholarship 21 Training Program (hereinafter in this s~ction referred to as 22 the `program') to obtain trained physicians, dentists, nurses, 23 or other health-related specialists for the National Health 24 Service Corps or other units of the Service. 25 "(b) To be eligible for acceptance in the program. an 26 applicant for the program must- PAGENO="0036" 21 1 "(1) be aceepted for enrollment, or be enrolled, as a full-time student in an accredited (as determined by the Secretary) educational institution in a State which 4 provides a course of study approved by the Secretary 5 leading to a degree in medicine, dentistry, nursing, or 6 other health-related specialty as determined by the 7 Secretary; S `~ (2) he eligible for, or hold, an appointment as a 9 commissioned officer in the Regular or Reserve Corps 10 of the Service or be eligible for selection for civilian 11 service in the Service; and 12 "(3) agree in writing to serve, as prescribed by 13 subsection (d) of this section, in the Commissioned Corps of the Service or as a civilian member of th~ Service. 16 To remain in the program an individual must. pursue at such 17 au illstitllti)u such an approved course of study and maiD- 18 tam au acceptable level of academic standing in it. 19 "(c) (1) (A) Each participant in the program sh?.ll 20 receive a sc.ho~arship for each approved academic year of 21 training, not. to exceed four years. A participant's scholar- 22 ship shall consist of (i) an amount equal to the basic pay 23 and allowances of a commissioned officer on active duty in 24 pay grade 0-1 with less than two years of service, and (ii) 25 payment of the tuition expenses of the participant and ~ll PAGENO="0037" 27 1 oth& educational expenses incurred by the participant, 2 ii~cludir~g fees, books, and laboratory expelises. 3 ` " (B) The Secretary may contract with an institution 4 in whk~h participants are enrolled for the payment to the 5 institution of the tuition and other educational expenses of 6 such participants. Payment to such institution may be made 7 without regard to section 3648 of the Revised Statutes (31 8 U.S.C. 529). 9 "(2) When the Secretary determines that an institu- 10 ti~m has increased its total enrollment for the sole purpose 11 of accepting members of the program, he may provide under 12 a contract ~itli such an institution for additional payments i3 to c~ver the portion of the increased costs of the additional 14 enrollment which are not covered by the iiistitution's normal 15 tuition and fees. 16 "(d) (1) Each participant in the program shall pro- 17 vide service as prescribed by paragraph (2) for a period of 18 time (hereinafter in this section referred to as a `period of 19 obligated service') prescribed by the Secretary which may 20 not be less than one year of such service for each academic 21 year of training received under the program. For persons 22 receiving a degree from a school of medicine, osteopathy, 23 or dentistry, the commencement of a period of obligated 24 service may be deferred by the Secretary for the period 25 of time required to comp1e~te internship and residency `train* PAGENO="0038" 28 23 1 ing if the National health Service Corps approves such 2 determent. For persons receiving degrees in other health 3 professions time obligated service period shall commence 4 upon completion of their academic training. Periods of 5 internship or residency shall not be creditable in satisfy- 6 bIg a service obligation under this subsection. 7 "(2) (A) Except as provided in subparagraphs (B) S and (C) an individual obligated to provide service on ac- 9 count of his participatioll in the program shall provide such 10 service for the period of obligated service applicable to him 11 as a member of the National Health Service Corps or the 12 Indian Health Service. 13 (B) If there are no positions available in the National 14 I[caltli Service Corps or the Indian Health Service at the 15 time an individual is required by the Secretary to begin his 10 period of obligated service, such individual shall serve in the 17 clinical practice of his profession for such period as a mem- 18 her of the Federal Health Programs Service. 19 "(C) If there are no positions available in the Na- 20 tional Health Service Corps, Indian Health Service, or the 21 Federal Health Programs Service at the time an mdi- 22 vidual is required by the Secretary to begin his period of 23 obligated service or the Corps and neither Service has a 24 need at such time for a member of the profession for 25 which such individual was trained, such individual shall PAGENO="0039" 29 24 I serve for such period as a member of the Public Health Serv- 2 ice in such units of the Department as the Secretary Ina.y 3 prescribe. 4 "(e) (1) If, for any reason, a person fails to either 5 begin his service obligation under this section in accordance 6 with subsection (d) or to complete such service obligation, 7 the United States shall be entitled to recover from such 8 individual an amount determined in accordance with the 9 formnla 10 ~ in which "A" is the amount the United States is entitled to 12 recover; ~ is the sum of the amount paid under this section 13 to or on behalf of such person and the interest on such 14 amount which would be payable if at the time it was paid 15 it was a loan bearing interest at the maximum legal prevail- 16 ing rate; "t" is the total number of months in such person's 17 service obligation; and "s" is the number of months of such 18 obligation served by him in accordance with subsection (d). 19 Any amount whicli the Uiiited States is entitled to recover 20 under this paragraph shall, within the three-year period 21 beginning on the date the United Sta.tes becomes entitled 22 to recover such amount, be paid to the United States. 23 "(2) When a person undergoing training in the pro- 24 gram is academically dismissed or voluntarily terminates ~ academic training, he shall be liable for repayment to the, PAGENO="0040" 30 25 1 Government for an amount equal to the scholarship which 2 he received under the program. 3 (3) The Secretary shall by regulation provide for the 4 waiver or suspension of any obligation under paragraph (1) 5 or (2) applicable to any individual whenever compliance 6 by such individual is impossible or would involve extreme 7 hardship to such individual and if enforcement of such 8 obligation with respect to any individual would be against 9 equity and good conscience. 10 "(g) Notwithstanding any other provision of law, per- 11 sons undergoing academic training under the program shall 12 iiot be counted against any employment ceiling affecting the 13 Department of Health, Education, and Welfare. 14 (h) The Secretary shall issue regulations for the im- 1~ plemei~tano~~ of this section. 16 (i) To carry out the program, there is authorized to 17 he appropriated $3,000,000 for the fiscal year ending June 18 30, 1974, $20,000,000 for the fiscal year ending June 30, 19 1975, $25,000,000 for the fiscal year ending June 30, 197G,. 20 and $30,000,000 for the fiscal year ending June 30, 1977." PAGENO="0041" 31 H. R. 14196. 93d Cong., 2d sess., introduced by Mr. Symington on April 10, 1974, and H.R. 15519, 93d Cong., 2d sess., introduced by Mr. Symington (for himself, Mr. Adams, Mrs. Boggs, Mrs. Burke of California, Mr. Convers. Mr. Davis of Geor- gia, Mr. Eilberg, Mr. Fraser, Mr. Frenzel. Mr. Gilman, Mr. Hawkins, Mr. Hechler of West Virginia, Mr. Luken, Mr. McCormack, Mr. Mazzoli, Mr. Mitchell of New York, Mr. Murphy of New York. Mr. Podell. Mr. Preyer. Mr. Roybal. Mr. Sar- banes, Mr. Thone, and Mr. Vander Veen) on June 20, 1974. are identical as follows: A BILL To establish a Health Action Corps. 1 Be it enacted by the Senate and Jirnise of J?epresenta- 2 tit~es of the United States of America in Congress assembled, 3 SHORT TITLE 4 SECTION 1. This Act may he cited as the "National 5 llealth Action Corps Act of 1974". 6 FINDINGS AND PTTRPOSE 7 SEC. 2. (a) The Congress finds and declares that- 8 (1) opportunities for young Americans to receive 9 training and practical work experience in the allied 10 health field should be increased; 11 (2) the Carnegie Commission has found that there PAGENO="0042" 32 2 1 is a serious shortage of trained professional personnel 2 in the allied health field; 3 (3) it is estimated that the shortage of trained 4 professional personnel in the allied health field will 5 exceed four hundred and thirty-two thousand by 1980; 6 and 7 (4) the current estimates of the future shortages of S trained professional personnel in the allied health field 9 do not reflect the potential impact of a national health 10 insurance program. 11 (h) It is the purpose of this Act to increase the iium- 12 her of trained professional personnel in the allied health i2 field by providing young Americans training and practical 14 work experience in the allied health field. 15 ESTABLISHMENT AND DUTY OF THE hEALTH ACTION COEPS 16 SEC. 3. (a) There is established an independent agency 17 within the executive branch to be known as the, "Health 18 Action Corps' (hereinafter in this Act referred to as the 19 "Corps") 20 (h) The Corps shall be headed by a Board of Directors 21 (hereinafter in this Act referred to as the "Board") which 22 ~hahl consist of the Secretary of Health, Education, and Wel- 23 fare, the Secretary of Housing and TJrban Development, 24 the Secretary of Labor, the Secretary of Commerce, and the 25 Director of the Office of Management and Budget, or their 26 respective desigiiees. PAGENO="0043" 33 3 1 (c) The Board shall appoint an Adiiiinistrator who 2 shall receive compensation at the rate authorized for level 3 III of the Executive Schedule by section 5314 of title 5 4 of the United States Code. 5 (d) It shall be the duty of the Corps to provide oppor- 6 tunities for young Americaiis to participate in programs 7 which provide training and practical work experience in 8 the allied he~1th field. Such programs shall include career 9 counseling, exposure to various health-related occupations, 10 and training and work experience iii clinical settings. 11 TERMS OF SERVICE 12 SEC. 4. (a) Any person shall be eligible for enlistment 13 in the Corps if- 14 (1) such person has submitted to the Administrator 15 an application therefor which shall be in such form, 16 and submitted in such manner, as the Administrator 17 shall by regulation prescribe; and 18 (2) such person has received a high school diploma 19 or its equivalent within three years before the date on 20 which he submits an application under paragraph (1) 21 of this subsection. 22 (b) The Corps shall be c-omposed of volunteers selected 23 by the Administrator, in accordance with policies and proce- 24 dures established by the Board, from persons eligible for 25 enlistment in the Corps under st~bsection (a) of this seotion. PAGENO="0044" :34 4 1 Such selections shall lie lilade without regard to social, 2 economic, or racial classification or sex and with special 3 ~ to veterans of the Arnied Forces of the United 4 States who have been honorably discharged. (u) `l'he Adiniiiistrator, in accordance with policies and ~ procedures established by the Board, shall pay to each 7 volunteer an allowance which shall be uniform in amount, S and niav provide additioiial allowances for uniforiiis, books, 9 or other supplies required in the volunteer's training program. 10 (d) Each volunteer shall enlist in the Corps for a period 11 of one year pius such period as the Administrator shall 12 prescribe as irecessarv for training in `the occupational 13 specialty selected by the volunteer. Each volunteer shall 14 have the option of reenhisting for an additional year. A volun- 15 teer niav be released from his duties if the Administrator 16 determines that continued service works a hardship on tile 17 volunteers immediate faniilv, threatens the health of the 18 volunteer, or works to the disadvantage of the Corps. 19 (e ) The Administrator shall arrange for transportation, 20 lodging. subsisteiice, equipment. training, and other services 21 wIliehl may lie iieeded liv the Corps volunteers iii fulfilling 22 their duties. Each Corps voluiiteer shall be assigned by the 23 Administrator to a project as near as feasible to his perma- 24 nent place of residence, so as to minimize transportation and 25 lodging costs to time Goverimimiemit. PAGENO="0045" :33 5 1 (f) (1) Except as provided in paragraphs (2) and (3) 2 of this subsection, volunteers in the Corps shall not be deemed 3 to be Federal employees and shall not be subject to the pro- 4 visions of laws relating to Federal emploiiient. 5 (2) For puiposes of subchapter 1 of cliapt er 81 of title 5 6 of the United States Code (relating to conipensatioli to Fed- 7 eral employees for work injuries) , volunteers shall be 8 deemed civil employees of the United Stales within the 9 meaning of the term "employee" as defined in section 8101 10 of such title, and the provisions of that subchapter shall 11 apply except as follows: 12 (A) The term ``performance of duty shall not iii- 13 elude any act of a volunteer while abseiit from his or her 14 assigned post of duty, except while participating in an 15 activity (including an activity while on pass or during 16 travel to or from such post of duty) authorized by or 17 under the direction and supervision of the Corps. 18 (B) Compensation for disability shall not begin 19 to accrue until the day following tile date on which 20 the injured volunteer is terminated. 21 (3) For purposes of the Federal tort claims proyi~i~ns 22 of chapter 171 of title 28, United States Code, vot~rg 23 shall be considered employees of the Government. PAGENO="0046" 36 6 1 INCENTIVE BONUS 2 SEC. 5. The Administrator, in accordance with policies 3 and procedures prescribed by the Board, may provide to any 4 voluiiteer who has completed his period of enlistment- 5 (1) a scholarship of $3,000 if such volunteer is 6 a full-time student at a junior college, college, or uni- 7 versity; or 8 (2) a bonus of $3,000, if such volunteer works for 9 one year in an area which (as determined by the Ad- 10 ministrator) has a critical shortage of trained pro- 11 fessional personnel in the allied health field. 12 TRAINING PROGRAMS 13 SEC. 6. (a) The Administrator, in accordance with 14 policies and procedures prescribed by the Board, may enter 15 into agreements with any public or nonprofit private entity 16 under which- 17 (1) such entity will provide training and practical 18 work experience in the allied health field to Corps 19 volunteers; and 20 (2) the Administrator will make grants to such 21 entity to assist it in providing such training and practical 22 work experience. 23 (b) The Administrator may not enter into any agree- 24 ment under subsection (a) of this section with any public 25 or nonprofit private entity unless an application therefor has PAGENO="0047" 37 7 1 been submitted to the Administrator. Such application shall 2 be in such form, and submitted to th Administrator in such 3 manner, as he shall by regulation prescribe, and shall con- 4 tam- 5 (1) an outline of the training and practical work 6 experience which will be provided to the Corps 7 volunteers; 8 (2) a description of the equipment and facilities 9 which will be available to provide training and practical 10 work experience to Corps volunteers; and 11 (3) such other information as the Administrator 12 shall by regulation prescribe. 13 AUTHORITY OF ADMINISTRATOR 14 SEC. 7. (a) The Administrator shall establish ten re- 15 gional offices for the Corps corresponding to the regional 16 offices established by the Secretary of Health, Education, and 17 Welfare within the Department of Health, Education, and 18 Welfare. The Administrator shall appoint a Director for 19 each regional office. 20 (b) The Administrator, in accordance with policies 21 and procedures established by the Board, may- 22 (1) appoint such personnel as may be necessary 23 to carry out the functions of the Administrator under 24 this Act; 25 (2) enter into contracts for the procurement, con- 38-698 0 - 74 - 4 (Pt. 1) PAGENO="0048" 38 B 1 struction, ~nd management of such equipment and facil- 2 ities as may be necessary to further the purposes of this 3 Act; and 4 (3) establish such policies, standards, criteria, and 5' procedures, and prescribe such rules and regulations as 6 the Administrator may deem to he necessary or appro- 7 priate to carry out the purposes of t.his Act. S NATIONAL ADVISORY COMMITTEE 9 Sec. 8. (a) The Board ~haIl establish a National Ad- 10 visorv Committee (hereinafter in this Act referred to as the 11 "committee") to advise, consult with, and make recommen- 12 dations to the Board on mat'tei~ relating to the following: 13 (1) Policies for the recruitment of Corps volun- 14 teers. 15 (2) Evalua'tion of the quality of the training pro- 16 vided to the Corps volunteers. 17 (3) The proje~ed future demand for trained pro- 18 fes'sionals in the allied health field. 19 (4) Innovations in the utilization of trained pro- 20 fe.ssional personnel in the allied `health field. 21 (b) The committee shall be composed of the Adminis- 2~ trator who shall be the chairman thereof and ten individuals 23 appointed by the Board. The individuals appointed by the 24 Board shall include individuals from t.he various regions of 25 the country who are actively involved in the health-care 26 field as practitioners. PAGENO="0049" 9 1 (c) The members of the committee shall be allowed 2 travel expenses, including per diem in lieu of subsistence, 3 in the same manner as such expenses are authorized by 4 section 5703 (b) of title 5 of the United States Code for 5 persons in the Government service employed intermittently. 6 REPORTS 7 SEC. 9. (a) The Board shall submit quarterly reports 8 to time committee which shall include a detailed statement of 9 the activities and accomplishnients of the Corps during the 10 preceding quarter. ii (b) The Board shall submit annual reports to the Presi- 12 dent and to Congress which shall include a detailed statement 13 of the activities and accomplishments of the Corps, during 14 the preceding year, together with such recommendations as 15 the Board deems appropriate. PAGENO="0050" 40 ~3o CONGRESS SESSION . 1 4357 IN THE HOTSE OF REPRESENTATIVES APT1IL 24. 19T4 Mr. Ro~ introduced the following bill; which was referred to the Committee on Interstate and Foreign Coinnrerce A BILL To amend the Public Health Service Act, to revise the programs of student assistance, to revise the National Health Service Corps program, to establish a system for `the regulation of postgraduate training programs for physicians, to provide assistance for the development and expansion of training programs for nurse clinicians, pharmacist clinicians, commu- nity a.nd public health personnel, and health administrators, to provide assistance for projects to improve the trainii~g provided by undergraduate schools of nursing, pharmacy, and allied health to provide assistance for the development and operation of area health education systems, to establish a loan guarantee and interest subsidy program for undergraduate studeiits of nursing, pharmacy, and the allied health profes- sions, and for other purposes. Be it enacted by the Sea ate and House of Representa- 2 tives of the United States of America in Congress assembled, PAGENO="0051" 41 2 1 SECTION 1. This Act may be cited as the "National 2 health Services Manpower Act of 1974". 3 SEC. 2. Title VII of the Public health Service Act 4 is amended to read as follows: 5 "TITLE VII-NATIOXA L 1IEA LTII SEll VICES 6 MANPOWER 7 "PART A-NATIONAL IIEALTIT SEnvrcE COIIPS 8 SCTIOLA1~SHTPS 9 "SEC. 701. (a) There is established the Nalional Health 10 Service Corps Scholarship Program (hereinafter in this see- 11 tion referred to as the `program') for the purpose of obtaining 12 physicians for the National health Service Corps established 13 within the Service by part~ B. 14 "(U) To he eligible for participa:ion iii the prrbgi'ani, an 15 iiidividual must- 16 "(1) be accepted for enroilnient, or be enrolled, as 17 a full-time student in an educational institution in the 18 United States, or its territories or possessI(~ns which 19 (A) is accredited (as determined by the Secretary) 20 (B) is in full compliance (as determined lv ~ ~ecre*- 21 tarv) with title VI of the (~v~l Ri~hits ~\ et f I ~ui4 ; and 22 (C) does not charge any student iii a degree piagram 23 any tuition in excess of the amount esi a 1 ii~hed f~ r ~1i('li 24 degree program under subsection (c) (2) 25 "(2) pursue an approved course of study, and PAGENO="0052" 42 1 maintain an acceptable level of academic standing, lead- 2 ing to a doctorate level degree in medicine, osteopathy, 3 dentistry, optometry, podiatry, or veterinary medicine, 4 01. a master level degree in clinical nursing, clinical phar- 5 macy, community or public health, or health administra- 6 tion. 7 ``(3 ) be eligible for, or hold, an appointment as a 8 commissioned officer in the Regular or Reserve Corps of 9 the Service or be selected for civilian service in the Na- 10 tional Health Service Corps; and 1 1 "(4) agree in writing to serve, as prescribed by 12 section 702. in the Commissioned Corps of the Service j or as a civilian member of the National Health Service 14 Corps. 15 " (c) (1) Except as provided in paragraph (3), each 16 eligible individual shall be entitled to the payment by the 17 Secretary of a scholarship for each approved academic year 18 of training (not to exceed four years). The annual amount of 19 such a scholarship shall be e(jual to- 20 "(A) the tuition cost (approved under paragraph 21 (2 ) ) for the degree program of the institution in whichi 22 the participant is enrolled, plus 23 "(B) $5,000 to cover living expenses, books, equip- 24 ment, and other necessary educational expenses which 23 are not otherwise paid as a part of the tuition payment. PAGENO="0053" 43 4 I If the average of the Consumer Price Index (pul)lished 2 by the Bureau of Labor Statistics) for the months in any 3 fiscal year exceeds the average of such index in the 4 months of the preceding fiscal year. the Secretary shall 5 increase the payments made tinder clause (B) for the 6 fiscal year following such increase ~ ~ iou to the 7 amount of such increase. 8 `` (2) (A ) The tuition Omount appI'1 ved by the Scere- 9 tarv for any institution shall not be mole than the lesser of- 10 " (i) one-half of the net educational expendit tires 11 per student in such degree program at that institution as 12 determined by regulations of the Secretary; or 13 "(ii) $7,500. 14 ``(B) In no case shall the tutitioti aniount approved 15 be less than an amount equal to the sum of (i) the greater 16 of (I) the amount paid to such institution for each student 17 in such degree program under either section 770 or 309 (c) 18 iii academic year 1 973-I 974 or (II) 20 per ceittum of the net 19 educational expenditure for ea(-hi stll(leIit Ui sin-li degree pro- 20 gram at such institution (as (Ieternuined by the ~ecretarv) 21 ~fl academic year 1972-1973: and (ii) the average amount 22 paid as tuition by each student in such degree program in 23 academic year 1973-1974. In determining such net eduea- 24 tional expenditures. the Secretary shall utilize the essential 25 elements of the methodology for determining such expendi- PAGENO="0054" 44 5 1 tures developed by the Institute of Medicine of the National 2 Academy of Sciences iii carrying out the study required by 3 section 2()5 of the Comprehensive Health Manpower Train- 4 ingActofl97l. 5 "(3) The Secretary may contract with an accredited 6 educational institution for the direct payment to the institu- 7 tion of the tuition and other educational expenses, otherwise 8 covered under this section, for students participating in the 9 program. Amounts paid under contracts shall be in lieu of 10 scholarship payments under paragraph (1) (A) to the stu- 11 dents for whom benefit the contracts were entered into. 12 "(4) Payments under this subsection shall be made from 13 the National Health Service Corps Trust Fund established 14 under section 704. 15 "SEC. 702. (a) (1) An individual participating in the 16 program shall be obligated to serve on active duty as a corn- 17 missioned officer in the Service or as a civilian member of the 18 National Health Service Corps following completion of aca- 19 dernic training. Such period of active duty shall be six months 20 of service on active duty for each year of training received 21 under the program with a minimum service time of twelve 22 consecutive months. The period of service required under 23 this subsection shall be spent providing health services- 24 "(A) to a population designated under section 712 25 as a medically underserved population, or PAGENO="0055" 45 6 1 `` ( B) if health nianpower is not needed by such 2 populations, in other areas or institiitioiis (including 3 Public llealtli Service and Veterans A (hiIillistralioll hos- 4 pitals aiid cliiiics, Indian II ealth Service hospitals, and 5 clinics, Federal and State prisons, State iiieiital hospitals, 6 and neighborhood aiid faniilv centers) designated by the 7 Secretary as having a priority need for health persoiinel. 8 "(2) The beginning of a period of service for medical 9 doctors or osteopaths shall be deferred for the period of 10 time required to complete an internship aiid resideiicy train- 11 ing in family practice, internal niedicine, pediatrics, obstetrics 12 and gynecology, general surgery, or psvchinut iv. Periods of 13 internship or residency shall not satisfy any active duty serv- 14 ice obligation under this section. For persons receivmg de- 15 grees in other health professions the obligated service period 16 shall commence ll~Ofl completion of their academic training. 17 "(3) Any person participating in the program may be 18 required to speiid a period of eight weeks during each spon- 19 sored year in an area designated by the Secretary under 20 section 712 for educational purposes and for introduction to 21 the type of practice to be engaged in during the period of 22 obligation. Travel costs to aiid froiii such area shall be pro- 23 vided by the Secretary. ¶4 " (h) (1) Except as provided in paragraph (2) or (3) 2~ if~ for any reason, a person fails to either legin his service PAGENO="0056" 46 7 I obligation uiider tins St(t 1011 iii accordance with subsection 2 (a) or to complete such service obligation, the United States 3 shall be entitled to recover from such individual an amount 4 determined in accordance with the formula 5 A=2~) 6 in which "A" js the amount the United States is entitled to 7 recover; ~ is the sum of the amount paid tinder section 701 S to or on behalf of such persoll and the interest on such 9 amount which would be payable if at the time it was paid 10 it was a loan bearing interest at the maximum legal prevail- 11 ing rate; ``t'' is the total number of months in such person's 12 service obligation; aiicl "s'' is the ninuuber of months of such 13 obligation served by him iii accordance with subsection (a) 14 Auiv amount \vllicil the [iuited Stales is entitled to recover ~ tinder this paragraph shall. within the two-year period begin- 16 ning on the date the ~iiited States becomes entitled to 17 recover such amount, be 1)aid to the United States. 18 "(2) The Secretary shall by regulation provide for the 19 waiver or siisi~eiision of any obligation under this section 20 applicable to any individual whenever compliance by such 21 individual is impossible or would involve extreme hardship 22 to such individual and if enforcement of such obligation with 23 respect to any individual would be against equity and good 24 conscience. 25 "(3) When a person undergoing training in the pro~ PAGENO="0057" 47 8 1 grain is a(~ademicalIv disniissed or voluntarily terminates 2 academic training, lie shall not be liable for repayment to 3 the United States of aniouiits paid under this section on his 4 behalf unless he, at some subsequent date, completes a doc- 5 torate level degree iii medicine. osteopathy, dentistry, op- 6 tometrv, podiatry, or veterinary medicine, or a niast er level 7 degree in clinical nursing. cliIli(al pharmacy. or public health 8 or health administration. 9 "Sec. 703. (a) Notwithstanding any other provision of 10 law, persons undergoing academic training under time pro- 11 gram shall not be counted against any employment ceiling 12 affecting the Department of Health, Education, and Welfare. 13 "(b) The Secretary shall issue regulations governing 14 the implenieiitation of this pn~~ within six months of the 15 enactment of this Act. 16 "SF~c. 704. (a) (1) There is established in the Treasury 17 of the United States a trust fund to he known as the National 18 Health Service Corps Trust Fund consisting of such amounts 19 as may l)e appropriated to the trust finid as provided in this 20 subsection. 21 " (2) For each of the fiscal years ending June 30, 1975, 22 June 30, 1976, and Juiie ~( ). 1977, there are authorized to 23 l)e appropriated to the trust fund an amount equal to the 24 total amount received in each such fiscal year by the See- ~ retarv under the Vrovi~~~Us of section 71(3 (a ) (:3 ) (B) (ii) PAGENO="0058" 48 9 1 for services rendered by IlIeIIll)ers of the ~atioiial Health 2 Service ( )rp~. The anioutits appropriated by this paragraph :~ shall he transferred at least quarterly from the general fund 4 of the ireasurv to the trust fund on the i)asis of estimates 5 lna(le h~ the Secretary of the amount to he received for the 6 provision of such services. Proper adjustments shall l)e made in the aiiinunts subsequently transferred to the extent prior S estimates were in excess of or less than the amounts required 9 to he transferred. 10 "(3) For each of the fiscal years ending June 30, 1975, ii June 30. 197(3, and June 30, 1977, there are authorized to 12 be appropriated to the trust fund such sums as may be neces- 13 sarv for the operation of the program. 14 "PART B-NATIONAl. HEALTh SERVICE CORPS 1.) "SEC. 711. There is established, within the Service, 16 the National health Service Corps (hereinafter in this see- 17 tion referred to as the `Coq~s) which shall consist of those 18 officers of the Regular and Reserve Corps of the Service and 19 511(11 other personnel as the Secretary may designate and 20 which shall lie utilized by the Secretary under this section 21 to improve the delivery of health services to medically un- 22 derserved populations. 23 "SEc. 712. (a) The Secretary shall designate the 24 medically iinderserved populations in the States. For pur- PAGENO="0059" 49 10 1 ~ ol this 5((~tiOfl. a iiicditallv IIlldelsclV(d iPlilation is 9 tue po~nihitioii 1 an un an r iiii;i I a rca ( \vii (ii d es a it :~ have to roiiforiii to the geogra~)il iral Jo ii ida nes of a politIcal 4 SUJ)diViSiOfl and which should 1 e a rational area for the de- 5 livery of health servic~) \vIli(ll the Secretary determines 6 has a critical health iiianj~ower shortage or a population 7 group detenniiied by the Secretary to have such a shortage 8 and the term `State' includes Guaiii. American Samoa. and 9 the Trust Territory of the T~aeific. Islands. In designating ~ medically underserved poj)ulations. the Secretary shall take ~ into account (1) the recoinniei~dations of the entities re- 12 sponsible for the development (if tile plans referred to in 13 Sectioll 314 (ii) which cover all or any I)art of the areas ill 14 which populations lInden colisi(hra tioii i r designation reside, is alI(l ( 2) Iii tue ease of aiiv stiehi area for which no such 16 entity is responsible for developiii~ such a P11l~L the reeoni- 17 niendations of the agency of the State (or Hates) iii \vhiieil i$ such area is located which administers on supervises the 19 administration of a State plan approved under section 20 314(a). 21 " (Ii) Any person may apply to the Seeretai~v (in such 22 mamier as lie may prescribe) for tile designation of a popu- ~ lation as a medicall underserved Pol)Illation. In considering 24 au application under this paragraph, tile Secretary shall PAGENO="0060" 11 i take iiito account the following iii addition to criteria utilized ~ liv hiiii iii iiiaking a desigiiatiori under subsection (a) "(1) Ratios of available health manpower to the 4 population for which the application is made. "(2) Indicators of the population's access to health services. 7 "(3) Indicators of health status of the population. "(4) Indicators of such population's need and de- 9 mand for health services. 10 "SEc. 713. (a) The Secretary may assign personnel of ii the (orps ti) provide, under regulations prescribed h the See- 12 retar. health servi(es for a medically underserved popula- 13 tion if- 14 (1) the State health agency of eat~h State in which such population is located or the local public health agency nr any other public or nonprofit. private 17 health entity serving such population makes application 1 to the Secretary for such assignment, and 19 " (2) the local government of the area in whieh 20 such p~piilation resides certifies to the Secretary that 21 such assignment of Corps peisoi~uiel is needed for such 22 population. 23 " (li) (1) The Secretary may not approve an applica- 24 tion under subsection (a) for an assignment unless the ap- PAGENO="0061" 51 12 1 plicaiit agrees to enter into all agreement with the Secretary 2 in accordance with section 716 (a) aiid has afforded- 3 "(A) the entity responsil)le for the development of 4 the plans referred to in section 314 (b) which covers 5 all or any part of the area in which the popuhiltioii for 6 which tile application i~ submitted resides, and 7 " (B) if there is a part of such area for which rio 8 such entity is responsible for developing such plans, the 9 agenc of the State iii which such part. i~ located which 10 administers or supervises the administration of a State 11 plan approved under section 314 (a) 12 an opportunity to review the apphicatiomi and submit its 13 comments to the Secretary respecting tue need for and 14 proposed use of manpower requested in the al)phie1ltioll. 15 In considering such an application, the Secmetarv shall take 16 iiito consideration the need of the popul;it ion for which the 17 application Was submitted for the health services \Vhiichl 18 may be provided under this section amid tue wilhiuigness of 19 tile population and the appropriate goverminieiital agencies 20 or health entities serving it to assist and (ool)erate with tile 21 Corps in providing effective health services to rite j)o1)ul~1tiOfl. 22 (2) (A) In approving an al) lication snbniittcd under 23 5U1)SCctiOtI (a) foi' the assignment of Corps personnel to 24 provide health services for a medically uumidersem'ved popii- 25 lation, the Secretary may approve the :1ssi~nuiieuit Of (~Orl)s PAGENO="0062" 52 13 1 personnel f ~r such population during a period (referred to 2 in this paragraph a~ the ~assistance period') which may iiot 3 excee(l four years from the date of the first assigiuneiit of 4 Corps p~rs~niic1 for sucht population after the date of the .~ approval of the application. No assignment of individual ~ Corps 1)~1's~111~e1 flay he made for a period ending after the 7 expiration of time applicable approved assistance period. (B) Tpoii expiration of an approved assistance period ~ for a medically underserved population. no new assigment 10 of Corps persommnel may be made for such population unless ii an application is subnntted in accordance with subsectioii i~ (a) for such assignment. The Secretary may not approve 13 sUch an application unless- 14 " (i) the application and certification requirements 15 of subsection (a) are met 16 (ii) the Secretary has conducted an evaluatioii 17 of the continued need for health manpower of the popu- 18 lation for which the application is submitted, of the 19 utilization of the manpower b such population, of the 20 growth of the health (are I)ractiCe of time Corps personnel 21 assigned for sticim population. and of community support for the assignment; and 23 (iii) the Secretary has determined that such 24 population has made continued efforts to secure its own health manpower, that there has been sound fisc~1 PAGENO="0063" 53 14 1 inanagenient of the health care practice of the Corps 2 personnel assigned for such population, including efficient collection of fee-for-service, third-party, and other funds 4 available to such population, and that there has been 5 appropriate and efficient utilization of such Corps 6 personnel. 7 "(c) Corps persoiiiiel shall be assigned to provide 8 health services for a medically underserved population on ~ the basis of the extent of the population's need for health 10 services and without regard to the ability of the members ~ of the population to pay for health services. 12 "(d) In making an assignment of Corps personnel 13 the Secretary shall seek to match characteristics of the 14 assignee (and his spouse (if any) ) and of the population ~5 to which such assignee may be assigned in order to increase 16 the likelihood of the assignee remaining to serve the popula- 17 tion upoii completion of his assignment period. The Secre- 18 tary shall, before the expiration of the last nine months of 19 the assignment period of a member of the Corps, review 20 such ineniber's assignment and the situation in the area to 21 which he w'as assigned for the purpose of determining the 22 advisability of extending the period of such member's 23 assignment. 24 "SEc. 714. (a) In providing health services for a mcdi- 25 cally underserved popalation under this section, Corps per- 38-698 0 - 74 - 5 (Pt. 1) PAGENO="0064" 54 15 1 sonnel shall utilize the techniques, facilities, and orgarliza- 2 tional forms most appropriate for the area in which the 3 population resides and shall, to the maximum extent feasible, 4 provide such services (1) to all members of the population ~ regardless of their ability to pay for the services, and (2) 6 in connection with (A) direct health servic~s programs 7 carried out by the Service; (B) any direct health services S program carried out in whole or in part with Federal finaim- 9 cial assistance : or (C) any other health sefviees activity 10 which is in furtherance of the purposes of this section. ii "(b) Notwithstanding any other provision of law, the 12 Secretary (1) may, to the extent feasible, make such ar- 13 rangements as he determines necessary to enable Corps per- 14 soimel in providing health services for a medically under- 1.3 served population to utilize the health facilities of the area 16 in which the population resides, and (2) may make~uch 17 arrangements as he determines are necessary for the use of 18 equipment amid supplies of the Service and for the lease or 19 acquisition of other equipment and supplies, and may secure 20 the temporary services of nurses and allied health profes' 21 sionals. 22 (c) If such area is being served (as determined under 23 rcgulatioii~ tf the Secretary) l)V a h051)ital or other health 24 care delivery facility of the Service, the Secretary shall, 25 in additiomi to such other arrangements as the Secretary may: PAGENO="0065" 16 ~ make under subsection (b) , arrange for the utilization 2 of such hospital or facility by Corps personnel iii providing ~ health services for the popiilattoii, but univ to the exteiit ~ that such utilizatioii will not impair the delivery of health ~ services and treatnient through such hosl)ital or facility to 6 persons who are entitled to health services and treatment ~ through such hospital or facility. If there~ are no health 8 facilities in or serving such area, the Secretary may arrange ~ to have Corps personnel provide health services in the 10 nearest health facilities of the Service or the Secretary may ~ lease or otherwise pro\~1de facilities in such area for the 12 provision of health services. 13 "SEc. 715. The Secretary may imiake one grant to 14 any applicatit with an approved application under section 15 713 to assist it in meeting the costs of establishing medical 16 practice mimanagement systems for Corps personnel, acquiring 17 equipment for their use in providing health services, and 18 establishing appropriate continuing education ~ and 19 opportunities for them. No grant may he made under this 20 paragraph unless an application is submitted tlierefqr amid 21 approved by time Secretary. The amount of any grant shall 22 be determined by the Secretary, except that 110 grant may 23 be made for more than $25,000. 24 "SEc. 71(3. (a) The Secretary shall require as a con- 25 dition to the approval of an application under section 713 PAGENO="0066" 56 17 1 that the entity which submitted the application enter into 2 an appropriate arrangement with the Secretary under 3 which- 4 "(1) the entity shall be responsible for charging 5 in accordance with subsection (6) for health services by 6 the Corps personnel to be assigned; 7 "(2) the entity shall take such action as may be 8 reasonable for the collection of payments for such health 9 services, including if a Federal agency, an agency of a 10 State or local government, or other third party would be 11 responsible for all or part of the cost of such health 12 services if it had not been provided by Corps personnel 13 under this section, the collection, on a fee-for-service or- 14 other basis, from such agency or third party the portioti 15 of such cost for which it would be so responsible (and 16 in determining the amount of such cost which such 17 agency or third party would be responsible, the health 18 services provided by Corps personnel shall be considered 19 as being provided by private practitioners) ; and - 20 "(3) the entity shall pay to the United States the 21 lesser of- 22 "(A) 75 per centum of the amount collected by 23 the entity in accordance with subsection (a) in each 24 calendar quarter (or other period as may be specified. 23 in the agreement), or ll.R. 14357-3 PAGENO="0067" 0~ 18 1 "(B) the sum of (i) the pay and allowances 2 for the Corps personnel for such quarter (or other 3 period), and (ii) an amount which bears the same 4 ratio to the total amount of payments made to Corps 5 personnel provided to the entity under section 701 6 as the number of days in such quarter (or other 7 period) bears to the number of days in the assign- 8 ment period for such personnel. 9 Funds received by the Secretary under such an arrangement 10 shall be deposited in the Treasury as miscellaneous receipts 11 and shall be disregarded in determining the amounts of ap- 12 propriations to be requested under section 722 and the 13 amounts to be made available from appropriations made an- 14 der such section to carry out this section. 15 "(b) Any person who receives health services provided 16 1iy Corps personnel under this section shall be charged for 17 such services on a fee-for-service or other basis at a rate 18 approved by the Secretary, pursuant to regulations, to re- 19 cover the value of such services; except that if such- person 20 is determined under regulations of the Secretary to be Un- 21 able to pay such charge, the Secretary shall provide for the 22 furnishing of such services at a reduced rate or without 23 charge. 24 "SEC. 717. The Secretary shall, under regulations 25 prescribed by him, adjust the monthly rate of pay of each PAGENO="0068" 38 19 1 physician and dentist member of the Corps who is directly 2 engaged in the delivery of health services to a niedically 3 underserved population as follows: 4 " (1) During the first thirty-six months in which 5 such a member is so engaged in the delivery of health 6 services, his monthly rate of pay shall be increased by 7 an amount (not to exceed $1,000) which when added 8 to the member's regular monthly rate of pay and allow- 9 ances will provide a monthly income competitive with 10 the average monthly income from an established practice 11 of a member of such member's profession with equiva- 12 lent training. 13 "(2) During the period beginning upon the expi- 14 ration of the thirty-six months referred to in paragraph is (1) and ending with the month in which the member's 16 regular monthly rate of pay and allowances is equal to 17 or exceeds the monthly income lie received for the last of 18 such thirty-six months, the member shall receive in 19 addition to his regular rate of pay and allowances an 20 amount which when added to such regular rate equals 21 the monthly income he received for such last month: 22 In the case of a member of the Corps who is directly engaged 23 in the provision of health services to a. medically underserved 24 population in accordance with a service obligation incurred 25 under section 702, the provisions of this paragraph shall PAGENO="0069" 59 20 1 apply to such member upon satisfactory C0n11)letiOlI of such 2 service obligation and the first thirty-six moiitfls of his being 3 so engaged in the delivery of health care shall, for purposes 4 of this paragraph, be deemed to begin upon such satisfactory 5 completion. 6 "SEc. 718. (a) (1) The Secretary shall conduct at medi- 7 cal and nursing schools and other schools of the health pro- 8 fessions and training centers for the allied health professions, 9 recruiting programs for the Corps. Such programs shall in- 10 elude the wide dissemination of written information on the 11 Corps and visits to such schools by personnel of the Corps. 12 "(2) The Secretary may reimburse applicants for posi- 13 tions in the Corps for actual expenses incurred in traveling 14 to and from their place of residence to an area in which 15 they would be assigned for the purpose of evaluating such 16 area with regard to being assigned in such area. The Secre- 17 tary shall not reimburse an applicant for more than one 18 such trip. 19 " (b) Time Secretary shall (1) provide assistance to 20 persons seeking assignment of Corps personnel to provide 21 under this section health services for medically underserved 22 populations, and (2) conduct such iuformation programs in 23 areas in which such populations reside as may be necessary 24 to inform the public and private health entities serving those 25 areas of the assistance available to such populations by PAGENO="0070" 60 21 1 virtue of their designation under this section as medically 2 underserved. 3 "Si~c. 719. (a) The Secretary of Health, Education, 4 and Welfare shall conduct or contract for studies of methods 5 of assigning under this part, National Health Service Corps 6 personnel to medically underserved populations and of pro- 7 viding health care to such populations. Such studies shall be 8 for the purpose of identifying (1) the characteristics of 9 health manpower who are more likely to remain in practice 10 in areas in which medically underserved popdations are 11 located, (2) the characteristics of areas which have been 12 able to retain health manpower, (3) the appropriate condi- 13 tions for assignment of independent nurse practitioners and 14 physician's assistants in areas in which medically under- 15 served populations are located, and (4) the effect that 16 primary care residency training in such areas has on the 17 health care provided in such areas and on the decisions of 18 physicians who received such training respecting the areas 19 in which to locate their practice. 20 "(b) Upon the expiration of the assignment of Corps 21 personnel to provide health services for a medically under- 22 served population, the Secretary (notwithstanding any other 23 provision of law) may sell to the entity which submitted 24 the last application approved under subsection (c) for the 25 assignment of Corps personnel for such population equipment PAGENO="0071" 61 22 1 of the United States utilized by such personnel in providing 2 health services. Sales made under this paragraph shall be 3 made for the fair market value of the equipment sold (as 4 determined by the Secretary). 5 "(c) Commissioned officers and other personnel of the 6 Corps assigned to provide health services for medically 7 underserved populations shall not be included in determin- 8 ing whether any limitation on the number of personnel 9 which may be employed by the Department of Health, 10 Education, and Welfare has been exceeded. 11 "Sec. 720. (a) The Secretary shall report to Congress 12 no later than May 15 of each year- 13 "(1) the number, identity, population, and extent 14 of underservice of all medically underserved populations 15 in each of the States in the calendar year preceding the 16 year in which the report is made and the number of 17 medically underserved populations which the Secretary 18 estimates will be designated under section 712 in the 19 calendar year in which the report is made; 20 "(2) the number of applications filed in such pre- 21 ceding calendar year for assignment of Corps personnel 22 under this section and the action taken on each such 23 application; 24 "(3) the number and types of Corps personnel 25 assigned in such preceding year to provide health serv- PAGENO="0072" 62 23 1. ices for medically underserved populations, the number 2 and types of additional Corps personnel which the Secre- 3 tary estimates will be assigned to provide such services 4 in the calendar year in which the report is submitted, 5 and the need (if any) for additional personnel for the 6 Corps; 7 "(4) the recruitment efforts engaged in for the 8 Corps in such preceding year, including the programs 9 carried out under section 718 (a) (1) and the number 10 of qualified persons who applied for service in the Corps 11 in each professional category; 12 "(5) the total number of patients seen and patient 13 visits recorded during such preceding years in each area 14 where Corps personnel were assigned; is "(0) the number of health personnel electing to 1 ~ remain after termination of their service in the Corps to 17 provide health services to medically i.mderserved popula- 18 tions and the number of such personnel who do not make 19 such eleëtion and the reasons for their departure; 20 "(7) the results of evaluations made under section 21 713 (b) (2) (B) (ii), and determinations made under 22 section 713 (b) (2) (B) (iii), during such preceding 23 year; and 24 "(8) the amount (A) charged during such pre- 25 ceding year for health services by Corps personnel, (B) PAGENO="0073" 24 i collected in such year by entities in accordance with 2 arrangements under section 716, and (C) paid to the 3 Secretary in such year under such arrangements. 4 "(b) The Secretary of Health, Education, and Welfare 5 shall report to Congress (1) not later than September 1, 6 1974, the criteria used by him in designating medically 7 undeserved populations for purposes of section 712 of the 8 Public Health Service Act, and (2) not later than Janu- 9 ary 1, 1975, the identity and number of medically under- 10 served populations in each State meeting such criteria. "Sec. 721. (a) (1) There is established a council to be 12 known as the National Advisory Council on the National 13 health Service Corps (hereinafter in this section referred 14 to as the `Council'). The Council shall be composed of 15 fifteen members appointed by the Secretary as follows: "(A) Four members shall be appointed from the 17 general public to represent the consumers of health care, 18 at least two of whom shall be members of a medically 19 underserved population for which Corps personnel are 20 providing health services under this section. 21 "(B) Three members shall be appointed from the 22 medical, dental, and other health professions and health 23 teaching professions. 24 "(C) Three members shall be appointed from State 23 health or health planning agencies. PAGENO="0074" 64 25 1 "(D) Three members shall be appointed from the 2 Service, at least two of whom shall be members of the 3 Corps directly engaged iii the provision of health serv- 4 ices for a medically underserved population. 5 "(E) One member shall be appointed from the 6 National Advisory Council on Comprehensive Health 7 Planning. 8 "(F) One member shall be appointed from the 9 National Advisory Council on Regional Medical 10 Programs. ii The Council shall consult with, advise, and make recoin.. 12 mendations to, the Secretary with respect to his responsi.. 13 bilities in carrying out this section, and shall review arid 14 approve regulations promulgated by the Secretary under is this section and section 225. 16 "(2) Members of the Council shall be appointed for a 17 term of three years and shall not be removed, except kr 18 cause. Members may be reappointed to the Council. 19 "(3) Appointed members of the Council, while attend- 20 ing meetings or conferences thereof or otherwise serving 21 on the business of the Council, shall be entitled to receive 22 for each day (including traveltime) in which they are so 23 serving the daily equivalent of the annual i~te of basic pay 24 in effect for grade GS-18 of the General Schedule, and 25 while so serving away from their homes or regular places of H.R. 14357-4 PAGENO="0075" 63 26 1 business they may be allowed travel expenses, including per 2 diem in lieu of subsistence, as authorized by section 5703 (h) 3 of title 5 of the United States Code for persons in the Gov- 4 ernment service employed intermittently. 5 "(b) The amendment made by subsection (a) shall 6 change the name of the advisory council previously estab- 7 lished under section 329 of the Public Health Service Act 8 shall not be construed as requiring the establishment of a. 9 new advisory council; and the amendment made by such 10 subsection with respect to the composition of such advisory 11 council shall apply with respect to appointments made to 12 the advisory council after the date of the enactment of this 13 Act. 14 "SEC. 722. To carry out the purposes of this part, there 15 are authorized to be appropriated such sums as may be nec- 16 essary for the fiscal years ending June 30, 1975, June 30, 17 1976, and June 30, 1977. 18 "(2) An appropriation Act which appropriates funds 19 under subsection (a) for any fiscal year, may also appro- 20 priate for the next fiscal year the funds that are authorized 21 to be appropriated under such paragraph for such next fiscal 22 year; but no funds may be made available therefrom for 23 obligation under this section before the fiscal year for which 24 such funds are authorized to be appropriated.". PAGENO="0076" 66 27 1 "PAIIT C-1POSTGRADFATE PIIYSICIAN TRAINING 2 "SEc. 731. (a) There is established in the Public 3 Health Service the National Council on Postgraduate 4 Physician Training (hereinafter in this title referred to as 5 the `National Council) 6 (h) The National Council shall consist of nineteen 7 meml)ers appointed by the ~eeretarv of Health, Education, 8 and Welfare (hereinafter in this title referred to as the 9 `~ecretar) without regard to the pro~~isioi~s of title 5 of 10 the United States Code relating to appointments in the 11 competitive service from persons who are not officers or 12 employees of the United States Government as follows: 1:3 " (1) Eleven members shall he appointed from per- 14 sons iii the medical and osteopathic professions. Of the eleven: 16 `~ (A) six shall he practicing physicians associ- 17 a ted with 5~ )( cia I tv a 11(1 ~iiJ )sj)erialty phlVSieia ii (in- 18 eluding osteopat Itic ) organizatiolis, including one 19 each from the specialties or siibspecialties of family 20 pmacti('e. internal medicine. pediatrics, obstetrics and 21 gynecology. surgery, and psychiatry; 22 "(B) two shall he physicians associated with 23 organizations associated with postgraduate physician 24 training: PAGENO="0077" 67 28 1 " (C) two shall he physicians associated with 2 medica.l schools or university health science centers; 3 arid 4 "(D) one shall be a. physician in postgraduate 5 physician training. 6 "(2) Five members shall be appointed from persons who are nonphysician health professionals. Of the five: s "(A) two shall be individuals associated with 9 hospitals which maintain postgraduate physician 10 training programs; ii "(B) one shall be a State or local health 12 planner or public health administrator; 13 "(C) one shall be a medical student; 14 "(D) one shall be a nurse or other allied 15 health professional. 16 "(3) Three members shall be appointed from the 17 general public. is The members of the National Council shall select a chair- 19 man from among their own number. 20 " (e) Each member of the Natirnal ~otmcil shall hold 21 office for a term of four years, except that- 22 "(1) any member appointed to fill a vacancy prior 23 to the expiration of the term for which his predecessor 24 was appointed shall hold office for the remainder of such 2~) term, and PAGENO="0078" 68 29 1 "(2) the terms of office of the members first takii~g office shall expire, as designated by the Secretary at the time of appointment, three at the end of the first ye~r, three at the end of the second year, and three at the e~d of the third year, and two at the end of the fourth ye~, 6 after the date of appointment. No member shall be eligible to serve continuously for more than two terms. "(d) Members of the National Council, while attenditig ~ meetings or conferences thereof, or otherwise serving on business of the National Council, shall be entitled to receive 12 compensation at rates fixed by the Secretary, but not exceed- 13 ing for any da.y (including traveltime) the daily equivalent 14 of the effective rate for grade GS-18 of the General Sched- ~ ule, and while so serving away from their homes or regular 16 places of business, they may be allowed travel expenses, 17 including per diem in lieu of subsistence, as authorized by section 5703 (b) of title 5 of the United States Code for 19 persons in the Government service employed intermittently. "SEC. 732. (a) Upon appointment and prior to July 1, 1976, the National Council shall conduct studies and other activities relevant to the various matters related to the post- 23 graduate training of physicians specifically including the 24 following: 25 "(1) The commissioning and supervision of the PAGENO="0079" 69 30 1 investigation of p1~ystcian specially distribution in the 2 United States and its possessions as prescribed by see- 3 tion 740. 4 "(2) The development of collaborative working 5 relationships with each physician specialty organization 6 to determine and assist their individual activities with re- 7 spect to the number and location of practitioners within 8 each specialty. 9 "(3) An assessment of the need for financial sup- 10 port for the postgraduate training of physicians, espe- 11' daily in primary care specialties. 12 "(4) An assessment of the service needs of hospitals 13 and other health institutions, the role of postgraduate 14 physician trainees in meeting such needs, and alternate 15 means of meeting such needs. 16 "(5) An assessment of the educational component 17 of postgraduate training programs for phiy~ieians. 18 "(6) The assessment of the impact of foreign medi- 19 Cal graduates on the present and future health care in 20 the United States and foreign nations. 21 "(15) After July 1, 1976, the National Council shall 22 administer the program established by section 735 and carry 23 out such other activities as may be incidental to such 24 administration. 25 "SEC. 733. (a) For each of the Department of Health, 38-698 0 - 74 - 6 (Pt. 1) PAGENO="0080" 70 31 1 Education, and Welfare regions there is established a Re- 2 gional Council on Postgraduate Physician Training (herein- 3 after referred to in this title as the `Regional Council'). Each 4 Regional Council shall consist of nineteen members appointed 5 by the Secretary without regard to the provisions of title 5 6 of the Fnited States Code relating to the appointments and 7 competitive service from persons who are not officers or 8 employees of the Lnited States Government as follows: 9 "(1) Eleven shall be appointedfrom persons in the 10 medical and osteopathic professions. Of the eleven: 11 "(A) six shall be practicing physicians includ- 12 ing one each from t.he specialties or subspecialties of 13 family practice, internal medicine, pediatrics, obstet- 14 rics and gynecology, surgery, and psychiatry; 15 "(B) two shall be physicians associated with 16 hopsitals which maintain postgraduate physician 17 training programs; 18 ` (C) two shall be physicians associated with 19 medical schools or university health science centers; 20 and 21 " (D) one shall he a physician in postgraduate 22 physician training. 2:3 "(2) Five members shall be appointed from persons: 24 who are nonphysician health professionals. Of the fiv~:: 25 "(A) two shall be individuals associated with PAGENO="0081" 71 32 1 hospitals which. maintain postgraduate physician 2 training programs; 3 "(B) one shall be a State or local health plan- 4 ner or public health administrator; 5 . "(C) one shall be a medical student; and 6 "~J~) one shall be a nurse or other allied health 7 profe~si~w~}. 8 "(3) T}~is~e members shall be appointed from the 9. geu~al pqbIii~ 10 Tb~ ~rs, of eao1~ regional council shall select a chairman ii. from among their own number. "(b) Each member of a regional council shall hold of- 13 flee for a term of four years, except that- 14 "(1) any member appointed to fill a vacancy prior to the expiration of the term for which his predecessor was appointed shall hold office for the remainder of such 17 term, and 1$ "(2) the terms of office of the members first taking office shall expire, as designated by the Seeretary at the 20 time of appointment, three at the end ~f the first year, 21 three at the end of the second year, three at the end of the 22 third year, and two at the ~nd of the fourth year, after 23 tue date of appointment. 24~ No member shall be eligible to serve continuously for more ~5 than two terms. PAGENO="0082" 72 33 1 "(c) Members of a regional council, while attending 2 meetings or conferences thereof, or otherwise serving on 3 business of a regional council, shall be entitled to receive 4 compensation at rates fixed by the Secretary, but not exceed- ~ ing for any day (including traveltime) the daily equivalent 6 of the effective rate for grade GS-18 of the General Schedule~ 7 and while so serving away from their homes or regular places 8 of business, they may be allowed iravel expenses, including 9 per diem in lieu of subsistence, as authorized by section 10 5703 (h) of title 5 of the United States Code .for persons ~ in the Government service employed intermittently. 12 "(d) All members of a regional council shall be resi- 13 dents, and fully employed to the extent of their employment, 14 within the region served by the regional council. 15 "Si~c. 734. (a) Upon appointment, and prior to July 1, 16 1976, each regional council shall conduct studies and other 17 activities relevant t.o the various matters related to the post- 18 graduate training of physicians within the region served by 19 the regional council, specifically including the following: 20 "(1) A survey of the institutions providing post- 21 graduate training of physicians within the region, includ- 22 ing an analysis of the types of training currently pro- 23 vided, as well as the types of training that might be 24 provided by such institutions. PAGENO="0083" 73 34 1 "(2) An assessment of the service needs of hospitals 2 and other health institutions within the region, including 3 an assessment of the role that postgraduate physician 4 trainees play in meeting such needs and alternative 5 means of meeting such needs. 6 "(3) An assessment of the educational component 7 of the postgraduate training programs for physicians con- 8 ducted within the region. 9 "(4) An assessment of the status of the financial 10 support of the postgraduate training of physicians within 11 the region, especially of primary care training programs. 12 "(5) Development of collaborative working rela- 13 tionships with regional medical programs, comprehensive 14 health planning programs, State departments of health, 15 and area health educ~ation system programs operating 16 within the region. 17 "(b) After July 1, 1976, each regional council shall 18 administer the program established by section 736 and carry 19 out such other activities as may be incidental to such 20 administration. 21 "SEc. 735. (a) On July 1, 1976, and not later than 22 July 1 Øf each year thereafter, the National Council shall 23 conduct a certification program as follows: 24 "(1) Establish the total number of postgraduate physi- 25 cian training positions to be certified for the year beginning PAGENO="0084" 74 35 1 on the next following July 1. Such certified positions shall 2 not exceed 110 per centum of the number of doctor of 3 medicine and doctor of osteopathy degrees expected to be 4 granted in the intervening year in the United States. 5 "(2) Assign the total number of certified positions so 6 established, to the various categories of specialty and sub- 7 specialty practice of medicine recognized within the United 8 States. In assigning positions to the various category of 9 specialty and subspec.ialty practice of medicine, the Na- 10 tional Council shall take into consideration the findings of 11 the study conducted pursuant to section 740. 12 "(3) Assign from the certified positions so established 13 in each physician specialty and subspecialty certified positions 14 to each of the ten regional councils. 15 "(b) The National Council shall on October 1, 1976, 16 and October 1 of each subsequent year directly cer- 17 tify positions in entities, and associations of such entities, 18 which directly provide postgraduate training of physicians 19 in those physician specialties and subspecialties in which suffi- 20 cient numbers of physicians are not needed nationally to 21 permit a proper distribution of such positions to the regional 22 councils. Such positions shall not, in any year of the program, 23 exceed 10 per centum of the total number of certified posi- 24 tion for such ear. On or before August 1, 1976, and Au- 25 gust 1 of each subsequent year the National Council shall PAGENO="0085" I~J 36 i inform the respective regional council of all positions pro- 2 posed to be directly certified within such region. No posi- 3 tion may be directly certified by the National Council, if the 4 respective regional council disapproves such position within 5 thirty days of notification by the National Council of such 6 proposed certification. 7 "SEC. 736. (a) Each regional council shall, not later 8 than October 1, 1976, and October 1 of each subsequent year, 9 certify postgraduate training posit.ions in entities, and asso- 10 ciations of such entities, which directly provide such training ~ within the region served by the regional council. In cer- 12 tifying such positions, the regional council shall not certify 13 any position- 14 "(1) in any physician specialty or subspecialty in 15 excess of the number of certified positions in such 16 medical specialty or subspecialt~y assigned to the 17 regional council by the National Council under section 18 735(a) (3). 19 "(2) in any entity, or association of such entities, 20 which has, or will have, in the aggregate, fewer than one 21 hundred and fifty such certified positions; 22 "(3) in any entity which maintains any post- 23 graduate physician training position, or any association 24 of entities in which any participating ent.ity maintains 25 any such position, which is not certified by the regional PAGENO="0086" 76 37 1 council as a graduate training position for physicians; or 2 "(4) which is not a pai1 of, at a minimum, an inte- 3 grated three-year postgraduate physician training 4 program. 5 " (b) In certifvin~ positions, each regional council 6 shall- 7 . "(1) to the extent feasible, insure that the certified 8 positions are equitably distributed geographically within 9 the region served by the regional council; 10 "(2) insure that the educational component of each 11 training program meets acceptable standards; and 12 "(3) give special consideration to certifying posi- 13 tions associated with, as an integrated part, an area 14 health education system, as defined by regulations of the 15 Secretary under section 751 of this Act. 16 "SEc. 737. In carrying out the provisions of sections 732 17 (a) (5), 734(a) (3) and 736(b) (2) relating to the edu- 18 cational component of postgraduate physician training, the 19 National Council and each regional council shall coordinate 20 its activities with the Liaison Committee on Graduate Medi- 21 cal Education. 22 "SEC. 738. (a) The Secretary shall make grants to, 23 and contract with, entities which directly provide, or associa- 24 tions of such entities which directly provide, or have the 25 capacity to provide directly, postgraduate training of physi- PAGENO="0087" 38 1 clans and which are certified to the Secretary by the National 2 Council and a regional council as likely to receive an in- 3 creased number of certified postgraduate positions subse- 4 quent to July 1, 1977, to allow such entities to develop new, 5 and expand existing, postgraduate pliysi~ian training pro- 6 grams. 7 " (b) In the awarding of grants, the Secretary shall.give 8 special priority to (1) programs to train primary medical, 9 especially family practice, physicians and (2) programs, es- 10 pecially programs described in clause (1), in regions with a 11 relative shortage of physicians. 12 "(c) No entity may receive- 13 "(1) a~ grant or contract for more than $100,000 for 14 the establishment, or the expansion of an existing pro- 15 gram in the training of physicians in any particular 16 specialty or subspecialty area, in any fiscal year. 17 "(2) a grant or contract for more than two consec- 18 utive years for the establishment, or the expansion of 19 an existing program, for the training of physicians in 20 any particular specialty or subspecialty area. 21 "(d) For each of the fiscal years ending June 30, 1975, 22 June 30, 1976, and June 30, 1977, there are authorized to 23 be appropriated such sums as may be necessary to carry out 24 the provisions of this section. PAGENO="0088" 75 39 1 "SEc. 739. (a) The Secretary shall make grants to en- 2 tities which- 3 "(1) directly provided postgraduate training of 4 physicians on July 1, 1977; and 5 "(2) because of the operation of this part, are able 6 to obtain a decreased number of postgraduate physician 7 trainees following July 1, 1977; and 8 "(3) have a plan to utilize such funds to initiate 9 the provision of services, previously provided by phy- 10 sicians in postgraduate training, by other health profes- 11 sionals and personnel, especially nurse clinicians. 12 The Secretary shall pay to such entities $10,000 for each 13 individual position decrease in the first year following such 14 decrease and $5,000 for each position decrease in the second 15 year following such decrease. 16 "(b) For each of the fiscal years ending June 30, 1978, 17 June 30, 1979, and June 30, 1980, there are authorized to 18 be appropriated such sums as may be necessary to carry out 19 the provisions of this section. 20 "SEc. .740. (a) The Secretnry shall, within ninety days 21 of the appointment of the National Council, contract, with 22 the approval of the National Council as provided in sub- 23 section (b), for the conduct of a study to: 24 "(1) Analyze the current distribution of physicians PAGENO="0089" 79 40 1 by speciality. The geographical distribution of medical 2 and osteopathic physicians by speciality and subspe- 3 ciality and by geographic area. shall be determined. IPhy- 4 sician specialities and subspecialities shall be defined ill 5 a manner consistent with recognized categories; geo- 6 graphic areas shall be defined as a reasonable medical 7 trade area for each speciality or subspeciality; special 8 attention shall be given to determining the percent of 9 time physicians in each speciality and subspeciality 10 spend in primary care activities. 11 "(2) Project the expected distribution of phy- 12 sicians by speciality and subspeciality by geographic 13 area in the years 1980, 1~85, and 1990. Such projec- 14 tion shall be based on current trends in physician spe- 15 cialty training and choice of practice sites, the activities m of various specialty boards and other organizations, and 17 the retirement-death rate of physicians by speciality and 18 subspeciality. 19 "(3) Examine and critically evaluate the various 20 methodologies for estimating the optimal distribution of 21 physicians by speciality and subspeciality by geographic 22 area. Methodologies examined and evaluated shall in- 23 elude methodologies utilized by foreign countries. 24 "(4) Develop a reliable and appropriate method- 25 ology to establish the optimal distribution of physicians PAGENO="0090" 80 41 1 by speciality and subspeciality by geographic area. Uti- 2 lizing such methodology, projections shall be made for 3 the optimal number of physicians by speciality and sub- 4 specialty by geographic area for the years 1980, 1985, 5 and 1990. 6 "(b) The Natioiial Council shall approve the organiza- 7 tion selected by the Secretary to conduct the study required 8 by subsection (a). Such organization shall- 9 "(1) have a national reputation for objectivity in the 10 conduct of studies for the Federal Government; 11 "(2) have the capacity to readily marshal the 12 widest possible range of expertise and advice relevant to 13 the conduct of such studies; 14 "(3) have a membership and competent staff which 15 have backgrounds in government, the health sciences, 16 and the social sciences; 17 "(4) have a history of interest and activity in health 18 policy issues related to such studies; and 19 "(5) have extensive existing contracts with inter- 20 ested public and private agencies and organizations. 21 " (c) An interim report providing a plan for the study 22 required by subsection (a) shall be submitted by the organi- 23 zation conducting the study to the Committee on Interstate 24 and Foreign Commerce of the house of Representatives and 25 the Committee on Labor and Public Welfare of the Senate PAGENO="0091" 81 42 1 by January 31, 1975; aiid a Iiiial report giving tile results of 2 the study shall be subiiiitted by such organization to the 3 Committee on Interstate and Foreign Commerce of the 4 House of Representatives and the Committee on Labor and 5 Public Welfare of the Senate by January 31, 1976. 6 " (d) There is authorized to be appropriated $10,000,- 7 000, which shall be available without fiscal year limitations, 8 for time conduct of the study required by subsection (a). 9 ~`SEc. 740A. No entity which is engaged in business in 10 interstate commerce as a health insurer and which receives 11 an annual gross income from the provision of health insur- 12 ance of not less than $1,000,000 may reimburse or other- 13 wise pay an individual or institution an amount resulting 14 froni expenses associated with the postgraduate trainiiig of 15 physicians after July 1, 1977, unless such training has been 16 certified by the National Council and, except for positions 17 certified under section 735 (b) , the appropriate regional 18 council. Any entity which makes a reimbursement or other 19 payment prohibited by this section shall for each such 20 reimbursement or other payment be subject to a civil penalty 21 of not more than $5,000. Such peiiaity shall lie assessed 22 by the Secretary and may i~e collected in a civil action 23 brought~ by the Tnited States in a United States district 24 court under section 1355 of title 28, United States Code. 25 No State may establish or enforce any law which would PAGENO="0092" 82 1 require as a condition of doing J)usiness in such State that 2 an entity described iii this section itiake reimbursements 3 or other payments prohibited by this section. 4 "PAIIT 1)-SPECIAL P1~oJI~cT Gnxxrs 5 "Si~c. 741. (a) The Secretary may make grants to pub- 6 lie and other nonprofit pii\'ate schools of podiatry and other 7 pu1>~ or miomiprofit private agencies, organizations, and insti- 8 tutions to iiieet tIme costs of projects to assist in- 9 ``(1) iiiergers between podiatric training ~fl0gfl1n15 10 and miiedical. osteopatinc. and other health professions Ii training programs and academic institutions, or 12 (2 ) other cooperative arrangements among podi- 13 atric training programs and medical, osteopathic, and 14 other health professions training programs amid academic 15 institutions. 16 " (b) There are authorized to be appropriated such sums 17 as may i~e necessary to carry out the provisions of this section 18 for the fiscal years ending June 30, 1975, Jumie 30, 1976, 19 and June 30, 1977. 20 "SEC. 742. (a) rrhle Secretary iiiav imiake grants to pub- 21 lie and other nonprofit private schools of nursing, pharmacy, 22 public health, and health administration and other public or 23 nonprofit private agencies. organizations, and institutions to 24 meet the costs of projects to develop and expand graduate 25 degree level training programs for- PAGENO="0093" 83 44 1 ``(1 ) cliiiical liursilig 1)er~oI1neI, includiiig programs 2 for the traiiiiiig of pe(liatIic nurse pi'ilct itionei's, nurse 3 midwives, and other types of liurse practitioners 4 (2 ) (Ii meal 1)110 rniacv persoi ii Ic! 0 iid 5 `` (3) Coflhlfluujtv and public health peisoiimiel 011(1 6 health adnunistrators. 7 " (1)) There are authorized to lie appropriated such suimis 8 as iiiay be necessary to carry (lilt the provisions of this section 9 for the fiscal years ending June 30, 1975, June 30, 1976, 10 and June 30, 1977. 11 ``S~c. 743. (a) The Secretary may make gi'aiits to Pt1l~- 12 lie and other nonprofit 1)I'i%ate uiidergraduate (including hac- 13 calaureate. diplonia. and associate degree granting) schools 14 of liaising. pharmacy, and allied health and other public or 15 nonprofit private agencies. organizations and nistitutions to 16 meet the costs of projects to- 17 "(1) Assist iii iIicreasimi~ the 5Up~)lV, or iiiiprove 18 the distribution of. ade(Juatelv trauied health pcr~oniiel 19 `` (2) Effect significamit imnprovenieuts iii the curric- 20 uluni of such schools 21 ~` (3) Plan, develop or cstal)IislI 11(~\V ~)IograI11s 01' 22 modifications of existing programs of health personnel 23 education; 24 " (4) Increase educational opportunity for dis- 25 advantaged students; and PAGENO="0094" 84 45 1 " (5) Otherwise strengthen, improve or expand 2 programs to train health pelsollnel. 3 " (b) Iii making grants under this section, the Secretary 4 shall give prionty to applications from entities whose appli- .5 cation for such grant has been approved by an area health 6 education system (as defined in regulations tinder section 7 751 ) serving a health education area in which the applicant S is located. 9 (e) There are authorized to be appropriated such sums 10 as may be necessary to carry out the provisions of this see- 11 tion for the fiscal years ending June 30, 1975, June 30, 12 1976, and June 30, 1977. 13 "PART E-AREA EDUCATION SYSTEMS 14 S~:c. 751. For purposes of this title: 15 "(a) The term `area health education system' means 16 a public or nonprofit entity which- 17 (1) Evaluates, on an on-going basis: Is "(A) the health education needs of the resi- 19 dents of the health education area; and 20 "(B) the effectiveness of the health education 21 ~ operated by the area health education 22 sVstc1fl. entities associated with the area health edu- 23 cation system, and other entities within the health 24 education area, in meeting the health education 2.5 needs of the residents of the area. PAGENO="0095" 85 46 1 `~ (2) Provides directly, and coordinates the provi- 2 sion hy other eiitities, of health education services to 3 the residents of the health education area including, at 4 a minimum: 5 "(A) The training of nurses and other allied 6 health personnel; 7 "(B) The postgraduate training of physicians 8 in, at the niinimum, primary care speciahies; 9 "(C) Continuing education for practicing phy- 10 sicians and continuing education and inservice train- 11 ing for nurses and other health professions; 12 "(D) CounseBng with respect to careers in 13 niedicine, nursing, and other health professions at 14 secondar schools and community colleges; and 15 "(E) The provision to the general population 16 of education about: 17 " (i) the appropriate use of health services; 18 and 19 " (ii) the contril)ution each ifl(lividual can 20 make to the maintenance of his own health. 21 "(3) Has contracts or other formal working ar- 22 rangeinents, with, at the minimum 23 "(A) A university health education center; 24 "(B) State colleges, community colleges, and 25 private universities and colleges, which provide 38-698 0 - 74 - 7 (Pt. 1) PAGENO="0096" 86 47 I e(lU(~1tiO11 111 tIle health prof(qOfls, Ilulsing, and 2 the allied 1n fessioiis 3 ((_` ) I losl)itals aiid other health delivery en- 4 titie~ \vhicll provide health services and which oper- ate health education trailling prog~~1115 6 (1)) 8tate and coniiiiunitv public health ageil- 7 cie~ wit nh provide health education ft t lie general 8 popiil;ition 9 ( E ) Voluntary health agencies and organiza- 10 tion~ whii(ll provide health education to the general 11 1)opUhlt ton 112 (F) State and local health services plan- 13 iiiiig agcllcies. including agencies estal)hslled pur- 14 ~uatit to section 314 (b) and title IX of this Act: and 16 ((~ ) Professional standards review orgailiza- 17 tiOns (stabhishlc(l Itulsualit to section 1152 of the 18 Social Security Act. 19 ` (4) has a governing board, the members of 20 wIt 1(11 shall include residents of the health education 21 area who are 22 (A) Individuals who are associated with in- 23 stitutions and organizations from the educational 24 field: 215 ` (B) 1 udividuals who are associated with in- PAGENO="0097" 87 48 1 stitutioiis, organizations, or are themselves involved 2 with the provisioli of health care services 3 " (C) Individuals who are associated with 4 appropriate State and local health services planning 5 agencies, including agencies estal)lislled piiisuaiit to 6 section 314 (b) and title IX of this Act 7 " (D) Individuals who are asso(iated with 8 county and municipal governnients; and 9 " (E) Individuals who are not 1)roviders of 10 health care services and who are broadly rep- 11 resentative of the various economic, socio, racial, 12 and geographic population groups of such health 13 e(lUcatiOn area. 14 ``(b) The term `health education area' means a geo- 1;5 graphic area designated by the Secretary. Sutli area shall 16 "(1) Be a rational area for the planning and co- 17 ordination of health education; 18 "(2) To the extent practical. include at least one 19 university health science ceiiter; and 20 ``(3) Follow the boundaries of one or more areas 21 established pu1'sI1a1~t to section 314 ft ) of this Act. 22 ``Si:c. 752. (a') The Secretary may iuake grants, subject 23 to the provisions c~f section 751 . to public or private iionprofit 24 entities, to assist in projects for planiiiiig, developing. and 25 operating area health education systems. ~(i proJect may PAGENO="0098" 88 49 1 receive more than $500,000 in grants in any fiscal year under 2 this section. 3 "(b) The Secretary shall make grants under this see- 4 tion only to entities whose application for such grant has 5 been approved by each agency established pursuant to 6 section 314 (b) and title IX operating in such area. 7 "(c) There are authorized to be appropriated such sums 8 as may be necessary to carry out the provisions of s.~ction 751 9 in the fiscal years ending June 30, 1975, June 30, 1976, and 10 June 30, 1977. 11 "PART F-LOAN GUARANTEES AND INTEREST SUBSIDIES 12 "SEC. 761. (a) In order to assist students in accredited 13 (as determined by regulations of the Secretary) schools to 14 pursue an approved course of study leading to a baccalau- 15 reate, associate, diploma or other undergraduate degree in 16 nursing, pharmacy, or the allied health professions (as de- 17 termined by regulations of the Secretary) to meet the cost 18 of tuition and living expenses, books, equipment and other 19 necessary education expenses, the Secretary, during the 20 period beginning July 1, 1974, and ending with the close 21 of June 30, 1977, may, in accordance with the provisions 22 of this section, and subject to the general provisions of this 23 Act- 24 "(1) guarantee to non-Federal lenders making 2~ loans to such individuals fo~ such purposes, payment of PAGENO="0099" 89 50 1 principal of and interest on such loans which are ap- 2 proved under this section, and. 3 "(2) pay to the holder of such loans (and for and 4 on behalf of the organization which received such loan) 5 amounts sufficient to reduce, but not `to exceed, 3 per 6 centum per annum the net effective interest rate other- 7 wise payable on such loan. No loan guarantee or 8 interest subsidy under this section may, except under 9 such special circumstances and under such conditions 10 as are prescribed by regulations, apply to or be made 11 for an amount which, when added to any grant or 12 other loan under this or any other law of the United 13 States, is in excess of $5,000 for any student in any 14 academic year. 15 "(b) The Secretary may not approve the application 16 of a student unkss- 17. "(1) he determines, in the case of `a loan for which 18 a guarantee or an interest subsidy payment is sought, that 19 the terms, conditions, maturity, security (if any), and 20 schedule and amounts of repayments with respect to 21 the loan are sufficient to protect the financial interests 22 of the United States and are otherwise reasonable and 23 in accord with regulations, including a determination 24 that the rate of interest does not exceed such per .25 centum per annum on the principal obligation out- PAGENO="0100" 90 51 1 standing as the Secretary determines to be reasonable, 2 taking into account the range of interest rates pre- 3 vailing in the private market for similar loans and 4 the risks assumed by the United States; 5 "(2) the term of a loan for which a. guarantee and 6 interest subsidy is sought does not exceed five years, or 7 such shorter period as the Secretary prescribes; and 8 "(3) he obtains assurances that the applicant will 9 keep such records, and afford such access thereto, and 10 make such reports, in such form and containing such 11 information, as the Secretary may reasonably require. 12 "(c) Guarantees of loans and interest subsidy payments 13 under this section shall be subject to such further terms 14 and conditions as the Secretary determines to be necessary 15 to assure that the purposes of this section will be achieved, 16 and, to the extent permitted by subsection .(e) , any of 17 such terms and conditions may be modified by the Secretary 18 to the extent he determines it to be consistent with the 19 financial interests of the United States. 20 "(d) In the case of any loan guaranteed under this 21 section, the United States shall be entitled to recover from 22 the applicant, the amount of any payments made pursuant to 23 such guarantee unless the Secretary, for good cause, waives 24 his right of recovery, and, upon making any such payment, 25 the United States shall be subrogate~ to all. of th~ rights PAGENO="0101" 91 52 1 of the recipient of the payments with respect to which the 2 guarantee wa~s made. 3 "(e) Any guarantee of a loan under this section shall 4 be incontestable in the hands of an applicant on whose 5 behalf such guarantee is made, and as to any person who 6 makes or contracts to make a loan to such applicant in 7 reliance thereon, except for fraud or misrepresentation on 8 the part of such applicant or such other person. 9 "(f) The cumulative total of the principal of the loans 10 outstanding at any time with respect to which guarantees 11 have been issued, or which have been directly made, under 12 this section may not exceed such limitations as may be 13 specified in appropriation Acts. 14 " (g) (1) There is established in the Treasury a health 15 service manpower loan guarantee fund (hereafter in this 16 section referred to as the "fund") which shall lie available 17 to the Secretary without, fiscal year in such amounts as may 18 be specified from time to time in appropriation Acts. 19 " (A) to enable l1iln to discharge his responsibilities 20 i,mder guarantees issued by him imder this section, and 21 "(B) to make interest subsidy payments on such 22 loan. 23 There are authorized to be appropriated to the fund from 24 time to time such amounts as may be required for the fund. 25 To the extent. authorized from time to time in appropriation PAGENO="0102" 92 53 1 Acts there shall be deposited in the fund amounts received 2 by the Secretary as interest payments or repayments of prin- 3 cipal on loans and any other moneys, property, or assets 4 derived by him from his operations under this section, in- 5 eluding any moneys derived from the sale of assets. 6 "(2) If at any time the moneys in the fund are 7 insufficient to enable the Secretary to discharge his re- 8 sponsibilities under this section to meet the obligations under 9 guarantees of loans under subsection (a) or to make interest 10 subsidy payments on such loans, he is authorized to issue to ii the Secretary of the Treasury notes or other obligations in 12 such forms and denominations, bearing such maturities, and 13 subject to such terms and conditions, as may be prescribed by 14 the Secretary with the approval of the Secretary of the Treas- 15 ury. Such notes or other obligations shall bear interest 16 at a ra.te determined by the Secretary of the Treasury, 17 taking into oonsideration the current average market 18 yield on outstanding marketable obligations of the United 19 States of comparable maturities during the month preceding 20 the issuance of the notes or other obligations. The Secretary 21 of the Treasury is authorized and directed to purchase any 22 notes and other obligations issued hereunder and for that pur- 23 pose he is authorized to use as a public debt transaction the 24 proceeds from the sale of any securities issued under the 25 Second Liberty Bond Act and the purposes for which securi- PAGENO="0103" 93 54 1 ties may be issued under that Act are extended to include any 2 purchase of such notes and obligations. The Secretary of the 3 Treasury may at any time sell any of the notes or other obli- 4 gations acquired by him under this subsection. All redemp- 5 tions, purchases, and sales by the Secretary of the Treasury of 6 such notes or other obligations shall be treated as public debt 7 transactions of the United States. Sums borrowed under this 8 subsection shall be deposited in the fund and redemption of 9 such notes and obligations shall be made by the Secretary 10 from such fund." ii TITLE Il-MISCELLANEOUS REPEALS 12 SEc. 3. Sections 225, 306, 309, and 329 and titles 13 VII and VIII of the Public Health Service Act are repealed 14 effective July 1, 1974. PAGENO="0104" 94 H. R. 14721 IN THE HOUSE OF REPRESENTATIVES ~\L~y 9, 1974 Mr. ROGERS (for himself, Mr. Kmos, Mr. SYMINGTON. Mr. HASTINGS, Mr. HEINZ, and Mr. HUDNUT) introduced the following bill; which was referred to the Committee on Interstate and Foreign Commerce A BILL To amend the Public Health Service Act to revise and extend the programs of assistance under title VII for training in the health and allied health professions, to revise the National Health Service Corps program and the National Health Service Corps scholarship training program, and for other purposes. 1 Be it enacted by the Senate and Howse of Representa- 2 tives of the United States of America in Congress assembled~ 3 SHORT TITLE; REFERENCE TO ACT 4 SECTION 1. (a) This Act may be cited as the "Health 5 Manpower Act of 1974". 6 (b) Whenever in this Act an amendment or repeal is 7 expressed in terms of an amendment to, or repeal of, a section 8 or other provision, the reference shall be considered to be PAGENO="0105" 95 I made to a section or other provision of the Public health 2 Service Act. 3 TITLE I-GENERAL PROVISIONS 4 SEc. 101. (a) Sections 701 through 711 are repealed. 5 (b) Sections 724, 725, 799, and 799A are transferred 6 to part A of title VII and are redesignated as sections 701, 7 702, 703, and 704, respectively. 8 (c) Section 701 (as so redesignated) is amended- 9 (1) by striking out "As used in this part and 10 parts C, E, and F-" and inserting in lieu thereof ii "For purposes of this title:"; and 12 (2) by inserting "or an equivalent degree" after 13 "degree in public health" in paragraph (4) 14 (d) Seëtion 702 (as so redesignated) is amended by 15 striking out "parts A and G" in subsections (b) and (c) 16 and inserting in lieu thereof "part G". 17 (e) Section 703 (as so redesignated) is amended to 18 read as fol1o~'s: 19 "ADVANCE FINDING 20 "SEc. 703. An appropriation under an authorization 21 of apptopriations for grants or contracts under this title 22 for any fiscal year may be made at any time before that 23 fi~I y~r ~nd may be included in an Act~ making an appro- PAGENO="0106" 96 3 1 priation under such authorization for another fiscal year; but 2 no funds may be made available from any appropriation 3 under such authorization for obligation for such grants or 4 contracts before the fiscal year for which such appropriation 5 is authorized.". 6 (f) Section 704 (as so redesignated) is amended by 7 adding at the end thereof the following: "In the case of a 8 school of medicine which- 9 "(1) on the date of the enactment of this sentence 10 is in the process of changing its status as an institu- 11 tion which admits only female students to that of an in- 12 stitution which admits students without regard to their 13 sex, and 14 "(2) change is being carried out in accordance 15 with a plan approved by the &cret8ry, 16 the provisions of the preceding seiitences of this section shall 17 apply only with respect to a grant, contract, loan guarantee, 18 or interest subsidy to, or for the benefit of such a school for 19 a fiscal year beginning after June P30, 1979.". 20 (1) The heading for part A of title VII is amended 21 to read as follows: 22 "PART A-GENERAL PRovIsIoNs". 23 (2) The heading for part H of title VII is repealed. PAGENO="0107" 97 4 1 TITLE IT-ASSISTANCE FOR CONSTRUCTION OF 2 TEACHING FACILITIES SEc. 201. Section 720 is amended to read as follows: 4 "GRANT AUTHORITY; AUTHORIZATIONS OF S APPROPRIATIONS 6 "SEC. 720. (a) The Secretary may make grants to assist 7 in the construction of teaching facilities for the training of 8 physicians, dentists, pharmacists, optometrists, podiatrists, 9 veterinarians, arid professional public health personnel. 10 "(b) There are authorized to be appropriated $100,- 11 000,000 for the fiscal year ending June 30, 1975, $125,- 12 000,000 for *the fiscal year ending June 30, 1976, and 13 $150,000,000 for the fiscal year ending June 30, 1977, for 14 grants under this part.". 15 SEC. 202. (a) (1) Subsection (a) of section 722 is 16 amended to read as follows: 17 "(a) The amount of any grant under this part for con- 18 struction of a project shall be such amount as the Secretary 19 determines to be appropriate a.fter obtaining advice of the 20 Council, except that no grant for any project may exceed 80 21 per centum of the necessary costs of construction, as deter- 22 mined by the Secretary, of such project.". 23 (2) The amendment made by paragraph (1) shall take 24 effect with respect to grants made under part B of title VII 23 of the Public Health Service Act from appropriations under PAGENO="0108" 98 0 ~ secticn 720 ~f such Act for fiscal years begrnmng after 2 June 30, 1974. (b) Suh~ection (d) f section 722 is amended by strik- 4 ing out " ( witliiii the ilitaililig of part A of this title) ``. SEu. 20:L (a) Subsections (a) and (b) of section ~ 729 are each amended by striking out "1974" and inserting 7 iii lieu thereof "1977''. 8 (h) The seeind sentence of section 729 (e) is amended 9 by striking out the period at the end thereof and inserting 10 in lieu thereof a comma and the following: "$2,000,000 ~ for tile fiscal year ending June 30, 1975, $2,500,000 for 12 tIme fiscal year ending June 30, 1976, and $3,000,000 for 13 the fiscal year ending June 30, 1977.". 1-1 SEc. 204. (a) Sect.ion 721 (c) is amended- 15 (1) by striking oat "section 770 (1) of this Act" 16 in paragTa.ph (2) and inserting in lieu thereof "see- 17 tion 771"; 18 (2) by striking out the sentence at the end of 19 paragraph (2); 20 (~) by stnking out paragraph (5) and redesig- 21 natimmg paragraphs ((3) and (7) as paragraphs (5) and 22 ((5) . respectively: and 23 (4) by striking out "and" at the end of paragraph 24 (5) (as so redesignated), by striking out the period at 25 the end of paragraph (6) (as so redesigmmted) and in- PAGENO="0109" 99 6 1 serting in lieu thereof " ; and", and by inserting after 2 paragraph (6) the following: 3 "(7) the application con~a.ins or is supported by 4 adequate assurance that any laborer or mechanic em- 5 ployed by a contractor or subcontractors in the per- 6 formance of work on the construction of the facility 7 will, be paid wages at. rates not less than those prevail- 8 ing on similar coiistruction in the locality as detern~ined 9 by the Secretary of Tiahor in accordance with the Act 10 of March 3, 1931 (40 U.S.C. 276a~-27Ga-5, known as the Davis-Bacon Act). 12 The Secretary of Labor shall have with respect io the labor 13 standards specified in paragraph (7) the `authority and func- 14 tions set forth in Reorganization Plan Numbered 14 of 1950 is (15 F.R. 3176; 5 T~S.C. Appendix) and section 2 of the 16 Act of June 13, 1934 (40 U.S.C. 276c) ." 17 (b) Sections 726, 727, 728, and 729 are redesignated 18 as sections 724, 725, 726, and 727, respectively. 19 TITLE ITT-STUDENT ASSISTANCE; NATIONAL 20 HEALTH SERVICE CORPS 21 SEc. 301. (a) Section 740 is amended (1) by striking 22 out "and" at the end of paragraph (4), (2) by redesignat- 23 ing paragraph (5) as paragraph (6), and (:3) by inserting 24 after paragraph (4) the following new paragraph: "(5) provide that the school shall advise, in writ- PAGENO="0110" 100 1 ing, each applicant for a loan from the student loan fund 2 of the provisions of section 741 under which outstanding 3 loans from the student lo~u fund may be paid (in whole 4 or in part) by the Secretary; and". 5 (ii) Subsection (a) of section 741 is amended to read 6 as follows: 7 "(a) Loans from a student loan fund establ~sbed under 8 an agreement under section 740 may not exceed for any stu- 9 dent for any academic year (or its equivalent) the sum- 10 "(1) the cost of tuition for such year at the school 11 for which such fund was established. ~nd 12 "(2) $2,500." 13 (c) Section 741 is amended- 14 (1) by redesignating subsections (g), (b), (i), 15 (k) , and (1) as subsections (h), (i), (k), (1), and 16 (m) respectively, and 17 (2) by inserting after subsection (f) the follow- 18 ing new subsection: 19 "(g) (1) In the case of any individual- 20 "(A) who has received a degree of doctor of 21 medicine, doctor of osteopathy, or doctor of dentistry 22 (or an equivalent degree) 23 "(B) who obtained- 24 . "(i) one or more loans from a student loan PAGENO="0111" 101 S fund established under an agreement tinder section 2 740, or 3 "(ii) any other educational loan for his costs 4 at a school of medicine, osteopathy, or dentistry; and 6 "(0) who ellters into an agreement with the Secre- 7 tary to practice his profession in a primary care spe- 8 ciality for at least five years: ~ the Secretary shall make payment in accordance with para- 10 graph (2), for and on behalf of that individual, on the prin- ~ cipal of any loan of his described in subparagraph (B) of 12 this paragraph which is outstanding on the date lie begins 13 the practice specified in the agreement described in sub- 14 paragraph (C) of this paragraph. 15 "(2) The payments described in paragraph (1) shall 16 be made by the Secret~ry as follows: 17 "(A) Upon completion by the individual for whom 18 the payments are to be made of the first year of prac- 19 tice specified in the agreement he entered into with the 20 Secretary in paragraph (1), the Secretary shall pay 20 21 per centum of the principal of aiid the interest on each 22 loan of stich individual described in paragraph (1) (B) 23 which is outstanding on the date he began such practice. "(B) Upon completion by that individual of the 25 second year of practice, the Secretary shall pay another 38-698 0 - 74 - 8 (Pt. 1) PAGENO="0112" 102 9 20 per centum of the principal of and the interest on 2 each such loan. 3 "(0) T~pon completioii by that nidividual of the third year of such practice~ tile Secretary shall pay an- other 20 per centulu of the principal of and interest on each such loan. "(D) Upon completion by that individual of the s fourth year of such practice, the Secretary shall pay 10 per centum of the principal of and the interest on each such loan. "(F) Upon completion by that individual of the 12 fifth year of such practice, the Secretary shall pay 13 another 10 per centum of the principal of and the 14 interest on each such loan. "(3) Notwithstanding the requirement of completion of 16 practice specified in paragraph (2), the Secretary shall, 17 on or before the due date thereof, pay any loan or loan in- 18 suallinent which nrny fall due within the period of practice 19 for which the borrower may receive payments under this 20 subsection. upon the declaration of such borrower, at such 21 times and in such manner as the Secretary may prescribe 22 (and ~upported by such other evidence as the Secretary may 23 reasonably reqinre) , that the borrower is engaged in the 24 practice of hi~ profession in a primary care specialty and PAGENO="0113" 103 10 1 that lie will continue to be so engaged for the period re- 2 quired to entitle him (iii the absence of this paragraph) to 3 have made the payments provided by this subsection for 4 SIKIl period. 5 "(4) A borrower who fai1~ to fulfill an agreement. with 6 the Secretary entered into under paragraph (1) shall be 7 liable to reimburse the Secretary for any payments made 8 pursuant to paragraph (2) or paragraph (3) in eonsidera- 9 tion of such agreement. 10 "(5) If the Secretary makes any payment under this 11 sul)section with respect to a loan from a student loan fund or 12 to another educational loan on behalf of the individual who 13 received such loan, the Secretary may not make payments 14 under subsection (f) with respect to such loan on behalf of lo such ill(liVi(hIal. 16 " (G) For purposes of this subsection, the term `primary 17 care specialty' includes family medicine, gutieral internal 18 medicine, and general 1)ediiltiics.' 19 (d) Subsection (a) of section 742 is ameiided to read 20 as follows: 21 "(a) For the purpose of making Federal capital con- 22 tributions into the student loan funds of schools which have 23 established such funds under an agreernemit under section 740, 24 there are authorized to be appropriated $200,0(H,000 for 25 the fiscal year ending June 30, 1975, $225,00U,itO() foj the PAGENO="0114" 104 11 1 fiscal year ending June 30, 1976, and $250,000,000 for the 2 fiscal year ending June 30, 1977. For the fiscal year endingS 3 June 30, 1978, and each of the two succeeding fiscal years 4 there are authorized to be appropriated such sums as may be S necessary to enable students who have received a loan under 6 this part for any academic,year ending before July 1, 1977, 7 to continue or complete their education." S (e) Section 743 is amended by striking out "1977" 9 each place it occurs and inserting in lieu thereof "1980". 10 (f) (1) Section 744 is repealed. ii (2) The health professions education fund created with- 12 in the Treasury by section 744 (d) (1) of the Public Health 13 Service Act shall remain available to the Secretary of 14 Health, Education, and `Welfare for the purpose of meeting is his responsil)ihties respecting participations in obligations 16 acquired under section 744 of such Act. The Secretary shall 17 continue to deposit in such fund all amounts received by him 18 as interest payments or repayments of principal on loans 19 under such section 744. If at any time the Secretary deter- 20 mines the moneys in the fund exceed the present and any rea- 21 sonable prospective future requirements of such fund, such 22 excess may be transferred to the general fund of the Treasury. 23 (3) Section 742 (b) is amended (1) by striking out 24 ", and for 1oan~ pursuant to section 744" in paragraph (1) 2S and (2) by striking out " (whether as Federal capital contri- PAGENO="0115" 105 12 1 l)UtiOn~ or as loans to schools uiider section 744) in para- *2 graph (3)". 3 (g) (1) Section 76 is repealed. 4 (2) Section 740 is amended (A) by striking out "of 5 Health, Education, and Welfare" in subsection (a) ; and 6 (B) by striking out ", except as provided in section 746," 7 in paragraphs (2) a.nd (3) of subsection (ii) 8 (11) (1 ) Subpart II of part C is repealed. 9 (2) Part C is amended by striking out "Subpart I- 10 Loans to Students Studying in the United States". ii (3) Sections 740, 741, and 745 are each amended by 12 striking out "this subpart" each place it occurs and insert- 13 ing in lieu thereof "this part". 14 SEc. 302. (a) Subparts I, II. and III of part F of title 15 VII are repealed. 16 (b) The Secretary of Health, Education, and Welfare 17 may, during the period beginning July 1, 1974, and ending 18 June 30, 1977, make grants to public and nonprofit private 19 schools of medicine, osteopathy, dentistry, optometry, podi- 20 atry, pharmacy, and veterinary mediciiie to enable such 21 schools to continue making payments under scholarship 22 awards to students who initially received such awards out of 23 grants made to the schools under part F of title VII of the 24 Public Health Service Act for fiscal years ending before 25 July 1, 1974. PAGENO="0116" 106 13 1 SEc. 303. (a) Section 329 is amended to read as 2 follows: 3 ~YATIONAT~ HEALTH SERVICE CORPS 4 ~`Si~c. 329. (a) There is established, within the Service, 5 the National Health Service Corps (hereinafter in this see- 6 tion referred to as the `Corps') which shall consist of those 7 officers of the Regular and Reserve Corps of the Service and 8 such other personnel as the Secretary may designate and ~ which shall be utilized by the Secretary under this section io to improve the delivery of health services to medically an- ii derserved populations. 12 (b) (1) The Secretary shall designate the medically 13 underserved populations in the States. For purposes of this 14 section. a medically underserved population is the popula- is tion of an urban or rural a.rea (which does not have to con- 16 form to t.he geographical boundaries of a political subdivision 17 and which should be a rational area for the delivery ~f health is services) which the Secretary determines has a critical 19 health manpower shortage or a population group determined 20 by the Secretary to have such a shortage; and the term 21 `State' includes Guam, American Samoa, and the Trust Ter- 22 ritory of the Pacific Islands. In designating medically under- 23 served populations~ the Secretary shall take into account 24 (A) the recommendations of the entities responsible for the 25 development, of the plans referred to in section 314 (b) PAGENO="0117" 107 14 1 which cover all or any part of the areas in which populations 2 uiidcr consideration for designation reside, and (B) in the case 3 of any such area for which no such entity is responsible for 4 developing such a plan, the recommendations of the agency 5 of the State (or States) in which such area is located which 6 administers or supervises the administration of a State plan 7 approved under section 314 (a). 8 "(2) Any person may apply to the Secretary (in such 9 manner as he may prescribe) for the designation of a popu- 10 lation as a medically underserved population. In considering ~ an application under this paragraph, the Secretary shall 12 take into account the following in addition to criteria utilized 13 by him in making a designation under paragraph (1): 14 "(A) Ratios of available health manpower to the 15 population for which the application is made. 16 "(B) Indicators of the population's access to health 17 services. 18 "(C) Indicators of health status of the population. 19 "(D) Indicators of such population's need and de- 20 mand for health services. 21 "(3) The Secretary shall (A) provide assistance to 22 persons seeking assignment of Corps personnel to provide 23 under this section health services for medically underserved 24 populations, and (B) conduct such information programs 25 in areas in which such populations reside as may be neces- PAGENO="0118" 108 1 sary to inform the public and private health entities serving 2 those areas of the assistance available to such populations 3 by virtue of their designation under this section as medically 4 underserved. 5 "(c) (1) (A) The Secretary may assign personnel of the 6 Corps to provide, under regulations prescribed by the Sec- 7 retary, health services for a medically underserved population 8 if- 9 "(i) the State health agency of each State in 10 which such population is located or the local public ii health agency or any other public or nonprofit private 12 health entity serving such population makes application 13 to the Secretary for such assignment, and 14 "(ii) the (I) local government of the area in 15 which such population resides, and (II) any State and 16 district medical or dental society for such area or any 17 other appropriate health society (as the case may be), 18 for such area certify to the Secretary that such assign- 19 ment of Corps personnel is needed for such population. 20 "(B) The Secretary may not approve an application 21 under paragraph (1) (A) (i) for an assignment unless the 22 applicant agrees to enter into an arrangement with the 23 Secretary in accordance with subsection (e) (1) and has 24 afforded- 25 "(i) the entity responsible for the development of PAGENO="0119" 109 ig 1 the plans. referred to in section 314 (b) which covers 2 all or any part of the area in which the population 3 for which the application is submitted resides, and 4 "(ii) if there is a part of such area for which no 5 such entity is responsible for developing such plans, the 6 agency of the State in which such part is located which 7 administers or supervises the administration of a State 8 plan approved under section 314 (a), 9 an opportunity to review the application and submit its 10 comments to the Secretary respecting the need for and 11 proposed use of manpower requested in the application. 12 In considering such an application, the Secretary shall take 13 into consider~ ion the need of the population for which the i~t application was submitted for the health services which 15 may be provided under this section; the willingness of the 16 population and the appropriate governmental agencies or 17 health entities serving it to assist and cooperate with the 18 Corps in providing effective health services to the popula- 19 tion; and recommendations from medical, dental, or other 20 health societies or from medical personnel serving the 21 population. 22 "(C) If with respect to any proposed assignment of 23 Corps personnel for a medically underserved population the 24 requirements of clauses (i) and (ii) of subparagraph (A) 25 are met except for the certification by a State and district PAGENO="0120" 110 17 1 medical or denthi society or by any other appropriate health 2 society required by clause (ii) (II) `and if the Secretary 3 finds from all the facts presented that such certification has 4 clearly been arbitrarily and capriciously withheld, the See- 5 retary may, after consultation with appropriate medical, 6 dental, or other health societies, waive the application of the 7 certification requirement to such proposed assignment. 8 "(2) (A) In approving an application submitted under 9 paragraph (1) for the assignment of Corps personnel to 10 provide health services for a medically underserved popu- ii lation, the Secretary may approve the assignment of Corps 12 peisoi~ne1 for such population during a period (referred to 13 in this paragraph as the `assistance period') which may not 14 exceed four years from the date of the first assignment of 15 Corps personnel for such population after the date of the 16 approval of the application. No assignment of individual 17 Corps personnel may be made for a period ending after the 18 expiration of the applicable approved assistance period. 19 "(B) Upon expiration of an approved assistance period 20 for a. medically underserved population, no new assignment 21 of Corps personnel may be made for such population unless 22 an application is submitted in accordance with paragraph 23 (1) for such assignment. The Secretary .nlay not approve 24 such an application unless- PAGENO="0121" 111 18 1 "(i) the application and certification requirements 2 of paragraph (1) are met; 3 "(ii) the Secretary has conducted an evaluation 4 of the continued need for health manpower of the pOpu- 5 lation for which the application is submitted, of the 6 utilization of the manpower by such population, of the 7 growth of the health care practice of the Corps personnel 8 assigned for such population, and of community support 9 for the assignment; and 10 " (iii) the Secretary has determined that such pOpU- 11 lation has made continued efforts to secure its own 12 health manpower, that there has been sound fiscal 13 management of the health care practice of the Corps 14 personnel assigned for such population, including effi- 15 cient collection of fee-for-service, third-party, and other 16 funds available to such population, and that there has 17 been appropriate and efficient utilization of such Corps 18 personnel. 19 "(3) Corps personnel shall be assigned to provide 20 health services for a medically underserved population bn the 21 basis of the extent of the population's need for health services 22 and without regard to the ability of the members of the 23 population to pay for health services. 24 "(4) In making an assignment of Corps personnel the 25 Secretary shall seek to match characteristics of the assignee PAGENO="0122" 112 19 ~ (and his spouse (if any) ) and of the population to which 2 such assignee may be assigned in order to increase the likeli- .~ hood of the assignee remaining to serve the population upon ~ completion of his assignment period. The Secretary shall be- ~ fore the expiration of the last. nine months of the assignment 6 period of a member of the Corps, review such member's 7 assignment and the situation in the area to which he was 8 assigned for the purpose of determining the advisability of ~ extending the period of such member's assignment. 10 "(5) The Secretary shall provide technical assistar.ce to all medically underserved populations to which are not 12 assigned Corps personnel to assist in the recruitment of 13 health manpower. The Secretary shall also gIve such popula- 14 tions current information respecting public and private pro- ~5 grams which may assist in securing health manpower for 16 them. 17 "(d) (1) Tn providing health services for a medically 18 underserved population under this section, Corps personnel 19 shall utilize the techniques, facilities, and organizational 20 forms most appropriate for the area in which the population 21 resides and shall, to the maximum extent feasible, provide 22 such services (A) to all members of the population regard- 23 less of their ability to pay for the services, and (B) in con- 24 nection with (i) direct health services programs carried out 25 by the Service; (ii) any direct health services program cai- PAGENO="0123" 113 20 1 ned out in whole or in part with Federal financial assistance; 2 or (iii) any other health services activity which is in further- 3 ance of the purposes of this section. 4 "(2) (A) Notwithstanding any other provision of law, 5 the Secretary (1) may, to the extent feasible, make such 6 arrangements as he determines necessary to enable Corps 7 personnel in providing health services for a medically 8 underserved population to utilize the health facilities of the 9 area in which the population resides, and (ii) may make 10 such arrangements as he determines are necessary for the 11 use of equipment and supplies of the Service and for the 12 lease or acquisition of other equipment and supplies, and 13 may secure the temporary services of nurses and allied 14 health professionals. 15 "(B) If such area is being served (as determined under 16 regulations of the Secretary) by a hospital or other health 17 care delivery facility of the Service, the Secretary shall, 18 in addition to such other arrangements as the Secretary may 19 make under subparagraph (A), arrange for the utilization 20 of such hospital or facility by Corps personnel in providing 21 health services for the population, but only to the extent 22 that such utilization will not impair the delivery of health 23 services and treatment through such hospital or facility to 24 persons who are entitled to health services and treatment 25 through such hospital or facility. If there are no health PAGENO="0124" 114 21 1 facilities in or serving such area, the Secretary may arrange 2 to have Corps personnel provide health services in the 3 nearest health facilities of the Service or the Secretary may 4 lease or otherwise provide facilities in such area for the 5 provision of health services. 6 "(3) The Secretary may make one grant to any appli- 7 cant with an approved application under subsection (c) to 8 assist it in meeting the costs of establishing medical practice 9 management systems for Corps personnel, acquiring equip- 10 ment for their use in providing health services, and estab- ji Ii~hing appropriate continuing education programs and 12 opportunities for them. No grant may be made under this m paragraph unless an application is submitted therefor and 14 approved by the Secretary. The amount of any grant shall 15 be determined by the Secretary, except that no grant may 16 be made for more than $25,00O. 17 "(4) Lpon the expiration of the assignment of Corps 18 personnel to provide health services for a medically under- 19 served population, the Secretary (notwithstanding any other 20 provisio1~ of law) may sell to the entity which submitted 21 the last application approved under subsection (c) for the 22 assignment of Corps personnel for such population equipment 23 of the United States utilized by such personnel in providing 24 health services. Sales made under this paragraph shall be PAGENO="0125" 115 99 1 made for the fair market value of the equipment sold (as 2 determined by the Secretary). 3 "(e) (1) The Secretary shall require as a condition to 4 the approval of an application under subsection (c) that the 5 entity which submitted the application enter into an appro- 6 priate arrangement with the Secretary under which- 7 "(A) the entity shall be responsible for charging 8 in accordance with paragraph (2) for health services by the Corps personnel to be assigned; 10 "(B) the entity shall take such action as may be 11 reasonable for the collection of payments for such health 12 services, includiiig if a Federal agency, an agency of a 13 State or local government, or other third party would be 14 responsible for all or part of the cost of such health services if it had not been piovided J)V Corps I)(~I'S0nnel 16 under this section, the collection, on a fee-for-service or 17 other basis, from such agency or third party the portion 18 of such cost for which it would be so responsible (and 19 in determining the amount of such cost which such 20 agency or third part would be responsible, the health 21 services provided by Corps personiiel shall be considered 22 as being provided by private Practitioners) ; and 23 "(C) the entity shall pay to the lnited States the 24 lesser of- 95 " (i) the amount collected by the entity in PAGENO="0126" 116 23 1 accordance with subparagraph (B) in each calendar 2 quarter (or other period as may be specified in the agreement), or 4 "(ii) the sum of (I) the pay (including the 5 amounts paid in accordance with subsection (f) 6 and allowances for the Corps personnel for. such 7 quarter (or other period), and (II) an amount 8 which bears the same ratio to the amount of any grant made to the entity under subsection (d) (3) 10 as the number of days in such quarter (or other 11 period) bears to the number of days in the assign- 12 ment period for such personnel. 13 Any amount of the amount collected by an entity in accord- 14 ance with subparagraph (B) which the entity is entitled to 15 retain under subparagraph (C) shall be used by the entity 16 to expand or improve the provision of health services to 17 the population for which the entity submitted an application 18 under subsection (c) or to recruit and retain health man- 19 power to provide health services for such population. Funds 20 received by the Secretary under such an arrangement shall 21 be deposited in the Treasury as miscellaneous receipts and 22 shall be disregarded in determining the amounts of appro- 23 priations to be requested under subsection (i), and the 24 amounts to be made available from appropriations made 2.5 under such subsection to carry out this section. PAGENO="0127" 117 24 1 " (~) ~ ~ \vlio receives health services provided 2 by Corps personnel under this section shall lie charged for 3 such services on a fee-for-service or other basis at a rate 4 approved by tile Secretary, pursuant to regulations, to re- 5 cover the value of such services; except that if such person 6 is determined under regulations of the Secretary to be 7 unable to pay such charge, the Secretary shall provide for 8 the furnishing of such services at a reduced rate or without 9 charge. 10 "(1) (1) The Secretary shall cotiduct at medical and ii nursing schools aiid other schools of the health professions 12 and training centers for the allied health professioiis, recruit- 13 ing programs for the Corps. Such programs shall include the 14 wide dissemination of written information on the Corps and 15 visits to such schools by personnel of the Corps. 16 "(2) The Secretary may reimburse applicants for posi- 17 tions 111 tile Corps for actual expenses incurred in traveling 18 to and from their place of residence to an area in which 19 they would lie assigned for the purpose of evaluating such 20 area with regard to being assigned in such area. The Secre- 21 tary shall not reimburse an applicant for more than one 22 such trip. 23 "(3) Commissioned officers and other personnel of the 24 Corps assigned to provide health services for medically 25 underserved populations shall not be included in determin- 38-693 0 - 74 - 9 (Pt. 1) PAGENO="0128" 118 25 1 ing whether any limitation on the number of personnel 2 which may be employed by the Departnient of Health, 3 Education, and Welfare has been exceeded. 4 "(4) The Secretary shall, under regulations prescribed 5 by him, adjust the monthly rate of pay of each physician 6 and dentist member of the Corps who is directly engaged in 7 the delivery of health services to a medically underserved 8 population as follows: 9 "(A) During the first thirty-six months in which 10 such a member is so engaged in the delivery of health 11 services, li~s monthly rate of pay shall be increased by 12 an amount. (not to exceed $1,000) which when added 13 to the niember's regular monthly rate of pay and allow- 14 ances will provide a monthly income competitive with 15 the average monthly income from an established practice 16 of a member of such member's profession with equiva- 17 lent training. 18 "(B) During the period beginning upon the expi- 19 ration of the thirty-six months referred to in suhpara- 20 graph (A) and ending with the month in which the 21 men1ber's regular monthly rate of pay and allowances is 22 equal to or exceeds the monthly income he received for 23 the last of such thirty-six months, the member shall re- 24 ceive in addition to his regular rate of pay and allow- 25 ances an amount which when added to such regular rate PAGENO="0129" 119 26 i equals the moiithly income he received for such last 2 month. 3 In the case of a member of the Corps who is directly 4 engaged in the provision of hcaith services to a medically 5 underserved population in accordance with a service obh- 6 gation incurred under section 225, the provisions of this 7 paragraph shall apply to such member upon satisfactory 8 completion of such service obligation and the first thirty-six ~ months of his being so engaged in the delivery of health 10 care shall, for purposes of this paragraph, be deemed to ~ begin upon such satisfactory completion. 12 "(g) The Secretary shall report to Congress no later 13 than May 15 of each year- 14 "(1) the number and identity of all medically 15 underserved populations in each of the States in the 16 calendar year preceding the year in which the report 17 is made and the number of medically underserved popu~ 18 lations which the Secretary estimates will be designated 19 under subsection (b) in the calendar year in which the 20 report is made; 21 "(2) the number of applications filed in such pre- 22 ceding calendar year for assignment of Corps personnel 23 under this section and the action taken on each such 24 application; 25 "(3) the number and types of Corps personnel PAGENO="0130" 120 27 1 assigned in such preceding year to provide health serv- 2 ices for medically underserved populations, the number 3 and types of additional Corps personnel which the Secre- 4 tary estimates will be assigned to provide such services 5 in the calendar year in which the report is submitted, 6 and the need (if any) for additional personnel for the 7 Corps; "(4) the recruitment efforts engaged in for the Corps in such preceding year, including the programs 10 carrie.d out under subsection (f) (1) and the number of qualified persons who applied for service in the Corps 12 in each professional category; 13 "(5) the total number of patients seen and patient 14 visi.ts recorded during such preceding year in each area 15 where Corps personnel were assigned; 16 "((3) the number of health personnel electing to 17 remain after termination of their service in the Corps to 18 provide health services to medically underserved popula- 19 tions and the number of such personnel who do not make 20 such election and the reasons for their departure; 21 "(7) the results of evaluations made under sub- 22 section (e) (2) (B) (ii), and determinations made under 23 subsection (c) (2) (B) (iii), during such preceding 24 year; and PAGENO="0131" 121 28 1 "(8) the amount (A) charged during such pre- 2 ceding year for health services by Corps personnel, (B) collected in such year by entities in accordance with 4 arrangements under subsection (e) (1), and (C) paid 5 to the Secretary in such year under such arrangements. 6 "(h) (1) There is established a council to be known as 7 the National Advisory Council on the National Health 8 Service Corps (hereinafter in this section referred to as the 9 `Council'). The Council shall be composed of fifteen members 10 appointed by the Secretary as follows: ii "(A) Four members shall be appointed from the 12 general public to represent the consumers of health care, 13 at least two of whom shall be members of a medically 14 underserved population for which Corps peTsonnel are 15 providing health services under this section. 16 "(B) Three members shall be appointed from the 17 medical, dental, and other health professions and health 18 teaching professions. 19 "(C) Three members shall be appointed from State 20 health or health planning agencies. 21 "(D) Three members shall be appointed from the 22 Service, at least two of whom shall be members of the 23 Corps directly engaged in the provision of health serv- 24 ices for a medically underserved population. 25 "(E) One member shall be appointed from the PAGENO="0132" 122 29 1 National Advisory Council on Comprehensive Health 2 Planning. 3 "(F) One member shall be appointed from the 4 National Advisory Council on Regional Medical Pro- S grams. 6 The Council shall consult with, advise, and make recom- 7 mendations to, the Secretary with respect to his responsi- S bilities in carrying out this section, and shall review and 9 approve regulations promulgated by the Secretary under 10 this section and section 225. ii "(2) Members of the Council shall be appointed for a 12 term of three years and shall not be removed, except for 13 cause. Members may be reappointed to the Council. 14 "(3) Appointed members of the Council, while attend- 13 ing meetings or conferences thereof or otherwise serving 16 on the business of the Council, shall be entitled to receive 17 for each day (including traveltime) in which they are so is serving the daily equivalent of the annual rate of basic pay 19 in effect for grade GS-18 of the General Schedule, and 20 while so serving away from their homes or regular `places of 21 bu~iness they may be allowed travel expenses, including per 22 diem in lieu of subsistence, as authorized ~by section 5703 (b) 23 of title 5 of the United States Code for persons in the Gov- 24 ernment service employed intermittently. 23 "(i) (1) To carry out the purposes of this section, there PAGENO="0133" 123 `,~ 1 are authorized to be appropriated. ~$25,000,000 for the fiscal 2 year ending June 30, 1974; $30,000,000 for the fiscal year 3 ending June 30, 1975; $35,000,000 for the fiscal year end- 4 ing June 30, 1976; and $40,000,000 for the fiscal year end- 5 ingJune30,1977. 6 "(2) An appropriation Act which appropriates funds 7 under paragraph (1) of this subsection for the fiscal year 8 ending June 30, 1975, may also appropriate for the next ~ fiscal year the funds that are authorized to be appropriated io under such paragraph for such next fiscal year; but no funds ii may be made available therefrom for obligation under this 12 section before the fiscal year for which such funds are author- 13 ized to be appropriated.". 14 (b) (1) The Secretary of Health, Education, andWel- 15 fare shall report to Congress (1) not later than September 16 1, 1974, the criteria used by him in designating medically 17 underserved populations for purposes of section 329 of the 18 Public Health Service Act, and (2) not later than January 19 1, 1975, the identity and number of medically underserved 20 populations in each State meeting such criteria. 21 (2) The Secretary of Health, Education, and Welfare 22 shall conduct or contract for studies of methods of assigning 23 under section 329 of the Public Health Service Act National 24 Health Service Corps personnel to medically underserved 25 populations and of providing health care to such populations. PAGENO="0134" 124 31 i Such studies shall be for the purpose of identifying (A) the 2 characteristics of health manpower who are more likely to 3 remain in practice in areas in which medically underserved 4 populations are located, (B) the characteristics of areas 5 which have been able to retain health manpower, (C) the 6 appropriate conditions for assignment of independent nurse 7 practitioners and physician's assistants in areas in which S medically underserved populations are located, and (D) the 9 effect that primary care residency training in such areas has 10 on the health care provided in such areas and on the de- ii cisions of physicians who received such training respecting 12 the~ areas in which to locate their practice. 13 (c) (1) The amendment made by subsection (a) which 14 ch~inged the name of the advisory council established under 15 section 329 of the Public Health Service Act shall not be 16 construed n.s requiring the establishment of a new advisory 17 council under that section; and the amendment made by 18 such subsection with respect to the composition of such 19 sdvisory council shall apply with respect to appointments 20 macic to the advisory council after the date of the enactment 21 of this Act. 22 (2) Section 741 (f) (1) (C) is amended by inserting 23 `in which is located a medically underserved population" 24 after ~`in a State". 25 SEC. 304. Section 225 is amended to read as follows: PAGENO="0135" 125 32 1 "PUBLIC HEALTH AND NATIONAL HEALTH SERVICE 2 CORPS SCHOLARSHIP TRAINING PROGRAM 3 "S~c. 225. (a) The Secretary shall establish the Public 4 Health and National Health Service Corps Scholarship 5 Training Program (hereinafter in this section referred to as 6 the `prograiii') to obtain trained physicians, dentists, nurses, 7 or other health-related specialists for the National Health 8 Service Corps or other units of the Service. 9 "(b) To be eligible for acceptance iii the program, an 10 applicant for the program must- ii "(1) be accepted for enrollment, or be enrolled, as 12 a full-time student in an accredited (as determined by 13 the Secretary) educational institution in a State which 14 provides a course of study approved by the Secretary 15 leading to a degree in medicine, dentistry, nursing, or- 16 other health-related specialty as determined by the 17 Secretary; is "(2) be eligible for, or hold, an appointment as a 19 comniissioned officer in the Regular or Reserve Corps 20 of the Service or be eligible for selection for civilian 21 service in the Service; and 22 "(3) agree in writing to serve, as prescribed by 23 subsection (d) of this section, in the Commissioned 24 Corps of the Service or as a civilian member of the 25 Service. PAGENO="0136" 126 33 1 To remain in the program an individual must pursue at such 2 an institution such an approved course of study and main- 3 tam an acceptable level of academic standing in it. 4 "(c) (1) (A) Each participant in the program shall 5 receive a scholarship for each approved academic year of 6 training, not to exceed four years. A participant's scholar- 7 ship shall consist of (i) an amount equal to the basic pay 8 and allowances of a commissioned officer on active duty in 9 pay grade 0-1 with less than two years of service, and (ii) 10 payment of the tuition expenses of the participant and all ii other educational expenses incurred by the participant, 12 including fees, books, and laboratory expenses. 13 "(B) The Secretary may contract with an institution 14 in which participants are enrolled for the payment to the 15 institution of the tuition and other educational expenses of 16 such participants. Payment to such institution may be made 17 without regard to section 3648 of the Revised Statutes (31 18 U.S.C.529). 19 "(2) When the Secretary determines that an institu- 20 tion has increased its total enrollment for the sole purpose 21 of accepting members of the program, he may provide under 22 a contract with such an institution for additional payments 23 to cover the portion of the increased costs of the additional 24 enrollment which are not covered by the institution's normal 25 tuition and fees. PAGENO="0137" 127 84 1 "(d) (1) Each participant in the program shall pro- 2 vide service as prescribed by paragraph (2) for a period of 3 time (hereinafter in this section referred to as a `period of 4 obligated service') prescribed by the Secretary which may ~ not be, less than one year of such service for each academic 6 year of training received under the program. For persons 7 receiviog a degree from a school of medicine, osteopathy, 8 or dentistry, the commencement of a period of obligated 9 service may be deferred by the Secretary for the period 10 of time required to complete internship and residency train- 11 ing ii the National Health Service Corps approves such 12 deferment. For persons receiving degrees in other health 13 professions the obligated service period shall commence 14 upon completion of their academic training. Periods of 15 internship or residency shall not be creditable in satisfy- 16 ing a service obligation under this subsection. H 17 "(2) (A) Except as provided in subparagraphs (B) 18 and (C), an individual obligated to provide service on ac- 19 count of his participation in the program shall provide such 20 service for the period of obligated service applical5le to him 21 as a member of the National Health Service Corps or the 22 Indian Health Service. 23 "(B) If there are no positions available in the National 24 Health Service Corps or the Indian Health Service at the 25 time an individual is required by the Secretary. to begin his PAGENO="0138" 128 35 1 period of obligated service, such individual shall serve in the 2 clinical practice of his profession for such period as a mem- 3 her of the Federal Health Programs Service. 4 "(C) If there are no positions available in the Na- 5 tional Health Service Corps, Indian Health Service, or the 6 Federal Health Programs Service at the time an mdi- 7 vidual is required by the Secretary to begin his period of 8 obligated service or the Corps and neither Service has a 9 need at such time for a member of the profession for 10 which such individual was trained, such individual shall 11 serve for such period as a member of the Public HeaJth Serv- 12 ice in such units of the Department as the Secretary may 13 prescribe. 14 "(e) (1) Ii, for any reason, a person fails to either 15 begin his service o4iligation under this section in accordance 16 with subsection (d) or to complete such service obligation, 17 the United States shall be entitled to recover from such 18 individual an amount determined in accordance with the 19 formula 20 A=24(~-~) 21 in which `A' is the amount the United States is entitled to 22 recover; `°`. is the sum of the amount paid under this section 23 to or on behalf of such person and the interest on such 24 amount which would be payable if at the ~me it was paid 25 it was a loan bearing interest at the maximum legal `prevail- PAGENO="0139" 129 36 I ing rate; `t' is the total number of months in such person's 2 service obligation; and `s' is the number of months of such 3 obligation served by him ui accordance with subsection (d). 4 Any amount which the United States is entitled to recover 5 under this paragraph shall, within the three-year period 6 beginning on the date the United States becomes entitled 7 to recover such amount, be paid to the United States. 8 "(2) When a person undergoing training in the pro- 9 gram is academically dismissed or voluntarily terminates 10 academic training, he shall be liable for repayment to the 11 Government for an amount equal to the scholarship which 12 he received under the program. 13 "(3) The Secretary shall by regulation provide for the 14 waiver or suspension of a.ny obligation under paragraph (1) 15 or (2) applicable to any individual whenever compliance 16 by such individual is impossible or would involve extreme 17 hardship to such individual and if enforcement of such 18 o~bligation with respect to any individual would be against 19 equity and good conscience. - 20 "(g) Notwithstanding any other provision of law, per- 21 sons undergoing academic training under the program shall 22 not be counted against any employment ceiling affecting the 23 Department. of Health, Education, and Welfare. 24 "(h) The Secretary shall issue regulations for the im- 25 plenientation of this section. PAGENO="0140" 130 37 1 "(i) To carry out the program, there is authorized to 2 be appropriated $3,000,000 for the fiscal year ending June 3 30, 1974, 820,000,000 for the fiscal year ending June 30, 4 1975, $25,000,000 for the fiscal year ending June 30, 1976, 5 a.nd $30,000,000 for the fiscal year ending June 30, 1977.". 6 TITLE TV-GRANTS FOR HEALTH 7 PROFESSIONS SCHOOLS 8 SEc. 401. (a) Subsection (a) of section 770 is amended 9 to read as follows: 10 "(a) GRANT Coi~fPuTATIoN.-The Secretary shall 11 make annual grants to schools of medicine, osteopathy, pub- 12 lie health, dentistry, veterinary medicine, optometry, phar- 13 macy, and podiatry for the support of the education pro- 14 grams of such schools. The amount of the annual grant to- 15 each such school with an approved application shall be corn- 16 puted for each fiscal year as follows: 17 "(1) Each school of medicine shall receive- 18 "(A) $3,250 for each full-time student enrolled 19 h~ such school in such year; and 20 "(B) $1,000 for each student who is enroll~d. 21 in such year on a full-time basis in a program of 22 such school for the training of physician extenders 23 (as defined by regulations of the Secretary). 24 "(2) Each school of dentistry shall receive- PAGENO="0141" 131 1 "(A) $2,475 for each full-tiine~ student enrolled 2 in such school in such year; and 3 "(B) $1,000 for each student who is enrolled 4 in such year on a full-time basis in a program of such school for the training of expanded duty dental 6 auxiliaries (as defined by regulations of the Sec- 7 retary). 8 " (3) Each school of osteopathy shall receive- 9 "(A) $2,350 for each full-time student en- 10 rolled in such school in such year; and 11 "(B) $1,000 for each student who is enrolled 12 in such year on a full-time basis in a program of 13 such school for the training of physician extenders. 14 "(4) Each school of public health shall receive 15 $2,000 for each full-time student enrolled in such school 16 in such year. 17 "(5) Each school of veterinary medicine shall 18 receive $1,850 for each full-time student enrolled in 19 such school in such year. "(6) Each school of optometry shall receive $1,050 21 for each full-time student enrolled in such school in such year. 23 "(7) Each school of pharmacy (other than a 24 school of pharmacy with a course of study of more than four years) shall receive $1,025 for each full-time PAGENO="0142" 132 39 1 student enrolled in such school in such year. Each school 2 of pharmacy with a course of study of more than four 3 years shall receive $1,025 for each full-time student 4 enrolled in the last four years of such school. For puT- 5 poses of section 771, a student enrolled in the first year 6 of the last four years of such school shall be considered 7 a first-year student. 8 "(8) Each school of podiatry shall receive $1,650 9 for each full-time student enrolled in such school in such 10 year.". ii (b) Subsection (c) of section 770 is amended to read 12 as follows: 13 "(c) APPORTIONMENT OF APPBOPRIATIONS.-If the 14 total of the grants to be made in accordance with subsections 15 (a) and (b) for any fiscal year to schools of medicine, oste- 16 opathy, public health, dentistry, veterinary medicine, optom- 17 etry, pharmacy, or podiatry with approved applications 18 exceeds the amounts appropriated under subsection (f) for 19 such grants, the amount of the grant for that fiscal year to 20 a school which may not because of such excess receive for 21 that fiscal year the amount determined for it under such 22 subsections shall be an amount which bears the same ratio 23 to the amount. so determined for it as the total of the amounts 24 appropriated for that year under subsection (f) for grants to 25 such schools bears to the amount required to make grants in. PAGENO="0143" 133 40 1 accordance with subsections (a) and (b) to such schools.". 2 (c) (1) Subsections (d), (e), (f) , arid (g) of section ~ 770 are repealed. (2) Subsection (h) of section 770 is (A) redesignated as subsection (d), and (B) is amended to read as follows: 6 "(d) ENROLLMENT AND GRADUATION DETERMINA- 7 TIONS.- 8 "(1) For purposes of this section and sections 771 and 772, regulations of the Secretary shall include pro- visions relating to determining the nunTher of students enrolled in a school or in a particular year-class in a 12 school, or the number of graduates, on the basis of 13 estimates, on the basis of the number of students who 14 in an earlier year were enrolled in a school or in a 15 particula.r year-class or who were graduates, or on such 16 other basis as he deems appropriate for making such 17 determination, and shall include methods of making such 18 determination when a school or a year-class was not in 19 existence in an earlier year at a school. 20 "(2) For purposes of this section and sections 771 21 and 772, the term `full-time students' (whether such 22 term is used by itself or in connection with a particular 23 year-class) means students pursuing a. full-time course 24 of study leading to a degree of doctor of medicine, doctor of dentistry, or an equivalent degree, doctor of osteop- 38-698 0 - 74 - 10 (Pt. 1( PAGENO="0144" 134 41 1 athy, bachelor of science in pharmacy or an equivalent 2 degree, doctor of optometry or an equivalent degree, 3 doctor of veterinary medicine or an equivalent degree, 4 or doctor of podiatry or an equivalent degree or to a 5 graduate degree in public health or equivalent degree.". 6 (3) Subsection (i) of section 770 is (1) amended by 7 inserting ", public health" after "osteopathy", and (2) re- 8 designated as subsection (e). 9 (4) Subsection (j) of section 770 is redesignated as 10 subsection (f) and is amended to read as follows: 11 "(f) AUnIoRIZATI0Ns OF APPR0PifiATI0Ns.- 12 "(1) There are authorized to be appropriated 13 $176,000,000 for the fiscal year ending June30, 1975, 14 $182,000,000 for the fiscal year ending June 30, 1978, 15 and $188,000,000 for the fiscal year ending June 30, 16 1977 for payments under grants under this section to 17 schools of medicine based on the number of full-time 18 students enrolled in such schools. 19 "(2) There are authorized to be appropriated 20 $7,559,000 for the fiscal year ending June 30, 1975, 21 $8,531,000 for the fiscal year ending June 30, 1976, 22 and $9,483,000 for the fiscal year ending June 30, 23 1977, for payments under grants under this section to 24 schools of osteopathy based on the number of full-time 25 students enrolled in such s~bools. PAGENO="0145" 135 42 1 "(3) There are authorized to be appropriated 2 $2,000,000 for the fiscal year ending June 30, 1975, 3 $3,000,000 for the fiscal year ending June 30, 1976, 4 and $4,000,000 for the fiscal year ending June 30, 1977, 5 for payments under grants under this section to schools 6 of medicine and osteopathy based on the number of 7 students enrolled in programs of such schools for the 8 training of physician extenders. 9 "(4) (A) There are authorized to be appropriated 10 $2,000,000 for the fiscal year ending June 30, 1975, 11 $3,000,000 for the fiscal year ending June 30, 1976, 12 and $4,000,000 for the fiscal year ending June 30, 1977, 13 for payments under grants under this section to schools 14 of dentistry based on the number of students enrolled 15 in programs of such schools for the training of expanded 16 duty dental auxiliaries. 17 "(B) There are authorized to be appropriated 18 $49,500,000 for the fiscal year ending June 30, 1975, 19 $50,800,000 for the fiscal year ending June 30, 1976, 20 and $52,000,000 for the fiscal year ending June 30, 1977, 21 for payments under grants under this section to schools 22 of dentistry based on the number of full-time students 23 enrolled in such school. 24 "(5) There are authorized to be appropriated 25 $11,000,000 for the fiscal year ending June 30, 1975, PAGENO="0146" 136 43 1 $12,000,000 for the fiscal year ending June 30, 1976, 2 and $13,000,000 for the fiscal year ending June 30, 3 1977, for payments under grants under this section to 4 schools of public health. 5 "(6) There are authorized to be appropriated 6 $11,729,000 for the fiscal year ending June 30, 1975, 7 $12,395,000 for the fiscal year ending June 30, 1976, 8 and $12,950,000 for the fiscal year ending June 30, 9 1977, for payments under grants under this section to 10 schools of veterinary medicine. 11 "(7) There are authorized to be appropriated 12 $3,832,500 for t~e fiscal year ending June 30, 1975, 13 $3,958,500 for the fiscal year ending June 30, 1976, 14 and $4,207,850 for the fiscal year ending June 30, 15 1977, for payments under grants under this section to 16 schools of optometry. 17 "(8) There are authorized to be appropriated $25,- 18 625,000 for the fiscal year ending June 30, 1975, 19 $25,625,000 for the fiscal year ending June 30, 1976, 20 and $25,625,000 for the fi~ca.l year ending June 30, 21 1977 for payments under grants under this section to 22 schools of pharmacy. 23 "(9) There are authorized to be appropriated $3,- 24 027,750 for the fiscal year ending June 30, 1975, $3,- 2~ 316,500 for the fiscal year ending June 30, 1976, and PAGENO="0147" 137 44 1 $3,481,500 for the fiscal year ending June 30, 1977 2 for payments under grants under this section to schools 3 of podiatry. 4 "(10) No funds appropriated under any provision 5 of this Act (other than this subsection) may be used to 6 make grants under this section." 7 (d) The heading for part E of title VII is a.mended 8 to read as follows: 9 "PART E-GRANTS AND CONTRACTS To IMPROVE TIJE 10 QUALITY OF ScHooLs OF MEDICINE, OSTEOPAThY, PUBLIC HEALTH, DENTISTRY, VETERINARY MED- 12 ICINE, OPTOMETRY, PHARMACY, AND PODIATRY". 13 SEc. 402. Part E of title VII is amended (1) by re- 14 designating sections 771, 772, and 773 as sections 772, 773, 15 and 774, respectively, (2) by redesignating section 774 (as 16 in effect before the date of the enactment of this Act) as 17 section 776 and placing it after section 775, and (3) by 18 adding after section 770 the following new section: 19 "ELIGIBILITY FOR CAPITATION GRANTS 20 "SEc. 771. (a) IN GENERAL.-The Secretary shall 21 not make a grant under section 770 to a.ny school in a fiscal 22 year beginning after June 30, 1974, unless the application 23 for such grant contains or is supported by reasonable assur- 24 ances satisfactory to the Secretary that- PAGENO="0148" 138 45 1 "(1) the enrollment of full-time students in such 2 school and- 3 "(A) in the case of a school of medicine or 4 osteopathy, the enrollment of students on a full-time 5 basis in a program of such school for the training 6 of physician extenders, and 7 "(B) in the case of a school of dentistry, the 8 enrollment of students on a full-time basis in a pro- 9 gram of such school for the training of expanded duty 10 dental auxiliaries, in the school year beginning after the beginning of the 12 fiscal year in which such grant is made will not be less 13 than the enrollment of such students in such school in 14 the preceding school year; and 15 "(2) the applicant will expend in carrying out 16 its functions as a school of medicine, osteopathy, 17 public health, dentistry, veterinary medicine, optometry, 18 pharmacy, or podiatry, as the case may be, during 19 the fiscal year for which such grant is sought, an amount 20 of funds (other than funds for construction as deter- 21 mined by the Secretary) from non-Federal sources 22 which is at least as great as the average amount of 23 funds expended by such applicant for such purpose 24 (excluding expenditures of a nonrecurring nature) in PAGENO="0149" 139 46 1 the three years immediately preceding the fiscal year 2 for which such grant is sought. 3 "(b) SCHOOLS OF MEDICINE AND OSTEOPATHL-The 4 Secretary shall not make a grant under section 770 to any 5 school of medicine or osteopathy in a fiscal year beginning 6 after Jane 30, 1974, unless the application for such grant 7 contains or is supported by reasonable assurances satisfactory 8 to the Secretary that- 9 "(1) for the first school year beginning after the 10 close of the fiscal year in which such grant is made and for each school year thereafter during which such a 12 grant is made the first-year enrollment of full-time stu- 13 dents in such school will exceed the number of such 14 students enrolled in the school year beginning during the 15 fiscal year ending June 30, 1974- 16 "(A) by 10 per centum of such number if such 17 number was not more than one hundred, or 18 "(B) by 5 per centum of such number, or ten 19 students, whichever is greater, if such number was 20 more than one hundred; 21 "(2) for the first school year beginning after the 22 close of the fiscal year in which such grant is made 23 and in each school year thereafter in which such grant 24 is made the number of students enrolled on a full-time 25 basis in a program of such school for the training of PAGENO="0150" 140 47 1 physician extendeFs will not be less than twenty-five and 2 for the second school year beginning after the close of 3 the fiscal year in which such a grant is first made 4 the number of students enrolled on a full-time basis 5 in a program of such school for the training of physician 6 extenders will exceed the number of such students so en- 7 rolled in the preceding school year by 25 per centum; 8 "(3) in the case of a four-year school of medicine, 9 for the first school year beginning after the close of 10 the fiscal year in which such grant is made and for each 11 school year thereafter during which such a grant is 12 made, at least 10 per centum of the third and fourth 13 year classes will be comprised of full-time students who 14 are [nited States citizens who previously attended 15 medical schools in foreign countries; or 16 "(4) the school has submitted to the Secretary an 17 application for a grant or contract for such fiscal year for 18 a~ special project under section 773 (a) or (b) and the 19 Secretary has approved such application. 20 "(c) SCHOOLS OF DENTISTRY.-The Secretary shall not 21 make a grant under section 770 to any school of dentistry 22 in a fiscal year beginning after June 30, 1974, unless the 23 application for such grant contains or is supported by rea- 24 sonable assurances satisfactory to the Secretary that- 25 "(1) for the first school year beginning after the PAGENO="0151" 141 48 1 close of the fiscal year in which such grant is made and 2 for each school year thereafter during which such a grant 3 is made the first-year enrollment of full-time students 4 in such school will exceed the number of such students enrolled in the school year beginning during the fiscal 6 year ending June 30, 1974- 7 "(A) by 10 per centum of such number if such s number was not more than one hundred, or 9 "(B) by 5 per centum of such niunber, or ten 10 students, whichever is greater, if such number was more than one hundred; 12 . "(2) for the first school year beginning after the 13 close of the fiscal year in which such grant is made and 14 in each school year thereafter in which such a grant is 15 made the number of students enrolled on a full-time ba- 16 sis in a program of such school for the training of ex- 17 panded duty dental auxiliaries will be not less than 18 twenty-five and for the second school year beginning 19 after the close of the fiscal year in which such a grant 20 is first made the number of students `enrolled on a full- 21 time basis in a program of such school for the training of 22 expanded duty dental auxiliaries will exceed the num- 23 ber of such students so enrolled in the preceding school 24 year by 25 per centum; or 25 "(3) the school has submitted to the Secretary an PAGENO="0152" 142 49 1 application for a grant or contract for such fiscal year 2 for a special project under section 773 (a) or (c) and 3 the Secretary has approved such application. 4 "(d) SCHOOLS OF PTJBLIC HEALTH.-The Secretary ~ shall not make a grant under section 770 to any school of 6 public health in a fiscal year beginning after June 30, 1974, 7 unless the application for such grant contains or is supported s by reasonable assurances satisfactory to the Secretary that~- "(1) for the first school year beginning after the close of the fiscal year in which such grant is made au4 for each school year thereafter during which such a 12 grant is made the first-year enrollment of full-time stu- 13 dents in such school will exceed the number of such stu- 14 dents enrolled in the school year beginning during the 15 fiscal year ending June 30, 1974- 16 "(A) by 10 per centum of such number if such 17 number was not more than one hundred, or 18 "(B) by 5 per centum of such number, or ten 19 students, whichever is greater, if such number was 20 more than one hundred; or 21 "(2) the school has submitted to the Secretary an 22 application for a grant or contract for such fiscal year for 23 a special project under section 773 and the Secretary 24 has approved such application. PAGENO="0153" 143 5() 1 "(e) SCHOOLS OF VETERINARY MEDICINE, OPTo~IE- 2 TRY, PhARMACY, AND PODIATRY.-The Secretary shall not 3 make a grant under section 770 to any school of veterinary 4 medicine, optometry, pharmacy, or podiatry in a fiscal year 5 beginning after June 30, 1974, unless the application for :6 such grant contains or is supported by reasonable assurances 7 satisfactory to the Secretary that- 8 "(1) for the first school year beginning after the * close of the fiscal year in which such grant is made and 10 for each school year thereafter during which such a grant is made the first-year enrollment of full-time students 12 in such school will exceed the number of such students 13 enrolled in the school year beginning during the fiscal 14 year ending June 30, 1974- 15 "(A) by 10 per centum of such number if such 16 number was not more than one hundred, or 17 "(B) by 5 per centum of such number, or 18 ten students, whichever is greater, if such number 19 was more than one hundred; or 20 "(2) the school has submitted to the Secretary an 21 application for a grant or contract for such fiscal year 22 for a special project under an applicable provision of 23 section 773 and the Secretary has approved such ap- 24 plication.". PAGENO="0154" 144 1 SEC. 403. Section 773 (as so redesignated) is'amended 2 to read as follows: 3 "SPECIAL PROJECT GRANTS AND CO~RACTS 4 "SEC. 773. (a) (1) ALL SdHooLs.-For the purpose ~ of assisting individuals from disadvantaged backgrounds, as 6 determined in accordance with criteria prescribed by the 7 Secretary, to undertake education to enter a health pr~fes- 8 sion, the Secretary may make grants to and enter into con- 9 tracts with schools of medicine, osteopathy, public health, 10 dentistry, veterinary medicine, optometry, pharmacy, and 11 podiatry to assist in meeting the cost described in paragraph 12 (2). 13 "(2) A grant or contract under paragraph (1) may be 14 used by the school receiving such grant to meet the cost of- "(A) selecting individuals~ from disadvantaged 16 backgrounds, as so determined, for the education pro- i17 vided by the school, 18 "(B) facilitating the entry of those individuals 19 into the school, 20 "(C) providing counseling or other services de- 21 signed to assist those individuals to complete success- 22 fully their education at the school, 23 "(D) providing, for a period prior to the entry of PAGENO="0155" 145 52 1 those individuals into the regular course of education of 2 the school, preliminary education designed to assist them 3 to complete successfully such regular course of education 4 at the school, 5 "(E) paying such stipends (including allowances 6 for travel and for dependents) as the Secretary may 7 determine for those individuals for any period of edu- 8 cation at the school, and 9 "(F) administrative expenses of the school in 10 connection with the activities described in the pre- 11 ceding subparagraphs. 12 "(3) No grant may be made or contract entered into 13 under paragraph (1) to a school unless its application i4 for such grant or contract contains or is supported by as- 15 surances satisfactory to the Secretary that in the school year 16 beginning alter the close of the fiscal year for which such 17 grant is made or contract entered into, such school will enroll 18 in its first-year class a number of full-time students from 19 disadvantaged backgrounds, as determined in accordance 20 with criteria prescribed by the Secretary, which is at least 21 equal to the lesser of- 22 "(A) 5 per centum of the number of full-time 23 first-year students enrolled in the school in the pre- 24 ceding school year, or 25 "(B) ten. PAGENO="0156" 146 53~ 1 "(b) SCHOOLS OF MEDICINE AND OSTEOPATHY.- 2 "(1) (A) The Secretary may make grants to and 3 enter into contracts with schools of medicine and oste- 4 opathy to meet the costs of projects to- 5 "(i) plan, develop, and operate, 6 "(ii) significantly expand, or 7 "(iii) maintain existing, 8 programs to train, in medically underserved areas geo- 9 graphically remote from the main site of the teaching 10 facilities of such schools, full-time students and studei~ts 11 enrolled in programs of such schools for the training of 12 physician extenders. 13 "(B) The Secretary may make grants to and enter 14 into contracts with schools of medicine and osteopathy 15 to meet the costs of projects to- 16 "(i) plan, develop, and operate, 17 "(ii) significantly expand, or 18 "(iii) maintain existing, 19 programs to provide residency training in medically 20 underserved areas geographically remote from the main 21 site of the training facility of such schools in family me4i- 22 cine, general internal medicine, and general pediatrics. 23 The costs for which a grant or contract under this sub- 24 paragraph may be made may include costs of constru~e- 25 tion of new primary care facilities and costs of remodel- PAGENO="0157" 147 54 1 ing existing ambu'atory care facilities, physicians' offices, 2 and medical school facilities necessary for the adminis- 3 tration of the training program for which the grant or 4 contract is made. 5 "(C) No application of a school for a grant or 6 contract under subparagraph (A) or (B) may be 7 approved unless the application- S " (i) contains or is supported by reasonable 9 assurances satisfactory to the Secretary ihat the 10 - training program for which the grant or contract 11 is to be made will have at least twenty-five mdi- 12 viduals enrolled in it ~ri a full-time basis; 13 " (ii) contains or is supported by reasonable 14 assurances satisfactory to the Secretary that the 15 school has sufficient resources to insure that all 16 individuals receiving training under the program 17 to be assisteçl by such grant or contract will receive 18 (I) a majority of their training at the main site 19 of the training facilities of the school, and (II) at least four weeks (in the aggregate) Of training 21 under such program in a medically underserved area 22 geographically remote from such site; "(iii) contains a list of the medically under- served areas where the training under such pro- grain is to be conducted and provision for periodic PAGENO="0158" 148 33 i review by experts in medical or osteopathic edu- cation (as may be appropriate) of the desirability of providing sucii training in such areas 4 (iv ) (010 alas a specific program for the hiring. a~ mdii ei.s ,l the laciilty of the school, of 1)la(ti(i111~ 1)hV5idiiI11~ 1~) serVe ~ llistilictOl5 ill tile 7 Ira mu P iognl Ill ~ii Ii RilidO liv ut uierscrve(l iui(a s v ) contains a detailed descrii)tiOli (If the type 011(1 0111011111 (If t1'iiiIling to he given iii mcdi- it) caIlv uiiderser\ ed areas 011(1 ~F0Vl51W1 for periodic review 011(1 evaluation of such training: and 12 "(vi) contains a plan for frequent counseling and eon~u1tation between the faculty of the school ii at tile main site of its training facilities and the 13 instructors in the school's training program in medi- 16 (ally underserved areas. 17 ``(2) The Secretary iiiay imiake grants to and enter is into contracts with schools of medicine arid osteopathy to meet the costs of projects to estalihsli and operate new 20 programs at such schools for the training of phvsiciaii 21 extenders. No application of a school for a grant or con- 22 tract under this paragraph may be approved unless time 23 application contains or is supported by reasonable assur- 24 anees satisfactory to the secretary that time training pro- 25 gram for which the grant is to be made will have at PAGENO="0159" 149 56 1 least twenty-five students enrolled in it on a full- 2 time basis. 3 "(c) SCHOOLS OF DENTISTRY.- 4 "(1) (A) The Secretary may make grants to and 5 enter into contracts with schools of dentistry to meet the 6 costs of projects to- 7 "(i) plan, develop, and operate, or 8 "(ii) significantly expand, 9 programs to train, in medically underserved areas 10 geographically remote from the main site of the teach- 11 ing facilities of such schools, full-time students and 12 students enrolled in programs of such schools for the 13 training of expanded duty dental auxiliaries. 14 "(B) No application of a school for a grant or con- 15 tract under subparagraph (A) may he approved unless 16 the application- 17 "(i) contains or is supported by reasonable as- 18 surances satisfactory to the Secretary that the train- 19 ing program for which tile grant or contract is to be 20 made will have at least twenty-five students enrolled 21 in it on a full-time basis; 22 "(ii) contains or is supported by reasonable 23 assurances satisfactory to the Secretary that the 24 school has sufficient resources to insure that all 25 students receiving training under the program to 38-698 0 - 74 - 11 (Pt. 1( PAGENO="0160" 150 57 1 be assisted by such grant or contract will receive 2 (I) a majority of their training at the main site of 3 the training facilities of the school, and (II) at least 4 four weeks (in the aggregate) of training under the 5 program in medically underserved areas geographi- 6 cally remote from such site; 7 "(iii) contains a list of the medically under- 8 served areas where the training under such program 9 is to be conducted and provision for periodic review 10 by experts in dental education of the desirability 11 of providing training under the program in such 12 areas; 13 " (iv) contains a specific program for the hir- 14 ing. as ~nemhers of the faculty of the school, of prac- 15 ticing dentists to serve as instructors in the training 16 program in medically underserved areas; 17 "(v) contains a detailed description of the 18 type and amount of training to be given students in 19 medically underserved areas and provision for pen- 20 odie review and evaluation of such training; and 21 "(vi) contains a plan for frequent counseling 22 and consultation between the faculty of the school 23 at the main site of its training facilities and the 24 instructors in the school's training program in med- 25 ically underserved areas. PAGENO="0161" 151 58 1 "(2) The Secretary may make grants to and enter 2 into contracts with schools of dentistry to meet the costs 3 of projects to establish and operate new programs at 4 such schools for the training of expanded duty dental 5 auxiliaries. No application of a school for a grant or con- 6 tract under this paragraph nmv he approved unless the 7 application eontainis or is suppoil ed by reasoiiahle assur- 8 anees satisfactory to the Secreta rv that the trailling pro- 9 gram for which the grant or (Ofli met is to he made will 10 have at least twenty-five students enrolled iii it~ on a 11 full-time basis. 12 "(d) SCHOOLS OF OPToI~1Emv.-The Secretary may 13 make grants to and enter into contracts with schools of op- 14 tometry to meet the costs of projects to assist in- 15 "(1) the affiliation between optometric training 16 programs and medical, osteopathic, and other health 17 professions training programs and academic institutions, 18 or 19 "(2) establishing cooperative arrangements be- 20 tween optometric training programs and medical, osteo- 21 pathic, and other health professions training programs 22 and academic institutions. 23 "(e) SCHOOLS OF PHARMACY.- 24 "(1) The Secretary may make grants and enter PAGENO="0162" 152 59 i into contracts with schools of pharmacy to meet the costs 2 of projects to assist in- 3 "(A) the affiliation between clinical pharmacy 4 training programs and medical, osteopathic, and other health professions training programs and aca- 6 demic institutions, or 7 "(B) establishing cooperative arrangements be- tween clinical pharmacy training programs and mcd- ical. osteopathic, and other health professions train- 10 ing programs and academic institutions. "(2) The Secretary may make grants to and enter 12 into contracts with schools of pharmacy to meet the 13 costs of projects to establish, expand, or improve- 14 "(A) programs for the teaching of pharmacy 115 in hospitals, extended care facilities, and other 116 clinical settings, 17 "(B) clinical pharmacology training, and 18 "(C) programs to train pharmacists to assist 19 physicians and counsel patients on the appropriate 20 use and effects of and reactions `to drugs. 21 "(1) ScHOOLS OF PODIATRY.-The Secretary may 22 make grants to and enter into contracts with schools of 23 podiatry to meet the costs of projects to assist in- 24 "(1) the affiliation between podiatric training pro- PAGENO="0163" 153 60 1 grams and medical, osteopathic, and other health pro- 2 fessions training programs and academic institutions, or 3 "(2) establishing cooperative arrangements be- 4 tween podiatric training programs and medical, osteo- 5 pathic, and other health professions training programs 6 and academic institutions. 7 "(g) SCHOOLS OF PUBLIC HEALTH.- 8 "(1) (A) The Secretary may make grants to and 9 enter into contracts with schools of public health to meet 10 the costs of projects to- 11 "(i) plan, develop, and operate, 12 "(ii) significantly expand, or 13 "(iii) maintain existing, 14 programs to train full-time students in State, county, 15 and local health departments, in migrant and Indian 16 health programs, and in hospitals and other health facil- 17 ities which are in medically underserved areas geograph- 18 ically remote from the main site of the teaching facili- 19 ties of such schools. 20 "(B) No appilcation of a school for a grant or con- 21 tract under subparagraph (A) may be approved unless 22 the application- 23 "(i) contains or is supported by reasonable 24 assurances satisfactory to the Secretary that at least 25 25 per centum of the fall-time students of such PAGENO="0164" 154 (~1 1 school will be enrolled in the training program for 2 which the grant or contract is to be made; 3 "(ii) contains or is supported by reasonable 4 assurances satisfactory to the Secretary that the 5 school has sufficient resources to insure that all 6 students receiving training under the program to be 7 assisted by such grant or contract will receive (I) 8 a majority of their training at the main site of the 9 training facilities of the school, and (II) at least 10 four weeks (in the aggregate) of training under ii such program in a health department, facility, or 12 program referred to in subparagraph (A) 13 "(iii) contains a list of the health departments, 14 facilities, or programs in which the training under 15 such program is to be conducted and provision for 16 periodic review by experts in public health educa- 17 tion of the desirability of providing such training in 18 such health departments, facilities, or programs; 19 "(iv) contains a specific program for the hir- 20 ing, as members of the faculty of the school, of pub- 21 lie health practitioners to serve in such health de- 22 partments, facilities, and programs as instructors in 23 the training of students; 24 "(v) contains a detailed description of the type 25 and amount of training to be given students and PAGENO="0165" 155 1 provision for periodic review and evaluation of suen 2 training; and 3 "(vi) contains a plan for frequent counaeling 4 and consultation between the faculty of the school 5 at the main site of its training facilities and the in- 6 structors in the school's training program in a health 7 department, facility, or program referred to in sub- 8 paragraph (A). 9 "(h) MEDICALLY TTNDERSFJRVED AREA.-For pur- 10 poses of this section, the term `medically underserved area' 11 means an urban or rural area designated by the Secretary as 12 having a shortage of personal health services. 13 (i) GENEBAL PHovIsIoNs.-The amount of any grant 14 or contract under this section shall be determined by the See- 15 retary. Payments under such grants or contracts may be 16 made in advance or by way of reimbursement, at such in- 17 tervals and on such conditions, as the Secretary finds neces- 18 sary. If the Secretary does not approve an application sub- 19 mitted under this section, he shall advise the applicant of the 20 reasons for disapproval of the application and provide the 21 applicant such technical and other imonfinancial assistance 22 as may be appropriate to enable the applicant to submit an 23 approvable application. Contracts may he entered into under 24 this section without regard to sections 3648 and 3709 of the 25 Revised Statutes (31 U.S.C. 529; 41 U.S.C. 5). PAGENO="0166" 156 1 "(j) AUTHORIZATIONS OF APPROPRIATIONS.- 2 "(1) (A) There are authorized to be appropriated 3 $25,000,000 for the fiscal year ending June 30, 1975, 4 825,000,000 for the fiscal year ending June 30, 1976, .5 and $25,000,000 for the fiscal year ending June 30, 6 1977, for payments under grants and contracts under 7 subsection (a). 8 "(B) Of the sums appropriated under subpara- 9 graph (A) for any fiscal year, 37 per centum of such 10 slims shall be made available for grants and contracts 11 under subsection (a) to schools of medicine, 3 per cen- 12 tum of such sums shall he made available for such 13 grants and contracts to schools of osteopathy, 18 per 14 centum &f such sums shall be made available for such 15 grants and contracts to schools of dentistry, 6 per centum 16 of such sums shall be made available for such grants and 17 contracts to schools of public health, 4 per centum of 18 such sums shall be made available for such grants and 19 contracts to schools of optometry, 24 per centum of 20 such sums shall be made available for such grants and 21 contracts to schools of pharmacy, 2 per centuni of such 22 sums shall he made available for such grants and con- 23 tracts to schools of podiatry, and 6 per centum of such 24 sums shall be made available for such grants and con- 25 tracts to schools of veterinary medicine. PAGENO="0167" 157 64 1 "(2) There are authorized to be appropriated 2 $30,000,000 for the fiscal year ending June 30, 1975, 3 $100,000,000 for the fiscal year ending June 30, 1976, 4 and $150,000,000 for the fiscal year ending June 30, 5 1977, for payments under grants and contracts under 6 subsection (b) (1) (A). 7 "(3) There are authorized to be appropriated $15,- 8 000,000 for the fiscal year ending June 30, 1975, 9 $25,000,000 for the fiscal year ending June 30, 1976, 10 and $40,000,000 for the fiscal year ending June 30, 11 1977, for payments under grants and contracts under 12 subsection (b) (1) (B). 13 "(4) There are authorized to be appropriated 14 $10,000,000 for the fiscal year ending June 30, 1975, 15 $20,000,000 for the fiscal year ending June 30, 1976, 16 and $30,000,000 for the fiscal year ending June 30, 17 1977, for payments under grants and contracts under 18 subsection (b) (2). 19 "(5) There are authorized to be appropriated 20 $15,000,000 for the fiscal year ending June 30, 1975, 21 $30,000,000 for the fiscal year ending June 30, 1976, 22 and $45,000,000 for the fiscal year ending June 30, 23 1977, for payments under grants and contracts under 24 subsection (c) (1). 25 "(6) There are authorized to be appropriated PAGENO="0168" 158 1 $5,000,000 for the fiscal year ending June 30, 1975, 2 $10,000,000 for the fiscal year ending June 30, 1976, 3 and $15,000,000 for the fiscal year ending June 30, 4 1977, for pavment~s under grants and contracts under subsection (c) (2) 6 "(7) (A) There are authorized to be appropriated 7 $10,000,000 for the fiscal year ending June30, 1975, S $10,000,000 for the fiscal year ending June 30, 1976, 9 and $10,000,000 for the fiscal year ending June 30, 10 1977, for payments under grants and contracts under ii subsections (d) , (e) (1), and (f) 12 "(B) Of the sums appropriated under subparagraph 13 (A) for any fiscal year,. 15 per centum of such sums 14 shall be made available for grants and contracts under 15 subsection (d), 75 per ceritum of such sums shall be 16 made available for grants under subsection (e) (1), and 17 10 per centum of such sums shall be made available for 18 grants and contracts under subsection (1). 19 "(8) There are authorized to be app~opri~d 20 $5,000,000 for the fiscal year ending Jun~ 30, 1975, 21 $5,000,000 for the fiscal year eiiding June 30, 1976, 22 and $5,000,000 for the fiscal year ending June 30, 23 1977. for payments under grants and contracts under 24 subsection (e) (2). 25 "(9) There are authorized to be appropriated PAGENO="0169" 159 66 1 $2,000,000 for the fiscal year ending June 30, 1975, 2 $2,000,000 for the fiscal year ending June 30, 1976, and 3 $2,000,000 for the fiscal year ending June 30, 1977, for 4 payments under grants and contracts under subsection 5 (g)." 6 SEC. 404. (a) Section 772 (a) (1) (as so redesig- 7 nated) is amended by striking out "or dentistry" and insert- 8 ing in lieu thereof ", dentistry, or optometry". (Q) Section 772 (a) (6) (as so redesignated) is 10 amended to read as follows: ii "(6) There are authorized to be appropriated $11,- 12 000,000 for the fiscal year ending June 30, 1975, $11,- 13 000,000 for the fiscal year ending June 30, 1976, and 14 $11,000,000 for the fiscal year ending June 30, 1977, for 15 payments under grants under this subsection. Sums appro- 16 priated under this paragraph shall remain available until 17 expended." 18 (c) Section 772 (b) (2) (as so redesignated) is ~ amended (1) by striking out "1974" and inserting in lieu 20 thereof "1977", and (2) by striking out "1975" and insert- 21 ing in lieu thereof "1978". SEC. 405. (a) Subsection (a) of section 774 (as so re- 23 designated) is amended to read as follow: 24 "(a) There are authorized to be appropriated $ 15,000,- ~ 000 for the fiscal year ending June 30, 1974, $15,000,000 PAGENO="0170" 160 67 1 for the fiscal year ending June 30, 1975, $15,000,000 for 2 the fiscal year ending June 30, 1976, and $15,000,000 for 3 the fiscal year ending June 30, 1977 for payments under 4 grants under this section." 5 (b) Section 774 i~ amended by inserting "public 6 health," after "dentistry" in subsections (b) and (d) 7 SEC. 406. (a) Section 776 (as so redesignated) is 8 amended to read as follows: 9 "AREA HEALTH EDUCATION CENTERS 10 "SEC. 776. (a) For the purpose of improving the dis- 11 tribution, supply, quality, utilization, and efficiency of health 12 personnel and the health services delivery system, and en- 13 couraging the regionalizaition of edueational responsibilities, 14 the Secretary may make grants to pu'blic~ or nonprofit private 15 educational entities, and may enter into contracts with pub- 16 lie or private educational entities, for new projects- 17 "(1) to encourage the establishment or mainte- 18 nance of programs to alleviate shortages of health per- 19 sonnel in areas, which are designated by the Secretary 20 and which are either rural areas with sparse popula- 21 tions or urban areas with dense populations, through 22 training or retraining of health personnel in community 23 hospitals and other facilities located in such areas or to 24 otherwise improve the distribution of health personnel 25 by area or by specialty group; PAGENO="0171" 161 68 1 "(2) to provide training programs leading to more 2 efficient utilization of health personnel; 3 "(3) to initiate new types and patterns or improve 4 existing patterns of training, retraining, continuing edu- 5 cation, and advanced training of health personnel, in- 6 cluding practitioners of family medicine, general internal 7 medicine, and general pediatrics, teachers, administra- 8 tors, specialists, and paraprofessionals (particularly 9 physician extenders, expanded duty dental auxiliaries, 10 and nurse practitioI~ers) ; and ii "(4) to encourage new or more effective ap- 12 proaches to the organization and delivery of health 13 services, reflecting the needs of all disciplines, through 14 training individuals in the use of the team approach to is delivery of health services. 16 "(b) (1) No grant may be made or contract en- 17 tered into under this section unless an application therefor is has been submitted to, and approved by, the Secretary. S~ieh 19 application shall be in such form, sul)mitted in such manner, 20 and contain such information as the Secretary shall by regu- 21 lation prescribe. The Secretary shall not approve or disap- 22 prove any application for a grant or contract under this 23 section except after consultation with the National Advisory 24 Council on Health Professions Education (established by 25 section 702). PAGENO="0172" 162 69 1 `~ (2) The amount of any grant under this section shall 2 be determined by the Secretary. Payments under grants 3 under this section may be made in advance or by way of 4 reimbursement, and at such intervals and on such conditions, 5 as the Secretary finds necessary. 6 "(3) Contracts may be entered into under this section 7 without regard to sections 3648 and 3709 of the Revised 8 Statutes (31 U.S.C. 529; 41 U.S.C. 5). 9 "(c) There are authorized to be appropriated $30,000,- ~o 000 for the fisca' year ending June 30, 1975, $40,000,000 ii for the fiscal year ending June 30, 1976, and $50,000,000 12 for the fiscal year ending June 30, 1977, for payments 13 under grants and contracts under this section." 14 (b) For the fiscal year ending June 30, 1975, and for 15 each of the next three fiscal years there are authorized to be 16 appropriated such sums as may be necessary to continue 17 payments under contracts entered into under section 7'~4 18 of the Public Health Service Act (as in effect before the 19 date of the enactment of this Act) for area health educa~ 20 tion centers. Such payments may only be made from such 21 sums for the periods and the amounts specified in such 22 contracts. 23 SFXJ. 407. Section 775 is amended- 24 (1) by striking out "770, 771, 772, or 773" each PAGENO="0173" 163 70 1 place it occurs and inserting in lieu thereof "770, 772, 2 773, or 774".; 3 (2) by inserting ", public health" after "dentistry" 4 in subsection (b) 5 (3) by striking out "this part" in subsection (c) 6 and inserting in lieu thereof "section 770, 772, 773, 7 or 774"; 8 (4) by striking out "770, 771, or 773" in subsec- 9 tion (d) (1) and inserting in lieu thereof "770, 771, 10 772, 773, or774";and ii (5) by amending subsection (d) (3) to read as 12 follows: 13 "(3) provides for such fiscal control and account- 14 ing procedures and reports, including the use of such 15 standard procedures for the recording and reporting of 16 financial information as the Secret~iry may prescribe, 17 and access to the records of the applicant, as the Secre- 18 ` tary may require to assure proper disbursement of and 19 accounting for Federal funds paid to the applicant under the grant and to enable the Secretary to determine the 21 éosts to the applicant of its program for the education 22 or training of students." 23 SEc. 408. Sections 306 and 309 are repealed. 24 SEc. 409. On and after January 1, 1976, the Secretary 25 of Health, Education, and Welfare shall assess the prograni PAGENO="0174" 164 71 1 of grants tinder section 776 of the Public Health Service Act 2 to determine the effect of the projects funded under such 3 grants on the distribution of health manpower and on the 4 access to and quality of health care in the areas in which such 5 projects are located. Not later than January 1, 1977, the 6 Secretary shall submit to the Congress a report on the assess- 7 ment conducted under this section. 8 TITLE V-ASSISTANCE FOR SPECIALIZED 9 TRAINING 10 SEC. 501. (a) Section 767 (entitled "Grants for Train- 11 ing, Traineeships, and Fellowships in Family Medicine") 12 is transferred to part F of title VII and redesignated as 13 section 781. 14 (b) Section 781 (as so redesignated) is amended (1) 15 by striking out "and" after "1973,", and (2) by inserting 16 after "1974," the following: "$20,000,000 for the fiscal year 17 ending June 30, 1975, $30,000,000 for the fiscal year end- 18 ing June 30, 1976, and $40,000,000 for the fiscal year ei%~d- 19 ing June 30, 1977,". 20 SEC. 502. (a) Section 769A (entitled "Grants for 21 Computer Technology Health Care Demonstration Pro- 22 grams") is transferred to part F of title VII, inserted after 23 section 781, and redesignated section 782. 24 (b) Section 782 (as so redesignated) is amended (1) 25 by striking out "and" after "1973,", and (2) by inserting PAGENO="0175" 165 72 1 after "1974," the following: "$5,000,000 for the fiscal year 2 ending June 30, 1975, $7,500,000 for the fiscal year end- 3 ing June 30, 1976, and $10,000,000 for the fiscal year end- 4 ing June 30, 1977,". 5 SEC. 503. Part F of title VII is amended by adding after 6 section 782 the following new sect ion: 7 "EDUCATION OF RETURNING UNITED STATES STUDENTS 8 FROM FOREIGN MEDICAL SChOOLS 9 "SEC. 783. (a) The Secretary may make grants to 10 schools of medicine aiid osteopathy to- 11 " (1) plan, develop, and initially operate new pro- 12 grains, or 13 "(2) substantially expand existing programs, 14 to train United States citizens who have transferred from 15 medical schools in foreign countries and who have enrolled 16 in such schools as full-time students with advanced standing. 17 The costs for which a grant under this subsection may be 18 1made may include the costs of identifying deficiencies in time 19 foreign medical school educatiomi of such students, the devel- 20 opment of materials and methodology for correcting such de- 21 ficiencies, and specialized training designed to prepare such 22 students for successful completion of hicensure examinations. 23 A grant under this subsection may only be made for costs 24 of such progranis for one school year. No school may receive 2~ more thanthree grants under this subsection. 38-698 0 - 74 - 12 (Pt. 1) PAGENO="0176" 166 73 1 "(ii) Any school of medicine or osteopathy which 2 receives a grant under subsection (a) for the fiscal year 3 ending June 30, 1975, shall submit to the Secretary before 4 January 1, 1976, a report on tile deficiencies (if any) ~ identified by the school ui tile foreign medical school edti- 6 cation of the students trained by such school under the 7 program for which such grant was made. The Secretary 8 shall compile the reports submitted under the preceding 9 sentence, amid before July 1, 1976, submit to time Congress. 10 his aiialvsis anti evaluation of the information coiitaiiied in i~. such reports. 12 " (c) There are authorized to be appropriated 13 $5,000,000 for tile fiscal year ending Jumie 30, 1975, 14 $10,000,000 for tile fiscal year emiding June 30, 1976, 15 and 815,000,000 for the fiscal year ending June 30, 1977, 16 for payments under grants under subsection (a) ." 17 SEC. 504. (a) Section 776 is transferred to part F of 18 title VII, inserted after section 783, and red~ignated as 19 section 784. 20 (b) Subsection (e) of section 784 (as so redesignated) 21 is amended by inserting before the period at the end a comma 22 and the following: "$10,000,000 for the fiscal year ending 23 June 30, 1975, $12,500,000 for the fiscal year ending 24 June 30, 1976, and $15,000,000 for the fiscal year ending 25 June 30, 1977". PAGENO="0177" 167 74 1 SEC. 505. Part F of title VII is amended by adding 2 after section 784 the following new section: 3 "ADVANCEMENTS IN hEALTh EDUCATION 4 "SEC. 785. (a) The Secretary may make grants to 5 schools of medicine, osteopathy, public health, dentistry, vet- 6 erinary medicine, optometry, pharmacy, and podiatry to 7 meet the costs of projects (1) to research, develop, or 8 demonstrate advances in the various fields related to the 9 education provided by such schools, or (2) to plan experi- 10 mental teaching programs. 11 "(ii) There are authorized to be appropriated $10,~ 12 000,000 for the fiscal year ending June 30, 1975, $10,000,- 13 000 for the fiscal year eiiding June 30, 1976, and $10,000,- 14 000 for the fiscal year ending June 30, 1977, for payments 15 under grants under subsection (a) ." 16 SEC. 506. (a) Section 769B is transferred to `part F 17 of title VII, inserted after section 785, and redesignated 18 section 786. 19 (b) Section 786 (as so redesignated) is amciided (1) 20 by striking out "under sections 767, 769, and 769A" each 21 place it occurs and inserting in lieu thereof "under this part", 22 and (2) by striking out "under sections 767 and 769A" 23 in subsection (b) and inserting in lieu thereof "under this 24 part". PAGENO="0178" 168 75 1 SEc. 507. Section 768 (entitled "GRANTS FOR SUPPORT 2 OF POSTGRADUATE TRAINING PROGRAMS FOR PhYSICIANS 3 AND DENTISTS") and section 769 (entitled "GRANTS FOR 4 TRAINING, TRAINEESITIPS, AND FELLOWShIPS FOR hEALTH 5 PROFESSIONS TEACHING PERSONNEL") are repealed. 6 SEc. 508. The heading for part F of title VII is 7 amended to read as follows: 8 "PART F-ASSISTANCE FOR SPECIALIZED Ti~JNINo". 9 TITLE VT-PUBLIC AND ALLIED HEALTH 10 PERSONNEL 11 5~c. 601. (a) Part G of title VII is amended to read 12 as follows: 13 "PART G-TRAINING PROGRAMS FOR PUBLIC AND COM- 14 MIJNITY HEALTH PERSONNEL AND ALLIED HEALTH 15 PERSONNEL 16 "Subpart 1-Public and Community Health Personnel 17 "DEFINITION 18 "SEC. 787. For purposes of this subpart, the term ~pub- 19 lie and community health personnel' means individuals who 20 are engaged in- 21 "(1) the planning, development, ormanagement of 22 medical care, 23 "(2) research on medical care development and 24 analysis of health statistics and other data, PAGENO="0179" 169 76 1 "(3) the development aiid iinproveiiient of individ- 2 ual and community knowledge of health and the heatth 3 system, or 4 "(4) the development of a healthful environment 5 and control of environmental health hazards. 6 "PROJECT GRANTS AND CONTRACTS 7 "SEC. 788. (a) The Secretary may make grants and 8 enter into contracts to assist eligible entities in meeting the 9 costs of development, demonstration, study, or experimenta- 10 tion projects undertaken with respect to one or more of the 11 following: 12 "(1) Methods of providing graduate education for 13 public and community health personnel. 14 "(2) Methods of providing short~term and contin- 15 uing education for public and community health person- 16 nel. 17 "(3) Model curricula for the education of pub- 18 lie and community health personnel. 19 "(4) Curricula and methods for the education or 20 training of individuals who will plan, study, or manage 21 the various components of the medical care system. 22 "(5) The utili~ation of equivalency arid proficiency 23 examinations as a method for determining compliance 24 with licensure and certification requirements for public 25 and oommunity health personnel. PAGENO="0180" 170 "(t3) The accreditation of educational or training 2 programs for health planning. "(7) Programs which maximize, for economically or culturally deprived individuals, opportunities for Ca- reers and advancement in public and community health. "(8) Methods of providing persons trained in non- health d1~ciplines short-term training in public and s community health. "(b) (1) No grant may be made or contract entered 10 into under subsection (a) unless an application therefor has j~ been submitted. to, and approved by, the Secretary. Such 12 application shall be, in such form, submitted in such manner, 13 and contain such information1 as the Secretary shall by 14 regulation prescribe. The Secretary shall give special con- 15 sideration to applications for projects (or categories of proj- 16 ects) which are concerned with public and community 17 health personnel for which there is the greatest national need 18 (as determined in accordance with regulations prescribed 19 by the, Secretary). 20 "(2) For purposes of subsection (a),' the term `eligible 21 entities' means those entities which have had an application ~!2 approved under parag~aph (1) and which are- 23 "(A) public or nonprofit private graduate schools 24 of public health, hospital administration, or health plan- PAGENO="0181" 171 78 1 fling, or other public or nonprofit private entities grant- 2 ing graduate degrees in fields of public and community 3 health; or 4 "(B) other public or nonprofit private health or 5 educational entities which have arrangements (meeting 6 such requirements as the Secretary shall by regulation 7 prescribe) with an entity described in subparagraph 8 (A). 9 "(3) Contracts may be entered into under subsection 10 (a) without regard to sections 3648 and 3709 of the Re- 11 vised Statutes (31 U.S.C. 529; 41 U.S.C. 5). 12 "(4) The amount of any grant under subsection (a) 13 shall be determined by the Secretary. Payments under such 14 grants may be made in advance or by way of reimburse- 15 ment, and at such intervals and o~ such conditions, as the 16 Secretary finds necessary. 17 "(c) No grant may be made or contract entered into 18 under subsectli?n (a) for a project for which a grant may 19 be made under section 770 or 789. 20 "(d) There are authorized to be appropriated for pay- 21 ments under grants and contracts under this section $10,- 22 000,000 for the fiscal year ending June 30, 1975, $12,- 23 000,000 for the fiscal year ending June 30, 1976, and 24 $14,000,000 for the fiscal year ending June 30, 1977. PAGENO="0182" 172 79 1 "INSTITUTIONAL GRANTS FOR GRADUATE PROGRAMS 2 IN HEALTH 3 "SEc. 789. (a) For the purpose of supporting grad- 4 uate educational programs for public and community health 5 personnel, the Secretary shall make grants to public or non- 6 profit private educational entities (except schools of public 7 health) with graduate programs in health administration or 8 health planning which programs have each been accredited 9 b a recognized body or bodies approved for such purpose 10 by the Commissioner of Education. 11 "(1)) (1) No grant may be made under subsection (a) 12 unless an application therefor has been submitted to, and 13 approved by, the Secretary. 14 "(2) An application for a grant under subsection (a) 15 shall he in such form, and submitted in such manner, as the 16 Secretary shall by regulation prescribe, and shall contain- 17 "(A) assurances satisfactory to the Secretary that 18 in each academic year (as such year is defined in regala- 19 tions of the Secretary) for which the applicant receives a 20 grant under subsection (a), at least twenty-five individ- 21 uals will complete the graduated educational programs 22 of the entity for which the application is submitted; 23 "(B) such assurances as the Secretary shall by 24 regulation prescribe respecting one or more of the fol- 25 lowing: Increases in overall enrollment, increases in PAGENO="0183" 173 80 1 enrollment of needed types of students, and increases in 2 eiirollment in programs for needed types of public and 3 community health personnel; and 4 "(C) such other information as the Secretary may 5 by regulation prescribe. 6 "(3) The Secretary may not approve an application 7 submitted under this subsection unless he determines that the 8 program for which the application was submitted meets such 9 quality standards as the Secretary shall by regulation pre- 10 scribe. 11 "(4) The amount of any grant under subsection (a) 12 shall be determined by the Secretary; but in determining 13 the amount of any such grant, the Secretary shall take into 14 account the number of individuals that will participate in the 15 programs which will be supported by the grant and the 16 need (as determined by the Secretary) for the types of pub- 17 lie and community health personnel who will participate in 18 such programs. Payments under any such grant may be made 19 in advance or by way of reimbursement, and at such intervals 20 and on such conditions, as the Secretary finds neces~sary. 21 "(c) No grant may be made under this section for a 22 project for which a grant may he made under section 788. 23 "(d) There are authorized to be appropriated for pay- 24 ments under grants and contracts tinder this section $4,000,- 25 000 for the fiscal year emiding June 30, 1975, $5,000,000 PAGENO="0184" 174 81 1 for the fiscal year ending June 30, 1976, and 36,000,000 for 2 the fiscal year ending June 30, 1977. 3 "mAINEESmPS 4 "SEc. 790. (a) The Secretary shall (1) establish and 5 maintain traineeships in the Department of Heiith, Educa- 6 tion, and Welfare to train individuals to perform public and 7 community health services for which the Secretary de- 8 termines there is unusual need, and (2) make grants to pub- 9 lie or nonprofit private entities for traineeahips to provide 10 such training. ii "(b) (1) No traineeship may be awarded by the Secre- 12 tary under subsection. (~) (1) to any ~dividna1 MnLese the 13 individual has submitted to the Secretary an applieatior~ 14 therefor and the Secretary has approved the application. The 15 application shall be in such form, be submitted in such man- 16 ncr, and contain such information, as tie Secretary by regu- 17 lation may prescribe. 18 "(2) No grant for traineeships may be made under sub' j9 section (a) (2) unlçss an application therefor has been sub- 20 mitted to, and approved by, the Secretary. 8uth application 21 shall be in such form, be submitted in such manner, and 22 contain such information, as the Secretary by regulation may 23 prescribe. Traineeships under such a grant shall be awarded 24 in accordance with such regulations as the Secretary shall 25 prescribe. The amount of any swth grant shall be determined PAGENO="0185" 175 82 1 by the Secretary and payments under such a grant may be 2 made in advance or by way of reimbursement and at such 3 intervals and on such conditions as the Secretary finds 4 necessary. 5 "(3) Traineeships awarded under subsection (a) (and 6 under grants made thereunder) shall provide for such sti- 7 pends and allowances (including travel and subsistence ex- 8 penses and dependency allowances) for the trainees as the 9 Secretary may deem necessary. 10 "(c) For the purposes of making payments under grants ii under subsection (a) (2), there are authorized to be appro- 12 priated $12,000,000 for the fiscal year ending June 30, 13 1975, $13,500,000 for the fiscal year er~ding June 30, 14 1976, and $15,000,000 for the fiscal year ending June 30, 15 1977. 16 "STATISTICS AND ANNUAL REPORT 17 "SEC. 791. (a) The Secretary shall continuously de~ 18 velop, publish, and disseminate on a nationwide basis sta~ 19 tistics and other information respecting public and com 20 munity health personnel, including- 21 "(1) det~i1ed descriptions of the various types of 22 activities in which public and community health per- 23 sonnel are engaged, 24 "(2) the current and anticipated needs for the PAGENO="0186" 176 0') Ot) 1 various types of public and. community health personnel, 2 and 3 "(3) the number, employment, geographic loca- 4 tions, salaries, and surpluses and shortages of public 5 and community health' personnel, the educational and 6 licensure requirements for the various types of such per- 7 sonnel, and the cost of training such personnel. 8 "(b) The Secretary shall submit annually to the Corn- 9 mit.tee on Interstate and Foreign Oommerce of the House of 10 Representatives and to the Committee on Labor and Public 11 Welfare of the Senate a report on- 12 "~(1) the statistics and other ii~formation devel- oped pursuant to subsection (a) ; and 14 "(2) the activities conducted under this subpart, 15 including an evaluation of such activities. 16 Such report shall contain such recommendations for Tegisla- 17 tion as the Secretary determines is needed to improve the 18 programs authorized under this subpart. The Office of Man- 19 agement and Budget may review such report before its 20 submission to Oongress, but the Office may not ievise the 21 report or delay its submission beyond the date prescribed 22 for its submission and may submit to Congress its comments 23 respecting such report. The first report under this subsection 24 shall be submitted not later than September 1, 1975. PAGENO="0187" 177 84 1 "SuBP&~r 2-ALLIED HEALTH PERSONNEL 2 "DEFINITION 3 "SEc. 795. For purposes of this subpart, the term 4 `allied health personnel' means individuals with training 5 and responsibilities for (1) supporting, complementing, or 6 supplementing the professional functions of physicians, den- 7 tists, and other health professionals in the delivery of health 8 care to patients, or (2) assisting environmental engineers 9 and other personnel in environmental health control activities. 10 "PROJECT GRANTS AND CONTRACTS 11 "SEc. 79~3. (a) The Secretary may make grants and 12 enter into contracts to assist eligible ~ntitk~s in meeting the 13 costs of planning, study, development, demonstration, and 14 evaluation projects undertaken with respect to one or more 15 of the following: 16 "(1) Methods of coordination, management, and 17 articulation of education and training at various levels 18 for allied health personnel within and among educational 19 institutions and their clinical affiliates. 20 "(2) Methods and techniques for State and regional 21 coordination and monitoring or education and training 22 for allied health personnel. 23 "(3) Programs, methods, and curricula (including 24 model curricula) for training various types of allied 25 health personnel. PAGENO="0188" 178 85 "(4) Programs, or means of adapting existing 2 programs, for training as allied health personnel special 3 groups such as returning veterans, the economically or 4 culturally deprived, and persons reentering any of the allied health fields. 6 "(5) New types of roles and uses for allied health 7 personnel. 8 "(6) In coordination with the Secretary's program under section 1123 of the Social Security Act, methods 10 of establishing, and determining compliance with, profi- ciency requirements for allied health personnel, in- 12 eluding techniques for appropriate recognition (through 13 equivalency and proficiency testing or otherwise) of 14 previously acquired training or experience. 15 "(7) Methods of recruitment and retaining of allied 16 health personnel. 17 "(8) Meaningful career ladders and programs of 18 advancement for practicing allied health personnel. 19 "(b) (1) No grant may be made or contract entered 20 into under subsection (a) unless an application therefor has 21 been submitted to, and approved by, the Secretary. Such 22 application shall be in such form, submitted in such manner, 23 and contain such information, as the Secretary shall by regu- 24 lation prescribe. 25 "(2) For purposes of subsection (a), the term `eligible PAGENO="0189" 179 86 i entities' means those entities which have had an application 2 approved under paragraph (1) and which are- 3 "(A) schools, universities, or other educational 4 entities which provide for allied health personnel educa- 5 tion and training meeting such standards as the Secretary 6 may by regulation prescribe, 7 "(B) States, political subdivisions of States, or 8 regional and other public bodies representing States or 9 political subdivisions of States or both, io "(C) entities established to represent the interests ii of allied health personnel, or 12 "(D) any entity which has a working arrangement 13 (meeting such requirements as the Secretary may by 14 regulation prescribe) with an entity described in sub- 15 paragraph (A) or (C). 16 "(3) Contracts may be entered into under subsection 17 (a) without regard to section 3648 and 3709 of the Revised 18 Statutes (31 U.S.C. 529; 41 U.S.C. 5). 19 "(4) The amount of any grant under subsection (a) 20 shall be determined by the Secretary. Payments under such 21 grants may be made in advance or by way of reimbursement, 22 and at such intervals and on such conditions, as the Score- 23 tary finds necessary. 24 "(c) For the purpose of making payments under grants 25 and contracts under subsection (a), there are authorized to PAGENO="0190" 180 87 1 be appropriated $40,000,000 for the fiscal year ending 2 June 30, 1975, $45,000,000 for the fiscal year ending 3 June 30, 1976, and $50,000,000 for the fiscal year ending 4 June 30, 1977. 5 "TRAINEESIIIPS FOR ADVANCED TRAINING OF ALLIED 6 HEALTH PERSONNEL 7 "SEC. 797. (a) The Secretary may make grants to pub- 8 lie and nonprofit private entities for traineeships provided 9 by such entities for the training of allied health personnel to 10 teach in training programs for such personnel or to serve 11 in administrative or supervisory positions. 12 "(b) (1) No grant may be made under subsection (a) 13 unless an application therefor has been submitted to and 14 approved by the Secretary. Such application shall be in 15 such form, submitted in such manner, and contain such 16 information, as the Secretary shall by regulation prescribe. 17 "(2) Payments under such grants (A) shall be limited 18 to such amounts as the Secretary finds necessary to cover 19 the cost of tuition and fees of, and stipends and allowances 20 (including travel and subsistence expenses and dependency 21 allowances) for, the trainees; and (B) may be made in 22 advance or by way of reimbursement and at such intervals 23 arid on such conditions as the Secretary finds necessary. 24 "(c) For the purposes of making payments under 25 grants under subsection (a), there are authorized to be PAGENO="0191" 181 88 1 appropriated $7,500,000 for the fiscal year ending June 30, 2 1975, $9,000,000 for the fiscal year ending June 30, 1976, 3 and $10,500,000 for the fiscal year ending June 30, 1977. 4 "GRANTS AND CONTRACTS TO ENCOURAGE FULL UTILIZA- 5 TION OF EDUCATIONAL TALENT FOR ALLIED IIEALTII 6 PERSONNEL TRAINING 7 "SEc. 798. (a) The Secretary may make grants to and 8 enter into contracts with State and local educational agencies 9 and other public or nonprofit private entities-.- 10 "(1) to (A) identify individuals of financial, edu- 11 cational, or cultural need who have a potential to become 12 allied health personnel, including individuals who are 13 veterans of the Armed Forces with military training or 14 experience similar to that of allied health personnel, and 15 (B) encourage and assist, whenever appropriate, the 16 individuals described in clause (A) to (i) complete 17 secondary school, (ii) undertake such postsecondary 18 training as may be required to qualify them to undertake 19 allied health personnel traini~ig, and (iii) undertake 20 postsecondary allied health personnel training; and 21 "(2) to publicize existing sources of financial aid 22 available to individuals undertaking allied health per- 23 sonnel training. 24 "(b) (1) No grant may be made or contract entered 25 into under subsection (a') unless an application therefor has 33-698 0 - - 13 (Pt. 1( PAGENO="0192" 182 89 i been submitted to, and approved by, the Secretary. Such 2 application shall be in such form, submitted in such manner, 3 and contain such information, as the Secretary shall by reg- 4 ulation prescribe. 5 "(2) Contracts may be entered into under subsection 6 (a) without regard to sections 3648 and 3709 of the Revised 7 Statutes (31 U.S.C. 529; 41 U.S.C. 5). 8 "(3) The amount of any grant under subsection (a) ~ shall be determined by the Secretary. Payments imder such 10 grants may be made in advance or by way of reimburse- ~ ment, and at such intervals and on such conditions, as the 12 Secretary finds necessary. 13 "(c) For payments under grants and contracts under 14 subsection (a) there are authorized to be appropriated is $1,000,000 for the fiscal year ending June 30, 1975, $1.5 16 million for the fiscal year eiiding June 30, 1976, and $2 17 million for the fiscal year ending Jui~e 30, 1977. 18 STATISTICS AND ANNUAL REPORT 19~ "Si;c. 799. (a) The Secretary shall continuously de- 20 velop, publish, and disseminate on a nationwide basis statis- 21 tics and other information respecting allied health personnel, 22 including- 23 "(1) detailed descriptions of the various types of 24 such personnel and the activities in which such personnel 25 are engaged, PAGENO="0193" 183 90 1 "(2) the current. and anticipated needs for the van- 2 ous types of such health personnel, and 3 "(3) the number, employment, geographic loca- 4 tions, salaries, and surpluses and shortages of such per- 5 sonnel, the educational and licensure and certification 6 requirements for the various types of such personnel, 7 and the cost of training such personnel. 8 "(b) The Secretary shall submit annually to the Corn- 9 mittee on Interstate arid Foreign Commerce of the House of 10 Representatives and to the Committee on Labor and Public ~ Welfare of the Senate a report on- 12 "(1) the statistics and nther information developed 13 pursuant to subsection (a) ; and 14 "(2) the activities conducted under this subpart, 15 iiicluding an evaluation of such activities. 16 Such report shall contain such recommendations for legisla- 17 tion as the Secretary determines is needed to improve the 18 programs authorized under this subpart. The Office of Man- 19 agement and Budget may review such report before its sub- 20 mission to Congress, but the Office may not revise the report 21 or delay its submission beyond the date prescribed for its sub- 22 mission and may submit to Congress its comments respecting 23 such report. The first report under this subsection shall be 24 submitted not later than September 1, 1975." 25 (b) (1) Section 704 (as so redesignated) is amended PAGENO="0194" 184 91 1 (1) by striking out "any training center for allied health 2 personnel'' all(l iiiserting in lieu thereof ``any entity for the :~ training of puhlic and community health personnel or allied 4 health personnel'', and (2) by striking out "or training 5 center" each place it occurs and inserting in lieu thereof 6 ``or entity''. 7 (2) Section 314 (c) is repealed. S TITLE `Vu-MISCELLANEOUS 9 STVDY OF DTSTRTBFTION OF PIIYSTCIAXS 10 Si~c. 701. (a) The Secretary of llealth, Education, and ii Welfare shall, within ninety days after the date of the 12 enactment of this Act, contract for the conduct of a study 13 for the following purposes: 14 (1) To analyze tIme current distribution of physi' 15 cians by specialty. In making such analysis- 16 (A) the geographical distribution of medicac 17 and osteopathic physicians by specialty and sub- 18 specialty and by geogTaphic area shall be deter- 19 mined, and in connection with such determination 20 physician specialties and subspecialties shall be 21 defined in a manner consistent with recognized cate- 22 gories and geographical areas shall be deftned as 23 reasonable medical trade areas for each specialty or 24 subspecialty; and 25 (B) special attentiomi shall be given to de- PAGENO="0195" 185 92 1 teriiiining (i ) the perceiitage of I line P1~~'~ic~a11s in 2 eadi specialty aiid ~iili~pecia1tv spciid iii primary 3 care activities and iii oilier activities iiiirelated to 4 their 51)ecialtV trai lung. aiid (ii) the percentage of a time primal care 1h1v~icialis s1)ell(l in specnilty 6 care. 7 (2) To project the expected distribution of physi- 8 clans by specialty and sul)specialty by geographic area 9 in the years 1980, 1985, and 1990. Such projection shall 10 be based on current trends in physician specialty train- 11 ing and choice of practice Sites, the activities of various 12 specialty boards and other organizations, and the retire- 13 ment-death rate of physicians by specialty and sub- 14 specialty. is (3) To examine and evaluate the various method- 16 ologies for estimating the optimal distributioti of physi- 17 claus by specialty a 11(1 sul )~pcrialtv liv gc Igraphuic area 18 coiutrolliiig the supply of specialists a 11(1 sul)specialist 19 Methodologies exaumiluied aiid evalua ted shall include (A) miietliodologies utilized by foreign countries, and 21 (B) consideration of the use of muonphivsieians to per- 22 form functions normally performed by lhlysicians. 23 (4) To develop a reliable and appropriate method- 24 ology to establish the optimal distribution of physicians 25 by specialty and Sul)Specialty by geographic area. Utiliz- PAGENO="0196" 186 93 1 ing such methodology, projections shall be made for the 2 optimal number of physicians by specialty and suhspe- cialty by geographic area for the years 1980, 1985, 4 and 1990. 5 (h) The organization selected by the Secretary to con- 6 duct the study required by subsection (a) shall- 7 (1) have a national reputation for objectivity in 8 the conduct of studies for the Federal Government; 9 (2) have the capacity to readily marshal the widest 10 possible range of expertise and advice relevant to the 11 conduct of such study; 12 (3) have a membership and competent staff which 13 have backgrounds in government, the health sciences 14 and the social sciences; 15 (4) have a history of interest and activity in health 16 policy issues related to such study; and 17 (5) have extensive existing contracts with inter- 18 ested public and private agencies and organizations. 19 (c) An interim report providing a plan for the study 20 required by subsection (a) shall be subrmtted by the orga- 21 nization conducting the study to the Committee on Inter- 22 state and Foreign Commerce of the house of Representa- 23 tives and the Committee on Labor and Public Welfare of 24 the Senate by .Julv 31, 1975; and a final report giving 25 the results of the study shall be submitted by such organiza- PAGENO="0197" 187 94 1 tion to the Committee on Interstate and Foreign Comnierce 2 of the House of Represeiitatives and the Committee on Labor 3 and Public Welfare of the Senate by July 31, 1976. 4 (d) There is authorized to be appropriated $10,000,- 5 000, which shall be available without fiscal year limita- 6 tions, for the conduct of the study required by subsection 7 (a). 8 QUALITY ASSURANCES RESPECTING EDUCATION AND 9 TRAINING OF ALLIED ITEALTII PERSONNEL 10 SEc. 702. The Secretary of Health, Education, and Wel- 11 fare shall within one year of the date of the enactment 12 of this Act (1) submit to the Congress a report which 13 identifies and describes each of the prograiiis which lie ad- 14 miiiisters uiider which the costs a! J)rogl'anis of education ~ and training for allied heal tli persol 111(1 (as defi iied in section 16 791 of the Public Health Service Act) are directly or mdi- 17 rectly paid (in whole or in part) ; and (2) take such action 18 as may be necessary to require that such assislatice is pro- 19 vided only those programs which meet such quality stand- 20 ards as the Secretary may by regulation prescribe. 21 ALLIED HEALTH PERSONNEL STUDY 22 SEc. 703. (a) (1) The Secretary of Health, Education, 23 and Welfare shall, in accordance with paragraph (2), ar- 24 range for the conduct of studies- 25 (A) to identify the various types of allied health PAGENO="0198" 188 95 1 personnel and the a('tivlties in which such personnel are 2 engaged and the various training programs currently 3 offered for allied health personnel; 4 (B) to establish classifications of allied health per- 5 sonnel on the basis of their activities, responsibilities, and 6 training; 7 (C) using appropriate methodologies, to determine S the cost of educating and training allied health personnel 9 in each classification; and 10 (1)) to identify the classifications in which there are 11 a critical shortage of such personnel and the training pro- 12 grams which should be assisted to meet that shortage. (2) (A) The Secretary shall request the National 14 Academy of Sciences to conduct such studies under an 15 arrangement under which the actual expens~s incurred by 16 such Academy in conducting such studies will be paid by the 17 Secretary. If the National Academy of Sciences is willing to 18 do so, the Secretary shall enter into such an arrangement 19 with such Academy for the conduct of such studies. 20 (B) If the National Academy of Sciences is unwilling 21 to conduct one or more such studies under such an arrange- 22 ment, then the Secretary shall enter into a similar arrange- 23 ment with other appropriate nonprofit p~ivate groups or 24 associations under which such groups or associations will PAGENO="0199" 189 96 conduct such studies and prepare and submit the reports ~ thereon as provided in subsection (b) (h) The studies required by subsection (a) shall be corn- 1 J)leted within the two-year period beginning on the date of ~ the enactment of this Act; and a. report oii the results of ~ such study shall be submitted by the Secretary to the Corn- 7 mittee on Interstate and Foreign Commerce of the House s of Representatives and the Committee on Labor and Public ~ Welfare of the Senate before the expiration of such J)eriod. 10 (c) Within six months after the date prescribed for the ~i completion of the studies under sul)section (a) , the Secretary 12 of Health, Education, and Welfare shall transmit to Congress 13 such recommendations for legislation as he deterniines is 14 necessary to provide appropriate support for the training 13 programs referred to in subsection (a) (1) (1)) 16 SEc. 704. If, withiii tweiilv years (or t(n years in the 17 case of a. facility constructed with funds I)ai(h under part A 18 as in effect before the date of the enactment of the health 19 Manpower Act of 1974) after conll)letioIl of the construction 20 of any facility for which funds have been paid under such 21 part A (as so in effect.) or under part D (as in effect before 22 July 1, 1967)- 23 (1) the applicant for such funds or other owner of 24 such facility shall cease to be a public or nonprofit 25 private entity, or / PAGENO="0200" 190 97 1 (2) such facility shall cease to be used for the 2 purposes for which such funds for its construction were 3 provided, unless the Secretary determines, in accordance 4 with regulations, that there is good cause for releasing 5 the applicaiit or other owner from the obligation to do so, (3 the Lnited States shall be entitled to recover from the 7 applicant or other owner of the facility the amount bearing S the same ratio to the then value (as determined by agree- 9 nmnt of time parties or by action brought in the TJnited 10 States district court for the district in which such facility 11 is situated) of the facility, as the amount of the Federal 12 participation bore to the cost of construction of such facility. PAGENO="0201" 191 93D CONGRESS 2D SESSION . 1 4722 IN TIlE IIOIJSE OF REPRESENTATIVES M~ 9. 1974 Mr. Rouans (for liiiiiself, Mi. Kynos, Mr. I~REyER, Mr. SYMINGToN. Mr. IL~s- TINGS, Mr. Jjarxz. and Mr. IlIDNUT) introduced the following bill ; winch was ref(rr((l to ta Coniniittee oii Interstate and Foreign Coninieice A BILL To amend title VIII of the Public Health Service Act to revise and extend the programs of assistance under that title for luirse training. 1 Be it enacted by the Senate and house of Representa- 2 tiies of the United States of America in Congress assembled, 3 ShORT TITLE; REFERENCE TO ACT 4 SECTION 1. (a) This Act may be cited as the "Nurse 5 Training Act of 1974". 6 (b) Whenever in this Act all amendment or repeal is 7 expressed iii terms of an amendment to, or repeal of, a 8 section or other provision, the reference shall be considered 9 to be made to a section or other ~ of the Public 10 Health Service Act. PAGENO="0202" 192 2 1 EXTENSION OF CONSTRTJCTION GRANTS 2 SEC. 2. (a) Section .801 is amended by striKing out 3 "and" after "1973,"; and by inserting before the period a 4 comma and the following: "$25,000,000 for the fiscal year 5 ending June 30, 1975, $30,000,000 for the fiscal year end- 6 ing June 30, 1976, and $35,000,000 for the fiscal year end- 7 ing June 30, 1977". 8 (b) Section 802 (c) (1) (A) is amended (1) by insert- 9 ing "(i) after "proposed facilities", and (2) by inserting 10 before the semicolon ", or (ii) in expanding the capacity ii of the school to provide graduate training". 12 EXTENSION OF SPECIAL PROJECT GRANTS AND CONTRACTS 13 AND FINANCIAL DISTRESS GRANTS 14 SEC. 3. (a) Section 805 is amended to read as follows: 1~ "SPECIAL PROJECT GRANTS AND CONTRACTS 16 "SEC. 805. (a) The Secretary may make grants to pub- 17 lie and other non-profit private schools of nursing and other 18 public. or non-profit private entities, and enter into contracts 19 with any public or private entity, to meet the costs of spe- 20 cial projects to- 21 "(1) assist in- 22 "(A) mergers between hospital training pro- 23 grams or between hospital training programs and 24 academic institutions, or PAGENO="0203" 193 1 "(B) other cooperative arrangements among 2 hospitals and academic institutions, 3 leading to the establishment of nurse training programs; 4 "(2) develop training programs, and train, for new 5 roles, types, or levels of nursing personnel, including 6 programs for the training of pediatric nurse practitioners 7 or other types of nurse practitioners; 8 "(3) plan, develop, or establish new programs, sig- 9 nificant improvements in curriculums, modifications of 10 existing programs of nursing education; ii "(4) increase educational opportunities for disad- 12 vantaged students; 13 "(5) provide continuing education for nurses; 14 "(6) provide appropriate retraining opportunities 15 for nurses who (after periods of professional inactivity) 16 desire again actively to engage in the nursing profes- 17 sion; or 18 "(7) help to increase the supply or improve the 19 distribution by geographic area or by specialty group 20 of adequately trained nursing personnel needed to meet 21 the health needs of the Nation, including the need to 22 increase the availability of personal health services and 23 the need to promote preventive health care. 24 Contracts may be entered into under this subsection without PAGENO="0204" 194 4 1 regard to sections 3648 and 3709 of the Revised Statutes 2 (31 U.S.C. 529; 41 U.S.C. 5). 3 "(b) The Secretary may, with the advice of the Na- 4 tional Advisory Council on Nurse Training, provide assist- 5 ance (including assistance under this section which may be 6 provided without regard to section 808) to the heads of 7 other departments and agencies of the Government to en- 8 courage and assist in the utilization of medical facilities under 9 their jurisdiction for nurse training programs. 10 "(c) For payments under grants and contracts under 11 this section there are authorized to lie appropriated $25,000,- 12 000 for the fiscal year ending June 30, 1975, $30,000,000 13 for the fiscal year ending June 30, 1976, and $40,000,000 14 for the fiscal year ending June 30, 1977.". 15 (b) Sections 808 an~1 810 are repealed; section 807 is 16 redesignated as section 808; and the following new section is 17 inserted after section 806: 18 "FINANCIAL DISTRESS GIIANTS 19 "SEC. 807. (a) Time Secretary may make grants to 20 assist public or nonprofit private schools of nursing which are 21 in serious financial straits to meet opetational costs required 22 to maintain quality educational programs or which have spe- 23 cial need for financial assistance to meet accreditation re- 24 quirements. Any such grant may be made upon such terms 25 and conditions as the Secretary determines to l)e reasonable PAGENO="0205" 195 1 and necessary, including requirements that the school agree 2 (1) to disclose any financial information or data deemed by ~ the Secretary to be necessary to determine the sources or causes of that school's financial distress, (2) to conduct a 5 compreheiisive cost analysis study in cooperation with the 6 Secretary, and (3) to carry out appropriate operational and ~ financial reforms on the basis of information obtained in the 8 course of the comprehensive cost ana1ysis study or on the ~ basis of other relevant information. 10 "(b) An application for a grant under subsection (a) ~ must contain or he supported by assurances satisfactory to 12 the Secretary that the applicant will expend in carrying 13 out its functions as a school of nursing, during the fiscal year 14 for which such grant is sought, an amount of funds (other i~ than funds for construction as determined by the Secretary) 16 from non-Federal sources which is at least as great as the 17 average amount of funds expended by such applicant for 18 such purpose (excluding expenditures of a nonrecurring 19 nature) in the three fiscal years immediately preceding the 20 fiscal year for which such grant is sought. The Secretary may. 21 after consultation with the National Advisory Council on 22 Nurse Training, waive the requirement of the preceding 23 sentence with respect to any school if he determines that 24 the application of such requirement to such school would he 25 inconsistent with the purposes of subsection (a). PAGENO="0206" 196 `3 1 "(c) For payments under grants under this section 2 there are authorized to he appropriated $5,000,000 for the 3 fiscal year ending June 30, 1975, $5,000,000 for the fiscal 4 year ending June 30, 197G, and $5,000,000 for the fiscal 5 year ending June 30, 1977.". 6 (c) Section 808 (as so redesignated by subsection (b) 7 is amended- 8 (1) by striking out "or 810" in subsection (a) and 9 inserting in lieu thereof "or 807"; 10 (2) by striking out "or 810" in the matter in sub- 11 section (c) preceding paragraph (1) and inserting in 12 lieu thereof "or 807"; 13 (3) by striking out "or 810" in subsection (c) (1) 14 and 15 (4) by striking out "agency, organization, or in- 16 stitution' in subsection (c) (1) and inserting in lieu 17 thereof "entity". 18 EXTENSION AND REVISION OF CAPITATION GRANTS 19 SEC. 4. (a) Section 80'3 (a) is amended by striking out 20 paragraphs (1) and (2) and inserting in lieu thereof the fol- 21 lowing: 22 "(1) Each collegiate school of nursing shall re- 23 ceive- 24 "(A) an amount equal to the product of $625 twd the uumber of nursing student equivalents PAGENO="0207" 197 7 1 determined under subsection (c) for each class en- 2 rolled in such school in such year; and 3 "(B) $1,200 for each full-time studeiit enrolled 4 in such school in such year in advanced nurse 5 training or in a program leading to a graduate de- 6 gree in nursing. 7 "(2) Each associate degree school of nursing 8 shall receive an amount equal to the product of $275 and the number of nursing student equivalents determined io under subsection (c) for each class enrolled in such ii school in such y~ar. 12 "(3) Each diploma school of nursing shall receive 13 $250 for each full-time student enrolled in such school 14 in such year." 15 (b) Subsections (c) and (d) of section 806 are repealed 16 and the following new subsection is inserted after subsection 17 (b): 18 "(c) NURSING STUDENT EQTJJVALENTS.-FOr pur- 19 poses of subsection (a), the number of nursing student equiv- 20 alents for a class enrolled in a school of nursing in any year is 21 the number obtained by dividing- 22 "(1) the product of (A) the number of students 23 enrolled in such class in such year, and (B) the number 24 of credit hours of instruction provided by the school ii& 25 such year to such class, by 3~J-698 0 - 74 - 14 (Pt. 1) PAGENO="0208" 198 8 1 " (2) the number of credit hours of instruction in 2 nursing required by the school to be taken by a student in that class." 4 (c) (1) Subsection (f) of section 806 is repealed and ~, ~ubsections (e) , (g), (h), and (i) are redesignated as sub- 6 sections (d), (e) , (f) , and (g), respectively. (2) Section 806 (g) (1) (as so redesignated l)y para- ~- graph (1) of this subsection) is amended by striking out ~ "and" after "1973," and by inserting before "for grants" j~o, the following: `~S93,900,U00 for the fiscal year ending ~i June 30. 1975. 8105,000,00() for the fiscal year ending i~ June 30, 1970. and $116,500,000 for the fiscal year ending ~ *June 30, 1977,". 14 EXTENSION OF LOAN Gt~ARANTEES AND INTEREST 1~5 SFBSIDIES FOR CONSTRITCTION PROJECTS ~6. SEC. 5. (a) Subsections (a) and (b) of section 809 17 are each amended by striking out "1974" and inserting in 1~hie.u,~hereof "19.77". 1~; .,, (b) Subsection (e). of such section is amended by strik- 20.0i.ng oi~t "~nd~' after "1973,~' and by inserting after "1974" 21 a comma and the following: "$2,000,000 for the fiscal year 22 ending June 30, 197~, $3,000,000 for the fiscal year ending ~3 June 30, 1976, and $4,000,000 for the fiscal year ending 2~ June 30, 1977". PAGENO="0209" 199 9 1 EXTENSION OF TRAINEESIIIPS 2 SEc. 6. Section 821 (a) is amended by inserting after 3 "next fiscal year," the following: "$30,000,000 for the fiscal 4 year ending June 30, 1976, and $30,000,000 for the fiscal 5 year ending June 30, 1977,". 6 EXTENSION OF STuDENT LOAN PROGRAM 7 SEC. 7. (a) Section 822 (b) (4) is amended by strik- 8 ing out "1974" and inserting in lieu thereof "1977". 9 (b) Section 823 (b) (2) (B) is amended by inserting 10 "(including training to be a nurse anesthetist)" after "pro- 11 fessional training in nursing". 12 (c) Eflective July 1, 1974, section 824 is amended to 13 read as follows: 14 "AUTHORIZATION OF APPROPRIATIONS FOR STUDENT 15 LOAN FUNDS 16 "SEC. 824. There are authorized to be appropriated for 17 allotments under section 825 to schools of nursing for Fed- 18 eral capital contributions to their student loan funds estab- 19 lished under section 822, $35,000,000 for the fiscal year 20 ending June 30, 1975, $40,000,000 for the fiscal year end- 21 ing Jane 30, 1976, and *S50,000,000 for the fiscal year 22 ending June 30, 1977. For the fiscal year ending June 30, 23 1978, and for each of the next two succeeding fiscal years 24 there are authorized to be appropriated such slims as may PAGENO="0210" 200 10 1 be necessary to enable students who have received a loan 2 for any academic year ending before July 1, 1977, to con- 3 tinue or complete their education.". 4 (d) Section 826 is amended by striking out "1977" 5 each place it occurs and inserting in lieu thereof "1980". 6 (e) (1) Section 827 is repealed. 7 (2) The nurse training fund created within the Treasury 8 by section 827 (d) (1) of the Public Health Service Act 9 shall remain available to the Secretary of Health, Education, 10 and Welfare for the purpose of meeting his responsibilities 11 respecting participations in obligations acquired under sec- 12 tion 827 of such Act. The Secretary shall continue to deposit 13 in sucl~ fund all amounts received by him as interest pay- 14 ments or repayments of principal on loans under such sec- 15 tion 827. If at any time the Secretary determines the mon- 16 eys in the fund exceed the present and any reasonable pros- 17 pective future requirements of such fund, such excess may be 18 transferred to the general fund of the Treasury. 19 EXTENSION OF SCHOLARSHIP PROGRAM 20 SEC. 8. Effective July 1, 1974, section 860 is amended- 21 (1) by striking out "1972" in subsection (b) and 22 in subsection (c) (1) (A) and inserting in lieu thereof 23 "1975"; 24 (2) by striking out "1975" in the second sentence PAGENO="0211" 201 11 1 of subsection (b) and iii subsection (c) (1) and insert- 2 ing in lieu thereof "1978"; and 3 (3) by striking out "1974" in the second sentence 4 of subsection (b) and in sul)section (c) (1) (B) and in- 5 serting in lieu thereof "1977". 6 EXTENSION OF PROGRAM TO ENCOURAGE FULL UTILTZA- 7 TION OF EDUCATIONAL TALENT FOR NURSING 8 SEC. 9. Section 868 (b) is amended by striking out 9 "and" after "1973 ;" and by inserting before the period a 10 semicolon and "$3,000,000 for the fiscal year ending June ii 30, 1975; $4,000,000 for the fiscal year ending June 30, 12 1976; and $5,000,000 for the fiscal year ending June 30, 13 1977". 14 TECHNICAL AND CONFORMING AMENDMENTS 15 SEc. 10. (a) (1) Section 802 is amended- 16 (A) by striking out "section 806 (e) of this Act" 17 in subsection (b) (2) and inserting iii lieu thereof 18 "section 806 (d) "; 19 (B) by strikiiig out " (hereinafter in this part re- 20 ferred to as the `Council')" in the first sentence follow- 21 ing paragraph (5) of subsection (b) ; and 22 (C) by striking out "section 806 (e)"in the last 23 sentence following such paragraph and inserting in lieu 24 thereof "section 806 (d) ". PAGENO="0212" 202 12 1 (2) Section 80(3 (a) is amended- 2 (A) by striking out "Council" and ins~rting in lieu thereof "National Advisory Council on Nurse Training"; (B) by redesignating clauses (A) and (B) as clauses (1) and (2), respectively; and 6 (C) by redesignating siibclaiises (i) (ii) and (iii) as subclauses (A), (B) , and (C), respectively. 8 (h) Sections 822(a), 823(b), 823(c), 825(b) (2), and 826 (a) (1) are each amended by striking out "of 10 Health, Education, and Welfare". (c) Section 822 (b) (2) (B) is amended by striking 12 out "under this part" and inserting in lieu thereof "from 13 allotments under section 825". 14 (d) (1) Section 825 is amended- is (A) by striking out "(whether as Federal capital 16 contributions or as loans to schools under section 827)" 17 in subsection (a) ; and 18 (B) by striking out ", and for loans pursuant to 19 section 827," in subsection (h) (1) 20 (2) Section 826 (b) is amended by striking out "(other 21 than so much of such fund as relates to payments from the 22 revolving fund established by section 827 (d) ) ". 23 (3) Section 828 is amended by striking out "or loans". 24 (e) Section 830 is- PAGENO="0213" 203 13 1 (1) transferred to section 823 and inserted after 2 subsection (i) of such section; and 3 (2) is amended by striking out "SEC. 830. (a)" 4 and inserting in lieu thereof " (j) "~ (f) Section 841 is amended (1) by striking out "see- 6 tarn 805" in subsection (a) (2) and inserting in lieu thereof 7 "sections 805 and 807"; (2) by striking out subsection (b) 8 (3) by striking out "(a) (1)" and inserting in lieu thereof ~ "(a)"; and (4) by striking out "(2)" and inserting in 10 lieu thereof "(b) ". ii (g) Section 860 (a) is amended by striking out "this 12 part" and inserting in lieu thereof "this section". 13 (h) Section 861 is amended by striking out "to the 14 sums available to the school under this part for (and to be 15 regarded as) Federal capital contributions, to be used for 16 the same purpose as such sums" and inserting in lieu thereof 17 "to the student loan fund of the school established under an 18 agreement under section 822. Funds transferred under this 19 seetion to such a student loan fund shall be considered as 20 part of the Federal capital contributions to such fund". 21 (i) (1) The matter preceding paragraph (1) of section 22 868 (a) is amended by striking out "not to exceed $100,000 2~ pe~ year per contract (without regard to section 3709 of 24 the Revised Statutes (4i~ U.S.C. (5) ) ". PAGENO="0214" 204 14 1 (2) Section 868 (a) is amended by inserting after and 2 below paragraph (3) the following: 3 "The amount of any grant or contract under this subsection 4 shall be determined by the Secretary, except that the amount ~i of any contract in any fiscal year may not exceed $100,000. 6 Contracts may be entered into under this subsection without 7 regard to ~eetions 3(348 and 3709 of the Revised Statutes 8 (31 F.S.C. 529; 41 F.S.C. 5)." 9 (j) Section 869 is repealed. it) (k) (1) Sections 828 and 829 are redesignated as see- 11 tions 827 and 828, respectively. 12 (2) Section 822 (b) is amended by striking out "see- 13 tion 829" each place it occurs and inserting in lieu thereof 14 "section 828". 15 (1) (1) Part D of title VIII is inserted after part B 16 of such title and redesignated as part C; and sections 860, 17 861, and 868 are redesignated as sections 841, 842, and 843, 18 respectively. 19 (2) The heading for part C (as so redesignated) is 20 amended by inserting at the end thereof "; ASSISTANCE TO 21 ENCOURAGE FULL LTILIZATION OF EDUCATIONAL TAL- 22 EXT FOR NURsING". 23 (m) (1) Part C of title VIII as in effect on the day 24 before the date of the enactment of this Act is redesignated 25 as part D; and sections 841, 842, 843, 844, and 845 are re- PAGENO="0215" 205 15 1 designated as sections 851, 852, 853, 854, and 855, re- 2 spectively. 3 (2) Section 843 (a) (1) (as so redesignated by subsec- 4 tion (1) (1)) is amended by striking out "section 843(1)" 5 and inserting in lieu thereof "section 853 (f) ". 6 INFORMATION RESPECTING THE SUPPLY AND 7 DISTRIBUTION OF AND REQUIREMENTS FOR NtTRSES 8 SEC. lit. (a) (1) Using procedures developed in accord- 9 ance with paragraph (3), the Secretary of llealth, Educa- 10 tion, and Welfare (hereinafter in this section referred to as 11 the "Secretary") shall determine on a continuing basis- 12 (A) the supply (both current and projected and 13 within the United States and within' each State) of reg- 14 istered nurses, licensed practical and vocational nurses, 15 nurse's aides, registered nurses with advanced training 16 or graduate degrees, and nurse practitioners; 17 (B) the distribution, within the United States and ~18 within each State, of such nurses so as to determine 19 those areas of the Uiiited States whic1i are ovei~supp1ied, 20 undersupplied, or which have an adequate supply of such 21 nurses in relation to the population of the areas and the 22 demand for the services which such nurses provide; and 23 (C) the current and future requirements for such 24 nurses, nationally and within each State. PAGENO="0216" 206 16 1 (2) The Secretary shall survey and gather data, on a 2 continuing basis, on- 3 (A) the number and distribution of nurses, by type 4 of eiiiployinent and location of practice; 5 (B) the number of nurses who are practicing full 6 time and those who are employed part time, within the 7 United States and within each State; 8 (C) the average rates of compensation for nurses, 9 by type of practice and location of practice; 10 (D) the activity status of the total number of 11 registered nurses within the United States and within 12 each State; 13 (E) the iiuiiiber of nurses with advanced training or 14 graduate degrees in nursing, by specialty, including is nurse practitioners, nurse clinicians, nurse researchers, 16 nurse educators, and nurse supervisors and administra- 17 tors; and 18 (F) the number of registered nurses entering the 19 United States annually from other nations, by country 20 of nurse training and by immigrant status. 21 (3) Within six months of the date of the enactment of 22 this Act, the Secretary shall develop procedures for de- 23 terrnining (on 1)0th a current and projected basis) the sup- 24 ply and distribution of and requirements for nurses within the 25 United States and within each State. PAGENO="0217" 207 17 1 (b) Not later than February 1, 1976, and February 1 2 of each succeeding year, the Secretary shall report to the 3 Congress- 4 (1) his determinations under subsection (a) (1) 5 and the data gathered under subsection (a) (2) 6 (2) an analysis of such determinations and data; 7 and 8 (3) recommendations for such legislation as the 9 Secretary determines, based on such determinations and 10 data, will achieve (A) an equitable distribution of 11 nurses within the United States and within each State, 12 and (B) adequate supplies of nurses within the United 13 States and within each State. PAGENO="0218" 208 H. R. 14930 IN TIlE JIOT~ISE OF REPRESENTATIVES M~ ~1.19T4 Mt. ~TAOOER5 (for himself and Mr. I)E\INI~) introduced the following l)ill whuIt was referred to the Committee on Interstate and Foreign Commerce A BILL To anieiid titles VII and VIII of the Public health Service Act, and for other purposes. 1 Bc it enacted by the Senate and House of Representa- 2 tice.s of i/o 1 ~n lied States of A inerica in Congress assembled. 3 ShORT TITLE; I~EFERENCES TO ACT 4 Si~"riox 1. (a) This Act may be cited as the "Corn- 5 ~ health Manpower Act of 1974". 6 (1)) Whenever in this Act aim amendment or repeal is 7 expressed in terms of an amendment to, or repeal of, a title, S part, section, or other provision, the reference shall be con- 9 sidered to be made to a title, part, section, or other provision 10 of the Public Health Service Act. PAGENO="0219" 209 1 TITLE I-LOAN GLABANTEES H )li (( )NSTIII `C- 2 TION FOil BEPLA(EMENT Oil 1~EM~I)ELIN(~ 3 OF TEA(IIIYU ~ 4 SE('. 101. (ii) (1) 8((tioll 729 (iii(1lldi1i~ tile (19)11011 5 thereof) i~ aiiieiided to read a~ foil) ~ 6 ``LOAN (~uA1L~NTEI:s 7 ``Si~ . 729. (9 ) To 1i~1~t eligil ~le liOnl)roiit ~V1Vil te eli- 8 ti ties to (1l1iV itit approved ])1( )je(t for ti ie (1)1 1~ I 111(1 011 I If 9 teaelu ug fa (11111 e~ of pnva te iioiipr( ifi t ~el1( a Il~ of ii ie(1i(ine, 10 0~teO1)a div. deiit 1 ~trv, vet eiiiia IV Ii iedi (11 ie. o1)t( lii iel rV. or 11 podiatry. other than the (1 ui~t ruel oi of i iew 10111(10 ig~ or 12 the e~i~aii~ion of exi~tiiig 1 )llildiIig~, the Seeretarv ii iOV. (br- 13 ilig the period liegiiiiiing July 1. 1974. and eiidin2 \vitli the 14 (lo~e of Juiie 3 ( ), 1 977, gua ia iii ee (iii a ee r(la i ue with i liii 15 ~eetion aiid ~Ill),jeCt to ~ub~ection (1) ) to any non-Federal 16 lender that iiiake~ a loan to au e112'il)le euititv. for dial iu~i~ 17 eet, 1)aVilielit wi ten due of the pri 191 pal 1 If a iìd i iitere~t oil 18 that bail. The Secretary may make ())luifllit1nent~, On 1)ellalf 19 of tiue I iiite(l States. to make tlio~e loan guaraiitee~ prior to 20 the making of the loans.''. 21 (2) Seetioii 729 (1)) 1~ repealed. Tlii~ repealer shall riot 22 he Construe(l to inipair the obligation of the Secretary to pay 23 any amount that the Secretary has agreed to pay. uiider that 24 section. with respeet to any loan iiiade under section 729 25 prior to the enactment of tins A (t. PAGENO="0220" 210 3 (3) There i~ added after section 729 (a) a new section 2 729 (li) t 1ea(l as follows (1) ~\ IlalIlIalit luivate eiitit shall he eligible to re- 1 eeive a 1 011 gail ra I ltee(l ui ider sul)se(tn in (a ) if the (ii tit V j iiieeN tile 1(illlil(Ill(1lt5 (as (letelluhlled l11I(ler ie~I1l~ltiO1i5 (if ; tie ~(~1(101V) it seiiui~ 721. 722. aid 723. insofar as they 7 are appli(ali( 1 iiiipralit private entities. exeeh)t that iii lieu of iiiiV ie~1iiiieitieiit of seetili 721 (e) re5~)eeti1Ig tile iiiaiiite- ~ iiaiue al ilirrease of stll(lellt eiirolliiieiit, au 111)1)ii(iltiOII for a 1(1 101(11 glIiil~uIlt(( 1111(1(1 tIii~ ~e(1iolI 5111111 (olitahli OY he situ- 11 1 ited y lea ~ na1 le aiiianee that the tea(hing facility 1~ wOll iegiii1 1 which! the luau i~uai'aiitee is obtained will 1 iiiaiiilaiii a fiu~t-vcai eiirolliiieuit of fuhl-tiiiie slIl(lellts after the 14 (aliIlii(1Iu1I ii tile ciiistuUctioui. 011(1 br each (1 the next nune 1.) ~(ll((l yeai~. that i~ itt l(~s thou that eiiiohluiieiit during the It; li~cal year (1l(li1l~ JllI1( :~. 1973. For PlflPos('s of the 01)1)11- 17 (atOll at ~ectio11~ 721. 722. and 723 to this section. the term 1 ~ Lriallt. a~ ii~ed iii sectioui~ 721 . 722. and 723 is deemed to 10 meati ~uauit by the Secietarv for a loan guaraiitee iuuider see- ~() 11(11 729''. 21 (4) ~e(tiui 729 ( e) is aullende(1 liv striking out ``or 22 ilIl ere~t sIll Nidy liavlIielIt in the first 011(1 second sentence. .~ ) Section 729 ( e ) is anieiided (A) hv striking out 04 "ilit(rest subsalv payments authorized by this sect iiiii' (`0(11 2~ Ii inc ii a~ pears 011(1 inserting in lieu thereof ``interest subsidy PAGENO="0221" 211 4 1 ~ for which an agreement was entered iiito under 2 this section prior to its aineiidinent liv the (iiiprehieiisive 3 Health Manpower Act of 1974''; and (B) liv inserting he- 4 fore the period1 after `1974'' the follo\vilig : atid for each 5 succeeding fiscal year such suiiis us may 1 a.' miecessa rv to immake 6 interest SUl)sidV I)avmellts for which an agm'eeiiieiit was 7 entered into under lids section prior to its aiiiendiiient liv I ho 8 Comprehensive health Manpower ~~ct ot 1974''. 9 (6) Section 729 ( f ) is aimieiidcd .( ~ ) h si miking out 10 ``(1) `` after `` ( f) ``, and (B) 1 v st miking out palagm ph (2) ii (b) (1 ) Section 809 (a) ( iu(lu(lillg the (~1pt ion there- 12 of) is amended to read as follow's 13 ``LOAN (;IrABANTEE~ 14 ``SEC. 809. (a) Iii order to assist liolijn'otit private 13 5(110015 (If nursing to (a nV lit (`((list 1U(t iOu ~)rOj('(ts for 16 training facilities, other tlmaii tli e (( ~ist rll(ti 1)11 (It ii ew 1 (lii Id- 17 ings or the expansion of exist ilig huildim igs, the Secreta iv 18 may, during the period l)egilIliiIig .Tuilv I . 1 974. and ending 19 with the close of June 30, 1977, guamaittec (in accordance 20 with this section and suh~ect to snl)~ection (f) ) to iioii-}cd- 21 eral lenders making loans to such schools, for such construe- 22 tion projects, payment when due of the prin('ip111 of and in- 23 terest on any loan for that construction. The Seeret~irv ma~ 24 make commitments, on hehaif of the liii ted St at es to iiiake 25 those loan guaramit (`(`S 1)1101 to ti ie milOkil ig 1 t lie loans.. PAGENO="0222" 212 1 (2) ~c(ti()Il 81)9 ( b) li repealed. rjl~1j~ repealer shall 2 iiot he (oIlstrll(d to 11111)011 tIle ohlig~t1ioii of the Secretary ~ to ~cIV OIIV aiii~iitt that the ~e(re1arv has agreed to pay, 4 iii dcr that sct i Ill. wi thl 1e~1)e(t to a ii loini iiiade under 5 S((tjOli 729 1I0h1 I)) tile (Ila('lIllcIIt of this Act. ~ ) TI crc is addc(l after sect ii 809 (a ) a new see- 7 tiui ~( )9 (h) to icad as! olIo~vs S (1 ) A iioiipn fit aiva te scho 1 of nursing shall he 9 (1 igil li t 1((eiVc a loan guil 111111 ee(l nuder sul)sectioII (a It) if it I lied 1d91 ii rdlileli ts (is (let (nil! iied under regulat bus ii of die ~d(Idtai ) (If 5((t lOIN ~) 2. 50%, aiid 8()4, iuisofai as 12 they Old al)1(li(ai(ld to 1lO1li(101it l)iiVate 5(110015 of 1itu1si1ig~ 1% (`NNl)1 that iii lOll 0! iluiV 1i(11111eliidlit 0! sctti°ii 802 (h) 14 1e~l)c(t ii i~ tI ( 11101111 dl 101 ice OI~ iI1(u(~lse of stiideuit enroll- 15 uileilt. 1111 01(1)11(0 11011 for 0 10011 i.tuaiauitee under this sect iou I ( ~hiahl eontaiui ((1 1 e supported by reasonal)le assurances that 17 tIle applieaiit with respect 1)) wInch a `oan is guaranteed I ~ IIlld(l thii ~((t 1(111 \vil I n at liii a iii a Ii rst-vca r cii 1(11111 ieuit 19 of !till-t line ~ttithuits after the d()ulll)letioll of the eouistruetion, 20 aiid for each of the next niuw school years, that is itot less 9j thaut that (lIrohIlilent duniig the fiscal year etiding June 30, ~2 1973. For purposes of the application of sections 802, 803, 2% and ~04 to this section, the term `gr~uit' as used in sections 24 ~()2. ~( 1%. and ~O 4 is deenied to uiiean `grant hv the Secre- 25 tarv of a loan ~tl0 111111cc 1111(1ev section 809'. ". PAGENO="0223" 213 1 (4) Setioii ~ )9 () i~ ;iiiuiiTed by stiik~ii~ ~iit "or 2 iiJt(l('~1 SUl)~i(lV pavilitlil iii tlu !!i~t ~liI(l ~roiol lIt(1o(. 3 (~) Sc~tioii ~~)9 (() i~ i111I(1I4l((~ (~\) liv 4 "iiiteie~t ~u1~idv p;1v1!I(iIt~ ~1u1]Hr!i(d liv iliN (1 o1~ 5 tiIll( it 1)1)(il1~'~ ~I11(l iiI~~(1tiiI~_~' ill Ii&ti 1Il(1( 0! ~i1It(l('t i!~It1v 6 p~Iv1neI1t~ for \Vl1i(l1 ~11 ~l~1t(1tl(111 WiN (lIt(1((1 ilIto 1111(1(1 7 this se(tioii prior to i1~ aIIlI1(ll11(Ilt liv IIW ( olIlpl'(loIlsivc 8 health \Ialllwwer Aet of I ~)74" : aiid ( I~) Lv ii~i~i~2 lie- 9 lore tile period alter "1 974' the Iollo\vhl~ : ". ~nd for ta~ii 10 ~1l((ee(1i1l.~ fit(ilI \e01 `11(11 11116 buy l;( 11((i~IFv 11) 11 iiiake illtel(st. 5llh)Si(i\ 1)ulvll!(11ti 1(11 \VI(!( ii 011 ul~l((iil(IIt \VuI' 12 (lIleled iIit() 1111(1(1 this 9eelioil 1)1101 to IN u)1II(ll(l1ll(1It by 13 thi ( (oil i prel ieii~i ye ITea It Ii 1\ Iai i~ o wet A (t f I 74 14 (() ~eCtiI)1i t~)9 (I) 1' u(Il1(11(T(d (A) Lv ~trikiiit~ alit 15 (I)'' u!ter "(I)". and (B) lv 5trikiii~ alt pai1l21apL (2). 16 TITLE l1~~(A PITATI( )N (~ HA NTS. ~TABT-I~P AS- 17 S1~TAME AM) ~ATI()NA1~ P1W)BITV 1X(~EX- 18 TIVE X\VABI)S 19 20 SE(. 2( 1. (1) ~eetioii 77( i~ 1111(11(1(11 to irad as 21 22 `~SE . 770. (a ) (~1t~NT (1O~I lIT ATI( )Y.-lhle Se(ietarv 23 shall make annual 2raiit~ to 5(11 al of 110(11(11 te. st~ pa I liv. 24 dentistry. optonietrv. po(liatrV. 011(1 veteiiiiuiiv biledi(ibie for 25 the support of the edueation pr~1al11s of hios( ~la ohs. r~ 38-698 0 - 74 - 15 (Pt. 1) PAGENO="0224" 214 1 ~iiii0iiiit ((I the iiiit~i1 ~iaiit II) each sei)001 with au iiI)1)iIIV((l 2 appiu(atuohl ~iOu11 lIe (01111)Ilted a~ t0110\V5 (1) ( ~\ ) Each ~clii (01 441 iuiedieiiie. ost eOl)atiiV. ahl(1 4 (hill istuv ~hiai1 receiVe f u t lie fiscal year ending .Tuiie ), 5 1975. 19i(;. ~iuitT 11)77. ~ s~1.250. and ~1,(()0 ic- 6 5p(~'t ivelv 1)1 ~ucIi veaN. Ioi each lull-I iiiie stiideiit en- 7 rolled. iii each of liaIse vear~. iii the medical or dental S uu~uiniilg ~iogiaii~ of the ~(lIoo1. 9 ( B ) Iii ti ie ea~c (If a 5(11001 t il~1t (Oildul(ts a tuaiiiil11I 1)14W1i1111 deS11IIl(d 1(4 pei'iiiit the stuideiit to coin- 1 1 ~ Witilill six veais a I tel (((illl)Iet ing 5(cOIidi~tl 5(11001, 12 tii e le1lliu'elIlelll s 1)1 tue degree of d~ let or of iiiediei iie. I I )~t C( pa ti IV. ((1 dell! I ~l iV tile uiiedical or deuit al I ia iuii ii~ 14 pu'o2TaIlI (1 the 5(11001. within the meaniuig of suhpara- ~iapli ( A ) ~IlIlhl 1 ~e (Teeilled to 1 (C the last three years 16 (41 tile ~ChIO0i s lraiiliulg ~1og~1~ 17 ( 2 ) Each schOOl (If ))1)tOiileti'V aiid 1)0(11111 cv 511011 IS receive IhI' the fiscal veai' euiding *Tune 30, 1975. 1976, 19 auid 1977. ~4( 10. ~3t)(). and ~2( 1)). resl)eetivelv f))! tli(lse vear~. for each IuII-tiiiie studellt enrolled iii the sehool 21 iii each f those years. 22 (3 ) Eacil school of vetei'iiial'V iiiedieiiie shall re- 23 ((IV( for jiie fi~eai veal eiudill~ .Tnuie 30, 1975. 1976, 24 and 1977. ~90( t. ~(3()) ). a iid ~3( 0. respectively for those PAGENO="0225" 215 8 1 years, for each full-time studeiit enrolled in the school 2 in each of those years. 3 `` ( li ) APPO1rrIONMEN'r ~F' Xp1'l~opHIATIoNs.-Ii the 4 total of the grants to be made iiiider subsection (a) for aiiv 5 fiscal year- 6 `` (1) to schools of niediciiie, osteopathy. and dcii- 7 tistrv with approved applicatiomis exceeds the aiiiouiils 8 appropriated under subsection ( f) (1) for ti ie grati t~, 9 or 10 ``(2) to schools of optoiimetrv, 1)odiatrv, and vetei'i- 11 nary niedicine with al)proved applications exceeds ilie 12 aniouiits appropriated nuder subsection ( f) (2) for the 13 grants, 14 the aniouuit of the grant for that fiscal year to each school 15 under subsection (a) shah l)e an amount that bears the same 16 ratio to time amount deternmumed for the school for thmat fiscal 17 year as the total of the amounts appropriated for that year 18 under subsection ( f) (1) ui' ( f) (2), as the case may be, 19 `bears to the amount re(juired to make ~iaiits iii acc u'da Inc 20 with subsection (a) to each school referred to iii clause (1 21 or (2) as the case may be. 22 " (c) MAINTENANCE oi' Ei~i-'owr.-Thme Secretary shall 23 not make a grant under this section to any 5(11001 for a fiscal 24 year beginning after June 30, 1 97-1-. unless the application 25 therefom' contains or is supported 1 y reas (101 hmie a~surances PAGENO="0226" 216 9 1 ~a t i~faut iv ti tile ~eeietarv ti iat 111 the seliool year that ends 2 diiriiiii. or with tIle ci se f. that fiscal year. the school wi11 3 niaiutain a fir~t-veav cilulluleilt of lull-tinie students that will 4 lie not less thaii the school's fir~t-vear fuli-tinie enrollment ~5 for the school year eiiding during, or with the close of, the 6 fiscal year eioliii~ .Tune 3(.). 1974. br purposes of this sub- 7 sec~i n. a ~tud&nt enr lied in the first year of the last three 8 years of the t ia iiii hg pr ~rai ii of a school described in sub- 9 section (a ) (1) (ii) or a st u(lent enrolled in the first 10 the two years f the inedicil training pt gi'aifl of a. two-year ii schiol of iiiedictiie. shall lie coiisidered a first-year student. 12 (d) ENI:orI~u~xT DI~rmt~rTxATIoxs.- 13 `` (1) 11 pui'pse~ of this 1)art aiid part F, regula- 14 tions of the 8ecret arv shall include provisions relating 15 to deteniiiiia 6oii of the number of students enrolled in a lii school, or iii a particular year-class in a school, or en- 17 tering re~ideiicies in the practice of family medicine, as 18 the ease may i.e. on the basis of estimates or on such 19 other basis as lie deems appropriate. 20 (2 ) For pulp se~ of this part and part F, the 21 term ~full-tiiiie ~ttident means a student pursuing a 22 full-time (4 ur~e of study leading to a degree of doe- 2:3 tor of medicine. d cli r of osteopathy, doctor of 24 deiiti~trv (1' it~ e(1hhivalehlt) . doctor of optometry (or PAGENO="0227" 217 10 1 it:~ ei1iiivaleiii ) detor ol 1)()diat iv (or its ri1tiivaleiit 2 01 dO(lO1' ol vrteriiia iv iiieditiiie ( i its eiIuivaleIlt 3 (e) X1~PL1(XT1ON~ FO1~ ~E\V S(lI()( )LS.-Iii tile case 4 of a iie\v 5(11)01 ol llie(liciile, 0~-t e~ pal liv. dciii i~liv. opt oiiic liv, 5 podiat iv. 01 veteriiiarv iiiedicine tIi~it applies for a giant 6 tinder this section in tile fiscal year preceding tile fiscal year 7 in which it will adniit its first class, tile eiiiolliiieiit for 1011- 8 p~~es of subsection (a) shall be the nuiiiher of lust-year 9 full-time sI udetits that the ~ecretarv deterniiiies, on tile 10 basis of assurances provided by tile school, will be enrolled ii in the school, in the fiscal year after the fiscal year iii which 12 the grant is niade. 13 `~ (f) AUTUOInZA'rlox OF' XPPIa)P1~1x'IIONS.- 14 (1) There ai'e authorized to he appropriated sncll 15 stuns as hay lie iiecessai'v for tile 1is('al year eiidiiig 16 June 30, 1973, and each of the iiext two fiscal years 17 for grants nuder this section to sillools of iiiediciiie, 18 osteopathy, aiid dciitisti'v. 19 ( *~ ) Ti are auttiorized to be appo priiited sli('hl 20 5111115 as may iiC iieces~ai'v for tile fiscal year ending 21 Jiiiie 31), 1973, and each of tile iiext two liscal years 22 for grants iindet' tins sect ion to scil( ols of op0 mel iv. 23 podiatry, and veterinary mediciiie.''. 24 (h ) Section 773 (b) is amended by strikiiig out 25 "pilariIla('y,''. PAGENO="0228" 21S 11 1 START-FP ~i5SISTANCE AMENI)MENTS 2 SEc. 20~. (a) SectiOn 771 (a) (1) is amended by 3 I iisert in~ I iefi ire the peru d at the end of the first sentence 4 there if the fi hawing: except that for any fiscal year 5 he~iiiniii~ after .Jiine 30. 1974. no ~raiit niav be made wider 6 this suhsectioii except to a new school that has received a 7 ~raiit nuder I lii ~ui ~ecti( in fir the prelutig fiscal year". S (hi) Scitiioi 771 (a) (6) is amended iii tile first sentence 9 liv iiisertii i~ 1 ofi Ic tile period at ti ie end thereof the follow- 10 ing : ~`. and such siiiiis as may be necessary for each (if the 1 1 next three ~eal years. 12 NATIoNAL PRIOHITY IN('ENTIVE AWARDS 1:3 SEc. ~03. (a) Sections 775 and 77(3 are redesignated 14 ~c(tio1N 77(3 and 777. respe(1 ively. and there is added after 15 section 774 the fohlowuiig new section: 16 `~NATIONAL PuTORITY INCENTIVE AWARDS 17 "Si:c'. 775. (a) FAMILY PRACTICE RESIDENCY IS Gi~~cT~.-To each school of niediciiie and osteopathy eli- 19 ~ili1e. in a fiscal year, for a giant tinder section 770, the 21) Secretary shah make a graiit, from tile sums appropriated 21 under section 77(1) (f) (1) for that fiscal year, of $~,000 for 22 (a(iI individual (i) who entered, in the preceding fiscal year, 2:3 the first year of a residency in the 1)ractice of family medicine 24 approved by the Council on Medical Education of the Amer- 25 iean Medical Association; arid (ii) who, during the school, PAGENO="0229" 219 12 1 year ending in that. or the J)receding fiscal year, received 2 from the school a degree of doctor of medicine or doctor of 3 osteopathy. 4 " (l) GIL~D1ATF: TnAI NI N(~ TN SIIOItTA ;E SI'Ecui~- 5 TIES.- 6 ``(1) In order to eiial )T( the Sc(rctarv to award 7 grants to plIl)lic or iionpn )fit private cut ities pro~di11g 8 graduate or specialized education or training in tile pro- 9 vision of health (are (including education or training in 10 systems or methods of health care delivery) . there are 11 authorized to he appropriated 511(11 5111115 as flhilV he nec- 12 essary for the fiscal year ending Juiie ~O, 1975, and 13 each of the next two fiscal years. 14 " (2) Grants under this subsection may he awarded 15 to an entity to plan, develop, and, as provided by pam- 16 graph (3) , pay part of the cost to operate or participate 17 in, for an initial period, a new or expanded program of 18 education or training (accredited, ccrtiiied, or approved 19 by such professional bodies, and in such manner, as the 20 Secretary may deem appropriate) in family medicine, 21 pediatrics, internal medicine, or such other specialties 22 for the delivery of health care services as the Secretary 23 may determine to lack practitioners sufficient to serve 24 a national need, including augmentation of stipends of 25 individual participants in any such program who plan to PAGENO="0230" 220 13 1 specialize or work in tile field in which they are to re- 2 ceive training unde~ the program. (3) ~ grant under paragniph (~) for payment 4 of part of the (`o~t. for a fNcal year, to operate or (in- s far as it niav rc1iiire the pavnient of operational costs) 6 itaititiPa tc iii a new r expanded program may be 7 awarded amlv to an entity that has provided assurances s ti~fa(t iv to the Secretary that there are sufficient iou-Federal fiiuids to ~ the remainder of that cost I a f r that 6 seal year: that ft r each year a grant is awarded ii for such peration of or participation in a new or ex- 12 panded program. the propoition of non-Federal funds empi ved iii the operation of, or participation in, that 14 progiam shall be increased over the preceding fiscal is year; and, if the award is for the operation of a pro- 16 gram. that there is a rcasonal tie prospect that the pro- 17 gram (or the program as expanded) will be continued, IS without Federal financial assistance, after eligibility for 19 assistance under this subsection has terminated. The 20 Sccretar may not award grants under this subsection 21 for defraying more than the first three years of the 22 costs of operating or participating in any new or ex- 23 panded program.''. 24 (it) Section 77(3 (as redesignated by this section) is 25 amended (1) Lv striking out "or 773'' each time it appears PAGENO="0231" 221 14 1 all(1 iii~ert~t~' iii lieu tllereof "773. (1 775 (a) ". and (2) lv 2 ( ~ ) stliL:ill~ out "and" at the ~`iid of SU] ne(ti(I1l (d) (2) 3 ( ii) rede~i~iia hug stil Ne(ti((u1 ((1) (3) as so.] )se(tion (d) (4) 4 011(1 ((1) iiiseitiult~ a new su])se(ton ( d) (3) to read as 5 follows 6 ``(3) ((Intaluls. ~ll tile ease of an application for 7 a grant uiuider section 775 (a ) , a clescript ion of the S a(tivities to lie un(lertaken liv the ap~)hi(ant. to assist 9 and ellcoulage its students to enter the practice of 10 faniiiv medicine, 011(1 0 certifhation liv tile appll(ault 11 that. it will i~'~e its best efforts to mcrease tile Iluml)er 12 of its students applying for residencies in. and entering 13 tile practice of. faiiiilv medicine : and". 14 (c) Section 770, as a~nendc(i liv tins Act, is further 1) amended (1) by adding before ``. of' at tile end of sill)- 16 section (li) (1) tile following : "(after reduction of the 17 amounts appropriated liv the total of grants to i~e macic 18 under sect ian 775) `` ; (2) by adding at the end of subsection 19 (li) the following new sentence : "If tue total of tile grants 20 to lIe made under section 775 for any fiscal year to schools 21 of inediciuie or osteopathy with approved applications cx- 22 ceeds tile total of tue amounts appropriated under sub- 23 section (f) (1) for that fiscal year, the amount of the grant 24 for that. fiscal year to each such school shall be reduced PAGENO="0232" 222 13 1 PlP iii iiatelv." ;iiid (3) Lv adding ``and section 775'' 2 after "this el loll ~ii sIlh~e(tion (f) (1) :~ TITLE III l~E(~T~ L PROJECTS, hEALTh MAN- 4 l'o\vi:R Ll)UCXTI()X INITIATIVE AWARDS, ANI) 1'lN\XCIAL DISTI1ESS GRANTS 3 (`N~()LI1)ATI()Y 01 iSPE(IAL PROJECT ATJTIIORITIES 7 ~i;c. 301 (a ) (1) Seeti n 772 (a) is amended in the 8 niatter preeediiig (`Iau~e (1) by striking out ``and podiatry'' 9 and insert ilig iii lieu thereof ~podiatry, nursing, and public 10 health, and au trainiuig (enter for allied health professions". 11 (2) Section 772 (a) is fuitlier amended (A) by striking 12 (lit ``or'' at tile end of e1au~e ( i3 ) ; (B) by striking out the I 3 period at the cud of (lailse (14) and inserting `` ; or'' in lieu 14 there 1; and (() iv adding after clause (14) the following 15 new clauses: 16 "(13) assist in- 17 ``(A) mergers between hospital training pro- 18 grams or between hospital training pI'oglams and 19 aeadeniic institutions, or 20 "(B) other cooperative arrangements among 21 hospitals amid academic institutions, 22 leading to the (51 ai dishuunetit of nurse training programs 23 or 24 "(16) provide appropriate retraining opportuinties 25 for nurses who (after periods of professional inactivity) PAGENO="0233" 223 16 1 desire agaill actively to engage iii the luirsing profes- 2 sion.". 3 (3 ) Section 772 (a) (3 ) is aniended liv insert ilig "nurse 4 prartitioners," before "physicians' assistants". 5 (4) Sections 77~ (a) (4) and 772 (a) (5) are amended 6 by striking out "in such health professions" and inserting in 7 lieu thereof "or training in health care''. 8 (5) Section 772 (a) (6) is anieiided b~y striking out `tin 9 such health professions". 10 (6) Section 772 (a) (8) is amended by striking out "and 11 podiatry of," and inserting in lieu thereof "podiatry, nursing, 12 and public health, and any training center for allied health 13 professions of,". 14 (7) Section 772 (a) (9) is amended by inserting "or 15 training centers" after "such schools". 16 (b) Section 724 is amended by adding at the end there- 17 of the following new paragraphs: 18 "(7) The term `school of nursing' means a school of 19 nursing as defined by section 843. 20 " (8) The term `training center for allied health pro- 21 fessions' means a training center for allied health professions 22 as defined by section 795.". PAGENO="0234" 224 17 1 CONSOLIDATION OF Sl'ECIAL PROJECT AND EI)UCATD)N 2 INITIATIVE AWARD APPROPRIATIONS AUThORIZATIONS 3 SEC. 302. (a) Section 777 (as redesignated by section 4 203 of this Act) is redesignated section 778, and there is 5 added after section 77(3 a new sectioii to read as follows: 6 "APPROPRIATIONS ATTTIIORIZED FOR SECTIONS 7 772 AND 774 8 "SEC. 777. There are authorized to be appropriated 9 such sums as may be necessary for the fiscal year ending June 10 30, 1975, and each of the next two fiscal years for the pur- 11 ~ of making payments under sections 772 and 774.". 12 (1~ Sections 772 (d) and 774 (e) are repealed. 13 EXTENSION OF FINANCIAL DISTRESS GRANT PROGRAM; 14 INELIGIBILITY OF SChOOLS OF PHARMACY; AMOUNT 15 01' GRANT; TEChNICAL ASSISTANCE 16 SEc. 303. (a) Section 773 (a) is amended (1) by 17 striking out "and" before "810,000,000", and (2) by in- 18 serting "amid such sunis as may be necessary for each of the 19 next three fiscal veal's," after "1974,". 20 (1) Sections 773 (h) aiiad 773 (d) are amended by 21 striking out "pharmacy,". 22 (c) Sections 773 (b) is further amended by adding 23 at the end thereof the following new sentence : "Iii the 24 case of a school that has i'eceived a grant in the immediately PAGENO="0235" 225 18 1 preceding fiscal year, the sums of amounts granted to that 2 school tinder this section for aiiv fiscal year may not exceed 3 75 per centiun of the stun of amounts granted to that school 4 under this sectioii for that niimediatelv preceding fiscal year." (d) Section 773 (c) is amended by adding at the end 6 thereof the following new sentence : "The Secretary flay 7 provide, to any school of niedicimie, osteopathy, (lentistry, 8 optometry, podiatry, or veterinary niedicine w1iicli is iii 9 serious financial straits to meet its costs of operation or 10 which has a special Ilee(l for financial assistance to meet 11 accreditation requirements, techmiical assistance to eIlal)Ie 12 the school to Con(lflCt a comprehensive cost analysis study 13 of its operations, to identify operational inefficiencies, or to 14 develop or carry out appropriate opt'ratioiial or financial 15 reforms.". 16 TITLE TV-STUDENT ASSISTANCE 17 1'READM ISSION ANI) FOLLOWI:P ASSISTANCE TO TIlE 18 DISAI)VANTAGED 19 SEC. 401. Section 774 (b) is amended- 20 (1) in clause (2) (A) by inserting after ``assisting 21 them" the following "(including the payment to them 22 of such pertinent stipends, with allowances for travel amid 23 for dependents, as the Secretary deems appropriate) "; 24 and PAGENO="0236" 226 19 1 (2) by striking out the matter following clause 2 (2) (C). 3 SChOLARShIPS FOR SERVICE 4 ~i:r. 41)2. (a) ~ectioii 225 (a) is amended by strikiiig 5 out tiier units of tile Service" and inserting in lieu thereaf 6 "such oilier unifornied or civilian Federal health service as 7 the Secretary may deteriiiine is appropriate, and to proiliote 8 the ito ire adequate provision of medical care for persons who 9 reside in arca~ deterniined by the Secretary, im(ler section 10 329 ( h ) (1) to have critical health manpower shortages''. 11 (b) Section 223 (b) (4) is amended to read as follows 12 (4) agree iii writing to serve, as prescribed by 13 sul section ( e ) of this section, (A ) as a civiliaii member 14 of tile ~ational health Service Corps or in such oilier 15 unif irnied or civilian Federal health service as the See- 16 reta iv miiav deteriiiine appri )priate or (B) iii an area 17 dci eimiiined by tile Secretary, under section 329 (b) (1 18 to have a critical health manpower shortage". 19 (c) Section 223 (b) (3) is ameiided to read as follows 21) (3 ) excel)t in the case of an applicant who enters 21 into an agreement under clause (4) (B), be selected for 22 civilian service ill the National Health Service Corps or i~ ~ii~1i other unifornied or civilian Federal health serv- PAGENO="0237" 227 20 1 ice as the Secretary may determine is appropriate 2 and". 3 (d) Section 225 (e) is amended (1) by amending the 4 first clause of the first sentence to read: ~~Iii accordance with 5 his agreement under subsection (b) (4), a ~ partici- 6 pating in the program shall be obligated following comple- 7 tion of academic training to serve as a civilian member of time 8 National health Service Corps or in such other uniformed 9 or civilian Federal health service as the Secretary may 10 determimme is appropriate. or in an area determined by the 11 Secretary, under section 329 (b) (1), to have a critical 12 health manpower shortage,'' ; (2) by striking out time second 13 sentence ; and (3) by amending time last sentence by inserting 14 "Federal health" before the word "facility", by placing a 15 p~r~od after time word "facility", and by striking o~it "of the 16 Service or other facility of time National Health Service 17 Corps.". 18 (e) Section 225 (`) (1) is aiiiemidcd by striking out "aim 19 active duty service obligation and inserting "a service ob- 20 ligation'' in lieu thereof. 21 (f) Section 225 (i) is amended to read as follows: 22 " (i) There are authorized to be appropriated such sums 23 as may be necessary to carry out the program.". PAGENO="0238" 228 21 1 FEDERAL CAPITAL CONTRIBUTIONS TO STUDENT LOAN 2 FFNI)S; DI1~ECT LOAN INTEREST RATE MADE EQUIV- 3 ALENT TO INSURED LOAN INTEREST RATE; AND 4 CLARIFYING CHANGE S SiC. 40:3. (~) Sections 743, 7941) (e) , and 826 are 6 each amended l)V striking out "1977" each time it appears 7 and inserting in lieu thereof "1980''. 8 (1)) Sections 741(e), 7941) (b) (2) (E) , and 823 (1)) 9 (5) are each amended l)V striking out ``3 P~' centuni" and in- 10 serting "7 per c'entum'' in lieu thereof. 11 (c) Section 741 (f) (1) is amended by adding at the 12 end thereof the following sentence : ``In the case of any in- 13 dividii~l who, on or after ~oven1l)er 18, 1971, meets the 14 reqiiireineiit~ of sul ~ ( ~\ ) and (B) and who prac- 15 tiees his professioii as described by sul)paragraphl (C) by 16 virtue of his (lllplovnlent as a member of the National 17 health Service Corps. the individual shall be deemed to 18 have eiitered into the agrccnient required by subparagraph 19 (C) with respect to that practice.". 20 TITLE V-EFFECTIVE DATE' 21 SEC. 501. This Act is effective with respect to appropria- 22 tions for fiscal years beginning after June 30, 1974, except 23 for section 40:3 (c) which is deemed to have become effec- 24 tive on ~oven1l)er 18. 1971. PAGENO="0239" 229 93o CONGRESS T T .~ 2D SESSION 11. K. 14931 IN THE HOUSE OF REPRESENTATIVES MAY 21,19~4 Mr. STAGGEnS (for himself and Mr. DEVINE) introduced the following bill which was referred to the Committee on Interstate and Foreign Commerce A BILL To extend the National Health Service Corps, aiid for other purposes. 1. Be it enacted by the Senate and Ilonse of Representa- 2 tires of the United States of America in Congress assembled, 3 That this Act may be cited as the "National health Service 4 Corps Amendments of 1974". 5 EXTENSION OF AUTHORIZATION 6 SEC. 2. Section 329 (h) of the Public Health Service 7 Act is amended (1) by striking out "and" before "$25,- 8 000,000" and (2) by inserting 1)efore the period at the 9 end thereof the following: ", and such sums as may he 10 necessary for each of the next three fiscal years". 3~-673 0 - 74 - 16 (Pt. 1) PAGENO="0240" 230 2 1 GRANT TO FACILITATE PROVISION OF hEALTh SERVICES 2 SEe. 3. Paragraph (2) of section 329 (d) is redesig- 3 nated as paragraph (3) and there is inserted a new para- 4 graph (2) to read as follows: (2) (A) The Secretary may award a grant, not to 6 exceed ~10,fl00, to a public or nonprofit private entity to 7 assist the entity in meeting, for an area determined under s siili~ection (1)) (1) to have a critical health manpower 9 shortage, any costs of establishing medical practice man- 10 agement systems, or acquiring supplies or equipment. Not 11 more than one such grant may be made with respect to any 12 one such area. 13 "(B) Iii time case of any supplies or equipment leased 14 or purchased with a grant under the preceding subparagraph, 13 or leased or purchased by the Secretary under paragraph 16 (1 ) . the Secretary may, at such time or times as he deems 17 appropriate, release to a public or nonprofit private entity 18 all right, title. and interest of the T~Jnited states, subject to 19 such terms and conditions as he may impose to assure the 20 continued use, for a reasonable period, of the supplies or 21 equipment (or their equivalent) in the provision of health 22 services within the area with respect to which they were 23 leased oi~ purchased." PAGENO="0241" 231 3 1 APPLICATION OF FEES TO COMMUNITY COSTS 2 SEC. 4. The last sentence of section 329 (b) (2) (C) is 3 amended to read as follows: "If, in aid of the provision of 4 health care and services by personnel of the Corps assigned 5 to an area under subparagraph (A), a public or nonprofit (3 private entity enters into an agreement with the Secretary 7 to provide any services, equipment, or facilities that the 8 Secretary would otherwise be authorized or required to pro- 9 vide under this section in connection with that assignment, 10 the Secretary may use, or provide for the use, of any funds 11 cQllected under this subparagraph for payment to the entity 12 of all or part of the cost of the services, equipment, or facil- 13 ities so provided, on such basis over t.he period of the as- 14 srgnment as the Secretary deems appropriate. There shall ~ 15 be subtracted from that payment the amount of any grant 16 awarded to the entity under subsection (d) (2) . Any funds 17 collected by the Secretary under this subparagraph, and not 18 used for such payment, shall be deposited in the Treasury as 19 miscellaneous receipts.". 20 EFFECTIVE DATE 21 SEC. 5. This Act shall become effective with respect to 22 appropriations for fiscal years ending after June 30, 1974. PAGENO="0242" 232 [H.R. 15051, 93d Cong., 2d sess., introduced by Mr. Patten on May 29, 1974; H.R. 15112, 93d Cong., 2d sess., introduced by Mr. Shipley on May 30, 1974; H.R. 15128, 93d Cong., 2d sess., introduced by Mr. Fulton on May 30, 1974; H.R. 15177, 93d Cong., 2d sess., introduced by Mr. Moorhead of Pennsylvania on June 4, 1974; H.R. 15211, 93d Cong.. 2d sess., introduced by Mr. Dulski on June 5, 1974, and H.R. 15225, 93d Cong., 2d sess., introduced by Mr. Jarman on June 5, 1974, are identical as follows:] A BILL To amend title VIII of the Public Health Service Act to revise and extend the progra.m~ of assistance under that title for nurse~ training. 1 Be it enacted by the Senate and house of Representa- 2 tires of the United States of America in Congress assenibled, 3 ShORT TITLE; REFERENCE TO ACT 4 SECTION 1. (a) This Act may be cited as the "Niir~e 5 Tniining Act of 1974". 6 (b) Whenever in this Act an amendment or repeal is 7 expressed in terms of an amendment to, or repeal of, a 8 section or other provision, the reference shall be considered 9 to be made to a section or other provision of the Public 10 health Service Act. PAGENO="0243" 233 1 EXTENSION OF CONSTRUCTION GRA~T$ 2 SEC. 2. (a) Section 801 is amended by striking out 3 "and" after "1973,"; and by inserting before the period a 4 comma and the following: "$25,000,000 for the fiscal year 5' ending June 30, 1975, $30,000,000 for the fiscal year end- 6 ing June 30, 1976, and $35,000,000 for the fiscal year end- 7 ing June 30, 1977". 8 (b) Section 802 (c) (1) (A) is amended (1) by insert- 9 ing "(i)" after "proposed facilities", and (2) by inserting 10 before the semicolon ", or (ii) in expanding the capacity ii of the school to provide graduate training". 12 EXTENSION OF SPECIAL PROJECT GRANTS AND CONTRACTS 13 AND FINANCIAL DISTRESS GRANTS 14 SEC. 3. (a) Section 805 is amended to read as follows: 15 "SPECIAL PROJECT GRANTS AND CONTRACTS 16 "SEC. 805. (a) The Secretary may make grants to pub- 17 lic and other non-profit private schools of nursing and other 18 public or non-profit private entities, and enter into contracts 19 with any public or private entity, to meet the costs of spe- 20 cial projects to- 21 "(1) assist in- 22 "(A) mergers between hospital training pro- 23 grams or between hospital training programs and 24 academic institutions, or PAGENO="0244" 234 1 "(B) other cooperative arrangements among 2 hospitals and academic institutions, 3 leading to the establishment of nurse training programs; 4 "(2) develop training programs, and train, for new roles, types, or levels of nursing personnel, including programs for the training of pediatric nurse practitioners 7 or other types of nurse practitioners; 8 "(3) plan. develop, or establish new programs, sig- 9 nificant improvements in curriculums, modifications of 10 existing programs of nursing education; ii "(4) increase educational opportimities for disad- 12 vantaged students; 13 "(5) provide continuing education for nurses; 14 "(6) provide appropriate retraining opportunities 15 for nurses who (after periods of professional inactivity) 16 desire again actively to engage in the nursing profes- 17 sion; or 18 "(7) help to increase the supply or improve the 19 distribution by geographic area or by specialty group 20 of adequately trained nursing personnel needed to meet 21 the health needs of the Nation, including the need to 22 increase the availability of personal health services and 23 the need to promote preventive health care. 24 Contracts may be entered into under this subsection without PAGENO="0245" 235 4 1 regard to sections 3648 and 3709 of the Revised Statutes 2 (31 U.S.C. 529; 41 U.S.C. 5). 3 "(b) The Secretary may, with the advice of the Na- 4 tional Advisory Council on Nurse Training, provide assist- 5 ance (including assistance under this section which may be 6 provided without regard to sectioii 808) to the heads of 7 other departments and agencies of the Government to en- 8 courage and assist in the utilization of medical facilities under 9 their jurisdiction for nurse training programs. 10 " (c) For payments under grants and contracts under 11 this section there are authorized to be appropriated $25,000,- 12 000 for the fiscal year eiiding June 30, 1975, $30,000,000 13 for the fiscal year ending Juiie 30, 1976, and $40,000,000 14 for the fiscal year ending June 30, 1977.". 15 (b) Sections 808 and 810 are repealed; section 807 is 16 redesignated as section S0~ ; and the following new section is 17 inserted after section 806: 18 "FINANCIAL J)ISTRESS GRANTS 19 "SEC. 807. (a) The Secretary ma make grants to 20 assist public or nonprofit private schools of nursing which arc 21 in serious financial straits to meet operational costs required 22 to maintain quality educational programs or which have spe- 23 cial need for financial assistance to meet accreditation re- 24 quirements. Any such grant may be made upon such terms 25 and conditions as the Secretary deterniines to be reasonable PAGENO="0246" 236 ~ and necessary, including requirements that the school agree (1) to disclose any financial iiiformation or data deemed by ~ the Secretary to he necessary to determine the sources or causes of that school's financial distress, (2) to conduct a 5 comprehensive cost aitalysis study in cooperation with the 6 Secretary, and (3) to carry out appropriate operational and ~ financial reforms on the basis of information obtained in the 8 course of the comprehensive cost analysis study or on the ~ basis of other relevant information. 10 " (h) An application for a grant under subsection (a) j~ must contain or he supported by assurances satisfactory to 12 the Secretary that the applicant will expend in carrying 13 out its functions as a school of miursing, during the fiscal year 14 for which such grant is sought, an amount of funds (other is than funds for construction as determined by the Secretary) 16 from non-Federal sources which is at least as great as the 17 average amount of funds expended by such applicant for 18 such purpose (excluding expenditures of a nonrecurring 19 nature) in the three fiscal years immediately preceding the 20 fiscal year for which such grant is sought. The Secretary may, 21 after consultation with the National Advisory Council on 22 Nurse Training, waive the requirement of the preceding 23 sentence with respect to any school if he determines that 24 the application of such requirement to such school would be 25 inconsistent with the purposes of subsection (a). PAGENO="0247" 237 6 1 "(c) For payments under grants under this section 2 there are authorized to be appropriated $5,000,000 for the 3 fiscal year ending June 30, 1975, $5,000,000 for the fiscal 4 year ending June 30, 1976, and $5,000,000 for the fiscal 5 year ending June 30, 1977.". 6 (c) Section 808 (as so redesignated by subsection (b) 7 is amended- 8 (1) by striking out "or 810" in subsection (a) and 9 inserting in lieu thereof "or 807"; 10 (2) by striking out "or 810" in the matter in sub- ii section (c) preceding paragraph (1) and inserting in 12 lieu thereof "or 807"; 13 (3) by striking out "or 810" in subsection (c) (1) 14 and 15 (4) by striking out "agency, organization, or in- 16 stitution" in subsection (c) (1) and inserting in lieu 17 thereof "entity". 18 EXTENSION AND REVISION OF CAPITATION GRANTS 19 SEc. 4. (a) Section 806 (a) is amended by striking out 20 paragraphs (1) and (2) and inserting in lieu thereof the fol- 21 lowing: 22 "(1) Each collegiate school of nursing shall re- 23 ceive- 24 "(A) an amount equal to the product of $625 25 ttnd the number of nursing student equivalents PAGENO="0248" 238 1 determined under subsection (c) for each class cmi- rolled in such school in such year; and 3 " (B) $1,200 for each full-time studeiit enrolled 4 in such school in such year in advanced nurse training or in a program leading to a graduate de- 6 gree in nursing. 7 "(2) Each associate degree school of nursing 8 shall receive an amount equal to the product of $275 and the number of nursing student equivalents determined io under subsection (c) for each class enrolled in such school in such year. 12 "(3) Each diploma school of nursing shall receive 13 8250 for each full-time student enrolled in such school 14 in such year." 15 (b) Subsections (c) and (d) of section 80~ are repealed 16 and the following new subsection is inserted after subsection 17 (b): 18 "(c) NURSING STUDENT EQUIVALENTS.-FOr pur- 19 poses of subsection (a), the number of nursing student equiv- 20 alents for a class enrolled in a school of nursing in any year is 21 the number obtained by dividing- 22 "(1) the product of (A) the number of students 23 enrolled in such class in such year, and (B) the number 24 of credit hours of instruction provided by the school iii 25 such year to such class, by PAGENO="0249" 239 8 1 " (2) the number of credit hours of instruction in 2 nursing required by the school to be taken by a student in that class." 4 (c) (1) Subsection (f) of section 806 is repealed and ~ subsections (e), (g), (h), and (i) are redesignated as sub- 6 sections (d), (e) , (f) , and (g), respectively. (2) Section 806(g) (1) (as so redesignated by para- 8 graph (1) of this subsection) is amended by striking out ~ "and" after "1973," and by inserting before "for grants" 10 the following: "$93,900,000 for the fiscal year ending ii June 30, 1975, $105,000,000 for the fiscal year ending 12 June 30, 1976, and $116,500,000 for the fiscal year ending 13 June 30, 1977,". 14 EXTENSION OF LOAN GUARANTEES AND INTEREST 15 SUBSIDIES FOR CONSTRUCTION PROJECTS 16 SEC. 5. (a) Subsections (a) and (b) of section 809 17 are each amended by striking out "1974" and inserting in `` ~,, 18 lieu thereor 1971 19 (b) Subsection (e) of such section is amended by strik- 20 ing out "and" after "1973," and by inserting after "1974" 21 a comma and the following: "$2,000,000 for the fiscal year 22 ending June 30, 1975, $3,000,000 for the fiscal year ending 23 June 30, 1976, and $4,000,000 for the fiscal year ending 24 June 30, 1977". PAGENO="0250" 240 9 1 EXTENSION OF TRAINEESIIIPS 2 SEc. 6. Section 821 (~i) is amended by inserting after 3 "next fiscal year," the following: "$30,000,000 for the fiscal 4 year ending Jime 30, 197(3, and $3(),000,000 for the fiscal 5 year ending .June 30, 1977,". 6 EXTENSION OF STLTDENT LOAN PROGRAM 7 Sec. 7. (a) Section 822 (b) (4) is amended by strik- 8 ing out "1974" and inserting in lieu thereof "1977". 9 (b) Section 823 (b) (2) (B) is amended by inserting 10 "(including training to be a nurse anesthetist) " after "pro- 11 fessional training in nursing". 12 (c) Effective July 1, 1974, section 824 is amended to 13 read as follows: 14 "ATJTIIORIZATION OF APPROPRIATIONS FOR STUDENT 15 LOAN FUNDS 16 "SEc. 824. There are authorized to he appropriated for 17 allotments under section 8Z5 to schools of nursing for Fed- 18 eral capital contributions to their student loan funds estab- 19 lished under section 822, $35,000,000 for the fiscal year 20 ending June 30, 1975, $40,000,000 for the fiscal year end- 21 ing Jane 30, 1976, and ~50,000,000 for the fiscal year 22 ending June 30, 1977. For the fiscal year ending June 30, 23 1978, and for each of the next two succeeding fiscal years 24 there are authorized to be appropriated such sums as may PAGENO="0251" 241 10 1 be necessary to enable students who have received a loan 2 for any academic year ending before July 1, 1977, to con- 3 tinue or complete their education.". 4 (d) Section 82(3 is amended by striking out "1977" 5 each place it occurs and inserting in lieu thereof "1980". 6 (e) (1) Section 827 is repealed. 7 (2) The nurse training fund created within the Treasury 8 by section 827 (d) (1) of the Public Health Service Act 9 shall remain available to the Secretary of Health, Education, 10 and Welfare for the purpose of meeting his responsibilities 11 respecting participations in obligatioiis acquired under see- 12 jion 827 of such Act. The Secretary shall coiitmue to deposit 13 in such fund all amounts received by hini as interest pay- 14 meats or repayments of principal on loans under such see- 15 tion 827. If at aiiy time the Secretary determines the mon- 16 eys in the fund exceed the preseiit and any reasonable pros- ~ pective future requirements of stidi fuiid, sueli excess may be 18 transfelTed to the general fund of the Treasury. 19 EXTENSION OF SCHOLARSHIP PROGRAM 20 SEc. 8. Effective July 1, 1974, section 8(30 is amended- 21 (1) by striking out "1972" in subsection (b) aiid 22 in subsection (c) (1) (A) and inserting in lieu thereof 23 "1975"; 24 (2) by striking out "1975" in the second sentence PAGENO="0252" 242 11 1 of subsection (b) and in subsection (c) (1) and insert- 2 ing in lieu thereof "1978"; and 3 (3) by striking out "1974" in the second sentence 4 of subsection (h) and in subsection (c) (1) (B) and in- 5 serting in lieu thereof "1977". 6 EXTENSION OF PROGRAM TO ENCOURAGE FULL UTILTZA- 7 TION OF EDUCATTONAL TALENT FOR NURSING S S~c. 9. Section 868 (b) is amended by striking out 9 "and" after "1973 ;" and by inserting before the period a 10 semicolon and "$3,000,000 for the fiscal year ending June ii 30, 1975; ~4,000,00() for the fiscal year ending June 30, 12 1976; and $3,000,000 for the fiscal year ending June 30, 13 1977". 14 TEChNICAL AND CONFORMING AMENDMENTS 15 Si~c. 10. (a) (1) Section 802 is amended- 16 (A) by striking out "section 806 (e) of this Act" 17 in subsection (1 ~) (2) and inserting in lieu thereof 18 "section 806 (d) "; (B) by striking out " (hereinafter in this part re- 20 ferrcd to as the `Council') `` in the first sentence follow- 21 ing paragraph (3) of subsection (b) ; and 22 (C) by striking out "section 806 (e) " in the last 23 sentence following such paragraph and inserting in lieu 24 thereof "section 806 (d) ". PAGENO="0253" 243 12 1 (2) Sectioii 806 (a) is amended- 2 (A) by striking out "Council" and inserting in lieu thereof "National Advisory Council on Nurse Training"; (B) by redesignating clauses (A) and (B) as clauses (1) and (2), respectively; and 6 (C) by redesigriating subclauses (i), (ii), and (iii) as subclauses (A) , (B) , and (C), respectively. 8 (b) Sections 822(a), 823 (b), 823(c), 825 (h) (2), and 826 (a) (1) are each amended by striking out "of 10 Health, Education, and Welfare". (c) Section 822 (b) (2) (B) is amended by striking 12 out "under this part" and inserting in lieu thereof "from 13 allotineiits under section 825". 14 (d) (1) Section 825 is amended- 15 (A) by striking out "(whether as Federal capital 16 contributions or as loans to schools under section 827)" 17 in subsection (a.) ; and 18 (B) by striking out ", and for loans pursuant to 19 scctioii 827," in subsection (b) (1). 20 (2) Section 826 (b) is amended by striking out "(other 21 than so much of such fund as relates to payments from the 22 revolving fund established by section 827 (d) ) ". 23 (3) Section 828 is amended by striking out "or loans". 24 (e) Section 830 is- PAGENO="0254" 244 13 1 (1) transferred to section 823 and inserted after 2 subsection (i) of such section; and 3 (2) is amended by striking out "SEC. 830. (a)" 4 and inserting in lieu thereof " (j) "* (1) Section 841 is amended (1.) by striking out "see- 6 tion 805" in subsection (a) (2) and inserting in lieu thereof 7 `~sections 805 and 807"; (2) by striking out subsection (b) 8 (3) by striking out "(a) (1)" and inserting in lieu thereof ~ "(a)"; and (4) by striking out "(2)" and inserting in 10 lieu thereof "(b) ". ii (g) Section 860 (a) is amended by striking out "this 12 part" and inserting in lieu thereof "this section". 13 (h) Section 861 is amended by striking out "to the 14 sums available to the school under this part for (and to be 15 regarded as) Federal capital contributions, to be used for 16 the same purpose as such sums" and inserting in lieu thereof 17 "to the student loan fund of the school established under an 18 agreement under section 822. Funds transferred under this 19 section to such a student loan fund shall be considered as 20 part of the Federal capital contributions to such fund". 21 (1) (1) The matter preceding paragraph (1) of section 22 868 (a) is amended by striking out "not to exceed $100,000 23 per year per contract (without regard to section 3709 of 24 the Revised Statutes (41 F.S.C. (5) ) ". PAGENO="0255" 245 14 1 (2) Section 8(38 (a) is amended by inserting after and 2 below paragraph (3) the following: 3 "The amount of any grant or contract under this subsection 4 shall be determined by the Secretary, except that the amount 5 of any contract in any fiscal year may not exceed $100,000. 6 Contracts may be entered into under this subsection without 7 regard to sections 3648 and 3709 of the Revised Statutes 8 (31 F.S.C. 529; 41 T~S.C. 5)." 9 (j) Section 869 is repealed. 10 (k) (1) Sections 828 and 829 are redesignated as see- 11 tions 827 and 828, respectively. 12 (2) Section 822 (b) is amended by striking out "see- 13 tion 829" each place it occurs and inserting in lieu thereof 14 "section 828". 15 (1) (1) Part D of title VIII is inserted after part B 16 of such title and redesignated as part C; and sections 860, 17 861, and 868 are redesignated as sections 841, 842, and 843, 18 respectively. 19 (2) The heading for part C (as so redesignated) is 20 amended by inserting at the end thereof `~; ASSISTANCE TO 21 ExcoFIt~GE FTLL tTILIZATION OF EDFCATIONAL TAL- 22 ENT FOR NURSING". 23 (m) (1) Part C of title VIII as in effect on the day 24 before the date of the enactment of this Act is redesignated 25 as part 1); and sections 841, 842, ~43, ~44, and 845 are re~ -h~R 0 - - 1. 1) PAGENO="0256" 246 15 1 designated as sections 851, 852, 853, 854, and 855, re- 2 spectively. 3 (2) Section 843 (a) (1) (as so redesignated by subsec- 4 tion (1) (1) ) is amended by striking out "section 843(1)" 5 and inserting iii lieu thereof "section 853 (f) ". 6 INFORMATION RESI'ECTING T}IE SUPPLY AND 7 DISTRIBUTION OF AND REQUIREMENTS FOR NURSES 8 Si~c. 11. (a) (1) Using procedures developed in accord- 9 ance with paragraph (3) , the Secretary of health, Educa- 10 tion, and Welfare (hereinafter in this section referred to as 11 the "Secretary") shall determine on a continuing basis- 12 (A) the supply (both current and projected and 13 within the United States and svithin each State) of reg- 14 istered nurses, licensed practical and vocational nurses, 15 nurse's aides, registered nurses with advanced training 16 or graduate degrees, and nurse practitioners; 17 (B) the distribution, within the United States and 18 within each State, of such nurses so as to determine 19 those areas of the United States which are oversupplied, 20 undersupplied, or which have an adequate supply of such 21 nurses in relation to the population of the areas and the 22 demand for the services which such nurses provide; and 23 (C) the current and future requirements for such. 24 nurses, nationally and within each State. PAGENO="0257" 247 16 1 (2) The Secretary ~haIl survey and gat.her data, on a 2 continuing basis, on- 3 (A) the number aind distribution of nurses, by type 4 of employment and location of practioe; 5 (B) the number of nurses who are practicing full 6 time and those who are employed part time, within the 7 United States and within each State; :8 (C) the average rates of compensation for nurses, 9 by type of practice and location of practice; 10 (D) the activity status of the total number of 11 registered nurses within the United States and within 12 each State; 13 (E) the number of nurses with advanced training or 14 graduate degrees in nursing, by specialty, including 15 nurse practitioners, nurse clinicians, nurse researchers, 16 nurse educators, and nurse supervisors and administra- 17 tors; and 18 (F) the number of registered nurses entering the 19 United States annually from other nations, by country 20 of nurse training and by immigrant status. 21 (3) Within six months of the date of the enactment of 22 this Act, the Secretary shall develop procedures for de- 23 terniining (on both a current and projected basis) the sup- 24 ply and distribution of and requirements for nurses within the 25 United States and within each State. PAGENO="0258" 248 17 1 (b) Not later than February 1, 1976, and February 1 2 of each succeeding year, the Secretary shall report to the 3 Congress- 4 (1) his determinations under subsection (a) (1) 5 and the data gathered under subsection (a) (2) 6 (2) an analysis of such determinations and data; 7 and 8 (3) recommendations for such legislation as the 9 Secretary determines, based on such determinations and 10 data, will achieve (A) an equitable distribution of 11 nurses within the United States and within each State, 12 and (B) adequate supplies of nurses within the United 13 States and within each State. PAGENO="0259" 24~ [NITEI Six ~ (`I\II. SFi~\ 1 Xi. MiSSIO'~ 9 i.~h~ogtai, Ii.( .. I- ~``ruary 2S, Hon. hARLEY U. STAOGERS, Chairman, CO/1/1,litt( i. I/Fl Ji/tri'Stut' (1/HI Ioi' 1 c; scitta tivcs, Washington, D.C. I (EAR MR. ChAIRMAN This is in further response 1 yOl re~UH-5l for the Coin- 1111 (SiOlls Vle\\5 //li hR. 11~39 and HR. I 1i~T, tWo 0nl ;~ 1115 `9 ;~ ~iiid extend the Public Health and National health Seiv~ ~`rps s~ training program. hR. 11539 and HR. 11557 are identical 1(1 a (Iraft ill submitted the Speaker (/f the house on Novellll(er 12. 1973. by the Secretary of Heal.. Edu- cation, and \Velfare, The bills would expand the authority of Section `~25 of the Public health Service Act in order to improve tile oppOrtlIhlities of students to receive e(lucation in the health professii Ills, and 1 o insure au adequate future supply of health professioiials to discilarge esselltial Federiii health care responsibilities. The Office of Management and Bu(Iget advises that from t ii standpoint of I lie Administration's program there is ilo oh~eetion 9) the ~:i :iiission of this report and that eiuactuuient of either hR. 11539 or hR. 11 5s~ `veuld be in ae~ coi'd with the program of the Presideilt. By direction of the Coriumission. Sincerely yours. RonEwl' IIAMP'TON. C li a irni a a. 1)F:PARTMF:NT OF hEALTh. EDUCAITON, ANI) WEI.FARE, 11(1.51/i//i/tOll. 1). (`.. iI(1i'Cll 6, 197h I lou. IIAIILEY ( ). S'r~~GnF:Rs, (`hairmnan, (`onimnitte Oil Iflt('l'stUte and J"OI'(i!/fl (`O1l/nl(/'(e, 11/Il/SI' (if J?(pr- sentatices, Washington, D.C. I )F:AR MR. (`IIAIRMAN This is iii respollse t( I V//ill' requests ((1 1 )ecernber 11. 1973. for reports on 11.11. 11539 and hR. 1 15i~7. 1/ills ``1')) inlprove and extend I he Public I lealthi a 11(1 ~\atioIIa 1 I lea itli Ser~' ice ( `orps 5(10 la rship training program." `Flie bill was transnlitte(l to the (` )mlgress ill I raft f run I y ii' otter (/f No- vend er 12. 1 973,Ac opv of t hat tra IlsIlIl tta I is enclosed fm ~/ ui. (` `I, vehileIlce, We believe that emlactnlellt of tllis legi sI :1 ti//Il W'IIlhld I (C au I ullhlorta nt step t) / Wi/I'd /l55111'i m~g an ade(Juate future supply if hlealtil ~F( (tessi( na is for Ill oeting essential federal health (`are resl))/IlsiI)ihiti)o.. 111(1 would sIlZilIIleIllltlV nh/rove lIe possibllit ot a IIealtll professit /lls ediii'a ti//ll f//I' Ia rgi I/I `015 ei. 5)rthy st iideiits. A('('( im'diiigly. we urge the (`(/ngress 9/ give fav no i ` 1/I/F to tile measure. We are ll(lvised by the Office of Maulagenleult and Bud~o ,~ here i- 1/0 /1/- je/'ti omi to the presentation (If tills ri! I) )rt a 11(1 ti/lit eIi~/ (`tile `i/I ~ 111. 11531 a 11(1 I I.R. 11557 wolhI(I he ill a/SI /1(1 with the pro aril Ill (If t lIe i ` r; "` Si Il('erely, ( `xsi'A ii \`. \\`O. I il/; /1/hER. .~eerefc h/f. Enclosure. I )F:u'\wrMENT (/1' lii: ~` 1(UOATION. ~.o ,to~,. 1~~' 1.~ HOII. CARl, AT.BERT. ~"J)( (t1'em' of th (` HOUSe of I' //FN'S(// to ti, 11'asli inqton, 1).('. I )~:AR MR. SPEAKF:R Elleli/sed with; thlis letter is i draft 1' legisia; . illll)rOve 1/11(1 expamid tile P111/In' hIellithi 1111(1 ~atio1Ih/I ITCh/Ithi ~`Hl'Vi,'( "T/5 Scll/ la rshil/ `Era llli Ilg I 1'(ogra Ill.'' On October 27, 1972. the I 9'esident 1/ pr/r//ve/l Puhil 1/' Thi so 91 TISS. `Th~ . - gemicv Healtil PCI's//I/n/I Act Al/IellclIl/ellts of 1972.'' ~` 9 9 of that a tilte lid/IC/I t// tile Puhi h hlealtbo Service A /t 1/ lle\V ``~ .. . svhIlell (`lil1"(h upon the Secretary of Ihel/itIl. Ed/lent//n. II II1 \Vl'9' 1 9 T ~althi 1111(1 .\ational 1~/bOlt1; Sei'vice (`orps 5/hF-b .. F: :~.b I'r/~ . to /Ihtlhifl tl'lliII('d ll/Ohltbl profe~ion1/I5 fe- 1 `//rJ/s ;;~o' oft (`F ;:/ the PAGENO="0260" 25~ Public Health Service. Participants in the Program could receive up to four years of scholarship aiid stipend assistance, in return for which they would Lie obliged to serve e'~lier as a commissioned officer in the Service or as a civilian member of the Corps for a period of not less than one year for each year of training received under the Program. Persons failing to meet their obligations under the l'rogram would be liable for repayment, with interest, of the Federal support they received. The section authorizes appropriations for the Program of $3 million for fiscal year 1974. The Administration strongly supports the objectives of section 225. The De- partu~ient of Health, Education, aiid Welfare believes it offers the potential not oiiiy of assuring an adequate future supply of health professionals to meet essential Federal health care delivery responsibilities, but also of truly opening the door to a health professions education to sizeable numbers of deserving students. including many from disadvantaged social or economic backgrounds. The preliminary experience of the Department of Defense with its similar health professions scholarship program (authorized by P.L. 92-426) is grounds, we think, for optimism over the long-run promise of the Program. For these reasons, the PresidenVs 1974 Budget contemplates not only full funding for this Program, but a substantial expansion of the Program beyond its present authorization level, for a total of $22.5 million in 1974. Funding of tile Program at that level would provide full support for in excess of 2,000 health professions students, and would accompany the phasing out of the tra- (litional scliolarship programs operated by the Bureau of Health Manpower Education in the Health Resources Administration. The basic philosophy re- tlecte(l iii these proposals is that the public is entitled to public service from those individuals who are beneficiaries of special scholarship assistance while receiving their health professions degrees. The traditional scholarship pro- graiiis-~vhiicli do not require such service-are inconsistent with that principle. The provisiotis of section 225 as presently drawn, however, are unnecessarily restrictive. The apropriations authorization not only is too low to permit fund- lug of the Program at ~22.5 million. but in addition covers only fiscal year l97-~. We believe that substantially larger funding than $3 million is warranted for this Program aii(l that it should i)e available for use indefinitely. We also believe that it would be desirable for the Secretary to have clear and unalnl)iguous authority to assign participants in the Program to any civilian or uniformed Federal health service. The National Health Service Corps and other health service delivery programs of this Department would doubtless he the primary users of the Program participants, and perhaps In the short run would be the sole users. At some future time, however, the Secretary might determine that certain of the participants could more appropriately serve elsewhere in the 1)epartment. or even in other Federal agencies (e.g., tue Veterans Administration) or State or local governmental units. It would he preferable to not have to appoint individuals to the commissioned corps of the Public Health Service in order to do this, hut rather to be able to assign them directly to other health service duties. The enclosed draft legislation. accordingly, is intended to expand the au- thioritie'~ in the present section 225. Briefly, the bill would: Authorize to be appropriated for the Program "such sums as may he necessary"; extend the Program for an indefinite period beyond fiscal year 1974; and authorize assign- ment of tue Program's particilialits to the National Health Service Corps, and "to such other uniformed or civilian Federal health service as the Secretary ntI'iv determine is appropriate.' We believe that enactment of this legislation would be an important step toward assuring an adeouate future supply of health professionals for meet- in~ e~sential Federal health cire responsibilities, and would significantly im- nrov~' thlO iiossii)ility of a health professions education for large numbers of worthy students. Accordingly. we urge the Congress to give favorable consiciera- tion to the mnea~ure. Tiu-' (~ffice of Manarenient nind Budget has advised that there is no objection f' tho suhmni~ion of this lerb~Iation, enactment of which would he in accord with the program of the President. Sincerely. FRANK C. CARLTJCCT, Acting Secretary. PAGENO="0261" 251 OFFICE OF MANAGEMENT AND BUDGET, EXECUTIVE OFFICE OF THE PRESIDENT, Washington, D.C., February 22, 1974. Hon. HARLEY 0. STAGGERS, Chairman, Corn ntittee on Interstate and Foreign Commerce. Hause of Repre- sentatives, Washington. D.C. l)EAR MR. CHAIRMAN: This is in response to your request of December 11, 1973 for the views of this Office on HR. 11539 and H.R. 11587, bills "To improve and extend the Public Health and National Health Service Corps schol- arship training program." H.R. 11539 and H.R. 11587 are identical to a draft bill submitted to the Speaker of the House on November 12. 1973 l)y the Secretary of Health, Edu- cation. and Welfare. The bills would expau(l the authority of Section 225 of the Publi.c Health Service Act iii order to improve the opportunities of students to receive education in the health professions. and to assure an adequate fu- ture supply of health professionals to discharge essential Federal health care respOflsil)ilities. We concur with the views expressed l)y the Department in its transmittal letter and, accordingly, recommend enactment of H.R. 11539 or H.R. 11587. Enactment of the legislation would he in accord with the program of the President. Sincerely, WILFRED H. ROM MEL, .4 ssi stan t Director for Legislative Reference. 1)EPARTMENT OF HEALTH, EDUCATION, AND WELFARE, Washington, D.C., June 27, 1974. Hon. HARLEY 0. STAGGERS, Chairman, Committee on Interstate and Foreign Co'mmercc, llnise of Repre- sen tat (yes, Washington, D. C'. I)EAR MR. CHAIRMAN: This is in response to your requests for our views on fIR. 14930, a 1)111 "To amend titles VII and VIII of the Public Health Service Act, and for other purposes.' and H.R. 14931. a bill "To extend the National Health Service Corps, and for other purposes.' 1I.R. 12930 was submitted by the l)epartment. on behalf of the Administra- tioli. on May 20, 197~. in the form of a draft bill to be cited as the "Com- prehensive Health Manpower Act of 1974.' It is intended to translate into legislation the health manpower themes of the President's budget for fiscal year 1975. A copy of our submission is enclosed for your convenience. HR. P931 was submitted to the Congress, on behalf of the Administration, by our letter of April 30. 1974. a copy of which is also enclosed for your con- venience. The latter bill, to be cited as the "National Health Service Corps Amendments of j974," would authorize the appropriation of such sums as may he necessary for the program for additional period of three fiscal years, 1975 through 1977. and would make several changes in the program structure. We urge that both bills receive the prompt and favorable consideration of VOiH Committee. We are advised by the Office of Management and Budget that there is no objection to the submission of this rel)ort and that enactment of H.R. 14930 and H.R. P931 would be in accord with the President's program. Sincerely. CASPAR W. WEINBERGER, Secretary. Enclosures. DEPARTMENT OF IIEAI.TH. EDUCATION. AND WELFARE, Washington. D.C.. May 20, 1974. lIon. CART. ALBERT. speaker of the House of Representatives. Wa~hington, D.C. DEAR MR. SPEAKER: There is enclosed for the consideration of the Congress a draft bill "To amend titles VTT and VIII of the Public Health Service Act, and for other purposes." The bill, when enacted, would he cited as the "Com- prehensive Health Manpower Act of 1974.' PAGENO="0262" - a i'aa>:att' 11111 It ~aiatioa the health manpower - *` `,at'l Hi' :a-.cal tar I :" ,a have assnrt'ti a major increase in the Jl',tlesslons sill tils. Since 1965, first-year a `` :1:11 a:' `5 a irtilli N~34 ri 13.726, a 55% increase. - a `in-a ii a. k'iliilasis will he placed on aiding stu- an r"ducing unnecessary Federal subsi- a' sc ii 1 az. v~' iii can anticipate high earnings, art' area claire itt their educational costs. Fed- * -. :11 :1 va :11 `to, itti proposed legislation will in- iii t tie liea Itli professions by raising cell- `a -I a an :a I tei requested for a scholarship - ,,-: ~l abuts intl 110111 nieet Federal requirements * `I a r'ciil 5 ni 11 10 provided in return for a com- A pen' program of fellowships will * , - 1:' fl, `J -uiq'rr. ( ;~aaral purpose support to in- -a I::. :i~ l".-dt'aai assistance shifts toward pro- * , au ::: I - z ~itI~i~t-. `i: 1975, Federal outlays for `.,:r'il at c7a( ~~i:uiitn. (At pp. 119-120.) a, :.`: ii `IF'.\CHiPPt FACILITIES fl'' `.` l:t'aiti, pretesc~onals graduates against * - `a -1" uc that existing facilities, if main- f `z'z-i"iiliIz' future uteri, For example, in 1970 a phy~ `:ans :n rho Fnited States, or 159 * If ti,z'u:anii'z'i' `f drst-year training places - - : `. :aa a: died wutnout change through 1990. :u,idirl,.n itt foreign medical graduates * . `.r: aa I,:' - mid-lOGO's, about 3.500 a year. * : a a' i `aitt'tl Stat esw ill grow to at least * ``aI,."zu:'ti(tii and 554.000 in 1990, or about l'i:l,lii' and lint-ate support to allow for :1:-Il vt 1 .3 percent for medical schools and * . ~. a id a not addition of 5.200 foreign medical * a `a's iaiatiiig recent levels) we would estimate 100,000 population to arrive at 237. We - -i,pJ' `- ti::it a projected increase of this size- ~0 percent. more physicians per 100.000 `i Iii he insufficient, if appropriately dis- . - -``Ity toni-ems addressed by aspects of our `I ` *` ` -` prospective national requirements for `a" `Ill a, .. ` :aat tiue focus of the current health pro- [a'' `I- . a *` ~. training facilities, construction pro- `-"nra ac, through the making of Federal `i *`,.f Ii-:',' :. a'' i:o'i titles. we would instead concentrate `ri-I `a : :,:-iiitit's to maintain and improve their "1 "`all a-ala. i'~l: this t 1) by allowing the expiration of -` -``I `" a"::'- f part B (if title VII of the Public Health I : . ` 2 t by amending the provisions that now a':: ``:` .`- : C::'] 1' for loans for the construction of health `a a `,aa<' a r":i,'':'iaz facilities. ti instead provide assistance ````-ri"::' `tItling if facilities. Loan guarantees for Ti'": ` `:i'l :`ias ` t'xet']tt as r"idacemuents for old buildings) `a'', a `a ` `f s I ` ` a I `a ``F ii a.' n' iit d no longer he available. In addi- `.-:-m'-"t `a''' `a a' ``.- `tI `a ,x~rt~cced in the President's budget of `a a 1 (I-C ` 1. -`P rh:', : `zur ens, we would no longer offer to sub- `I a - ` a a. zr ``i : :"n'g:ia ranteed loanc under the program. it':: a-n `it' :`vailahle under the program for schools a' -`` ilie replaet'ment or remodelinz of these a -"it'':, aunt `a' ` a a ritual need. The draft bill al~o omits a `l"I :: :1 ```dzatittzi a " :: Iroltniations for the construction of I': ` ` : ii' ` ` `` `a: a liii (It'' -`U:,"'- PAGENO="0263" 253 CAPITATION AWARDS In the Comprehensive Health Manpower Training Act of 1971, the establish- ment of a capitation grant program reflected a judgment by both the Congress and the Administration that "first dollar" funding of health manpower edu- cation was au appropriate and needed mechanism of Federal support. Experience to date suggests that the capitation grant program has achieved certain of its original objectives, in that the financial viability of many of these educa- tional institutions has improved, and in that some portion of the enrollment increases experienced would probably not have come about in the absence of the expansion requirements in the capitation grant law. Despite these positive aspects, which the Administration recognizes, an analy- sis of the capitation program and consideration of future trends reveal serious flaws in the capitation grant concept.. These defects call into question the ap- propriateness aul(1 desirability of the capitation mechanism as the Federal Governments primary tool for the support of health manpower education. Chief among the deficiencies are that the capitation program: due to its in- herently rigid allocation formula, resulted in comparative windfalls for cer- tain schools and shortfahs for other schools-that is to say, the funds were not targeted based on an assessment of need for such support: the incremental enrollment increases that may have resulted from the program proved to be very costly; the amounts authorized and appropriated for the program were arbitrary and unrelated to any concept of actual educational costs; the costs of this program would only be expected to continue to increase, with the schools and the students becoming increasingly and undesirability dependent upon the continued flow of Federal subsidies for the health manpower edu- cational process; and reasonable alternative sources of funding support for the health education process are available in lieu of Federal across-the-board, formula-type institutional subsidies. In this regard, we would emphasize that capitation support must be viewed, at least iii part, as a means of subsidizing health professions students indi- rectly through institutions. In conjunction wit~ other assistance to health professions schools, Federal capitation grants enable a student to pay a tuition that commonly defrays less than 30 percent of a school's costs of training him. Nevertheless, health professionals, particularly physicians and dentists, have high earnings. The annual rate of return on the total costs of a basic me(lical aul(l dental education has been estimated to be over 20 percent, a rate that is two to three times the ratio of return for graduate education gen- era thy. In view of these earnings, health professions students can and should be called upon to pick up a larger share of their educational costs. The Federal Governuuient should not call upon the general public, through tax revenues. to suul)sudize the training of individuals who arc themselves able to hear the real costs of their training and who, hecaus of that training, will quickly re(.'oul) those (`Osts from members of the public iii the form of compensation for their urofessional services. Accordingly, we propose to extend eapitation for most health professions schools for an additional thro*' years. hut modified as follows 1 The statutory cajitat~on anionnts for schools of medicine, osteopathy, and dentistry. now $2.i~00 for e;I"i~ stndent in each of the first three years of training and $4000 for ea Ii stolen; in a gra(1uat~ng class, would he set at $1,500 per enrolled student ( without regard to year-class) for fiscal year 1975, $1,250 per student for fiscal year 1976. mod $1,000 per student for fiscal year 1977. This compares to an aver:u~' actual capitation level, under the 1974 appro- priation for this activity, of about $2,000 per student. 2. Schools of veterinary medicine, for which capitation is now set at $1,750. would he set at $900. $600. and $300. for the fiscal years 1975, 1976. and 1977, respectiv~lv. Arain. this compares with the actual 1974 appropriations level of about ~1 .325 ner student. ~. Schools of optometry and podiatry, for which capitation is now et at $500 per student. would be set at $400. $300. and $200. for fiscal yea~ 1975. 1976. and 1977. respectively. The actual 1974 appropriation for these di~ciplines averaged about $625 per student. ~l. Because the draft bill would not imnose any enrollment increase require- ments on the school (merely renuiring that the schools maintain their 1974 level of first-year enrolment) the capitation for "enrollment bonus students" PAGENO="0264" 254 (i.e., students in year-classes nieeting certain enrollment increase require- ments) would be dropped. 5. Capitation of uiidergraduate training-i.e., the training provided by schools of pharmacy and nursing-as well as general assistance, ~pnder section 309(c) of the l'ublic Health Service Act, to schools of public health, would be allowed to expire. 6. The current program of grants for small medical, osteopathic, and dental scliools-esseiitially a one-time bonus of $50000-and the capitation for three- year schools of medicine ($2,500 for each student enrolled in a fiscal year, plus ~6.000 for each stu(lelit graduating in that year) would be repealed. START-UP ASSISTANCE The current program of start-ill) assistance would be phased out by limiting it to schools that have received a start-up grant for fiscal year 1974. NATIONAL PRIORITY INCENTIVE AWARDS The draft bill would establish a new program of National Priority Incentive Awards to increase the iiumher of health professionals who enter critical health shortage specialties. The program would have two principal features 1. It would award to each school of medicine and osteopathy an amount equal to $2000 for each of its graduates who enters a residency in the practice of family medicine. As a condition of receiving this award, a school would be required to use its best efforts to increase the number of its graduates who enter such practice. 2. It \VOUld award grants to pay part of the cost of planning, developing, and operating for au initial period (not to exceed three years), programs of graduate or specialized education 01' training in family medicine, pediatrics, internal medicine, and other health care shortage fields. The grants could include amoumits intended to auguuieuit time conipensation otherwise payable to an indi- vidual in consideration of his participation in a program. (0 N SOLI I)ATION OF SPECL~L PROJECT AUTHORITIES The existing health manpower special proiects authority would he amended iii order to embrace assistance miow authorized under comparable special project authority contained in the nursing. allied health, and public health professions portions of time Public Health Service Act. Those latter authorities would be allowed to expire. (`oNSOLII)ATION OF SPECIAl. PROJECT AND HMEIA APPROPRIATIONS AUTHORIZATIONS The authiorizatiomis of appropriations for the special project grants for the health professions and the health l)rOfessiofls Health Manpower Education Ini- tiative Awards would ic consolidated in a single provision. That provision would extend both progranis for three years. FINANCIAl. DISTRESS The health professions financial distress grant program would he extended for three years. but would he amended to terminate the eligibility for financial distress gramits of schools of pharmacy. The hill w-ould also limit the financial distress grant to amly school for a fiscal year to 75 percent of the financial dis- tress grant awarded for tile preceding fiscal year. This limitation is intended to make clear that amounts awarded under the financial distress provisions of the law are not intended as aim increase of the general educational support that a 5(11001 receives under the previously-described capitation provisions, but are truly amounts awarded on a short-term basis to meet an extreme and unusual exigency. PRE-AD MISSION A ND FOLLOW-UP ASSISTANCE TO THE DISADVANTAGED The draft bill would amend time existing program of special assistance to the disadvantaged, for training in the health care field, by authorizing the payment to eligible individuals of stipends. with allowances for travel and for depend- ents. for post-secondary education or training required to qualify the individual for admission to a school providing health training, or to assist a person in undergoing that training. PAGENO="0265" 255 The Department proposes to administer this authority as follows: 1. It would restrict the assistance to study in preparation for, or leading to, a first professioiial degree in the health care field. That is. stipends would not be provided in connection with training, such as in nursing or pharmacy, at the undergraduate level. . 2. It would limit assistance to fields that prepare the individual to provide health care. Stipends would not be provided, for example, for the study of pub- lic health administration. 3. As previously discussed, persons who enter most health care fields enjoy a high iiicome potential. As their professional education progresses they are in- creasingly able to command loans for the completion of their education. Indeed, to facilitate the availability of these loans the Administration has recently proposed a substantial increase in the cumulative total of educational loans that such students may carry under the student loan insurance program established by title TV-B of the Higher Educatioii Act of 1965. Accordingly, stipends awarded for professional study (as (listinct from pre-a(Inlission assistance under the amended health professions program of special assistance to the disadvan- taged will he limited to the first year of training. SCHOLARSHIPS FOR SERVICE We believe that the Public Health and National Health Service Corps Schol- arsliip Training Program offers the potential not only of assuring an adequate future suppiy of health professioiials to nieet essential Federal health care de- livery responsibilities. but also of truly opening the door to a health professions education to sizeable numbers of deserving students. For these reasons, the l'resideiit's 1973 Budget contemplates lint OOl~ full funding for this Program, but a substaiitial expansion of the Program beyond its present $3 million author- ization level, for a total of $22.5 million iii 1975. Funding of the Program at that level would provide full support for in excess of 2,000 health professions students, iiIi(1 would accompany the l)hasing out of the traditional scholarship programs operated by the Bureau of Health Resources Development in the health Resources Administration. The basic philosophy reflected in this disposi- tion of resources is that the public is ordinarily entitled to public service, or service meeting a public iieed, from those individuals who are beneficiaries of special scholarship assistance while receiving their health professions degrees. The traditional scholarship programs-which do not require such service-are inconsistent with that principle. We propose to broaden and strengthen the program. consistent with these views, as follows 1. We would extend the Program indefinitely, and authorize appropriations for it of such suiiis as may he necessary. 2. We would provide the Secretary with clear and unambiguous authority to assign participants in tile Program to any civilian or uniformed Federal health Service. Tile National l-Iealth Service Corps and other health service delivery l)rogranis (If this i)epartnient ~vould doubtless he the primary users of the Program participa nts. 011(1 perhaps in the short run would he the sole users. At some future time. however, tile Secretary might determine that certain of the participants could more appropriately serve elswhem'e in the Department, or even in other Federal agencies (c.q., the Veterans Administration) or State or local governmental units. It would be preferable to not have to appoint mdi- viduals to the Conimnissiomied Corps of the Public Health Service in order to do tins, 1)llt rather to be able to assi~n them directly to other health service duties. 3. Finally, we believe there should he room within the Program to assist in- (lividuals who wish to remain in the private sector. hut who are prepared to practice a health profession in a geographic area of critical health manpower shortage. These individuals would miot he employed by tile Federal Government but would undertake to serve in shortage areas, as determined by the Secre- tary, for the same perio(l of service to which other individuals assisted under the Programii are obligated to serve the Federal Government that is. one year of service for each year of scholarship assistance. hEAlTh PROFESSIONS AND NFRSING STUDENT LOAN PROGRAMS The draft hill would also limit further Federal capital contrihutions to health professions and nursing student loan funds to the amounts required to con- tinue loans to students previously assisted from the funds. However, the funds 38-bbb 0 - 74 - lb (0. 1) PAGENO="0266" 256 would renlaili available. for the next three years. for the schools to make new studs'iit loans fi'om aiiiouiits revolving back into the student loan funds ; and tar eoiitinuatioli loaiis. The 1 iii wOul(l also raise the interest rate on these loans from three to seven percent the sanie maximUm mate of interest now prescribed under the student Is an insurance ~r~gm~lIi1 c litaine(l in tist' Higher Education Act of 1965). * * * * * * * We believe that eiiactiiieiit of this legislation would he an important step toward assuring an ashs'iuate future supply of health professionals, both for meeting tims' general heeds of time public and meeting essential Federal health care responsibilities. It would remedy the problemmi of unnecessary public subsidi- zati ml it the education of individuals prepa ritig to enter highly paid health s'are o('clmpatiolls. Nevertheless. it would sigmiifi('alltly improve time possibility of a boa It Ii pr fessiomis education for large numbers of students. We urge the (`omigm'ess to give the miieasurs' its ~u' mnpt and favorable consideration. We arm' advised by the ( )ffi('e of Management and Budget that enactment of this Waft bill wi uI(l hi' in ace rd with time program of the President. i'~ incerely. (`ASPAR W. WEINBERGER, Secretary. DEPARTMENT OF hEALTh. EDT'CATION, AND WELFARE, April 30, 1974. lion. CARL ALBERT. Spooler of the house of H(prcRentatire5', Washington, D.C. DEAR MR. SPEAKER: Enclosed for the consideration of the Congress is a draft bill. "To extend the National Health Service Corps and for other purposes." The bill, which would he sited as the National Health Service Corps Amend- ments of 197-1. would authorize the appropriation of such sums as may be neces- sary for the program for an additional period of three fiscal years, 1975 through 1977. an(1 would make several changes in the program structure. The Secretary is now authorized by section 329(d) (1) of the Public Health Service Act. in connection with the assignment of personnel of the Corps to a boa Ithi mima np wer slim irta go area. P "inn ke snob a rra migemmmeiits as he determines are ne('essary for the use of equipment and supplies of the Service and for the lease or acquisition of other equipment and supplies, and ... secure the tern- horar~ servi('es of nurses and allied health professionals. in order to make the miiost effective use of program resources, and to encourage the assisted community. insofar as may he practicable, to particiPate in the hroam'amn. it is the Department's practice to assign i~'rsonnel to an area under an agreemiieat whereby the comiimiiunity contributes some portion of the supplies, equipment. facilities, or su~)~)ortim1g services that aid Corps personnel in providing health care. In order to encourage greater use mif community resources in the making of these ancillary arrangements, the (lraft bill would authorize the Secretary to award one grant, not to exceed S1O,O(1h. to each assisted community, to enable time comiimnunity to meet the costs of establishing medical practice management svstenis. and acquiring supplies or equipment. In addition. in order to encourage a (`omnhumty to imsake these arrangements without, or at a cost in excess of. this grant, time bill would enable the Secretary mini ho an ea m'ly rejnl y imieuit if the (`hiS ilium ty's imivestmnent frommi time fees (`01- lec'ted for tIme health (`are pm'ovided liv the Corps. Umhder existing law the corn- mnunitv is reimnbursed for this investment. However, because the law now con- templates simm immediate tixe(l divisiomi of fees between the Federal Government and I lie (onhmliumnity. ifl relatiomi to their contribution to the costs (including Corps salary costs ) of providing health care services under the program, a commauitiity that has made a heavy initial investmnent in the program must wait a suk~tantial l)eriod to recoup that investment. This (lelay in repayment acts as a substantial disincentive to nmamiy health shortage areas to undertake this initial immvestment. Finally. 1mm order to encourage a shortage area to become independent of the Corps if it has the capacity to (10 so, the 1)111 would authorize the Secretary to release to the area any right, title, or interest he may have in equipment or PAGENO="0267" 257 supplies used in connection with the Corps' provision of health care services. In this regard, it should be pointed out that there is ample precedent for vesting authority in the Secretary to waive accountability to the United States for equip- merit I)UrChased with Federal assistance under grant programs. See, for example, section 436 of the General Education I'rovisions Act, 20 U. S.C. 1232e, and Public Law 85-934, 72 Stat. 1973, 42 U.S.C. 1591 et seq. We urge that the draft bill receive prompt and favorable consideration. We are advised by the Office of Management and Budget that enactment of this draft bill would be in accord with the program of the President. Sincerely, FRANK C. CARLLTCCI. Acting secretary. OFFIcE OF MANAGEMENT AN!) BtI)aET, ExEcU'rIvF: OFFICE OF' THE PRE5II)ENT, Bash ington. 1).('.. `June 18, 1974. 1101!. hARLEY 0. STAGGERs, Chairman, (`oinm ittee on Intcr.stat( and Foreign (`ma inerce. house of Repre- sen tat ices, Washington, D. (`. I)EAR MR. CHAIRMAN : This is in response to vinir re(luesl of May 30. 1974 for the views of this Office on HR. 14930, a bill `To anreiid titles VII and VIII of tire Public Health Service Act, and for other purposes.' hR. 1493() is identical to draft legislation suh)nritte(l by the Secretary of health. Education, and \Velfare on May 20. 1974 for the purpose of implementing the health manpower policies of the President's budget for fiscal year 1975. The legislation is (lesigned to gradually shift tire method of supln)rt for medical C(1UCi1- tion from general institutional operating subsidies to (liI'ect assist~i nec to medical stu(lents through individual loans and scholarships. The hill is 015(1 designed to assure au adequate future supply of health professionals, both for meeting the general urueds of the public and meeting essential Federal health care respon- siiriliries. \Ve concur with the views expressed by the Secretary of health, Education. md W'elfau'e in his transmittal letter'. Accordingly, we recommend that I lie Corn- niittee give favorable couisideratiorm to the hill. Erractnrienit of 11.11. 14930 would he iii ac~'ord with the program of the President. Si ncerel y, WII.FREn H. ibM MEL. Assistant T)irr (`for for Lcqislati re Reference. OFFIcE OF' MANAGEMENT AN!) BUDGET, EXECVTIVF: OFFICE OF TIlE PRESIDENT, 1l'ashington, D.C.. June 18, 1974. lion. HARLEY 0. STAGGERS. (ire, noun. (on, in it tee on Jo tens tote an (I Foreign (`o,n in crcc, 11(1 1I5(' of Ii'(prese'n tO tires. 1l'a.s/i in!/tOn. !).(`. I )u;Aim Mu. (`uu.~IE\u~~N : This is in response to your request of May 30, 1974 for tire views of this Office our HR. 1-~931. a liii! "To extend the National health Service (`nips, and for otirer purposes.' hR. 1 ~931 is identical to draft legislation submitted by tile Secretary of health, Education, and Welfare on April 30. 1974 for the purpose of authorizing tire approl)I'iatiour (if such sunrs as may lie necessary for tIme next three years an(l niaking several changes iur tire implementation of the National Health Service Corps jii'i grrm in. \Ve concur with tire views expressed by tire Secretary of Health, Education, nnd Welfare lii Iris transmittal letter. Accordingly, we reconiinend that the Corrmniittee give favorable consideration to time Phi. Enactment of HR. 14931 would he iii accord \Vitll tile program of the President. Sincerely, WII.FRF.D H. ROM MEL. -tssixtqn t Dire et or for Legislative Ref erence. PAGENO="0268" 258 Mi. 1~( (;F:Rs. We are pleased that our first witnesses for this hear- lug are rej)reSeiltatives from the Institute of Medicine who will high- iu.rht the hhI(lings of the study for the. subcommittee~. With us this morning are the acting president of the Institute. I)r. Roger Bulger, and ~I is. I~iith ~. l-ianft. study director for the report. l)r. Bulgei and Mrs. Hanft, if you will come to the witness table you univ proceed as von desire. We are delighted to have you with Us. I \vaIIt to say oii behalf of t lie committee that we are most ap- preciative of the work that the Institute of Medicine of the National Academ of ~cieiices has done. and I am sure it will be helpful to this commjttee in writing this legislation. Thin nk von for voiii presence here this morning. STATEMENT OF ROGER BUIGER, M.D., ACTING PRESIDENT, INSTI- TUTE OF MEDICINE, NATIONAL ACADEMY OP SCIENCES; ACCOM- PANIED BY RUTH S. HANFT, SENIOR RESEARCH ASSOCIATE, INSTITUTE OF MEDICINE I )r. Bui~enu. `I'hiank von very much. Mr. Chairman. Mr. Chairman and members of the committee : I am pleased to be here to(lav to represent the Institute of Medicine, on behalf of its I)ieSidellt. and to colnnu9lt briefly on the Institute's recently corn- plete(l stll(lv of the costs of education in the health professions. With tue is Mrs. I~iithi Ha tift, senior research associate of the Institute, who (hirected the l~-nionth study. Before Mrs. Hanft presents her stat~tuient. I should like to say a few words about the Institute of Medicine and the manner in which it conducts its work. The Institute was established liv the National Academy of Sci- ences iii 19~() to bring together experts in a variety of fields and oc- cujiat Ions to examine issues of health policy in the public interest. The I uistitnte has an elected nleml)ership which currently numbers men and women a mid may ultimately total 400. One quarter of the members must be drawmi from professions other than health and muiedicine-law. i)uisimiess. economics. 1)ublic administration, en- ~iiieeiiuu~. the natural. social, and behavioral sciences, and the hlliflUuilitieS. ihe mnenibers are assisted in the conduct of studies and analyses liv a uuuuiltidiscuphinaiv professional staff that has grown fourfold duumiier the past ~ yeats. The Institute's program consists of both in- tcinahlv initiated P1oI(~cts and projects undertaken at the request of ( ~oiigress and the executive branch. The Institute depends on funds (oiltrihullted l)v I)rivate organizations to conduct a sizable portion of its activities. ~Ilie study of educational costs in the health professions was the Hrst major undertaking of the Institute of Medicine stemming from a (ouIgresslomlal request. It was performed under contract with the I )epa rtnieiit of T-Iealthi Lducation. and Welfare, and was conducted by a staff of some ~() people. headed by Mrs. Hanft, assisted by a ~rionp of con uiltants. The entire project was supervised by a steer- iuu~ (ommittee appointed liv the Institute presi~e1it. Assisting the sta if a uid commui ittee were eight 1)rofessioiial advisory panels chosen fionu the eight professions included in the study. PAGENO="0269" 250 The selection of Peol)le for working committees of the Institute is made on the basis of competence in dealitig with particular kinds of issues. Membership in the Institute of Medicine is not a require- ineiit for service. An effort is made in the case of each committee, or study group, to achieve a balance of disciplines appropriate to the project. The steeling committee of the Costs of Education study is chaired by I)r. ,Julius Richmond. professor of child psvchiatry and human development at Harvard and director of the Judge Baker Guidance Center in Boston. Other members of the committee are: l)r. Martin (1herkasky, director of the Moiitefiore Hospital and ~[~dic~il Center, Bronx. ~\ew York; I )r. Eli Ginzbe ig. professor of economics in the Graduate School of Business, Columbia Lniversitv Mr. James F'. Kelly. former vice president foi' Administrative Af- fairs at Georgetown University. and now vice chancellor of the State I iiiversitv of New York; Mrs. Anne Kibrick, professor and chairman, T)epartment of Nurs- ing of the Graduate School of Arts and Sciences. Boston College; Mr. living .1. Lewis. professor iii the Department of Community Health of Albert Einstein College of Medicine, Yeshiva University; Mr. ` lorton I). Miller. executive vice president and chief actuary, Equital)le Life Assurance ~ocietv of the Unted States l)r. Alvin L. Morris. vice president for administration at the University of Kentucky; T)r. I)avid E. Rogers. former dean of .Johns Hopkins University School of Medicine, and now president of the Robert Wood Johnson Foundation ; and 1)r. I)aniel Tosteson. professor and chairman, I)epartment of Physiology and Pharmacology of l)uke University Medical Center. The report of the costs of education study is in three parts. Re- sponsibilitv for the substantive aspects of each part rests with the steering committee. The recommendations made do not necessarily reflect the attitudes and opinions of the Institute's governing council or of the membership at large. All Jiistitiite study reports and policy I)ilPerS are given an inde- 1)endent review prior to public release. The reviews are performed by separately constituted panels according to procedures established and monitored by the National Academy of Sciences. I shall now turn the discussion over to Mrs. Hanft. Mr. Ro~Eiis. Thank von. 1)r. Bulgei. Mrs. Hanft. STATEMENT OF RUTH S. HANFT Mrs. I-L~xrr. i~Ir. Chairman and members of the committee `\Ve are pleased to appear before your committee to report the re- sults of a study on the costs of education ill the health professions. required by your committee in the (`omprchensive Health Manpower rfj.~j~~j~g Act of 1971. Public I~l\v 9~-l~7. se(tiou ~ Parts I ~ind IT of our findings were transmitted to oil on February 26, 1974. That volume contains the simmniarv of our findings and recommenda- PAGENO="0270" 260 tions. aggregate data on the health professional schools, the costs of education and variations in cost in each of the eight fields studied, and a (tiscussion of capitation support as a means of financing health professional education. Part III was transmitted to you on April 26 and is a detailed description of the methodology used to determine costs and a descrip- tion of the constructed cost seminars held in medicine, dentistry, atid veteriiiarv medicine. The congressional charge for the stud, in essence, requested in- formation in four areas. rfhe first was the average annual cost of edll('at ion pe~ student in schools of eight health professions-medi- Ci tie, OSteOj)athv. deiit st I, ol)tonietry. pl1a11~1acy. 1)Odiat ry. veteri- i in iv iile(l icifle. and lilirsing. The second was methodologies for determining such historical costs and an aiialvsis of variations in costs among schools of the nine professioii. The third type of information requested was a set of uniform na- t ional standards for determining annual education costs per student ii future years. The fourth request was for recommendations on the Federal Gov- etiimeiits use of the educational cost data for determining the amount of capitation grants to health professional schools. We believe that the methodologies and the findings generated in this stu(lv can be useful to the Federal Government in establishing ~I1I)p0rt for health professional schools and/or students. State gov- einments also can employ the study results for planning of financ- lug the schools. And the schools, themselves, can use the study as a management tool to keep track of their own costs and compare data with other schools. T~sefuh as we believe the data and methodology to be, however, there are limitations. (~ost data. for example. cannot provide infor- utiation on differences related to the quality of the education process 01 the health maiipo~ver needs of the country. This study measured only costs-not iieeds. processes. effectiveness, or quality. The first part of the congressional charge was to determine an- nuial average costs pci student on a national basis, an undertaking ii at ue~ jiii yes a ha ige collect iOfl and analysis of data. Moue than lMi)) schools in the IThited States provide education ~n tile eight professions These schools spent more than $3 billion in the edu(atioii of nioue than 3()0.00() stu(leilts in 1972. Two-thirds of all health professional students are in nursing. and of the students guadiiated. iiuisiiig pioginuns produce the largest manpower pool. The othiet seven piofessioiis graduated 22,900 students in 1973. A sample of 52 schools in the eight professions was studied ~in depth ( see tai)le 1 ` . The sample was drawn to be as representative as 1)os.zi1)1e of the s(hools within each profession. However, the sam- ple was small iii melation to the wide diversity of institutions. In nursing, which has such a large number of schools, a questionnaire was sent to each nuilsilig program in the country to supplement the hel(l studies. Questionnaire responses w~ue received from more than ~° ~ of the nursing piogiams. PAGENO="0271" 261 PROBLEMS OF DEFINING COSTS Health professional schools vary greatly in their curricula, mix- ture of students, organization, and financial structure. Institutional settings range from the free-standing school which educates one type of professional, to a health science center complex of schools, w-hich may educate students toward the first degree in five or six l)rofessions and also train graduate students and house staff. Schools with major ~)rograms of biomedical research and patient care may direct only a small portion of their activities toward education for the first degree. There are a iiumber of difficulties in developing methodologies to separate education costs frotit other costs iii the coml)lex milieu of these institutions. Many of the institutions I)I'ovide instruction to undergraduate and graduate students while producing biomedical research I)i'odlicts and patient care services. There are numerous joint activities that simultaneously benefit more than one program of the chool. For example. a patient care round caii provide instruction to ~\LI). students, nursing and pharmacy students, residents, and in- terns while providing a patient care service to a hospitalized patient. In addition, many costs occur without expenditures or with ex- penditures unrelated to costs. These include such items as volunteer faculty, use of house officers on affiliated hospital payrolls, the un- dervaluing of salaries of part-time faculty, depreciation, and trans- feis among different schools on the university campus. The costs developed for this study were based on faculty activity analysis and program cost allocation. Faculty at each of the 82 schools was asked to keep a 1-week time log of all activities for a representative w-eek iii the spring of l~)73. In a followup subsample of schools, an additional week was recorded in the fall. It disclosed little aggregate difference in total costs. Time logs were coded into 13 activities (see clia it 1). and profiles of the average distribution of faculty time spent in tlio~e activities was developed for each of the eight types of health professional schools (see table 2). This analysis of faculty activities was the basis for determining instruc- tion and education costs. EDFCATIOX (`05T5 A p;ii't of each institution's cost is clearly attributable only to the education program. These cost items include teaching activities and the portion of joint activities, such as clinical teaching, that are conducted for the benefit of students. This pa~'~ of total costs, plus a share of general support costs, are the costs of instruction. Instruc- tion costs are those incurred principally because there is an edu- cation program. The study group believed, however, that instruct ion costs reflected only I)~urt of the cost of educating health professionals. Such educa- tion in the Vnited States today usually is conducted in a setting of quality clinical practice and biomedical research. Accordingly. the study group interpreted the congressional charge to estimate "education costs" as one of identif\ing the full cost of the educa- PAGENO="0272" 262 tional program. The costs of education were defined to consist of instruction costs plus those portions of a school's patient care and research programs that are considered essential to education. In brief, the methodology used to determine education costs is as follows: First, instruction costs were computed to include teaching activities, general sul)port activities, and portiQns of joint activities. Then, judgments were made to determine the amounts of research and p~tient care activities that are essential to education. Finally, education costs were divided by the number of first degree students to determine costs per student. The amounts of research and patient care included in education are clearly judgmental. In all the professions except medicine, osteopathy, dentistry. and veterinary medicine, the study group be- lieved that all research and patient care activities should be included in education costs. In medicine, osteopathy, dentistry, and veterin- ary medicine, however, these activities assumed large proportions and therefore the study group felt some judgments were required as to how much research and patient care should be included in education. These judgments were derived by leading educators and adminis- trators in medicine. dentistry. and veterinary medicine through con- structe.d cost seminars. The judgments were then used to allocate, to education, portions of the actual costs of research and patient care determined in the field studies. So, the education costs shown in the study are the instruction costs plus the research and patient care costs considered essential. (Table 3.) The education costs present in this study are historical costs. His- torical costs, as well as mixture of activities vary among the schools of the different professions. in large part because the funds avail- able for research and patient care have been greater in some pro- fessions and in some schools than in others. VARIATIONS TN COSTS The second part of the congressional charge entailed an analysis of variations in costs among schools in a profession. Education costs vary widely within each profession. (Table 4.) `While we are continuing to refine the analysis of variation, certain key factors were identified in the report. Since instruction costs rep- resent the largest component of education costs, the variation anal- ysis concentrated on the differences in instruction costs. The main reason found in all the professions for variation in instruction costs among schools within the same profession was instructional faculty/ student ratios (see table 5). These are the ratios of full-time eqiuv- alent faculty time spent in instruction of first degree students to the number of first degree students. In medicine, costs were lower for public schools. In dentistry, optometry, and pharmacy, the situation was reversed. In medicine, costs were lower for schools in health science centei's than for free- standing or university-based schools. In pharmacy~ veterinary medi- cine, and baccalaureate nursing the situation was reversed. The in- cliviclual chapters on the professions in parts I and II of the report PAGENO="0273" 263 provide more detailed discussion of the reasons for variability within each profession. It should be noted again that the study did not produce data or information that could provide any analysis of differences in quality among schools within the same profession. The basic methodology used to determine education costs can be used as the basis for the uniform national standards for determining annual education costs per student in future years. the third part of the congressional charge. Part III of the report contains a detailed description~ of the methodology. We are currently refining the cost finding methodology for use and will publish a "users" manual this summer. NET EDUCATION EXPENDITURES While education costs are a useful measure of the resources used in ~)roviding education for first degree students, these costs do not illuminate the sources of financing for education. They do not take into account the fact that the patient care and research included in the educational prograni can generate income thereby reducing the amount of income needed from other sources to finance educa- tion. To take into account this income, the study group developed the concept of net education expenditures. Net education expenditures are the costs of education less the income that the education program receives from research and patient care income sources. Net educa- tion expenditures, therefore, are that portion of the education costs not offset by research and patient care income (see table 6). These income flows vary among schools and affect the ability of schools to fund the various component.s of the educational program. For ex- ample, in schools with large third party payments for patient care and/or sponsored research programs. these offsets can be large. The use of net education expenditures allows a clear distinction between actual resource costs, as defined by education costs, and the financing of these costs. Net education expenditures were the basis on which the study group made its recommendations on capitation. CAPITATTON The study group was cognizant of a growing national discussion regarding different methods of financing higher education and health professional education. Possible methods include institutional sup- port. with alternative forms such as capitation. distress grants, and special project grants: and also various types of student aid. The study group concluded that judgments on the relative merits of all these financing methods would exceed the congressional charge. and that the time limits of the study did not permit sufficient analysis for comment on financing programs other than capitation. The study group. therefore, limited its recommendations to the question of how the data could be used to determine the amount of capitation. A principal objective of the 1971 Comprehensive Health Man- power and Training Act and the Nurse Training Act of 1971 was to provide financial support for education in health professional PAGENO="0274" 264 schools by means of a capitation grant for each full-time student. Federal aid programs for health manpower have long recognized a dependence between the health care delivery system and the perform- aiice of the schools in providing for national health manpower needs. The Government's interest in a stable base for health professional education has increased along with the Federal share of health expenditures. Federal interest in health professional schools also reflects their status as a national resource of value beyond the boundaries of the States in which they are located. The distribution of schools bears little relation to the distribution of the Nation's population, and the mobility of health professionals induces a State's motives to provide sole support for their training. Federal aid recognizes the schools' status as a national resource and supplements State invest- ments in health education. Stability of direct support for health professional education, and ParticularlY education toward the first professional degree, can en- able institutions to plan and manage education programs. unaffected by shifting Federal emphasis on such products of those institutions as research and patient care. The study group employed two criteria in making a judgment on an appropriate level of capitation: The Federal contribution to health education should be disproportionate with respect to other sources of funds. and capitation grants should be used only as a com- plement to other existing sources of income, never as a substitute for them. Health professional schools historically have been supported by a variety of sources, which differ in amount from one profession to another. These sources are tuition, State appropriations. philan- thropv. sponsored research, patient care and other Federal funds. In public schools, education income is higher as a proportion of total income than in private schools. The major factor, of course, is the State support received by the public schools. Revenues from re- search and patient care also can be large factors in school income. The study group compared the authorized and actual average capitation awards for 1972-73. and the average annual net education expenditures in each profession (see table 7). The authorizations amounted to 25 to 40 percent of the average~ net education expendi- tures, except podiatry and nursing. However, actual average capita- tion awards were substantially lower as a percentage of the average net education expenditures in 1973. Capitation within a range of 25 to 40 percent of net education expenditures-roinihl v the amount authorized-should enable schools to maintain present enrollments without incurring financial distress; it also should facilitate planning by the schools and maintain exist- ing other sources of financing at proportionate levels. The study group therefore concluded that a range of capitation between 25 and 40 percent of net education expenditures would help assure the sta- bility of both the public and private institutions, and the mainte- nance of proportionate levels of State assistance. tuition, and philan- thropy. Table 8 shows per student capitation at 25, 33 1/3, and 40 percent of net education expenditures. PAGENO="0275" 265 Although capitation could theoretically be established according to a variable formula within a profession in an effort to develop in- centives for specific goals, the data in this study did not provide any guidance with respect to the incentives for matching quality and costs. We had no basis on which to discuss alternatives to a flat capitation rate within a profession. Present legislation ties receipt of capitation grants to expanded enrollments, and enrollments have increased considerably in response to this and earlier legislative stimuli. It is the study group's belief that capitation as a method of support is of limited effectiveness in achieving certain objectives other than expanded enrollment. Since there is considerable uncertainty about the adequacy of the future supply of health professionals and considerable, dispute on how to calculate these supply figures, the study group concluded that capitation grants should require institutions to maintain exist- ing enrollments but not require expansion. As to qualitative objectives, the study group believes capitation programs for the first degree can alter only slightly the geographic and specialty distribution of health professionals, which is more affected by post-graduate training. And, although the study group believes that increases in the enrollment of minority and women students should be encouraged, it is the judgment of the study group that capitation is not the most effective policy tool for that purpose. Other forms of Federal assistance can contribute to health profes- sional education and help to achieve specific national goals at the same time. Redistribution of graduates by specialty, for example, probably can be effected better by project grants and third-party reimbursement policies, than by capitation grant.s. Equality of access to education can be enhanced by project grants and student aid programs. A major reason for continuation of a capitation program is the role that such a capitation program can play in assuring a stable source of financial support for health professional schools. Although capitation is only one source of income for these institutions, it could become a secure source of educational support if fully funded at au- thorized levels. At the present time, most of the other Federal sources of income-research grants, teaching and training grants, third-party payments-can no longer be viewed with certainty from one year to the next. This is largely a function of the changes tak- ing place in those programs for reasons not related to the first degree education mission of the health professional schools. Nevertheless, decisions on these other sources of funds greatly affect the total amount of resources available to these institutions, and the amounts that can be allocated for their education activities. RECOMMENDATIONS The recommendations of the study group are summarized below. The study group endorses a policy that health professional schools be regarded as a national resource requiring Federal support. The study group recommends that the Federal Government use net education expenditures as a basis for establishing rates of capi- tation payments to health professional schools. 38-698-74--pt. 1-19 PAGENO="0276" 266 The study group endorses a capitation grant program as an ap- l)1~01)1~i11te I~ederal undertaking to provide a stable source of financial ~u1)I)ort for health professional schools. The study grout) is of the opinion that capitation grants ranging l)et\veen ~ and 4U percent of average net educational expenditures would contribute to the financial stability of public and private health professional schools and would be an appropriate complement to iii('ome from tuition and gifts and support by State governments, all of which should be maintained as nearly as possible in their p1e~(11t proportions. Ti ie study group recommends that capitation be based on grad- uat~o. with appropriate transitional support to schools that have greatly increased their enrollments in the past few years, or have recetitlv changed to a 3-year degree program. The study group recommends that capitation not encourage one lentrth of curriculum over another in any one profession : that capi- tation should be neutral at thi~ time and not encourage or discourage changes in educational patterns. rule Stu(lv group recommends that a mechanism be established in the Federal executive and legislative branches to coordinate the im- plemeiitation of any financing policy for health professional ed- ii cat ion. \Ve hope our report will pro\e useful to the Congress and the Lxeciotive for further deliberations on the support for health pro- fessional manpower training. ihe tables and chart referred to follow :] TABLE 1.-NUMBER OF SCHOOLS SAMPLED IN ESTIMATING COSTS OF HEALTH PROFESSIONAL EDUCATION, 1972-73 Sampled schools Percent of Profession Total 1 Number total Medicifle 104 14 13 Osteopithy 3 Dentlstr' 50 8 16 O~tsmetrs 12 Pharma:y 73 10 14 PcWe~rs Vetersars mediene 18 5 28 ~urs;g; 1.377 35 3 Baccarreote 293 14 5 Associate 5o3 8 Diploma -- 541 13 2 1 Totals incluie the number o~ schocts v.h~h had graduated at leant I clans by 1972-73. (IInIcT 1.-BiCekii,i,-i, (,t fI(tiiI1ICS fnr (1 icpi-cscntativc week at 82 schools Ttoi~d not net ivities ~l'eacIii lIg Prelarsitinil farina 111111 devel pisslit 111111 tv~i Ian ti a jIlt Ii etivi ties Jint te~te1iiiig nail iatieflt care .1(11 lit re-en reli 1111(1 teaihing a s(-li :nti vities I 1l(IeleIl(lelit aerial ccli PAGENO="0277" Total - 100 100 100 100 100 100 100 100 Teaching activities 21 36 35 39 48 47 30 58 Teaching 8 12 14 16 17 18 11 13 Preparation for tenchins 9 19 14 17 23 23 13 32 Curriculum development and evulua- tion `1 5 7 6 8 6 6 13 Joint activities 18 26 25 27 7 29 16 20 Joint teaching and patient care 15 26 24 26 4 29 13 20 Joint teaching and research 3 0 1 1 3 0 3 0 Research activities 16 2 9 4 9 1 18 1 Patient care activities' 10 5 5 4 3 8 5 0 General support activities 2 35 31 26 26 33 15 31 21 `Includes hoopitalclinical administration. 2 Includes administration, service, professional development, writing, and absence. Note.-These figures show the distribution of faculty time by the broad activity categories used in the study. Chapters 5 through 12 show distribution of faculty time in the instruction of 1st-degree students for each profession. Ratio of education Total Components costs to education -------------- ~------------------ instruction Profession costs Instruction Research Patient caie cost Medicine Osteopathy Dentistry Optumetry Pharmacy Pediotry Veteiinury medicine Nursing: Baccalaureate Associate Diploma 1 8, 950 6. 550 $1. 750 1.65 9,050 8, 000 400 1. 2, 050 1.37 4.400 2 0 1. 13 3,550 2,600 200 20 1.05 5,750 150 1.37 7,500 5,550 6,700 50 850 150 2 Q 1.04 1. 12 2.500 1,650 2 500 1 050 1.00 1.00 i Totals do not equal the sum of the components due to rounding. 2 Clivic costs included in instruction. 267 f'~t titi~t. (an(' a'tivities I `aliesit (`21 1'~-I1() ~l It(lelifS I a'ero'iit I1~pita1 (lilli(' 2l(lI1iii11r'~t1'1itiiiI! (~iii's~iJ `tlIlI)til't I1('liVIt1('r~ -` (huH iii sot i'ati~ii ~ (`I'Vi('' I `1 fi'soroi 11211 (I('V(l' )1111(llt 1sVritiiig A I seai,~e TABLE 2-DISTRIBUTION OF FACULTY TIME IN HEALTH PROFESSIONAL SCHOOLS BY ACTIVITY AND PROFESSION, 1972-73 By percentj Veteri- Medi- Osteop- Den- Optnm- Phar. Podia- nary Activity cine athy tiotry etry mucy try medicine Nursing TABLE 3.-COMPONENTS OF AVERAGE ANNUAL EDUCATION COSTS PER STUDENT BY PROFESSION, 1972-73 Note-Dollars are rouvded to nearest $50. PAGENO="0278" 268 TABLE 4.-AVERAGE AND RANGE OF ANNUAL EDUCATION COSTS PER STUDENT BY PROFESSION, 1972-73 Profession Average Range Medicine $12,650 $6, 900-18, 650 Osteopathy 8,950 6,900-12,350 Dentistry 9,050 6,150-16,000 Optometry 4,400 3,750- 5,300 Pharmacy 3,550 1,600- 5,750 Podiatry 5,750 4,400- 6,700 Veterinary medicine 7,500 6,050-10, 500 Nursing: Baccalaureate 2,500 1,200- 4,050 Asoociute 1,650 1,050- 2,150 Diploma 3,300 1,850- 4,850 Note-Dollars are rounded to nearest $50. TABLE 5.-AVERAGE AND RANGE OF INSTRUCTIONAL FACULTY/STUDENT RATIOS BY PROFESSION, 1972-73 Proteonion Average Range Medicine 1:8 1:6 -1:13 Ooteopathy 1:13 1:10-1:14 Dentistry 1:7 1:3 -1:9 Optometry 1:11 1:8 -1:15 Pharmacy 1:22 1:15-1:50 Podiatry 1:10 1:8 -1:12 Veterinary medicine 1:9 1:7 -1:13 Nursing: BaccaIaureat~ 1:13 1:8 -1:22 Associate 1:14 1:9 -1:25 Diploma 1:7 1:6 -1:14 Note-The Lsstructional toculty student ratio is defined as the ratio ot toll-time equivalent faculty instruction ut 1st-degree students ts the somber ot 1st-degree studentu. $9, 700 7,000 7,400 3, 300 0, OfO 4. 900 55i) time spent in $5, 150-14, 150 6,350- 7,800 5, 050-13, 400 2, 550- 3,700 1,600- 4,950 3,850- 5,950 4,300- 7,750 Prstsssisn TABLE E-~ AVERAGE AND RANGE OF ANNUAL NET EDUCATION EXPENDITURES PER STUDENT BY PROFESSION 1972-73 Average Range Medicine - Usteopails Dentstry ~.- Optometry Pharmacy Podiatry Veterinary mesicirie Nursing: Bacuaiaureate Assocats DipIoma~ 2,450 1,200- 4,050 1,650 1,050- 2,150 1, 500 400- 2,550 Note.--Dsttors rounded to nearest 550. PAGENO="0279" 26.9 TABLE 7.-AVERAGE ANNUAL NET EDUCATION EXPENDITURES PER STUDENT, BY PROFESSION, 1972-73 . ProfessIon Net education expenditures per student Authorized basic capitation grant Amount Percent Average actual capitation grant Amount Percent Medicine Osteopathy Dentistry Optometry Pharmacy Podiatry Veterinary medicine Nursing: Baccalaureate Associate Diploma $9, 700 7,000 7,400 3,300 3,050 4,900 5,550 82,450 ~1,65O 1, 500 `$2, 850 ` 2,850 ~2, 850 800 800 800 1,750 3346 3213 250 29 41 38 24 26 16 32 3 14 313 17 $1, 961 20 1,346 19 1 1,982 27 333 10 386 13 403 8 753 14 `3226 ``9 ~~139 $48 a 214 `14 1 A basic capitation amount of $2,850 has been used, rather than the $2,500, to reflect the $4,000 capitation award made for the students in the graduating class. 8 1 school did not receive any capitation award in 1972-73. a Per student equivalent. 44 out of 8 associate degree programs did not receive any capitation award in 1972-73. `Represents the average for these 5 schools, since cnly 5 out of 12 diploma schools received capitation awards in 1372-73. TABLE 8.-CAPITATION AT CURRENT AUTHORIZATION LEVELS AND AT DIFFERENT LEVELS OF AVERAGE ANNUAL NET EDUCATION EXPENDITURES, 1972-73 Net education expenditures Currently authorized capitation Average net e ducation expe nditures 25 33~ 40 Profession per student amount percent percent percent Medicine $9,700 `$2,850 $2,450 $3,250 $3,900 Osteopathy Dentistry Optometry Pharmacy Podiatry Veterinary medicine 7,000 7,400 3,300 3,050 4,900 5,550 2,850 `2,850 800 800 800 1,750 1,750 1,850 800 750 1,250 1,400 2.300 2,450 1,100 1,000 1,650 1,850 2,800 2,950 1,300 1,200 1,950 2,200 Nursing: Baccalaureate Associate Diploma 2,450 1,650 1,500 346 3 213 250 600 400 400 800 550 500 1,000 650 600 `Dollars rounded to the nearest $50. 2 A basic capitation amount of $2,850 has been used rather than the $2,500, to reflect the $4,000 capitation awsrd made for the students in the graduating class. Per student equivalent. Mr. ROGERS. Thank you very much, Mrs. Hanft. This is a very helpful report. I am sure the committee will use it to a great extent in writing the new legislation. Dr. Carter, do you have questions? Mr. CARTER. Thank you, Mr. Chairman. I have a few questions. It certainly is a good report. I notice that there are 300,000 stu- dents in the health professions in the United States, is that correct? Mrs. HANFT. That is correct; in 1972. Mr. CARTER. We are spending how much on them in education? Mrs. ITANFT. The schools, themselves, are spending $3 billion. Those are 1972 data. Mr. CARTER. That is a cost per student of how much? Mrs. HANFr. It varies among the professions because you have graduate students as part of that as well as undergraduate students. PAGENO="0280" 270 We isolated it out the first degree students from the graduate plogialli. Mi. L~RTl~ri. ~3 billion. 300.000 students: For 300,000 students, that would be ~ 00 per student, on an average; is that correct? ~\Irs. HAYFT. That is correct, for all costs, but it is not merely the educational costs. Mr. CAnTER. That is according to your figures. Mrs. }JAxFT. That is according to the national aggregate. There are two types of figures: There arc national aggregate figures for all 1 .Gte~ schools. Mi. (.~iri'rri. You are speaking of that which you have on page 7 o I- vain report? ~ JL\XFT. Ies. \[r. C~urnri. If we were to take the capitation amounts and give thle5(~ out directly to the students to use for tuition payments, what woIIl(l be the result to the school \fr~. ~ FT. Frankly, tile study group did not go into that in deta~1. We were lookin~ at the capitation aspects. Mr. (`ainrri. Would this availability not maintain economic sta- hjhtv for the schools Mrs. HANFT. It seems to me there are many ways to achieve sta- bility but the study group. itself. did not analyze the different methods of providing the stability. They limited their charge to the (olnrIessa)ulal char~re as they read it. which was to speak to how the (Iota could be ii~ed to set capitation. Mr. CARTER. Your figures on the cost of training a physician in- dicate S1~.650 per year; is that correct? Mi's. HAXFT. That is correct. Mr. CARTER. Where does that extra $17,000 come in which would make the total of $30,000? This data, the Sl~.650. is derived by the intensive analysis of the financial data and the activities in 14 medical schools. Mr. CARTER. But still we arrive at an inescapable conclusion that the average cost of training each health professional in the United States, whether he. be undergraduate or postgraduate, is on an average s~10.000 per year. Mrs. TI\XFT. One of my staff members has just given me a break- (Town of the S3 billion figure. It includes ~1 billion of research funds. The actual per student, if von just divided the number of students without. separating our graduates and undergraduates. comes to al)ont ~10.000 per student on that basis. Mi. Caizrrri. ~l0.~)01) per student. Mi's. HAXFT. And that is all kinds of students, some who are less expensive to educate and some. of whom are more expensive to etluicate. Mr. C'\riTr:ri. Whei'e (II) we get the $10.000 per student? How do we net that hijghi Mi's. ITANFT. It includes costs other than education. Mr. CARTER, Costs other than education. What are. those costs? Mu's. IL\NFT. T~eseaiclu, a certain amount of sponsored grants of other types that are not education costs. There was no way from PAGENO="0281" 271 the aggregate data to separate it out. That is wli we did an in-depth a~~alvsis of 52 schools. i\11. (1airri:i~. I believe that our authorizations were not funded fi~i lv ; is that correct Mrs. IIAYFT. rut is correct.. Mr. Uairrri~. T)own to between 20 and 00 percent; is that about ri~hit ? Mrs. ILIXFT. At the authorization level it would have been be- t~vren 23 to 40 percent and it varied. Podiatry was much lower and Illilsing was much lower. Mr. (h\riTEll. And of the 300~000 health professionals trained each vcai. two-thirds of them are nurses is that correct? Mis. JLINFT. That is correct ; more than that. Mr. (~Aun;1l. In reference to the chart S-2 on page ix of your sum- nu~rv. I notice in the report of the different institutions that we le~ve unrestricted Federal support for tuition and fees. What part of this is Federal support? Mrs. iL~xrv. A large part. of tile teaching and training, a large pait. of tIle research, and a pait of the diagnostic 1)atiellt care under ()d icr sources some from Federal funds. Mi. (~~irn:e. nile large pait Mrs. IL~XFT. I would say SO to ~)0 percent of the research support. iIIl(l. depending on the particular institution and what the patient IleRis of nicdicare and medicaid patients are, different amounts of the patient care funds. Mr. (~~l~T1:ll. What. percentage of tile whole expenditure is actually federally funded ? I)r. BULGER. While they are looking at it, somebody made a cal- culation that 3 billion divided by 300,000 comes to $10,000 each. Mr. CARTER. You are correct. Mrs. HAYFT. Federal funds of general nonrestricted grants in medicine amounted to ~112 million in 1972. That was the general nonrestricted. We do not have a breakout in these tables for the amount for research and the amount for diagnostic patient care but we could get. them and submit them for the record. Mr. C~~irrrri. Then you don't know actually what percentage of the cost of education for health professionals is paid for by the Federal Governmeiit: is that correct? Mrs. HAXFT. At the moment. I can't. give you an answer but. we could go back and add up the figures for you. Mr. CARTER. Call you estimate if it is as much as 50 percent or more Mrs. TIANFT. I don't. think it is that much. Mr. (~\uTrR. It has been up until 110w. Mis. T-L~xFT. For the education portion; I am just talking about the education portion. Mr. (h~iirrri. For all parts. Mrs. IL~xrr. For all parts; yes. Mr. C~~uT1:uu. It. is more than .)0 percent.. Mrs. 1-L\xFT. For all parts. including patient care and research. Mr. C~\R'lTR. Is there much variation among schools throughout (1)11 ut iv ii~ Feihc'ral col)tril)lltions ? PAGENO="0282" 272 Mi's. HANFT. Yes. Mr. CARTER. `What schools in our country receive the largest share of Federal funds, percentagewise? Mrs. HANFT. I can't give you that answer. Mr. CARTER. You can't tell us that? Mrs. I-IANFT. Wrhat particular school? Mr. CARTER. ~es, ma'am. Mrs. HAXFT. I can tell you what type of schools. The medical schools do. Mr. CARTER. What individual medical schools? Mrs. HANVr. I cannot give you that answer, sir. Mr. CARTER. There is one medical school that receives 70 percent Federal funding. I believe I am correct in that. It is one of the most heavily endowed schools in the United States. It is rather unusual to see those things, the richer schools get more in many cases, the wealthier ones do. I)o most medical schools have financial officers who are responsi- ble for maintaining detailed records of institutional income and expenditures? Mrs. HAXFT. In the schools we went into in our sample, most of them had quite good records. They vary, however. In some cases, the school, itself, does not track the total flows of income because the university does part of it and in some cases it is the State that collects the funds and then returns it to the university. So, the financial officers don't always have the total picture. Mr. CARTER. Would you submit for the record the average cost or the average contribution of the Federal Government per student for each medical school in our country? Mrs. HA XFT. Yes: we could submit it for the record, not for each of the schools in the country. `We can tell you them for the 14 schools of medicine that we studied in detail. [See letter dated June 19, 1974, with attachments. p. 274.] Mr. CARTER. What were the 14 schools? Mrs. HANFT. We agreed at the beginning of the study that we would retain the names of the institutions who participated as con- fidential. They are not listed in the report by name. Mr. CARTER. You mean you would retain as confidential the Fed- eral contribution? You would not st.ate what that was for each school? We are not asking for the schools' total expenditure but the Fed- eral contribution, and we think we are entitled to know that per stu- dent in each medical school in the country. I can see no reason why not: we authorize the funds. Mi's. I-TANFT. Our agreement with the institution, to be able to draw the sample. was that we would not disclose, and our contract with HEW- Mr. CAii'TER. You would not disclose the Federal contribution? Th~. H~xv'r. I can disclose it by the number of t.he school but not the name of the school. Mr. CARTER. i~iv goodness. Mr. ROGERS. May I suggest this? I think, since the. National Acad- PAGENO="0283" 273 emy of Sciences was under contract, I think we can get the figures from the Department of HEW. Mr. CARTER. I see no reason why that should not be a matter of public record. We know that one school in the United States, and I said perhaps the most heavily endowed school, receives 70 percent of the cost of its medical school program out of Federal funds. This has been brought out time after time. It is not fair; it is not right. How were the 14 schools you mentioned selected? Mrs. HANFT. In medicine, they were selected through a statistical technique called the factor cluster analysis. where some 42 charac- teristics of the schools were used to group them into like clusters of institutions. We then drew one or two schools from each of the clusters. depending on the size of the cluster. Mr. CARTER. That is a rather complicated method, I should think. Does the current Federal program require grantee schools to sub- mit. detailed financial reports on how they use Federal funds? Mrs. HAXFT. As far as I Imow. they do in certain areas. Mr. CARTER. You cannot say absolutely? Mrs. HAXFT. Not from our perspective because we are not a Fed- eral agency receiving the reports. Mr. CARTER. Ma'am? Mrs. HAXFT. We were not the Federal agency that received the reports. Mr. CARTER. Are all of the capitation funds used solely to support teaching activities by the grantee institutions? Mrs. HANFT. As far as we could determine in the schools that we went to, they were. Mr. CARTER. As far as you could determine? But you would not say that your determination went to the length to where you could say yes or no; is that correct? Mrs. IIANFT. No. because we didn't trade individual dollars from oiie source through to the other. Mr. CARTER. Thank you very kindly. Mr. RoGERs. What would you think about the capitation figures in hR. 14721 and H.R. 14722? I don't know if you have had a chance to look at those. I just wondered if you thought they were fairly accurate in terms of the number of students projected to be enrolled in the next. 3 years. Mrs. I-TANFT. We didn't do a.ny projections on the enrollment. We were pleased to see that you did use our data and that it is about one-third of our net education expenditures except in nursing. Mr. Rooms. Which is about what you propose. Mrs. HA NET. A range of 25 to 40. Mr. ROGERS. A middle position? Mrs. JL~xr'r. Yes. Mr. ROGERS. In the nurse bill we use the term "student equivalent." Do you think that is a correct definition? Mrs. HANFT. That is a correct. definition. That is the definition we used and we used it. for tecimical reasons because von have nurses starting at different, times during the nursing curriculum. You have them in different courses and different patterns of work. You have PAGENO="0284" 2~4 l)ait-tUlle iiuising stiideiits and we needed a measure and developed the sti~dent e(1uiv~l1eflt measure. Mr. lh ~vus. If (al)itatiol1 SUPPOrt is continued, there wifl be a need for coi~tiniiin~ study of net educational costs. Whom do von think shoulti (10 such a study ? Could hEW (TO it ? Mis. TL\NFT. I think they could. I think, from the methodology tFoit V~ilS (levelolied. IIE\ could do it. 1 thirik to ~l certain extent as it ~-vts refined the schools could almost self-administer it. Mi. R( GERS. A vet to he introcTuced administration bill, as I under- stan(l it. will recOmmefl(l substantial paring down of capitation slip- 1)01t. The statutory capitation amount for schools of medicine, osteo- patliy. and dentistry would be reduced about 1.500 per enrolled stu- dent h)r' fiscal year 1~)T5. S1.~50 pci' student for 1976 and $1,000 for 19~T. For schools of optometry and podiatry. the capitation would be reduced ~1OO. ~ si~0 for 19T5. 19T6. 1977, respectively. hhieie would be no capitation support for schools of pharmacy end niflsin~!. ~-~1ioo1s of vcteiiuei'v medicine would receive capitation levels of 0 I. (hi, and ~ ~\o\v. if this were to he adopted. I wonder if you could give us some ~ as to what effect that might have on tile schools and the: i' students. \Ii's. l-L~xi-'i'. We would have to (10 some calculation of the figures. I will tell von that I think that schools that have come to depend even omi the amounts they receive to date would be in difficulty with- alit a substitute of otliei' funds. i\Ir. RoGn~s. I think it might be well if von could let us have for the record some detailed projection of how you think it might affect it if this is a reasonable request. [The following letter, with attachments, was received for the record :] NATIONAL ACADEMY OF SCIENCES, INSTITUTE OF MEDICINE, Washington, D.C., June 19, 1974. I-Ion. PAUL G. ROGERS, Citairnian, Subcommittee on Health and Ent'ironnient. Committee on Interstate and Foreign Commerce. U.S. House of Representatives, Rayburn house Office Building, Washington, D.C. I)EAR Ma. ROGERS: In accordance with your request, I am enclosing two staff liajers relating to the Institute of Medicine testimony on health manpower legis- lation on May 20. 1974. The first paper analyzes the differences in the amount of capitation support that would be provided to health professional schools in II.R. 1-1721 and HR. 14722. and H.R. 1~1930 introduced by the Administration. The second paper analyzes the distribution of income, by source, for medical schools in the IOM sample where there was available data, to determine what proportion of total income was derived from Federal funds. Data for this paper were obtained from the annual finance questionnaire circulated to all accredited 1~. medical schools by the AAMC Liaison Committee on Medical Education. The capitation rates proposed in H.R. 14721 and HR. 14722. would supply 5342.2 million in 1t173 to health professions schools for eight professions; $234.5 million to schools of medicine. osteopathy. and dentistry : ~41.2 million to schools f veterinary nwdicine. optometry. pharmacy. and podiatry ; and $66.5 million t nursing. In contrast, the Administration's bill would provide $124.6 million in 1971 to institutions in six health professions only (pharmacy and nursing eXclu(lcd) : ~117 million to schools of medicine, osteopathy, and dentistry; and PAGENO="0285" 275 $7.6 million to schools of veterinary medciine, optonietry, and podiatry. This compares with a total actual 1974 appropriation of $223.5 million : $152.5 mil- lion to MOl) schools and $71 million to the other five professions. The cost estimates for this analysis were computed by multiplying the capi- tat ion rates proposed in each bill for each health profession by the Institute of Medicine estimates of 1975 enrollment in each profession. Secondly, using the financial data collected annually by the AAMC, we have computed the percentage of total revenues to medical schools obtained from Federal sources. Federal payments to these schools. exclusive of patient care fees from Medicare and Medicaid, averaged 44.9 l:ercent in 1971-72 for 97 medi- cml schools. If sponsored research revenues are excluded, Federal support to these institutions averaged 22.2 percent. tsing time schools in time IOM sample for which data were available, we found that Federal support averaged 47.2 percent of total reveimues for seven sample schools in fiscal 1972. and 52.4 per- ctuit of total revenues for five sample schools in fiscal 1973. Again, excluding sponsored research revenues, Federal non-research support amounted to 23.7 per- cent of medical school revenues iii 1971-72, and 29.4 percent of revenues in 1972- 73. Needless to say, if Federal third party payments to the teaching hospitals and physicians associated with these medical schools could he estimated, these percentages would increase considerably. I hope the enclosed analyses will he useful to your Subcommittee. Please let us know if we can be of further assistance. Sincerely, ROGER BFLGER. M.D.. E,i'ecutitc Officer. Enclosures. Ax EVALIATION OF CAPrrATI0N SUPPORT TO hEALTH PROFESSIONS SCHOOLS FOR 1975 tNDER hR. 14721, HR. 14722 AND hR. 14930 This paper analyzes the amount of capitation support to health professional schools that would be I)rovided in fiscal 1975 under two different proposals for extending time health manpower legislation. The bills introduced by Congress- man Rogers. hR. 14721 and hR. 14722, would establish capitation rates based on the net education expenditures developed in time Institute of Medicine Study eu the Costs of Education im time lieu ith Professions. These capitation rates would be higher than the amounts actually appropriated in 1973 for all profes- sions, and with the exception of dentistry and osteopathy, would represent an increase in time 1973 authorized capitation amounts. By contrast, the Adminis- tration proposal, HR. 14930, would result in a cutback from 1973 authorized capitation amounts for all professions, and would call for increases over 1973 actual appropriations only in osteopathy, optometry, and veterinary medicine. On an aggregate basis, HR. 14721 would cost $234.5 million for medicine, Os- teopathy, and dentistry in 1975, a 5.5% increase over actual 1973 capitation on a per student basis. The Administration's proposal would cost $117-million for the MOD schools in that year, $95-million less than the 1973 actual appropria- tion adjusted for 1975 enrollment levels in those schools. For comnhined optom- etry. pharmacy, podiatry, and veterinary medicine. hR. 14721 would cost $41.2 million, nearly 51/P times the amounts authorized in hI.R. 14930. The Adminis- tiation proposal for these schools would total only 50~- of what the costs would be if actual 1973 appropriations rates were applied to 1975 enrollments. Further- more. the Administration proposal w-ould result in a $5.6-million decease from actual 1973 capitation expenditures. Since the Administration bill would de- crease capitation rates even further in 1976 and 1977. the impact of those rates on the health professional schools would he greatert han in 1975. HR. 14722 would authorize .~66.5-million for all nursing programs-$31.6- million for baccalnuremife nursing. $1 7.5-million for associate degree nursing, and $17.5-million for diploma nursing. This represents a 3S.1~. increas~ over fiscid 1973 authorizations for nursing capitafion. The Administration, mean- while, proposes no capifafion funding at all for schools of nursing. The total costs of the legislative proposals being annlyzed iii this paper have been computed by multiplying the proposed 1975 capitation rate in each bill by pro~e~ted 1975 enrollment figures for each profession. Since capitation rates are niiilfiplb~d by TOM's estimate of 1973 enrollment, the total cost shown for HR. 14721 will not exactly match the authorization amounts in the bill. Tn two pro- PAGENO="0286" 276 fessions-optometry and dentistry-the H.R. 14721 authorization falls short of the TOM estimates of total cost. For comparative purposes, data Is also Included on the average actual capitation rates for schools in the IOM Cost Study and authorized capitation rates for 1973, and the costs associated with those capi- tation rates at 1975 enrollment levels. Although detailed data are not presented for 1974. HEW indicates that actual capitation rates for 1974 were very sim- ilar to the 1973 levels. TABLE 1.-MEDICINE Fiscal year 1973 Fiscal ye ar 1975 Capitation rate Total cost I Capitation rate Total cost I 1973 actual capitation $1, 961 $92,674,899 1973 authorized capitation 2,850 134, 688, 150 HR. 14721 HR. 14930 (administration bill) $1, 961 2,850 3,250 1,500 $105, 894,000 153, 900, 000 175, 500, 000 81, 000, 000 Capitation rate times total enrollment. Actual 1973 enrollment was 47,259; estimated 1975 enrollment is 54,000. Note-HR. 14721 would provide $175,500,000 in capitation funds for medicine in 1975. This is an increase of $21,600,000 over the costs of a 1973 program extended to apply to 1975 enrollments, and an increase of over $40,000,000 from the 1973 authorization amount. The administration bill (HR. 14930) would authorize $81,000,000, less than half of the au- thorization in H.R. 14721. The administration finure represents a 12.6 percent decrease from the actual amount of canitntion funds paid in fiscal year 1973, and is almost $25,000,000 short of the amount necessary to maintain the fiscal year 1973 actual capitation rate of $1,961 at 1975 enrollments. TABLE 2.-DENTISTRY Fiscal year 1973 Fiscal yea r 1975 Capifatisn rate Total cost1 Capitation rate Total costl 1973 actual canitatios $1,982 $36,421,232 1973 authorized cavitation 2, 850 52, 371, 600 HR. 14721 HR. 14930 (administration bill) $1,982 2,850 2,475 1,500 $41,622,000 59,850,000 51,975,000 31,500,000 1 Canifafion rate times total enrollment Actual 1973 enrollment was 18,375; estimated 1975 enrolllment is 21,000. Notv -~While HR. 14721 decreased the authorized capitatior' rate from $2,850 to $2,475, this new rate would be a sub- utantia! increase over actual 1973 cavitation expenditures, from $36,400,000 to $52,000,000. The administration bill would reduce total costs to $31,500,000, thi° represents a 13.5 percent dropoff from actual 1973 funding, and is over $10,000,000 less than the $41600000 necessary to maintain fiscal year 1973 actual capitation at 1975 enrollments. It should be noted that if the 1975 uiiroflmerto in dental schools approach 21,000, the $49,500,000 total authorization for capitation grants to dental schools contained in HR. 14721 would be less than the $51,975,000,000 in costs estimated above. TABLE 3.-OSTEOPATHY Fiscal year 1973 Fiscal yea r 1975 Capitation rate Total cost1 Capitation rate Total cost1 1973 actual capitation $1,346 $3,471,334 1973 authorized capitation 2,850 7,350, 150 HR. 10721 HR. 14930 (administration bill) $1,346 2,850 2,350 1,500 $4,038,000 8,550,000 7,050,000 4,500,000 Capitation rate times total enrollment. Actual 1973 enrollment was 2,579; esttmated 1975 enrollment is 3,000. Note-If the 1973 actual capitation rate were maintained in osteopathy, the total cost of $4,000,000 would be lesu than the costs required by both new bills. If capitation levels in this field were to increase, the administration rate of $1,500 per student would give far less support to the schools than the HR. 14721 rate of $2,350. The administration figure allows little more than a 10 percent increase over total 1973 actual capitation costs, while the bill introduced by Congressman Rogers would allow increases of approximately 75 percent. PAGENO="0287" 277 TABLE 4.-OPTOMETRY Fiscal year 1973 Fiscal yea r 1975 Capitation rate Total cost 1 Capitation rate Total cost1 1973 actual capitation $333 $1, 108, 224 1973 authorized capitatios 800 2,662,400 $333 800 $1, 265, 400 3,040,000 HR. 14721 HR. 14930 (administration bill) 1,050 400 3,990,000 1,520,000 1 Capitation rate times total enrollment. Actual 1973 enrollment was 3,328; estimated 1975 enrollment is 3,800. Note.-Both HR. 14721 and H.R. 14930 would authorized more money in optometry than was actually available in 1973. However, H.R. 14721 would increase the authorized capitation rate to $1,050 (1973 rate=$800) while the administration bill would halve the authorized 1973 rate. Consequently, HR. 14721 would cost $2,500,000 more than H.R. 14930. It should be noted that the total amount authorized in H.R. 14721 for capitation grants to schools of optometry in 1975 was $3,800,000, more than $150,000 less than the required cost estimates summarized above. TABLE 5.-PHARMACY Fiscal year 1973 Fiscal yea r 1975 Capitation rate Total cost1 Capitatlon rate Total cost1 1973 actual capitation $386 $7, 317, 016 1973 authorized capitation 800 15, 164, 800 HR. 14721 H.R. 14930 (administratioo bill) $386 800 1,025 0 $8, 762, 200 18, 160, 000 23,267,500 0 1 Capitation rate times total enrollment Actual 1973 enrollment was 18,156; estimated 1975 enrollmeot is 22,700. Note-The administration bill completely stops capitation tusding for pharmacy, a profession that received $7,300,000 in fiscal year 1973. The bill introduced by Congressman Rogers includes pharmacy as a recipient profession, and increases its authorized capitatisn rate from $800 to $1,050 per student at an estimated total cost of $23,300,000. TABLE 6.-PODIATRY - Fiscal year 1973 Capitation rate Total cost' Fiscal yea r 1975 Capitation rate Total cost1 1973 actual capitation $403 $565, 409 1973 authorized capitation 800 1, 122, 400 HR. 14721 H.R. 14930 (administration bill) $403 800 1,650 400 $685, 100 1,360, 000 2,805,000 680,000 Capitation rate times total enrollment. Actual 1973 enrollment was 1,403; estimated 1975 enrollment is 1,700. Note.-H.R. 14930 would provide funds just short of the 1973 actual capitation rate of $403; the administration authoriza- tion of $680,000 in only 60.6 percent of the 1973 authorization of $1,000,000. H.R. 14721 would more than double the 1973 authorized capitation rate. The $2,800,000 in HR. 14721 in 4 times the administration's proposal in podiatry. PAGENO="0288" 278 TABLE 7.-VETERINABY MEDICINE Fiscal year 1973 Fiscal year 1975 Capitation Capitatins rate Total csst rate Total cost 1973 actual cavitation $753 54.095.567 5753 54,518.000 1973 authorized capitation 1,750 9,518,250 1,750 10,500,600 H.P 14721 1.850 11, 100.000 H.B. 14930 (admisistratisa bill) 900 5,400,000 Cavitation rate timns total eorullment. Actual 9973 enrollment was 5,439; estimatod 1975 esrollment is 6,000. Note H B 14721 cafls tsr a sliyhl ii crease is the zuthorized capitatius trem $1,750 is tiscal year 1973 to $1,850. with as accsmpairs;rg is.urease $1,500,004 in t~55 rut'srned ca7itatise costs. Both tIthe H.P. 14721 hgnes are more thus double the H.P. 14930 proposed rate ut $909. with total casts rt $5,400,000. TABLE 1.-NURSING Fiscal year 1973 Fiscal year 1975 Capitatis.i Capitatios rate Total coot 1 rate Total cost i Baccalaureate uureirg: l973actaalcayitatioo 2 $226 $11,295,308 25726 $11,414,130 l973aothorrzedcapitatiue 2 345 17,216,268 2346 17,474,730 H.P 14722 2625 31,565,625 Asssciate degree sunning: 1973 aclual capisatiun 2139 8.512,499 2139 8,822, 191 1973 authorized capitalios 2 213 13, 044,333 2213 13, 518, 897 H.P. 14722 2275 17,453,975 Diplema earring: 1973 actual capitatioo 214 15,342,516 214 14,980,000 1973 authorized capitatioo - 250 17,923,500 250 17,500,000 H P.14722 250 250 17,500,000 Total, au oursiirg programs; 1973 actuat capiiatioo 35, 100,323 35,216,321 1973 authorized capitation 48, 184, 107 48,493,627 HP. 14722 66,519,600 I Capitatioo rate times enrollment (in student equisaleeta where appropriate). Actual 1973 enrollment was 49,758 student eqaisalento is baccataareale cursing, 61,241 otadent equiraleots in associate degree nuroieg, and 71,694 students in diploma eursiog. Estimated 1975 esrullmeirtu tsr each program are respectively; 50,505 student equiealento, 63, 469 otudent equisaleotn, aod 70,000 students. Deootes rate per studeot equivalent. Note-H.P. 14722 increases the capitation rate tar baccalaureate nursing schools to $625 per otudent equivalent and to $275 per student equivalent br associate degree programs. Diploma nursing programs remain at the current capitation rate at $250 per student. In aggregane terms, this iepreseoto a $14,300,000 increaoe in authorized capitation br baccalaureate programs over 2973 authorization leselo, aod as iocrease ot $4,400,000 br associate degree nursing ochooln. The total coot nt H P 14722 is estimated at $56,500,000, mare teat $30,000,000 greater than actual 1973 appropriations br the 3 typen ot nurniog prograsu. The adniinistratiun does oat propose to contisue capitation support tar nurnng school. It should be ruled that cavitation rates tar baccalaureate and associate degree naming are based on otudent equieatentn. From its sumoiirg qaeationnaire tha 1DM coat study eonimaled that the average student equivatentu per student enrolled in 0.9067 tar associate degree nursing programs and 0.6734 tar baccaualreate program. Theoe ration were muttiptied by eot- mated 1975 enrollments and proposed H.P. 14722 capitatian rates to reach the total coot recorded above nt each prograim ANAn.Ysos rw TOtE DIsrnsrnnuTEoN OF INCOME, BY SouRcE, AT SELECTED MEDICAL ScoaOOLs, 1971-72 AND 1972-73 I sitt~.E (littlE re~iitrted liy nnnedical schools inn tiae AAMC Liaisons Cononnnaittee on Merlierti Edttcatiiinn I LCME i1uestiiinoaaires, ant analysis was nusade of tiae (us- trilititiont of reveintoes. by source. for (a) seven seinools ira tite Institute of MetIic'inae sannatile for Fl 1971-1972 : i hi five sample scinools for FIT 1972-1973; ctnirl I e tine total fur itil the 97 onnedieal schools respondinag to tine LCME ques- tuiiiinura ire for FIT 1971-3972. As Table 1 ititlicates. for FIT 1071-1972, Federal funds averaged 47.2% of total revettttes for severn sanntiale seinools for winnein data were available, ranging froiin 3S.;V~ at School 12 to G5~'~ tnt Selnool 1. A major share of the Federal frontds for anuechical schools supports sisonasored research projects ; on the average, PAGENO="0289" 279 Federally sponsored research funds contributed 23.3% of income to the seven schools for that year. It Federal support for sponsored research is excluded, the relesailling Federal fiiiids accounted for 23.7% of incense. Federal nonresearcis funds clustered a round 19-20% at the individual schools, except at School 6 (29.1 % ) and School I 39% ) . ~vhiicli together brought the average above this level. The major dif- feretice hetweeii public and private 5(110015, of course, is the extent to which s~ ate and local dolla is provide funds for general sul)port, research, and training I Otailed iiitorniation on the sources of incuisie for the seven schools is displayed iii Table 2. I )uring the fiscal year 1972-1073. 1"edeial funds averaged e2.4% of income bce sa in~ b schools for wli icli dat~i were ava i ha ble. Tue 1)elc'elltage of revenue stippi led lv Federal 11111(15 ranged tim 30.9% at Sclioi 1 2 to 63.6~ at School 9. Fi ileral fu d~ for slalisored 1esear(I1 accounted for a ii average if 23.0% for o live si ails iii thi is year. ra ngiiig fu rn 11 5( at Sd a ni 2 0 330' ~-, at School I. Exelud I hg resin tel funds. renia iiiiig Federal funds tended to 5111)1 ily a! out a I hOd a! t he i ne one at i itivate s('lim is and under 20% of i ticoine at pul lie I robs. I )et ailed iiiloiin~ 1 iii a the sources if income fi ii tI ie five schools is ~iu'vn in Table 3. Tie iia ti ii~a 1 average for fiscal 1971-1972. taken from 97 a ecredited medical 5(1 ol s sd it lug to the L( `ME questionnai ie. shows that 14.9' ~ of the income ti hII((licrtl 5(1)015 that year, exclusive of third party payments, was derived fioiii Federal Patient (`are sources. This 14.9% WaS divide(i about evenly between 1 sored re~ea rehi funds 22.7% of total ii ci me) a iid revenues for other pur- I ~(5 (22.2'~ it total income I TABLE 1.-PERCENT OF INCOME DERIVED FROM FEDERAL SOURCES IN SELECTED MEDICAL SCHOOLS FOR 1971-72 AND 1972-73 In percent! 197 1-72 1972-73- 5 IOM National 7 IOM Federal income sources avera'e 97 schcols sample schools sample schools 1 Total income from Federal sources 44.9 47.2 52.4 Income from sponsored research funds 22.7 23.5 23.0 Income from other Federal sources. 22.2 23.7 29.4 There is silly 1 school for which data was available in both 1971-72 and 1972-73. Source: AAMC, Liaison Committee on Medical Education Questionnaire. PAGENO="0290" TABLE 2.-PERCENT DISTRIBUTION OF MEDICAL SCHOOL INCOME, BY SOURCE, 1971-72 [In percent School I Source of Income (private) School 4 (public) School 6 (private) School 8 (private) School 11 (private) School 12 (private) School 13 (public) Average for 7 ~ampIe schools National average 97 medical schools 1 Income from Federal sources 55.5 38.9 51.6 40. 1 49.8 38.3 46. 3 47.2 44. 9 Income from State and local government sources Income from tuItIon, fees, endowments, and gifts Income from patient care revenues I Income from other sources 2. 1 12.6 5.3 24.8 39.3 5.9 0 15.7 23.2 13. 1 6.0 6.0 5.4 14.2 21. 1 18.3 2.7 11.0 6.4 30.1 29.8 14.2 0 17.7 38. 1 11.4 0 4.3 15.4 11.6 6.4 19.5 16.8 8.0 6.4 19.5 1 Source: AAMC Annual LIaison Committee on Medical Education Questionnaire. 2 This does not reflect Income to the teaching hospitals for patient care from Federal sources. PAGENO="0291" 281 TABLE 3-PERCENT DISTRIBUTION OF MEDICAL SCHOOL INCOME, BY SOURCE, 1972-73 By percenti Source of income School 1 (private) School 2 (public) School 3 (public) School 9 (private) School 10 (private) Average for 5 sample schools Income from Federal sources 53.8 30.9 33.3 65.6 52.9 52.4 Income from State and local government sources 2.7 41.7 43.8 0 3.2 12.1 Income from tuition, fees, endowments, and gifts Income from patient care revenues Income from other sources 13.2 3.2 27. 1 2.3 22.0 3. 1 3.5 17.2 2.2 12.2 7.0 15.2 15.2 1.9 26.8 10.4 8.7 16.3 Mr. ROGERS. Your report recommends continuing capitation Sup- port, and I presume you would think it would be needed to main- tain current enrollment levels-do you think a reduction would affect current enrollment levels? Mrs. HANYr. My own opinion is yes, if it were substantial reduc- tion without any kind of substitute financing. Mr. ROGERS. Now, we have calculated capitation support at 33 1/3 percent for a nursing baccalaureate program, and 25 percent for nursing diploma and associate programs. Do you thmk this amount would insure financial stability? I don't think the term "rnsure" is a very good word, but would continued capitation provide an adequate base for ftnancial stability? Mrs. HANrr. It would help. One of the problems is that there are multiple sources. If you pull on three or four sources at once, for example, and have no replace- ment from a new source, the stability goes down. We think that the capitation can provide a base for the educational portion of the pro- gram. Mr. ROGERS. As Dr. Carter had said earlier, some have proposed that we might adopt an approach of simply allowing so much money to go to each student and allow the student to select a school and that money would then go to a school via the student. What do you think of that approach? Mrs. HANYr. I would rather not comment since we really have not studied it or its effects in detail. Mr. ROGERS. Well, could you do it off the record for me and we won't put you on the record. What do you really think of that, per- sonally? This will be off the record. [Discussion off the record.] Mr. CARTER. Mr. Chairman, as you know, for many years the Federal Government has supported medical schools to the extent of 50 percent or more. I think the figures will show that. Schools throughout the country have come to depend upon it. I see no way other than for us to continue our support and I want to make it quite plain that I feel that way. However, I do feel that there should be an accounting of funds by each and every medical school in our country and that there should be a fairness doctrine in the awarding of these funds to the various medical schools. That was part of what I was bringing out, that the percentage of funds going to different schools varies, and I don't, feel that that is good. 38-698-74-pt. 1-20 PAGENO="0292" 282 Mr. ROGERS. Now. I notice in one of the recommendations, "The st 11(1 V group recommends that cap it ation not encourage one length of ciiiriculmn over another in any one profession; capitation should be neutral at this time and not encourage or discourage changes in educational patteins. Do we need changes in educational patterns? Mis. lL\NFT. The study groups feeling was that so much of it is now in flux that our data did not provide any quality measures of wlietlici you were producing the same product in a 3-year period or in a 4-ear perio(l. They therefore fell until there had been more expei~e~ice with the changes in cnrriculuin-for example, pharmacy is nnder~oing a substantial change in curriculum-that they would iathci the finding staved neutral until some conclusions were avail- able. Mr. lorns. Von say copitation goes mainly, I believe your study fonin!. to euicoura~e increased enrollment? Mrs. T-L'~xFT. ~eS. Mr. ROGERS. Suppose we said there must be so many students in faniilv medicine Mrs. IL\xFT. The feeling of the study group was that when you get into the specialty area it was the graduate training, the resi- dences and internships had more influence on both the specialty dis- tribution and the geographic distribution than did the first degree program. Their feeling was that capitat ion approached the first degree level of education while residencies and internships are sup- porte(l largely through third-party reimbursement policy, and that capitation of the first degree could really not touch those other specialties too greatly. Mr. ROGERS. Suppose we wanted to encourage the formation of departments concerned with family practice. Mrs. HAYFT. The study group felt that were better done through the project grant mechanism than necessarily capitation. Mr. ROGERS. You said earlier that it is not very dependable. Mrs. HANFT. No. because it is generally a short term- Mr. ROGERS. It can he taken away. Mrs. HANFT. But it is good for a start-up of a new program and thie.ii it. could be picked up through on-going support. There are start-up costs in any new program that they felt were better suited through a project grant approach to get it started than on-going with capitation. ~ ROGERS. I understand the group was not charged with trying to determine what the needs were and so forth but mainly to study the costs. I w-as thinking if there was any byproduct of that because this committee must make some judgments in that area. I realize we have not asked that that be done by the Institute of Medicine. But it seems to me that if we are going to begin to meet the needs, capitation can still he a very effective means of bringing about change. We found that so in increasing enrolloment. *We found it even in some movement to new approaches, some even changed the length of their programs. So. if you have any thoughts along these lines, you might give them to us because I am not sure that the committee wants to be neutral in everything. PAGENO="0293" 2S3 I think we may want to be positive in trying to meet the needs as hey are presented to the committee. But I understand that was not 1 he. charge to your group. I think you have done. an excellent study, which will be very help- hiT to us. Certainly, we are going to review these facts very care- fully. As you know, it. is already the basis of what has been proposed in the legislation. Mr. CARTER. I was interested in the selection of the group who carried out this study. With the exception of one man from Ken- tucky. and I am certaiiilv proud you chose him, the rest of the members came from the eastern seaboard; I believe every one. Really, I think it would not be a sin to have a fellow from Indiana or Michigaii. Ohio, Oklahoma. or Texas, or California in this group. Now, given tile possibility of a reduction in capitation, do you feel that. there may be some substitute ~)rOgram which can get money for schools while, enabling the Federal Government to impact greater on specialty and geographic distribution? Mrs. HANFT. Of tile current funds out there we really do not see any new sources at tue moment. They are still basically capitation, tuition, philanthropy. State appropriation. The States are becoming very concerned about the distribution process and are beginning to close off their enrollment to out-of-State students, leaving certain of tile States who do not have health professional schools in some dif- beultv as to their placement. It seems to us that the larger the role of the State grows, the more restrictions will be place.d on out-of-State residents and there aren't schools all over tile country in each of the eight professions. Mr. CARTER. If we give more money to the student, we can better assure that he will practice in a. way most beneficial to our Nation; is that correct? Mrs. HANFT. I would say it depends on who the student is, what income group he comes from, what he thinks his future earnings will be, and how fast he thinks he can repay any loans or scholar- ~-1iips. I think some experience with some programs of loan forgive- ness has shown that they did not do the distributional things that had been hoped initially. Mr. CARTER. I am afraid that is correct.. Our forgiveness feature has not secured the distribution it should have. Thank ou, Mr. Chairman. Mr. ROGERS. Now I wonder if it would be possible for you in a iat.her short time to let us know what you think would be a reason- able figure. for capitation support for schools of public health. We aie proposing in tile bill a figure of $2,000 per student. Mrs. HANFT. We could not in a short time undertake a cost study. Mr. ROGERS. I understand that. Maybe you could get tile schools to cooperate. I think there are 19. Dr. BULGER. How short is a short time? Mr. ROGERS. I was thinking maybe you could get them to fill out a short questionnaire, just to tile main points, if that would be pos- sible. Mrs. HANET. Any questionnaire we send out. to more than 10 insti- tutIons has to go through the Office of Management and Budget clearance. PAGENO="0294" 284 Mr. ROGERS. Do this for us. Give us a copy of your questionnaire and we wifl send it out. That would be helpful. Then, if you will, analyze it for us when it comes back. I would hope that this com- mittee would get 100 percent cooperation. I think you got 50, which was pretty good. Mrs. HAi~r. Well, on the nursing questionnaire. Mr. ROGERS. Did your study indicate how severe the problem of attrition is in schools of nursing? Mrs. HANFr. There is a very high attrition problem in nursing. Mr. ROGERS. Very high? Mrs. HANFr. Very high. Mr. ROGERS. Any suggestions on how to get to that problem? Mrs. HAN~r. No; it is very difficult. Mr. ROGERS. Thank you for being here. Your testimony is most helpful. If you will let us have that questionnaire and the items for the record that we asked for, the committee would be grateful. Mrs. HANFr. Thank you. Mr. ROGERS. Thank you for being here. The committee stands adjourned until 2 o'clock this afternoon, when the Assistant Secretary for Health of the Department of Health, Education, and Welfare will appear. [Whereupon, at 11 :20 a.m., the subcommittee recessed, to recon- vene at 2 p.m. the same day.] AFTER RECESS [The subcommittee reconvened at 2 p.m., Hon. Paul G. Rogers presiding:] Mr. ROGERS. The subcommittee will come to order. This afternoon, the subcommittee continues its hearings on legisla- tion which would revise and extend laws relating to education of health professionals. The bills we will consider are H.R. 14721, the Health Manpower Act of 1974, introduced by myself and five other members of the subcommittee, H.R. 14722, the Nurse Training Act of 1974. introduced by seven of us on the subcommittee, H.R. 14357, introduced by Dr. Roy and six other members of the subcommittee, a yet to be introduced administration bill-it was introduced at noon- day, and the committee will give consideration to that bill. There are several other related bills. These bills differ widely in scope and approach. but all have a common purpose-to insure quality health education in the United States and to attack the problems of the accessibility to quality medical care in this country. In the view of many experts, four complex and interrelated prob- lems make access to qualified health professionals virtually nonex- istent in many parts of this country. The first problem is shortages. While I recogrnze that the question of shortages of physicians, nurses, and other health professions is a matter of considerable debate today, in my view, this country, taken as a whole, has a manpower shortage. A 1974 National Institute of Health study reports a shortage of 30,000 physicians. 1964 figures from HEW indicated a shortage of 50.000 doctors, 150.000 to 200,000 nurses and 150,000 allied health personnel. PAGENO="0295" 285 Second, maldistribution of physicians by specialty is acute. The percentage of physicians in general practice has dipped from over 50 percent in 1949 to 36 percent in 1960 to under 22 percent m 1970, while percentages of certain medical and surgical specialties have increased about twofold. Third, geographic distribution of physicians reflects wide dis- parities. There are now 195 physicians per 100,000 persons in the Middle Atlantic States compared with only 102 in the East-South Central State per 100,000 persons-a variation of almost 100 percent. Comparisons of physician,/population ratios in our Nation's inner cities and their suburbs are even more striking. Fourth, there is a severe problem with respect to the status of foreign medical graduates. About half the gain in the total supply of physicians from 1960 to 1970 is attributable to FMG's, many of whom experience problems of language barriers and absence of quality clinical training. Despite these acknowledged problems, the number of new licenses granted in the United States each year is almost evenly divided between graduates of foreign medical schools and U.S. medical schools. It is said the problems of distribution and quality of health pro- fessionals can be attacked in two ways: (1) government regulation or (2) use of medical and other health professions' schools as tools to influence resolution of t.hese problems. I personally favor the latter course. Health professions' schools have responded well to the tasks demanded of them in previous legislation. I know of no reason to believe they will not respond to today's problems if they are given the incentives to do so and a proper financial base from which to proceed. Others may have different views. As always, we approach these hearings with no preconceived notions of how to solve the problems before us, but I believe each of us acknowledges that the problems surroimding health manpower are active and must he met head on immediately. I would ask that, at this time, the texts of the bills before us, summaries thereof, and agency reports thereon, be printed in the record. I also ask that, since the portion of H.R. 14721 dealing with allied health (subpart II of part G of the Public Health Service Act) is identical to H.~R. 9341. which was the subject of hearings on July 24 and 25, 1973, the hearings on that legislation (Serial No. 93-57, Public and Allied Health Personnel) be incorporated by reference at this point. Our witness this afternoon is Dr. Charles Edwards, Assistant Secretary far T-Iealth of I-JEW. I-Ic is aceompf~nieuT by Dr. Theodore Cooper. Deputy Assistant Secretary for Health: Dr. Kenneth Endi- coft. Administrator of the Health Resources Administration; Mr. Harold Buzzell. Acting Administrator of tha Health Services Ad- ministration; Dr. Stuart Altman. Deputy Assistant Secretary of Health Planning and Analysis; and Frank Samuel. Deputy Assistant Secretary for Health Legislation. We welcome you to the committee. and we will be pleased to have your statement. You may proceed as you desire. PAGENO="0296" 2S6 STATEMENT OF DR. CHARLES C. EDWARDS, ASSISTANT SECRETARY FOR HEALTH, DEPARTMENT OF HEALTH, EDUCATION, AND WEL- FARE, ACCOMPANIED BY DR. THEODORE COOPER, DEPUTY ASSISTANT SECRETARY (HEALTH); DR. KENNETH M. ENDICOTT, ADMINISTRATOR, HEALTH RESOURCES ADMINISTRATION: HAROLD 0. BUZZELL. ACTING DIRECTOR, HEALTH SERVICES ADMINISTRATION: DR. STUART H. ALTMAN. DEPUTY ASSISTANT SECRETARY (HEALTH, PLANNING. AND ANALYSIS): FRANK E. SAMUEL. JR.. DEPUTY ASSISTANT SECRETARY FOR HEALTH LEGISLATION: AND DR. EDWARD MARTIN, DIRECTOR, NATIONAL HEALTH SERVICE CORPS I)r. Li)w~\RDs. Thank von. Mr. Chairman and Dr. Carter. We do hive a fai liv len~rtliv sti~tement. Mr. Chairman. but I think, unless \~O11 ha V(' SOme object iou. we will llttelrlI)t to go through it with von. F think it outlines most of the positions or most of the issues that von are concerned with and gives our analysis of these issues. Mi. l~o(wRS. I think it would be well for us to go through it. as veii say. I dont know that it is necessary to read every bit of it. but I think von could 1)Oint out your major points, and that would be helpful Di. Li)w~\1~Ds. Thank von. ~\rr. Chairman. Before, von mentioned we are (hisduss1n,~ a number of 1)1oposals. I think before we get into d~sci~ssiuni. particularly, the admiiiistration's proposal. it might be useful to (lesclihe how we arrived at our present position. Over tfle pact decade. the nature and extent of Federal interven- tioii Iii the health care system and its associated education and train- ing programs have grown very substantially. Only 10 years ago, the ITealth Professions Educational Assistance Act marked the be- ~iniiing of the Federal role in providing direct support for the educa- tion of health professionals. Numerous studies had concluded that a health crisis would result unless the production of physicians was substau tjahlv increased. Initially. therefore. the primary objective of the Federal health man power effort was to increase the aggregate 5iii)plv of physicians. Public attention was focused on the fact that the supply of M.D.'s was not keeping pace with the growth in popu- lation. Over time, however, with greater lun(lerstanthng of health nianpower problems, the objectives of Federal policy changed and expanded. The health Professions Educational Assistance Act was amended at various times to provide for the accomplishment of additional ei)]ect ives, such as curriculum reform. maintenance of accreditation, end the recruitment of minorities. The Federal role was also ex- ~ nled to provide basic operational support to the schools. During the late 1910's. special improvement grants were provided to assist ~ehools that were in serious financial difficulty. Tui I 9G1~. concern over the issue of supply adequacy was intensified. T~epouts from both governmental and nongovernmental groups sug- ~ested that there was a shorta~e of approximately 50.000 physicians. ~)ft()()O nurses. and almost 150.000 technicians. In 1970, the Carnegie PAGENO="0297" 287 Commission issue(l a report wh jell concluded that medical and dental e(lucation were inadequately funded and reCOlflhiIeIl(le(l that the Federal Goveriiment increase its role iii the financing of health man- pow~ education. I would like to 1)Oillt Ollt that. wiiiie these stU(lieS have been helpful in highlightiii~r certain iIniull)O\Vel problems. they have, for the most part. only concentrated on a ~regate numberS and l)!ovider,l)ol)ul:ltioil iatio~. Such measures fail to deal with the corn- l)leX questlouis of al)P1oP1illte manpower utilization and diStril)UtiOfl. The Comprehensive health Manpower Training Act of 1971 rep- resented a significant departure from previous national policies. It provided for Federal operational support of schools of the health l)ro~ess1ons and that in return for such financial assistance, schools would have to agree to address national 1)riority needs. ACCOMPLIShMENTS OF IIEAT:rn ~L~NPOWLTi Pi~OIlLEMS Several effects flowed from health manpower prot~rams developed over the past 10 years. First, the have substantially increased the na- tional capacity to train health professionals. Since 1963, Federal ~ograms have assisted in the building of 21 medical schools, 9 dental schools, and 1 school of osteopathy. About 1.1U)~) medical and G5() uental school slots have been substantially assisted as a result of Federal construction programs. Second. enrollment has increased significantly for schools of medi- cine, dentistry, and nursmg. First-year rne(lical school l)laces grew from 8,759 in 1965 to 13,790 in 1973. Although it is impossible to measure the exact impact of this increase, it is clear that our efforts had a significant impact. \Vhere flrst-vear enrollment rose at an annual rate of 1.3 percent between 1950 and 1965 the annual growth sji~ce 1965 has been 6.6 l)erceflt. Third. minority enrollment has risen substantially in medical and dental schools. First-year enrollment of black students in F.S. iiiedical schools has increased from 4.2 percent in academic ear 1969-70 to 7.1 percent in academic ear 1972-73. There has also been a correspondhng increase in the enrollment of women iii medical schools. ~ ROGERS. Do we have those figures of the increase of women in medical schools ? T)r. ALTMAN. les. sir. Mr. ROGERS. I think it might be well for the committee to have that on the record. Dr. EDWARDS. Do you want to have us provide that for tile record? Mr. ROGERS. As soon as you have that, interrupt us and let us know. T)r. COOPER. The comparable figures for women are 9.2 percent in 1969 and 16.9 percent in 1972-73. T)r. EDWARDS. How-ever, the Federal health manpower prograilis have utilized and generated a demand for considerable fiscal re- sources and have tended to create a serious dependence on the Fed- ct-al Government. The ready availability of Federal fuiid~. includiin~ medicare and medicaid reimbursement, has provided limited cost consciousness in health professional schools and. accordingly, we have PAGENO="0298" 2S8 seen the cost of such education rise substantially. Over the past 10 vea~s. annual Federal obligations for health manpower programs, not. inchiding research training or mental health manpower, have crown from S65 million in 106.~l to S536 million in 1973. Between 1963 and l~'3. a total of approximately ~3.4 billion was obligated for the training of health professionals. Federal funds from all sources now account for at least 50 percent of the revenue to U.S. medical schools. making the Federal Government the largest supporter of medical schools. But. even with this large investment in terms of Federal dollars, health education manpower pro~rams have not been successful in addressing issues beyond that of increasing numbers of health pro- fessionals. With the exception of expenditures for biomedical re- search. most. Federal spending to health professional schools has gone for general institutional support. rather than being directed to- ward solvin~ specific problems. In particular. Federal programs have hee~ less than effective in solving the problems of specialty distribit- tion. I~ecent pro~rarns in family medicine are an exception. Furthermore. geographic distribution of health care providers has not been affected significantly by Federal policies which have relied mainly upon loan forgiveness as the principal mechanism for change. Sin(P 19(~5. 170.000 students were provided loans under the Health Professions Educational Assistance Act loan program. which con- tained a forgiveness provision to encourage graduates to locate, in medically nnderserved areas. WThile we cannot, of course. draw defi- nite conclusions about this program since many of those who have taken out loans are still in training. it is important to note that since l~(~ very few graduates have taken advantage of the 1o~i-i fnrgiv"~- ness l~T~o~~om Mr. Chairman. in trying to determine the appropriate future Fed- eral role in the development of health manpower, we believe the folTowin~ critical issues must be addressed: Adequacy of supply; geo~ra~hic and specialty distribution: productivity; and equity. ADEQUACY OF SUPPLY With respect to the supply adequacy of health professionals, we find that. in general, the allied health and nursing professions adjust reasonably well to market demands without substantial Federal as- sistance. The shortness and relatively low cost of the training pro- grams, to~ether with localized demand, contribute to this response. T~oth public and private training institutions have responded quickly a~ the demand for nurses and allied health personnel grew. Based upon current projections which assume maintenance of our current end planned output. capacity, we anticipate a 60-percent increase in reeisterin~ nurses from 1970 to 19~5. With respect to the medical and dental professions. we have de- veloped a series of manpower supply and requirements projections. These 1~rojections indicate that if we maintain our present and plan- ned output capacity, we can expect by 1985 to have increased the niiin~er of physicians by more than 50 percent and dentists by 40 percent. PAGENO="0299" 289 In terms of absolute numbers. the U.S. physician pool is expected to be between 495,000 and 520.000 and the U.S. dental pooi 140.000 by 1985. These supply projections for physicians take into account the future inflow of foreign-trained physicians. a subject of significant concern to this subcommittee. and are based on a reduction in the number of such individuals below the 1972 levels of approximately 50 percent to 80 percent. Recent. changes in the exchange visa regula- tions, increases in the numbers of U.S. graduates, and the likely actions of both the private and public sectors in addressing the foreign medical graduate quality issue should produce a downward trend in the influx of foreign medical graduates. These projected increases in supply are even more significant when viewed in connection with the expected population growth. Assum- ing a population growth rate of slightly greater than 1 percent, the physician population ratio will increase substantially from 158 per 100,000 in 1970 to between 207 and 217 in 1985. These rates would place the United States near the top of all the industrialized nations in terms of overall physician supply. Yet, population growth is only one of the variables influencing physician requirements. We have also considered how changes in insurance coverage and provider productivity may affect manpower requirements. Using what we consider to be a reasonable range of estimates for demand and productivity, we estimate that by 1980, physician requirements will be. between 400.000 and 450,000. This compares to a supply projection for 1980 of between 435,000 and 450.000. In our judgment, if the rate-of-enrollment., increases of the past 5 years were to continue unabated, we are likely to have a surplus of health professionals, especially physicians and nurses-a situation which is undesirable. A surplus of medical manpower may at first seem attractive but upon more careful examination several undesirable consequences emerge. Because physicians tend to have considerable control over the volume and mix of services they deliver, and the pricing of these services, a. surplus of physicians is likely to yield: An increase rather than decrease in the total and per unit cost of health services: A reduction in productivity, which may affect the quality of care rendered: A displacement of other types of health manpower from their roles in the health delivery system-e.g., the physician extender. These supply and requirement. projections obviously raise the critical question of w-hether the Federal Government should continue to follow policies which would encourage continued expansion in the output capacity of U.S. health professional schools. GEOG1~APIIIC AND SPECIALTY DISTRIBUTION In the past. Federal policies toward specialty and geographic distribution of health professionals have relied too heavily on a notion that an increase in total supply would solve the distributional problems. PAGENO="0300" 290 If iai~e enough ni nhers of health professionals are produced. it. ~V5S ie:i SniIe(l. competitive pressure would force them to practice in 1i1)IIh1-i(~t 1op()l itan niecs and in the medical specialties that offer lower iaOIne potentials. loiujei working hours, and/or relative1 lower levels ot prestige. Experience has shown this reasoning to be in- con ect. T)urinr the 19&Ys and lip to this time. while there was a substan- t~cl iuei(ase in the supply of physicians, the absolute number of 1)1lmiirv care physicians. pecicily those i~i general practice, de- creased sharly. There are, for example. strong indications to suggest at we are t~ninin ~i tno manY sur~ieons. A number of other profes- ~eoual spee~aitv as5nc~at1oP5 are increasingly concerned about the Pci ihood of oversnppl v in their specialties. As a result of this t iii tmn. pr~ mciv ca ~e is often delivered by high-priced specialists ifl eT~)(-fl5iVC seitin~. On tn~ `o~.~~apP P side. wli~le we were experiencing a large in- ce1~se in our n1ivsuIc n-pOplll at~on ratio during the 1910's and early I 070's. d~sparit'es in the distribution of physicians by States actually \vOIsefled. Population ~rroups ~n rural areas and in the inner city had dPTwnltv ~ainin~ acce~s to health care. Policies aimed at solving the problem of geographic and specialty itu~id~strihiut ion which concentrate on increasing the aggregate supply of health manpower probably will continue to be extremely expensive and lar~elv ineffective. The Canadian experience substantiates this conclusion. PRODUCTIVITY Sheer numbers seem not to he the answer. Increased physician and dentist. productivity, on the other hand, has the Potential to contain the cost of medical services and to lower the necessary resource in- vestments for the training of health manpower. If. for example. annual physician productivity, as measured by physician visits, were to increase by 1 1)erc(~nt annuall for 10 years. over 30,000 fewer physicians would be needed to provide the same total number of vi~its. This is a. goal clearly within our grasp. It is now well docu- mented that many tasks performed by Physicians and dentists can be performed by less expensive health persoiiuel. Yet, the.re is evidence that phvs~c~aiis and dentists are employing too few assistants arid that increasiinr the nuinil~er could ~reatlv increase their output. A 10 percent increase in vjs~ts is possible if the number of traditional aides pci physician is increased from two to two-and-a-half. In addition. physician assistants, nurse lractitioners. and ex- panded dental auxiliaries offer even greater potential for productiv- itv Yiicrecse~ than traditional aides. Dentists practicing with teams of four specialty trained auxiliaries have, been known to increase I Inc i pic4~ctivity In' I 1() percent over that of the dentists working with Oily one chair-side assistant. Other studies have shown that a physician assP~tant. can increase a physicians prochictivity by be- t ween till and ~ peicent. Therefore. it is in the interest of the Federal Government to con- tinue to address the issue of appropriate task delegation and non- an traIning programs. PAGENO="0301" 291 EQITITY As a generalizatioii. schools of the health professions have looked for Federal support as a primary source of income for many pro- grams and have sought non_li ederal support to meet financing re- (jillrements unmet by the Federal Government. From 1959 to 1970, total support for medical schools from all sources and for all purposes increased by 437 percent. Federal revenues increased by 728 1)ec.reflt. State appropriations by 423 per- cent. and tuition income by only 159 percent. Expressed differently. Federal suport. has increased from 29.5 percent of the total income ior medical schools in 1959 to more than 50 percent in 1973. At. the s~nne time. State appropriations remained constant at 15 percent and nition income decreased from 7.6 pe~ceiit to 3.~ percent. It should 1)e noted. however, that these fi~ures relate to income from all sources. Students of health professional schools have not. been asked to essiime a proportionate share of their increased e(lilrational costs. A review of the distribution of tuition charges by schools shows that. ~() percent of the publicly supported institutions plan next year to charge resident students ~1.200 or less, with TO percent of the private ~chiools expected to charge S3,000 or less. In view of the high earniii~s of health professionals. particularly l)hlysicians and dentists, and the relatively low educational costs they l)ear, the rate, of return on a basic medical and dental education has been estimated to be two to three times that of graduat.e education generally. Stated another way, the full personal investment in a medical education can be recouped on the average with 5 years of practice. A clear reflection of the economic attraction of these pro- fessions is the ratio of the applicants to places-currently in excess of 3 to 1 and increasing steadily. An examination of the stated career plans of today's undergraduate student population reveals that enthusiasm for a health professions education and career is rising dramatically. hEALTh MANPOWER OBJECTIVES After a thorough analysis of these issues, we have concluded that. Federal support to health manpower education should meet the fol- lowing objectives 1. Encourage the maintenance, of existing enrollment. levels of critical health professional schools. - 2. Target Federal Support on distribution, both specialty and geographic. 3. Increase provider productiv~tv through more efficient. use of paramedical l)ersonflel. 4. Beduce unnecessa iv and i neqiutable Federal subsidies for health professional schools arid students. \Vhen we evaluated the alternative ways to meet these objectives. it 1)ecalne increasingly clear that. the solutions to many of todays major issues, unlike the issues of a decade ago, are not within the jurisdiction of ediicatioiial training instltutions. For examule. to l)11fl~ about a 1)etter geo~raphic distribution of personnel. our great- est hope seems to lie in the enactment of the Administration~s Com- PAGENO="0302" 292 prehensive Health Insurance Plan. H.R. 12684 and an improved health resources planning capability throughout the Nation. This leads us to conclude that we should not expect more from our train- in~ institutions than they can deliver. Accordingly, we should not support them for things they cannot accomplish. There are two basic ways to provide support for health profes- ~onal training-direct grants to institutions or direct assistance to students. We have attempted to weigh the efficacy of these types of support regardless of the budget implications. The question simply was. "What are the most effective funding mechanisms to accomplish the national objectives?" Capitation grants to health professional schools can be viewed, at least in part. as a. subsidization of enrolled students. To the extent that health professional students are willing and able to pay, sub- ~dization must be called into question. Of course, if training institu- tions are requested to take new actions. such as increasing enrollment, one cannot view capitation as just a student subsidy. After weighing these alternative uses of capitation support. we have concluded that it is less efficient than special projects in achiev- in~ changes that are necessary to address the major manpower prob- lerns of our country. Greater flexibility is necessary in negotiating with individual training institutions to mount innovative or special types of training projects. Special projects give us this flexibility. A ~ such. the current levels of capitation support are unnecessarily lihih. Current levels of capitation are not needed to encourage health professional schools to maintain current enrollment levels. Health professional students can and should be called upon to assume an increasing share of their educational costs. We are not asking students to pay for their entire educational costs. However, current tuitions covering only 10 or 20 percent of such costs are, in our view, too low. Furthermore. the need and purposes of student assistance also has changed over the past decade. Ten years ago health educators believed that scholarships and subsidized loans were necessary to assure enough qualified applicants. But lack of qualified applicants is really not a problem. The high personal satisfaction and the anticipated financial rewards in all health professions are more than sufficient to attract adequate num- hers of qualified applicants. Instead, future Federal policy for health manpower student as- s~stance should he directed toward achieving three goals: 1. Equality of access to medical education. independent of stu- dents~ financial resources. Access in this context does not mean a subsidy hut the opportunity to obtain funds. ~. Appropriate types and levels of support for economically and secially disadvanta~ed students. to encourage their greater repre- nntnt~nn in the health professions. ~ AdeqUate numbers of health professionals to staff Federal pi~n~i~ni needs. I heve set forth these health manpower objectives and alternative fnnd ii~ apronches in order to provide a framework for discussing fLo Qiplilaritics and contracts between our proposal and the other mn~nr hills pending before this subcommittee.. PAGENO="0303" 293 THE ADMINISTRATION PROPOSAL Before proceeding to that discussion, Mr. Chairman, I would like to describe some of the major themes of the administration's pro- posal. The changing nature of our health manpower problems necessi- tates a significant change in Federal policy direction and spending patterns. Thus, Federal dollars will have to be withdrawn from old programs and placed into new programs. Being cognizant that insti- tutions, particularly complex ones like health science centers, need time to adjust, we will be phasing-down or out of most old programs as we move into new areas. PROBLEMS OF DISTRIBUTION Many different provisions of our legislative proposal are directed at the twin distribution problems-specialty and geographic. These are complex problems which have no easy solution. We plan to address these problems in the health training legislation at both the professional and post-professional training levels with incentives for both students and institutions. In addressing the primary care problems. we propose a new authority-national priority incentive awards. Under part A of this authority medical and osteopathy schools will receive $~,OOO for each of their graduating students that ent ers a residency in family medicine. Obviously, those schools that have taken the lead in the production of primary care physicians would receive the largest bonus. I believe this is appropriate. However, given the magnitude of the problem, we would hope that all schools would increase their efforts to produce more primary care practitioners and therefore benefit from this program. Part B of this authority would provide grants, including stipends, for post-professional training in shortage occupations. We will focus this authority on primary care training. In particular, we will sup- port the development of ambulatory based residency programs in family medicine and other primary care specialties. These grants will provide start-up and early operating assistance. When necessary, the grant will cover residency salaries. In addition to the national priority incentive awards, we will be increasing grant support for nurse practitioner and physician assist- ant programs that train primary care specialists. Those training pro- grams that emphasize the team training of physicians with physician extenders will be looked upon most favorably. Finally, we plan on expending a larger portion of the special projects money on curriculum changes in medical and nursing schools. In particUlar, we will support efforts to develop family medicine departments and to reorient the pediatrics and internal medicine programs toward primary, rather than specialized, care. I believe the geographic problem will be the harder of the distri- bution problems to solve. The days of the solo general practitioner- GP-establishing a practice in rural America are gone. The long-run solution, I believe, hinges upon developing a medical care delivery PAGENO="0304" 294 sv~tein W1UC11 links ph sician practices with paramedical personnel in those rural areas not capable of supporting physicians. We cali eiicouraue this development-by admitting students that 1i~nl inral life preferable ; by developing educational centers in non- metropolitan conlinunjties ; and by moving more residency training out of major teaching hospitals. Through our legislation, we will support such eiloits-articularlv through area health education celitis and special project grants. \Ve believe that I)1~ysiciaI1 extenders can contribute greatly in biingiiig about a better geographic redistribution of health services. Physician extenders programs, particularly MEDEX, have been di- iected at rural America. We plan to give high priority to those IIU1Se practitioner and physician assistant programs that are con- centrating on providing rural practitioners. Finally, we will piovicle direct economic incentives for students to enter pi~ctice in uiideiserved areas through scholarships for service. Loan forgiveness has not been successful in getting physicians to practice in underserved areas. However, we believe that a scholar- ship pioglam. providing larger awards, will be more effective be- cauSe students will make an affirmative commitment early in their training. As you can see, we plan a multifaceted approach to solving the distribution problems. This is because no one knows the single best way. If. with further study, we learn of better approaches, we will be able to uluplenleilt them through our flexible grant ~)rog1am. CAPITATIOX Over the next 3 years, as we increase our efforts to address the distributional problems, we plan on phasing down some Federal cal)Itatiofl support. The capitation grants set forth in the Compre- Ii ci isi ye IJea Ith Manpower Training Act were unrealistically high. As von know. they have been funded at only about 60 percent. Yet, at this ieduced level, most schools have not been financially pressed. since we asked schools to expand enrollment for the capitation sup- po~t, they had to incur some additional costs. In our new proposal, no expansion in enrollment is required. Thus, we feel capitation u(nhl(I be reduced with no dire consequences. Uoiitimiued capitation under our proposal amounts to a subsidy for cuircu~tlv enrolled students. Capitation is merely one source of rev- emita for meeting the costs of education; student tuition is another somimue. Given the high earnings one derives from a health profes- sioiial education, for example, the. average annual physician adjusted income is approximately S45.000, the rate of return to the student is in excess of almost all other professions. This relationship would not change if students were asked to assume a larger share of the costs of their own e(lucation. Given these facts, Mr. Chairman, we find little rationale for the current subsidy provided by capitation. Let me emphasize one point. If students were paying more rea- sonable tuitions. as is the case for most private undergraduate schools and most professional schools, our concern over the unneces- sary subsidization, provided by capitation would be greatly di- minished. PAGENO="0305" 295 A substantial, immediate reduction of capitation support might be very disruptive to some institutions, paiticulai1y those receiving the highest. rates of capitation. Accordingly, we propose to extend cal)ltation for most health professional schools for an additional 3 yea is. For post baccalaureate schools training provicleis of personal health services, we plan on gradually phasing clown capitation. The statutory capitation amounts for schools of medicine, osteopathy, and dentistry would be reduced to $1,500 per enrolled student- without regard to class year-for fiscal year 1975, $1,~50 per student. for fiscal year 1970, and $1,000 per student for fiscal year 1977. For schools of optometry and podiatry capitation will be reduced to $400. $300, and $~200 for fiscal years 1975, 1976, and 1977 respec- tivelv. The effects of these phase-do~vns will be monitored closely and at the end of 3 years, we will reevaluate the need for con- tinned capitation support. Schools of veterinary medicine will receive capitation support for the next 3 years. However, we propose to end capitation support for these. professioiial schools upon the expiration of this legislation. We find little rationale to continue general basic inst.itut.ioiial support to those schools that train individuals not providing personal health care services. \Ve do not propose the continuation of capitation support for Un- clergraduate education provided at. schools of nursing and pharmacy. in general, these undergraduate professional schools are responsive to local needs and should if necessary be funded with local resources. We will continue, to support particular program development such as clinical pharmacy through the special project mechanism. STUDENT ASSISTANCE 1. Loans. As a larger portion of the cost of education is shifted t.o the student, it is essential that we have adequate loan and scholar- ship assistance to assure that all students, regardless of family in_ comime background have access to a health professional career. The administration has already pioposed in ll.R. 13059 an ex- pamideci guaranteed student. loami program for graduate level train- ing. We have recommended that the total existing loan ceiling be increased from S10~000 to $25,000, and the annual ceiling also be increased from ~2,500 to $7,000. Most students will have little difficulty in paying back these higher loans. In addition, these students would be eligible for our proposed expa tided scholarship/service program. We also propose to maintain the current direct. loan program op- (rated liv the educational institutions. \Ve will, however, phase out 0111 capital contribution over the next 3 years. The capital contribu- tion funds and the repaid loans would remain available for the iimaking of new and continuation of student loans. The interest, rate for these direct loans will be raised from 3 to 7 percent-the same rate paid by those assuming guaranteed loans. ~2. Pie-admission and sc/wla.rsli ip assistance for the disadvantaged. There has been significant underrepresentation of students in health PAGENO="0306" 296 prof~ ssions schools from among individuals who, due to socioeco- nonii factors, are financially or otherwise disadvantaged. This has heei~ a malor factor in the resulting underrepresentation of racial miii ~ities amomr practitioners of the health professions. I~ recent years significant progress has been made. For example, the ~~ercentage of minority representation in the first-year classes of ni'dicai ~chools has risen steadily from 4.2 percent in 1968 to 1OJS nercent in 1972. These students are largely from families of low ~icome, 20 percent are from families with less than $5,000 per year tucome and 67 percent from families of less than $10,000 per year. llegardless of the gains made through improved educational oppo!tluutles in the preparation of such students for entry into lieiilth profession schools, these students remain the most vulnerable in te ~ms of educational and economic risks. propose that a special preadmissions and scholarship program be e~rabhshed for the disadvantaged enrolled in post baccalaureate pro~rinms. It would 1ro\~ide: Stipends for students in preadmission pro~rrarns. and scholarships for students from disadvantaged back- grounds for their entry year in a health professional school. The sch~ arship is limited to the entry year because upon successful com- pletion of the first year in school. students gain confidence and there- fore I)ecome. more willing to take out loans. Nursing students in both college and hospital training programs, as well as other health prof~ssiona1 students in undergraduate train- iii~ and in need of financial assistance, will have access to the basic opportunity grant-BOGS-program, administered by the Office of Education. COMPARISON OF PENDING BILLS Ii~ terms of overall objectives, there are a number of similarities between our bill and H.R. 14357, the National Health Services Man- power Act of 1974. This proposed act cleraly states that the distri- butioii issues are of paramount concern. Like our scholarship pro- vidons. H.R. 14357 would address the geographic distribution prob- lem through scholarships for service. However, whereas we envision about 10 percent of all students participating in this program, H.R. 14357 would make available such support to all eligible students. If 1)0 percent of our graduating health professional classes agree to the service conditions in the bill, a high proportion of suburbia would soon have to be identified as underserved for purposes of fiil- filling the agreement called for in H.R. 14357. While the geographic problem is real, the magnitude of the solution suggested in H.R. 14357 is clearly excessive. Moreover, the payback provision for the sub- stantial Federal support received, that is, 6 months of service for each year of support, is far too short. In our view, the administra- tion's proposal for a scholarship program, and continuation of the National Health Service corps effort are appropriate actions. Both our bills and H.R. 14357 would address the problem of medi- cal specialty distribution by concentrating on the graduate training phase. Generally, current health insurance coverage inadequately covers outpatient care and the associated primary care training. To PAGENO="0307" 297 oticome fins 1)101)1Cm, we plan on si~niiicantiv increasing our sup- ~t for prinla iv care tiainin~. particularly at the graduate level. The ability of 1)ositive incentives to have an impact is clearly 1e41at(d in the remarkable ~.rrowth over the last few years in the (tenland for end support of family medicine residency positions. As Vmi know. for this comimr~ year, the number of individuals (I(siring flist-vear residency plac~s in family medicine exceeded the ni~mubei of a~ailable places by approximately L000. This occurred at the same time as the number of first-year Places increased by al- nio,~t ~0 percent. This encouraging event leads me to conclude that we can achieve a better balance in the distribution of residencies without the total regulatory control required by 1-LB. 14357. li.R. 11721. the Health Manpower Act. of 1974, and H.R. 1472.2, the Nurse Tiaiiiin~r Act of 1971. differ greatly from the administra- tions bill in terms of national priorities and funding mechanisms. These proposals call for sizable increases in basic institutiona.l sub- ~-i(lies. In return for these increased subsidies, training institutions would be requested only to take minimal actions addressed at the pIessing distribution problems I have outlined above. For example, to receive basic support. a medical school need only develop an ac- teptahie special project proposal, such as enrolling more students from rural backgrounds. rrhilis, a medical school with 500 students would receive over ~1.5 million for developing just an approved plan, not necessarily one which is even funded. I cannot believe that the average American taxpayer would willingly accept such a large SI1l)Si(ly program. Also, unlike our proposal and H.R. 14357, H.R. 14721 attempts in numerous ways to increase the number of training positions. As I stated earlier, to saturate the market in hopes of solving our ci ist ribut ion problems seems inconsistent with historical evidence. Producing more and more physicians in the hope that some will eventually filter into the rural areas is unrealistic. At a minimum, to bring about such a migration of physicians would first require a reduction, and a sizable one, in the average income of physicians in manpower rich areas. However, there are no grounds for assuming that. a large increase in physician supply will bring about these re- ductions in income. Furthermore, income is not the most important factor in determining where a physician locates. Mr. Chairnian. I have spent my time today discussing our per- ceptions of the health manpower problem and the basic philosophical differences between the various approaches advanced to deal with the health manpower issue. W~e would be pleased, however, to dis- cuss further the details of the various pending bills. TilE NATIONAL }IEALTFI SERVICE CORPS PROGRAM Mr. Chairman. I would now like to turn our attention to proposals on the National Health Service Corps program which we feel should be stren~thened and extended. The Corps represents an exciting and challenging mechanism for placing health professionals in areas with criticRl health manpower shoitages. The National Health Service Corps is in every sense ~ 35-GOS--74----it. i-21 PAGENO="0308" 29S people prograrn-linkiiig health professionals in a very important peis~~ial and professional wa to communities and to patients with needs aiicl probhein~. who in many cases have not had other than dis- tant emergency care available for long periods of time. rfhe primary mission of the National health Service Corps addresses the docu- meiited problems of geographic maiclistribution of l)roviders, especiaUy in rural communities. In a(lditiOn. this program assists corn- munities in (leVclOl)imn! the cal)al)ilitV to independently attract and retain heal tl~ profess~oiials. Considering such factors as the loss of the physician draft and the clithculties associated with establishing new programs, we believe time National I-Iealthi Service Corps has macic reasonable progress in its fir~t years of operation. We have, in the last several months, focused more attention on the Corps and brought about a beneficial redirection and strengthening of the pmo~~mn. The accomplishments I have cited as examples pro- vide us with sufficient encouragement to wholeheartedly endorse the continuation of this ~)rogramn for 3 years. The. Corps has now pi~en that it is an elective mechanism for assisting communities crit- icaflv short of health manpower to establish and sustain appro- p1]ate health practices. However, because of flue objective to ultimately have as many co~nilluiiitieS as possible estal)lish independent practices, we have inaiv;:ed tIme current legislation in order to identify an existing impediments to achieving such status. \Ve have identified three areas where lc~islative changes would facilitate independence. First, we propo~ that communities beginning practices be given collsi(lerabie latitude with regard to cost recovery in the initial stages of operation. Sites are now required to pay for the services received through National health Service Corps on the basis of a cost recovery formula. The present formula does not allow flexibility dur- ing the start-up period of the practice when utilization and billings may be low and at a time when the community is assuming the Iaigest share of time start-up costs. Many practices thu.~ incur large debts during the initial 6 to 12 months of o erat~on. These debts serve as a disincentive with respect to movin~.r away from Federal support. The administration's bill would provi (Te the I )epa rtment flexibility to deal with cost recovery mis most ol)propliate during initial periods. Aiiothier I)1ovlsiohl of time a clministration 1)111 would also aid corn- mumiulties in avoi(ling large initial operating debts and would also serve to develop local resources. Presently, the Department conducts initial surveys of communities and helps in preparing for the arrival of a provider. ~\Io~t of these functions. such as locating and setting ill) ~iO~ei facilities and establishing billing systems could be done thrruurh local resources. We are not, however, authorized to provide f~iunls to tire communities for this purpose. The administration's bill therefore includes authority to make small loans or grants not to exceed $10,000 as appropriate for this preoperational develop- ment. We intend that most of these loans and grants b'e in the neigh- borhood of $2,500. PAGENO="0309" 290 Another impediment identified is the absence of an effective mech- anism for transferring equipment to the communities. Purchase of ((litipiflent being used at the site should not I)e permitted to stand in the way of a site becoming iiidependent. It should be borne in iiiind. of course, that title would not go to the health practitioner but to the ]iO1i1)rOfit entity established by the community. Also, no l)uildings or facilities would be involved since tue corps does not fuII(l construct ion or renovation of facilities. We note that H.R. 14721 provides similar although more restric- tive authoiitv wjth regard to pieoperatioiial loans and equipment. We would stiess that flexibility for cost recovery (hirnig initial op- erat ion is more important from tile perspective of achieving site iiidepenclemmce. 11.11. 113~7, on the other haiid, provjdcs 110 Inecilanism to recoup time pmeoperatioimal giant re~rardless of time ability of the conmnmujiitv to do so. II is iniportui~t to make a (listinction between critical health man- ~ shortage areas amid niedieallv lni(lelserved areas. ~ ~atiomial I fee ltl~ Service ( ol1)s is directed to time pioblemmi of availability of lice Ith manpower resources. Although we do not wish to enter into a difference of semantics, we do believe that tile designation of iiiedically uiideiseivecl Pol)ulations for the ~\ational I lea Itli Service (omps plo~Lm-a!n ~15 Speciiicd iii i1.1~. l4~~i colildi ciiii~-e (`OlifuSlon vithi other pi'o~n1'miiIis in the I)epartment. Many communities seen as n~ed~cahTy undemserveci do not call for the assistance available under I lie ~~ationa1 Ilittith SerVice Corps ploUmallI. lor eXmunl)le. their needs immn.rhit be limited to transportation, organization or delivery of serv- ices or financial miecess. Time extension of National I Tealthm Service Corps coverage to these other areas, as might be inferred from the pro- ViSIOUS in IT.R. 14721, could result in the improper utilization of scarce resources. rFlIe provisions for cost recover in ll.R. 14721 would create serious difficulties. ITiilike present law and the administration's bill, ll.R~. 14721 establishes rigid cost recovery requirements which we believe would Seiloiisly inliihiit development of these practices. Presently, sifts InC me1mmmh)u~se the Government on time basis of a I)ercentage of rcceipts. If. as Il.R. 14721 piOposes. time site was required to pay to time lnited Stat('S all re('eipts or to fully icimnbu~se the Corps 101 its (osts from time initiation of the practice, we would ia i that limanc. it not most communities. would l:~e discouraged from developing such l)ract ices. II.I~. 113~7 recognizes that a community should not, especially in tIme initial operating perioh be placed in the I)osition of turning over all its receil)ts to time tiemisitry and therefore requires omllv T~ l)ercent of ieceipts to be paid when a community cannot offset the full costs to the Federal Goveinnieiit. This is an arbitrary figure which in p001(~1~ COiullilllIiiti(S. may l)C muCh too hugh and indeed in others be too low. We therefore reconunend the administration's flexible al)proach. lIme pr0v~sion in II.f~. 1-1-721 authorizing the Secretary to pay in- stitutions for time costs of increasing their enrollment for the pti~'- pose of accepting members of the program would be impractical. cx- PAGENO="0310" 300 t Fe! V i~tiv a ci we 1 c" ieve it is inappropriate and unnecessary I I f o~ I I [e~ i Ii ~crv ice (1ori )S. A v iIec~mc ~o i[.lh 14~1 and IT.IL 14351 is the provision \vI~.cJ v~t~ ~~n~fIative approval authority in the National Ad- vis' ~iV C cccii on t1~e ~ational Health Service Corps with 1eSl)ect to tii~ selielalehlip ~ \\~e believe it would seriously undermine prociulil inanageineilt to vest administrative authority in such a coni~~. The role of the Council should be that of providing advice to c v':~iii managenieiit hut should not be one of essentially ad- lli1~i~.~ ~ci~ ~ program. lie ~ incentive piovislons of ILR. 14721 and 11.11. 14357 are als essa iv in vIew of legislation, Public Law 93-274, which deci~ \vciI all service~. CONCLUSION In ~uinmitiv. Mr. Chairman. I strongly recommend enactment of the mi i iist iation's health manpower pioposals. These proposals on tl~e level of Federal support and funding mechanisms reflect a camefuJ assessment of 1)riorities and projections of health manpower. I kno~v we can move forward together in developing a new health mnamipo'ver strategy that is fi~iaiicially prudent and appropriately t a ige t C (I. \Ve look forward to working with you and your colleagues on this ill11)oIt ant legislation. Mi. ~ Thai~k you very munch, Mr. Secretary. We appreciate the statement von have made. Mm'. Nelsen. Mr. ~i:csrx. Thank you. Mr. Chairman. I notice the reference made to provide some leadership in the change as to teaching in the medical schools of "physician extenders" as von call them. Will the medical schools follow the recommenda- tiomi along those lines and has it been accepted fact that HEW di- rects policies pertaining to medical schools? I)r. EDWARDS. I think it is an accepted fact by the medical schools at least that HEW does not direct policy. One of the things that we feel strongly about is we have to begin to utilize our funding power for more directly providing some of the answers in terms of health ma npcwer. As we pointed out. I think to date we have certainly been very successful in terms of aggregate numbers in all of the areas, not just physicians, dentists, and osteopaths. In addition, the numbers of allied health professions have increased, and we propose to continue this via the special project grant, rather than on a capitation or other basis. Mr. Ninsrx. In our legislative process I recall for years the leader- ship ~\hlS. Ilolton supplied where she wanted bedside nurses and we found organized opposition to the acceptance of the idea. Yet it would seem like some of the terms, "physician extender" and "nurses' aides" and what have you. would do two things: Supply adequate manpower and at the same time a long education which is beyond the reach of some. Maybe one of these other positions would be PAGENO="0311" 301 reachal)le as far as costs are concerned and wOuld serve a good pur- I tli ~ik tbe idea is rely ~ood if von can sell it. What al)out the foreign medical School graduates that come here? Wi~at do von now do that guarantees quahi hheation of those people t~ at cone l1e1~ 1)1) we know w ea~ getting physicians that come to the TTnited t~tates aS doctors tl~at have tiie proper qualifications in your ]n[uuieilt. and what do von do about it if they do~it I) r. Einoir~us. As von know. tiI~;3 has not been a direct Federal i~Si)O1lSi1)1l tv. r1~e prIvate sector audi the States have had responsi- I olifv of first of all giving the e:~aiminations which will admit for- eign me(iical giadiiates to the Tinted States and. secondly, in ad- nilisteling Siate hicellsule exain~nation. I think everv~me here, con tainlv all of my associates and I. ae?ree that the requirements for loleigli ule(iical graduates have not LCeIi adequate that we. in a ~1~'~e have had two standards of medical examination, one for our own students onid one for the foreign meolical gradi~ate. \Ve believe i his has to (llnnge. We beljeve it has to change through several dif- f'lnt routes. First of all. in QUO view the examinations have to be beefed up uOiISideritl)lv. The examinations that Th\IG's take in order to obtain ie~ddencies and mternships in tIle I T~iited States have to be compara- l)ie to those which our graduates have to take. Thirdlv. we believe the specialty groups and appropriate educa- tional groups have to take a hard look at all the graduate training ~~1ograius t I iat are currently available in the I ~nited States. There aie a lot of them that~ ale not adequate programs. In many cases these progranis aie the piograins that are taking the foreign medi- cal graduates. These programs have to be eliminated. We bei jeve that raising examination standards along with the ci inijnation of some of these poor quality graduate traiiiintr programs will have a significant impact on the numl)ers of FMG's entering the .~. health care system. Mr. Nri.si:x. Among students coming to tins country, do many of them come to the United States who are already U.S. citizens who have gone al)Ioad for their education and have then come back? I )r. LnwAnDs. About 10 peicent of time FMG~s are LS. citizens. Mr. Ni:rsi:x. Why do they go there? Is it cheaper? T)r. LInvAlws. No. I think they can not get into our medical schools. Mr. Ni:isi~x. I notice the construction grants von ale going to phase back but I am concerned about areas where commitments were made to schools and they pioceedied with a program of construction with the anticipated income that would come from the grants when they come through. What is going to happen to those areas where commit- mnents were made, where the Government and HEW~ encouraged a school to expand and then because of the fact that there was a short- age of dollars to go around, you now change plans and leave them out there without those ciohiars that we committed ourselves to sup- ply. What is tile plan there? J)r. EI)w~~nI)S. I think we have moved to honor most of the commit- ments but I would ask T)r. Eridlicott if he would speak on this partic- milar issue. PAGENO="0312" 302 I )i. Exnicorr. I would like to address the question first of commit- illents. As a matter of fact, schools had to assure us that they would ad- mit additional students Oil the basis of receiving the construction grants a] ready made so there really have not beeii any firm commit- inents on the part of the Government. What has happened though is that in appTving for earlier construction grants schools have indicated to us that it was then intention to have a phased construction pro- grain in which there would l)C several additional buildings con- stru('reI in the future. But the awarding and accepting of the grants were riot contingent upon receiving additional future funds. However, a number of schools have felt that as they admitted the addi~ jonah students as required in their earlier construction grants, tins put a strain on their facilities which would he substantially removed if they went ahead with earlier plans for additional con- st ructiou. We recognize this pioblem and are now in the process of awarding coin lrmletion ~rrants with top priority being given to these phased con- Stimietlon Pi0P0S11'S. A sul stantial part of this backlog we feel will be relieved with the funds wiuch are now in the piocess of being obligated. Perhaps not all of it b~t a sni stantial part of it. Mi. ~\rL~I:x. I iiinlerstand. and shoul(l point out that our University of i\Iii~ncsota was one. What about new starts? It seems to me as far as new 1arts in nielical schools that we did not advance money iei~eIv Lecanse of a e~iphoard-getting-bare type of situation. Now are then on~initnments~ there that \Oll feel will be honored or will we dma age 0111 I)lanS there lii rIme Instance of tIle medical schools. T think our big hope was tint \V 1v(ilid eXteIl(l the act an(1 then catch up later. hut now if the pie s ale `lialige I iiiavbe we will never make that move. I P. 1'. Nil: `IT. -~ von 1)rol)ably are aware, requests for construction grin its I iuve ci~Lsta~ ~tialiv exceeded the amount of money available. Foi- ia ox~mnateP- the last 4 yeats institutions which were proposing to ~ 11 1 new medical school hit ye been advised to seek some other 5011 `c at consti'uction funds lecaimse it did not look as though we were goiiii.~ tO ave the fmuids. -~ ~ a i'entlv a iiuimmher of them did go ahead with their plans to open ~-i no] ii luTe i'st a ~iding that there pinl ably would not l)e Federal asst: mae iv ailaile. i\Ii. Xruu:v. I note in tIme area of schools of vetem'inai'v medicine that von intend to ~)li~i~e them out at the end of a 3-veai' period. Now, in time event that there appears to he a need for rehiabil itating that idea we an still (hman~-e it and go hack to more emphasis depending 11mw hOW tIle situation develops. Of course I am ver much inter- eszt (j ii that area and find it to he something that we have macic good use of in tile past. `Iii imP au i\h. Chairman. `di. F~arjis. ~\1r. Kvios. T\['. Kypo~i. Thank von. Mr. Chairman. a. ~~u'tarv. I uot~ce ni your statement you state that in the next PAGENO="0313" 303 1() or 15 °`~ pe~1iaps ~0 years-going into the 1990's-we will have suf- Orient doctors and other allied manpower peisoiinel in the country. Is that what the estimate is? 1)r. EDWARDS. We figure that in 1985, a little over 10 years. Mr. Krrios. In this figure you are assuming that we have an input of approximately 5,000 foreign health manpower subjects each year, is that correct? I)i. EDWARDS. We have calculated our figures on the basis of a 50 percent to 80 l)elcent reduction in the number of foreign medical graduates. In either case we feel, as I have mentioned earlier, that by l)et\veen 1980 and 1985, we will have nearly double the current imiiiher of nurses, doctors, and dentists. Mr. Kyims. T)o you assume that with the present capacity of all 0111 medjeal schools we will be able to fulfill these objectives, the iiuinber ? T)r. EI)w\lins. We believe strongly that in terms of aggregate num- i)els we will i~e able to pi'ocluce sufficient numbers. In the meantime we have to begin to move in several other areas. how do we redistribute these doctors? lIow do we get the right kind of specialty in the mix, and so forth. These are other issues that von are interested in and we are interested in. Mi. K~ims. They ale really difficult issues. One of the variants will be the i111)llt of foreign doctors and their quality. A second will be cliangiiig specialization trends, and a third, changing geographical distribntjon of tile doctors. Xou pointed out in your statement that despite our efforts on loan forgiveness, for example. underserved areas are still not served by doctors going there. We have not been al)le to give the proper incen- tives yct and it will be hard to come up with the piOper formula. I )i. Enw.~uns. That is correct. There are a number of things that aie llell)Iinr. but iii terms of totally solving the problem, it will be very diliiriift. ~\lr. l\YT1(,~. ~Ioll liICOII the adiniiiistration P1oPosedl national health piagialu I )r. lmv.\Tr)~. ()i11S or anyone else's. Mr. Kyims. Will help. Why won't it exacerbate what we already have larai~se the demands by a lot of people that they will not get tIle kind of medical care they are getting now will increase and very P10l)('1lY. i\ Er. Einv~i~ns. It gives them a degree of purchasing p~'~ Both (liii 1 i~l1 011(1 the heil1Iedv-MIlls proposal move 111 t~ie (lirectioli of mi~r lltaithi rare in an ambuiatoiv setting away from the in- ~Hti~tio~nil kln(l of setting. We allow for plIyments under our proposal of the ant `ust for phvs~c~ans but for other kinds of health providers w Ii id i ne iii ik will be an a dde(l impetus to in a king a mole meaning- fiil role for those allied health professionals in the health system. Mr. Kynos. Winit I was trying to get at, if von upgrade education, the (plahity of medicare, to a certain standard by a national health ~liI11 of somiie sort, wouldn't, then, the demand on tile present dioctor mnaiipowei and the applied manpower be such that they would be failing shiomt. Wouldn't that be the case? PAGENO="0314" 304 l)~. LaWAImS. I think we all agree that with any kind of national Iieali li financing scheme there will be an increased demand. WTe feel t here will he an inccease in the order of 10 pei~cent. ~i. Kyris. And it wolit even exacerbate the geographical distri- I ui au. I ieause flulist people are still located in urban areas? Di. Imv~ui ~. TI at riii~ht. but by trying to focus on preventive ii a: foi;~i.~a~ 1ucilnr for am~)u!atorv care rather than just i~wtiitioiiai ca Ic. we \vi]1 irobablv be better able to cope with them tiiilll\Ve are at the ~ ~h. ~ in light of the foregoing discussion. why don't you liir e ~t ar~ -ili funds for medical schools for small States like mv own? I )r. Ai:ii'n~x. I am selne\vllat concerned. iou are implying this dein.klid for medical cole on the part of the rural areas is not tlicia 110W. III fact, these people lire not getting the care. National Joe th ~nai~i'ance \vduid provjde the financial resources for these peo- ple to lcd nicie efFceti :elv than they now bid. I itimatc~v. in i~ianv of Out rural areas. they actually can pay the pile that the provideis feeT tflev have to have in order to be there. ~0. ill SOHIC sense. there ale two types of demand. The medical demand is I lYle ito~v. \Vltat re a ic trying to do under National Health Insur- IS to put the huiauiciuig where the medcial demand is. ~~~1Ci1 on tue all said and clone, you are talking about rates of utcicase \vllicll are not substantial. So, what Secretary Edwards sa.id, what we are trvintt to do under both our l~ealth insurance and our inaiipower hills is to push the dollars toward attracting the doctors to tile rural areas. Our problem is not total supply-in answer to your c1uest~oii-it is some way of both pushing and pulling p1~sicians and oft ~i practitioners into these areas. Mi. Kviios. One Way to have doctors in rural areas that are under- served is to bring tile very people that are going to become health manpower providers from those areas. Isn't that a common precept? If ~oii pull them out of some place, they will go back to their own hometown ? I)i. Eow~nns. I think that is certainly one of the answers. I think that we have to pay a lot more attention than we have in the past to the individuals that we are taking into our medical schools, and I think von ale probably right. ~\hi'. Kyros. Theie ale only a few regions that do not have medical schools, and your bill does not provide any funds for start-up funds to solve tllis problem. l)i'. Auri~rAx. One of the problems we have found is, quite often, they bring p(ople from their own areas, train them, and themi they go to the financially wealthy areas of the west and east coast. T)i. L!)wMIl)s. I think the real issue is that as long as we have a health care financing system as we have now, where a doctor can do less but still make an overadequate income in an area, he will go to that area if there are more advantages for both he and his family. I think, as Di. Altman pointed out, just because we have a medical school, say, in a. rural State does not really give us any real indica- tion that it is effective in retaining graduates for that area. Mr. Kynos. But if von have a medical school in a rural State. tied PAGENO="0315" 305 ii Pledi('al center that does internships and some post school work, I think you will find over and over that then the doctor does stay iii that area. Isn't that so? I )i. Ar:r~n~x. It is a movement in the right direction. It is an cx- pnsive way for the rural States to accomplish that. I think, there ale mole ethcieiit ways to (10 it. Mr. l~uus. You want the rural State to be accepting Only foreign cloctois. then I)r. Ai:r~rsx. I think the general experience has been that, doctor that~ stay in the area are people in specialties. The difficulty in the rural area has l)een the development of a patient pooi sufficient to estnhhishi a well-meaning and competitive training program. [think the availability of the financing program will provide ac- cess so that the 1)1111 to the training prog~~rn could be developed. See- 0101. I think the training program would have to change its charac- tIlistics to reflect its rural setting. This type of residency program niighit not be the type of program that would hold doctors in that area. Mr. Kyllos. Let me give you another specific instance. I know, in Maine, we have a residency in psvchiatry at the Maine Medical Cen- tem. ihe result has been that people that have gone through this training have often ended up staying in Maine. I understand that in Duluth, Minn., the medical schools train rural- oriented physicians. and they have had considerable success; isn't that right, J)r. Endicott ? I)r. EN1)I('or'r. I cannot answer that question specifically for Du- I mith. but I think it would be fair to say that, nuclei' the worst condi- tions. that I am aw-are of States which do have medical schools have at least half the graduates in their schools remain in the States. To that extent, having a medical school is better than not having one. There has been, for some time-as Mr. Nelsen is. I am sure, ade- (hllatel aware-an out-migration of physicians from States of the Middle West. especially to California. I am told, perhaps. the largest alumni association of Minnesota ~(hIool of Medicine is in Los Angeles. So, it is not a total success to have a nwdie~il school, but there is a substantial advantage to having one. ~\1r. KrRos. The bill that you are discussing today, Mr. Secretary, aho do~s riot contain-in addition to start-up funds for medical schools-does not contain funds for construction of new facilities; is that correct'? I)r. EDWARDS. W~e ai'e letting the grant~ authority expire. However, the loan authority will be continued. l)m. LxlncoT'r. Thieie is legislation already enacted, which might in part ans\ver this problem. rfhis legislation, enacted last year au- tlloiizes the Veterans' Administration to establish up to eight new ~tot liie(licOi schools'. I believe that Maine is one of the States that \volI!dl he most likely to benefit from that. \f~. Ki-nos. But, still, there is no construction fund, and they are not eligible for loan guarantees. either. Mr. Secretary. PAGENO="0316" 306 Dr. EXDTCOTT. Loan guarantees are continued, but are limited to replacement or remodeling. Mr. hyws. But not construction, so von could not start and build an all new medical school I )i. EDWARDS. That is correct. ~\Ii'. Kynos. What about nurses? Why do you phase down the capi- tatio~i grant on nurses. where in my own experience, in the north- (`aste Ill States. the nursing schools reall require this money. They have all told me they require it, and they point out their desperate situation financially. I dont understand why you point out the need iii your statement and theii point out there will be no capitation ~iants for nursing students. I )r. EDw~~nDs. We I e1 ieve that the need for, and the response to the need for muses is a local issue, and localities will respond to this need and will fund most of these programs themselves. There are starter programs. The fact of the matter is, over the last ~ or 6 years. we have been capitating these programs at a very, very lOW rate anyway. appioximatel $200 pci student. Mi. Kyiios. but. i\lr. Secretary~ on page 21. von point out- I)i. Enw~~rms. We still plan to continue special project support for new and innovative programs. Mi. Kyos. Two things ale on my mind-why are doctors a national and nurses a local issue ? What does that mean? I )r. EDw~\RI)s. I think the doctors are a national issue for several reasons. such as the distribution of physicians. since where they seems to have very little to do with where they go to school. Probabi more impoitantlv than that. I think, is the length of education for physi- cians. \Ve are not talking about 1. 2. or 3 years. We are talking about a program that is (; or ~ ears, or even longer. Mr. Kynos. The nurses are 4 ? i)~. EnwAims. Some programs are 4. There are other programs that are 2 year programs. Mr. K~nus. l)o von know why I thought. perhaps, you discrim- inate(l against nurses the way you did? On page 21. you say, "Given the high earnings one derives from a health profession education-." Then, you point out the average annual physician's adjusted income. Aie you suggesting also that, the nurses also get a high return, and therefore, they (10 not require capitation grants? l)i'. ALTMAN. I might add, salaries of nurses today compare favor- ably to other trained professions. baccalaureate or 2 year schools. Their rates of return are nowhere near as abnormal as, say, physi- ci~uis, but they are in line with the rates of return of say B.A.'s in English or teaching or an~ other profession. That is without a subsidly. If von subsidlize them in terms of equity, I (lout know how you can justify stopping at nursing. We have never been able to figure out~ why we should not, as a department of health education. move into other areas as well. Mr. Ki~nos. I thought the reason was, if there are no shortages, we (1o11't subsidize anybody. I)i. ALTMAN. We are getting close to where there is no longer a shioitage of nurses. PAGENO="0317" 307 Mr. RoGl:ns. Where (10 you get information, if I may interrupt? Everywhere I go, I find there is a shortage of nurses, and I have been getting around extensively. Who gave you that? Dr. ALTMAN. Even the Xmeiicaii Nursing Association is now con- ceined with the continued categorization of nursing as a shortage occupation, allowing foreign-tiainecl nurses in. They also want to be removed from the shortage occupation category. There are, as in other professions. geographic problems, but in terms of total num- hei, the supply of nurses is staggering. Mi'. BOGERS. 1)o you know hospital wings have to be closed because there are not nurses available 1)o von know, in New Orleans, a hospital is using 41 nurses from the Philippines who cannot pass 1 R'sl using Icqul rernent ? I )r. XJ~'r~rAx. There are a nlImi)er of States which have in(licated l)1ol)lelns, but there are more than that which indicate surpluses. Mr. ROGERS. The Area Health Education Center program at the IThiversity of North Carolina cannot get nurses. l)r. Ai;r~n~x. As of now, tile Problem is reaclnng what might be called a close delivery. But if one looks a couple of years in the fu- tine with existing training capacity, the supply of nurses, which is 1l0\v in the pipeline, will increase within the next. 3 or 4 years to over 1 million. ~\[i'. ROGEIiS. I tlioughit one of voui rationales in cutting 1)ack the doctors we need to traiii is. that you are going to use more nurses and more allied health personnel. Dr. ALTMAN. I would hope we would. Mr. Ro;EIis. how are you going to do that if you are not going to pioduice the nurses? 1)r. EDWARDS. \Ve believe, with existing programs. that. we are going to continue to increase the supply of nurses, increase it. suf- ficiently so that by 1980. we will have about 60 percent more nurses thaii we have today. Mr. ROGEIlS. \Ve cannot even keep open some of the clinical center wards out at XIII. Now, the nurses may be available: they may be just. slots, but you had to close two cancer programs because of 27 vacant positions. l)i. EDWARDS. That was not a shortage issue. Mr. RoGERS. I am not sure. I )r. Em)\vAlms. We can get. the nurses. Mr. ROGERS. Why (but WC (10 it ? T)r. Ai;r~r~~x. Iii tile letter to A1'\IA sent to the Department of La iioi. they listed 16 States which now have a surplus of nurses. i\Iu. llow:uus. What kind of nurses? 1)i'. ATI'MAX. 1-Tospital trained. Mi'. RoGvRs. Have on checked any nursing homes? Some of them do not even have a registered nurse. I was just in a VA hospital in Miami with one nurse covering an entire ward. She did have volunteer help on the floor, but she was so scared, she did not know what to do, because she did not have anybody to help her. We can go right down the list. You may be talking figures. but I am talking facts. PAGENO="0318" 308 T)r. Er)w\llls. Von ale assuming these nurses will go to nursing homes Mc. 1 ~ ari~s. I aiii assuming that, if von don't have enough, they Wont ~O to nursing homes. and there will be continued shortages. Now. if we produce enough, we may get. some out. J)i. Low~rms. Maybe we better look at the nursing home system, and in cvi e we (lout need nurses as such. i\ii. Ryrin~. Let me call your attention to your statement, on page ill v:Licii von said. "4 or .5 years ago. when a study was made, we had a shortage of approximately 200.000 nurses." Are you saying here today thy gap is entirely closed? I )i. LI'W~Tms. Di. Altman said that. I don't think by any stretch of the ii ic~nction we solved the problem. I think we made dramatic St(1)5 in tci ~as of the total number of nurses. I don't think, if we were to increase caj)itation. it is going to solve some of the problems the !IC iiinin J)~111~S up. \Ve believe it can be handled with local and State fundin~. M~. Kvnc~. I have been advised that nursing schools have difficulty gettIng funds. and they feel discriminated against_when the money goes to other schools for capitation grants and von do not. put any more luonev into Illusing schools. How do you make that division in the aniounts of nioiie von are making? Why? I don't see the dif- ference. I)r. Emvaims. T think the main reason we picked medical and dental schools is. probably, the length of training and cost of training, which i s~inficantlv greater than that in the nursing or in the allied health professional fields. Von mentioned earlier al)out the $45.000 figure. That was merely used to iIi(licllte that we believe strongly that~ the medical student can pay 0 greater portion of his tuition than he has been in the past. For a doctor to be al)le to make ~40 or ~4.5.000 in his first or second year. is rather si~tnificant. Mi. h-cia ~. That is all well and good, but what about the nurse? She is not going to do that. so, all the more reason to assist her in going thii'~ei~rli. T agree with the point you just made, about the doc- tors. ~~eii~aps. T)c. A!:riurc. The overwhelming percentage of nurses are now being trained in our 2-yeai associate degree programs, which are supported at the (oIlntv or State level by and large. There are a small per- cent;uze of the niirces that are being trained in the 4-year baccalau- reate programs: a still significant percentage in the 3-year schools. The spreading of this cah)itation money throughout the whole nurse tie iniiut program comes to a relatively small amount per school, so that the idea their financial viability is dependent on this amount seems rather stretching the point. Just to set the record straight. in terms of that 200.000. I think the testimony indicates that tins had been su~t~ested. Tt did not jnd~cate however that we supported that 200.01)i~ figure. That has been a very controversial number from the day it sew the page. and I personally have (lone some research in tins area and never supported that 200.000. Now, most analysts I know find it difficult. Most people feel there PAGENO="0319" 309 is no longer a shortage of nurses in this country. although there is a geographic problem and the nursing homes could be one of those a IeaS-~- r. lv~-i~os. The Labor I )epa etment would like to take nurses off the shoitage list, but it does not have the data to substantiate that. ~` ALTMAn. ~ Government~ tends to ~rind slowly. It takes a v:l lie to put thin~s on lists and take them off. 1 )r. Luwanus. This is an undergraduate kind of training. Students have access to the basic opportunity grants. Mr. Kynos. Thank you. Mr. Secretary. Thank you. Mr. Chairman. Mi. iloc;rns. Let me just develop this now. .Jnst one second. The In- stitute of Medicine does not agree with your conclusions at all. Dr. Altman, about the graduates from the appioved plogiams for nurs- ing education. It shows, on page 23~, figure ~, in 1953, we had 95 baccalaureate piogianis-the were not sure of associate degrees. 926 diploma schools have gone down to 543, 541 associate degree, and liaciilauiieate I )ack up to 293. So. baccalaureate programs are gtowmg. I )i. Ai:r~rax. As I said, the figure I indicated is a maloritv of the uiuises are be~n~ning to come out of the 2-veai schools. If one looks at the projection. since a ear or two ago, the number of schools has increased by almost one a week. The flow is overwhelming. Mi. R(;GERS. But the diploma is still producing- I )r. Aii~rax. I (lid not mean to say they were not a major force. Mr. ROGERS. The diploma schools are still producing more than anybody else. l)i. An'r~n~x. I was trying to contrast those 2-year schools with the 4-rear baccalaureate, which is still a~ small percentage. Mr. ROGERS. It is 293, but it is a longer period of time, too. I)r. ALTMAN. The correct figures to look at are not the number of schools, but the number of graduates from each school. Mi. ROGERS. I think you will find. strangely enough. that it coin- cides. There are more in the diploma schools, so I think the figures ame consistent. i\lr. I'iever. Mr. PREYER. Thank you, Mm. Chairman. Mi. Secretary, I would like to ask a question first on the National health Service Corps. I understand that some of the literature that goes out to medical students from the National Health Service Corps states that the period of obligated service ordinarily begins following the first year of post graduate training. Some of the medical school professors have suggested to me that they have been discouraging stu- lents from going into the National Health Service Corps because of that. I wonder if you think it would be practical for the first year of obligated service to begin following all post graduate training and set some reasonable time limit oui it. The thought being. if you can put the man in his area after he has completed his training and he know-s he is going to star there without leaving again foi training, that you would be more likely to keep him there. Do von think that would pose any problems? PAGENO="0320" 310 J)i. L~cnnoi'T. That has been one of the issues that we have had Ufl(ki (~nsideIat ion. Mr. Buzzell, who runs that program, might be I)Ptter able to answer that question. Mr. 1 zzi~~r~. Absohitely not. We are very anxious to provide de- feiineiits until such tune mis they complete their residency. The coin- reason that we have lost a number of assignees from these coiai1nmmmitie~ is not one of not likini~ to serve in a rural area. hut roth era de~ire to go back to complete their training. Consequently, tim t e ~fl amid that prol)lemn is yesterdays problem. That is not time inoilem of time future. ~\Ji. Pnr;ri-:rm. I am glad to lmeai' that. Iii your comparison of the various bills, von emphasize the distribution issues, which you say aie of paramount concern. I would agree that maldistribution geo- graphical iv and lv specialty is certainly a troublesome problem. We all want to allocate health resources in the most efficient way, but we want to (10 it short of ordering a doctor where he has to practice and ordering what specialty he has to 1)e in. So, this business of having time right kinds of incentives that are strong enough to do that, short of regulation, is a problem. You mentioned the pay back provisions in H.R. 14357. which are 6 months of service for each 1~ months of assistance. You suggest that that 6-month service is far too short. I would like to see it~ be 1~ months or ~ ears myself. but I think the reason Dr. Roy 1)lcked the 6 months' provision is that he simply felt a one for one- 1 year for 1 year-formula is too oppressive, and that otherwise we run into the same piollern we have with the loan program. The students simply won't take it. You have to get their cooperation. What do you think is a -fair ration? Mr. I zzrr~i. Our objective is. to obtain a minimum of 2 years' service end to l)rovide a scholarship or loan for a period covering 2 years or more. At his time. we have had some problems implementing both the loan forgiveness program and the scholarship program. We do have a current dilemma. but we are going to be able to manage. On the other hand, a period of service of 6 months would present a n~a1or problem to the community~ to the physician, and to the eomisuuie~. (`onsequentlv. our basic objective is two years of service. Mr. Pm:vrrm. You would want to have some system whereby you ale glir m-~utee d a nmaxiinhiin ~ years no matter what? 1)r. ( i~n. On a one for one basis. not on a one for two. One for one. \vc (to mInt consider oppressive. Mr. Pnrn:r. You think that would work as a practical matter? Mr. live:1nevv. I think it would be desirable to restate the objective. The oh~cctive of the National Health Service Corps is to get as many bonah11e o1)l)h~(~a11ts as we can for the positions we have. WTe are rap~diy reaching time point where we are going to have at least four or five applicants for every opening in time National 1-Iealth Service Corps. (~ie that basis, our objective next year is to recruit residents or mid-career 1nofession~s. Our ml jectiue i)efoi-e was directed to txetting any physician to these sites. t~a. ~.:e a me. in ebeet. going to be in a very healthy bargaining ~ ~ sLi-~ lv. cuT n-c won't need, as 1)r. Cooper jndicated, the one PAGENO="0321" 311 for two kind of thing. But anyway. I did want to point out we are in a tough transitional period right now. That, however, is about to end. Mr. PRETER. On this problem of maldistribution by specialty, which is a difficult question for a layman to get involved with, it seems to tue I have read some place that our present distribution of primary care of physicians is about 44 percent of our doctors; that is, pedi- atiicians, internists and family practitioners. That, our surgeon pro- portion, runs something like 24 percent; is that approximately right? Dr. ALTMAN. Twenty-seven percent. Mr. PREr:R. And that, in the rest of the world, in Britain, or in Germany, and in prepaid group practices, the percentage of surgeons is about half of that. The implication would seem to be that we may have twice as many surgeons as we need, and I think, from all we heai, considerably fewer primary care physicians than we need. So, how do we get them out of surgery and into primary care? Your statement says that the regulatory approach of H.R. 14357 is not time best way to go about it. I would certainly prefer not to go about anything with a regulatory approach could that be avoided, but do you think von can have incentives strong enough to right something like this maldistribution in specialties without some sort of regula- tory approach? Dr. EDWARDS. I think. Mr. Prever, only time will give us that answer. As I mentioned in my testimony, we are proposing that each medical school be given $2,000 annually for each graduate that ~roes into family practice. Whether this voluntary approach works, only time will tell. It certainly worked in terms of increasing aggregate numbers, but that alone will not do it. First, our medical schools, perhaps rightfully or wrongfully, are very specialty oriented in this day and age and have l)ecome more and more so over the last several decades. One of the things we have to do is develop more orientation to- wards the family practice or primarY care kind of training. That is not going to happen today or tomorrow. It will happen over the next decade. I think with these incentives we are proposing, and perhaps there will be others as we move along, we probably can reach this goal. I ani not sure we can do it by a regulation anymore than we can do it by a voluntary incentive kind of program. Mr. PIiEYER. That is a harsh way to do it. We prefer not to do it that way, but I understand the p~~ojections are that the discrepancy- that is, too many surgeons and too few primary care physicians- will worsen. It is projected to get worse rather than better. Is that vonr information? ~ EDWARDS. It could well, over the next several years. That is right. The medical school education is not something that changes on a year-to-veer basis. You build a faculty over a long period of time, end that faculty turns out a certain kind of product. In order to change this. it takes time. It seems, in order to develop a new orienta- tion towards the output of your medical school, it takes time in terms of developing iiew faculty, new programs, and so forth. There is no reason to believe the situation won't become worse over the next PAGENO="0322" 312 several years. But, the fact of the matter is, developing some kind of regulatory approach to it is not going to necessarily solve the problem over the next several years either. 1)r. ALTMAN. One of the things we both recognize, both Dr. Roy's bill and our bill, is that the residency activity is a key factor in this. The key that we have been trying to work on is on the reimburse- ment side. One of the things we found, looking at National Health Insurance and at cost control and manpower, is that the residency in this count iv have bee~i built, up based on the service neeft~ of the hospital and on the reimbursement practices of the thitc-parties. medicare. medicaid, and Blue Cross. I ~nfortunafel they tend to underfinance primary care, because pri- inaiv care, after all, has not been hospital based. So, many hospitals and medical schools when they go to try to set up these residencies cannot get* funded for them, because the reimbursement won't pay for them. We are attempting. both with respect to our health insurance pro- I)osal anti with respect to the special projects' categories, to try to help medical schools and hospitals fund these residencies. We are hopeful that they see the same problems that we do. I guess. the feeling that I)r. Edwards indicated. which I think is sliaied by everyone at this table. is that we would hope we could move that way short of regulation. If we are not successful ulti- mately. we may have to use that. but we are trying to address the same problem that I)r. Roy a(1dres~es without going that far. Di. CoopEii. The surgical specialists, including the American Col- lege of Surgeons. is undertaking a study of surgical sciences in the United States. They are concerned about. implications that there are growing excesses of sin ical specialists in the country. I think. the point that is well-taken in their studies thus far is that some surgeons. while identified as specialists, are not always certi- fied surgeons. and the amount of surgery, that is, compared in this country with other countries like Great Britain, is often done by noncertifled surgeons. So. the question of whether or not an excess of surgery is done must go beyond the question of whether certified surgical specialists are at issue or whether just too much surgery is done by people who are not certified specialists. That comes halfway between your point about some form of regu- lation of these specialists and the surgica.l question. I think the medical community is trying to respond to that. Mr. PnE~rR. I certainly think you are on the right track on this residency point. too. An economist at the University of North Caro- lina. Dr. Sheffier-vou may be familiar with his study, points out there is a. very strong correlation between the place where a physician has his residency training and where he ends up. So, I think, if we can increase the number of residencies available in certain locations, we will increase the number of physicians ending up there. Dr. EDWARDS. You are absolutely right., but it still does not address itself to the specmltv issue. Although there is a tendency to stay in tl~e location where you take your training, still we have to accept the fact that by and large. the health care s~stein is a hospital-based PAGENO="0323" ) 1 0 .3 1') S stem that gives the prestige and fil incilig to the, specialIst and not the. guy ~)rovidiflg the primary care. That is where changes are needed. \ir. PJIEYER. It seemed to me. when we considered mailpower legis- lation before, we had students from niedical schools who testified that. there was a change in the. way the me(liCal Student viewed medicine. They felt that. in the future. many moie would be going lato family practice and not quite so man in the status-symbol siihspec~altjes. ILis that been realized. or are we pretty much going the same route of the glamorous specialties? 1)r. Enw~~i~ns. I think that predmcton was accurate. There are figures that. indicate the popularity of family practice programs has increased considerably over the pmiSt several years. We have every reason to believe it will continue to do so. But, again, that reflects an interest on the part of more faculties in providing primary care. In other words, an interest on the 1)aIt of the medical school, an interest omi tile part. of the Government and Congress. It is something that is evolving. ~\Ir. Pnr~n. Thank you gentlemen. I think we all agree on the problems of mnaldistribution, and it is a. question of finding the best and most balanced way of getting at it. It is a tough problem. Thank you, Mr. Chairman. Mr. ROGERS. Dr. Carter. Mr. CARTER. By 1980. according to voni' pa~)~'. I believe. we will have an oversupply of phvsicians~ is that. correct? Dr. EDWARDS. ~ I would not say. Di. Carter. that. we would have an oversupply. I think we would have an adequate supply. ~\Ir. CARTER. Your figures show a little over, do they not, at that time? Dr. EDWARDS. These figures are at best rough figures much like the figures of most of the predictions that were made earlier. The phv- s'ician-population ratio is not an exact way of measuring physician need or physician requirements. It might be a little over, yes. Mr. CAIirni. I believe you are emphasizing physician-extenders, is that. correct? I)i'. EDWARDS. That is correct.. Mr. CARTER. rf asks performed by physicians and dentists can be performed by less expensive health personnel. Would you like to have your health cared for by these physician-extenders regularly? Dr. EDWARDS. If tills case were under the supervision of a phy- sIcian, yes. Mr. CARTER. If the were under rather direct supervision of a physician, wouldn't you think? Dr. EDWARDS. Depending on what was being done. but certainly, under the direction of a physician. Mr. CARTER. At the present time, we have 13.~'90 freshmen medics, is that correct? I)r. EDWARDS. I believe that is approximately correct, yes. Mr. CARTER. Xot exactly, but approximately iight? T)i' EDWARDS. It may be exactly. I don't i~ave that exact figure. Mr. CARTER. We are paying 50 percent of the cost of our medical 3S-69S-~4-pt. i-22 PAGENO="0324" 314 schools-the Federal Government is doing that-to the tune of some Si59G million, is that correct ? T)i. Enw~~RDs. Annually, that ~s correct. Mr. (`AnTLn. Is this a lather burdensome and heavy expense on the Ie(iili G ove~iiment l)r. EnwAims. Well, it certainly is significant. When you get in the aider of over half a billion dollars, it obviously is significant. Mr. (~b~irrrn. But somewhat less, I guess, than, really, the cost of a Trident T)r. L1)wAIIDS. I WOU1(l point out that is only the (lirect educational support. That figure does not include our research training and other ilie(lical school costs. - i'slr. (`A TITER. I believe your figures-in this State, you were spend- I)i-. EDWARDS. We were spending in excess of $500 million for (inert educational training costs, where, in addition to that total, we are paving over ~ perceiit of the medical school costs each year. Mr. (1~im'rrn. That brings up another question. Fifty percent of the cost of each medical school in the country; we have been doing that for several years haven't we? I)r. EmVARDS. Yes. sir. Mr. CARTER. We P~Y more than that for some. Why is that? Dr. Emv~~im'~. Well. T think there are a number of reasons for that. I think some schools have more programs that we are involved in. S(-)nle schools know how to get to the Federal pocketbook better. There are a miinber of reasons. Mr. C\1nTr~. What percentage do we pay on the costs of Harvard Medical School? I believe it is the most heavily endowed school in the Frited States, isn't it? T)r. Exoicorr. Yes. sir, it is the most heavily endowed institution. Fntil 10 years ago. we were not making any direct support of medical education, Iut we were. even at that time, heavily subsidizing medical i ese arch. Mr. (~~nTvTm. I believe. 10 years ago. we were paying about 50 per- cent. if T recall. Soon after I came to Congress, and it has been that long. we began payilnr i~0 peicent one way or other. 1 )r. ENDICOTT. `Iiieie is a substantial difference in the basis upon which educational subsidy is distributed and research subsidy is distributed. Mr. (`~~ircrn. I realize they do very fine research at Harvard. and they also are heavily endowed. The fi2ure strikes me, 70 percent of the ecet of that school is paid by the Federal Government. I believe that i~ correct. Dr. ENDICOTT. Yes. sir. but it should he borne in mind that a very sub4antial part of their total effort is in the field of research. In ternis of enrollment they have about the same number of students as other medical schools, and therefore receive the same capitation supnort as schools of equal size. Mr. C~~Rmu. i~esearch is not supposed to be figured in as the real cost of the school, is it? Where capitation is SuppOsedi to take care of that~ is it not? Dr. EDWARDS. No, in calculating the cost of medical schools, I PAGENO="0325" 315 tliiiik, fortunately or unfortunately, tile educational service and tile 1CSelllcll costs ale all lumped together. Mr. CARTER. In the ~OO millioti winch you mentioned, that is entirely separate from the research. though~ isn't it? I)r. EDWARDS. rfliat is right. but that does not necessarily mean-~ Mr. (~nTIrm. Mv point is. why dont some of these funds go to schools like Indiana and Kentucky and some of our other schools mather than concentrating all the funds in one area on the east coast ? 1)r. ENDTCOTT. The educational funds are distributed by formula based on a. number of enrolled students. Mr. CARTER. That is what we are dealing with here, capitation. I)r. ENDICOTT. This is uniformly and evenly distributed among all the schools. Mr. CARTER. Of all tile funds we are dealing with, Harvard gets the largest percentage. or did until a year or so ago of any school in thie~JJnited States. I)r. ENDICOTT. This was a result. of research training grants, not education. Mr. CARTER. Anyway you say it. it is more money. I)r. EDWARDS. The point Dr. Endicott is making in talking about our capitation is that the capitation fornmla is applied evenly. Mr. CARTER. We agree on that. but the research is not, i~ it? I)r. EDWARDS. Nor is the talent at each institution the same. Mr. CARTER. Let's help the talents of these other schools to im- prove. Maybe. if they had more funds, they could become much better. We are trying to do that for our underprivileged students mire we not ? We are trying to help them, give them extra funds, so shouldn't. we do that. for their schools. other schools. l)ulild them up, or should we continue to make tIme rich richer? T)r. EDWARDS. No. we certainly don't. Mr. C,\riTrim. Tt has been ar~mm~d that high capitation levels would allow greater stability for medical schools than would a system of direct assistance to stulerits, is this so? Dr. Eruv~~nns. There are those that l)eheve that. `We doii't. Mr. C~~nvrru. Are there more would-he medical students than there mime places f'~r them now Dr. FAWARDS. Yes, sir. Mr. (~lr1Tn. Some of them go down to \Iexico. places like Guada- lajara : what are the chances of any of them returning to the United States? Dr. Em v:~rins. If they (`an ~ time examniimaticmas, they can practice. i~[r. (~,urcm;n. Are they treated as other graduates of foreign medical schools? Dr. EDwARDs. `les. 1\im. CAnTER. `Would a system of (lirect Supl)Ort to students create a I)OSsii)il ~tv that. some medical schools would have some unfilled or is the si'tpplv and (icmaud such that all mmiedical schools would he sine to fill their classes? I)r. EDwARDS. `With the three amid foam to one ratio of applicants ~er slot we feel that the medical ~ciioois would have little difficulty tedav filling their allotted spaces. Mr. (1AruTER. I don't believe they would have any difficulties. For ca'l~ place. the me are how many applicants? PAGENO="0326" 316 Ut. Ll)wAims. A little over three. between three and four. i\1 r. (~~ru. In some places, seven or eight? l)r. EIuvAm)s. It will vary from school to school~ but as an average, it rims ClOse to four. Mr. (`~~rcrmn. Are we doing some nations a disservice by taking tlte~ r physicians in the T~nited States? I )i. Ei)~~v~\T1n:~. I think some nations perhaps. I thmk certam of the iiti1(ieieiope(I coiitttries probably have en excess of physicians, and 500 1 01 tI iu~ C eiill~ the I iiited States. ~ [r. (~ll'rut. ~Vitat io'mtries have excesseS? ic. L v~uii~. The Pniilpniiies iitici other parts of Southeast Asia. in are a ot of ti xi dii vets in the Philippines Islands who are ph v~icIans. i~ ~r. ( :nci'ioi. Are we ~~etting ninny taxi driver physicians ? I trust we tire not. I )r. EinvAllIw. ~Ve hope tint. While von were gone, we talked t~bout thi~ probleiii. and we all recognIze that we need to upgrade the re- qa ircnte ts~ 01 our lore intl med~ccl graduates. Mi. (`~icri:n. You think so. ~\Vhat about edmitt~ng barefoot doctors? Einvarnis. If a JlnIefoot doctor can pass the examination- Mr. CARTF:R. Is titcie any difierence. ieallv. between a barefoot tieeior and tin extender? I )r. Linvaia)s. It depends on whether he can p~ the examination. Mr. (~~rernr. The examination for an extender would hardly be so difficult. would it Dr. EDWARDS. Oh, no. `I'hie barefoot doctor per se if- Mr. C~u1T1:R. He rendeisec omparable service to that of the ex- tender. does he not? Dr. Ei)\vAnDs. That is depending on how yoU define the barefoot doctor. Mr. (~~u'rnn. Everything is relative. On what basis? 1)i. Euw~nns. If he provides that kind of service, he more than lilielv would not be licensed, lie could not get his certification to pi~ct jce. Mr. L\R'i'ER. Even as an extender? Dr. EDWARDS. As an extender, yes, but not as a physician. Mr. CARTER. On what basis have you determined the capitation levels ill your bill ? I)i. Ei)w-~RnS. We have worked it out based on the percentage in- crease we feel that is reasonable with regard to the portion of the educational cost that the student can bear. In other words, what we have said throughout is, that we believe the student can bear a lot more of tile weight of his educational cost than he is now doing. We are talking, principally, here about the medical student. Mr. CARTER. About the S1.200 tuition that an in-State student pays. is that correct ? I)r. EDWARDS. That is correct. and when you figure that student, a year or two out of medical school, can be making in the order of ~1ftOOO, we believe that he is in a position to pay a greater portion of his educational cost. PAGENO="0327" 91 `i-I-' Mr. CARTER. 1)o von support buy-out provisions for students who rceeive Federal assistance? I)r. EDWARDS. Ies. Sir. ~ CARTER. You favor buy out. That is. after they have gotten out, in takin~ the Federal assistance instead of going to a rural area. they can pay back ~1~.~O() and buy out? Dr. Euw~~RDs. ~o. It has been done in the past. but we are iiot in favor of it. Mr. C~\rrrER. \Vhat about a system which would allow no oppor- tuiiitv to buy out, hut would require a mandated period of service after the doctor is fully trained? I )r. Eow~~ims. I am not sure we could do it by law, and I think that it would be too rigid. I think we have, to have some kind of 1)ily-out provIsions, but I think they have to be far stricter than they have been in the Past. Mr. CARTER. If we embark on a medical manpower saturation pro- gram. and if our attempts to achieve better geographical specialty distributions are not successful, do we stand a chance of worsening our current manpower problems? l)r. EDWARDS. I think we stand a chance not only of worsening manpower. but worsening the operation of the total healt.h care system. Mr. CARTER. Do you think, if we get more doctors-and I don't. find that right here-but if we get more physicians. you say it might hurt the quality of the practice of medicine, is that correct? Dr. E1uv~\RDs. No, I said, if we saturate the market with physicians. I think. any time you saturate the market with a product that can create its own demands. you stand a pretty good chance of creating a rather serious situation. ~rr. CARTER. A product that can create its own demands? I)r. EDWARDS. I think that saturating the mai'ket. with physicians ]S different than saturating the market. with other kinds of man- power or other products generally. I think we all recognize that physicians are in a position to generate their own demands, and this creates a totally different situation than if these physicians were responding to the same kind of marketplace responses as other ieoile. Mr. CARTER. Then, competition in that case would not be the life of trade. Di'. EDWARDS. That. is correct, would not have the same effect as competition in other situations. Mr. CARTER. That is difficult to agree with. I think, the more ~)l~ysI~1ans we have, the better training they will have, and pei'haps they will answer theii' calls more quickly, be on the ball a little l)lt mnoi'e and not on the golf ball but trying to earn a living, trying to take care of the sick. Perhaps we can~ T)r. E1aw~~RDs. I think von are perhaps partly correct. I think it is also a. matter of the way we fund or finance our health care. How we pay doctors and so forth. A doctor call make an adequate income w-ithout necessarily increasing his productivity-can make an ade- qiiate living without necessarily greatly increasing the number of patients per day he sees. PAGENO="0328" 31S Mi'. CARTER. Ilumaii beiiigs having the nature that they have, tend usually in this comI)etitive world to see as manY patients as they can and to make as much as they can. I believe that is human nature. Of course, you know some people are different, and it varies a great ~leal. I certainly think that I would rather see a sufficiency of physicians an(l riot necessarily have to depend on extenders. I)r. EDWARDS. \o one here. cei'tainly~ is suggesting that we are not for an adequate number of physicians. but. your original statement was. we saturate the market with physicians. Mr. CARTEr.. No. I asked about saturating it. I asked that question about it. I)r. Enw~~ims. So. what I said has been in response to saturation. MI. CARTER. I think, if we have a saturation-that means full, cempletely full-we have enough-that is what. we should aim at. T)i'. EDWARDS. One of the big piobleins is, we don't know what enough is. Mi. CARTER. W~e1l. if we don't know what enough is. we had better heep going until we firid out. pai'ticuilai'ly, since it won't cost us half as much as a rf ident submarine. T)i'. EIwARDS. I am not sure about that. Mr. CARTER. I ann ~OG million is not the cost of half as much as a Trident. I)i'. EDWARDS. You know what is happening to the cost of health care in this countr . It is escalating at a rate von are well aware of, and uiow we are over ~1O() billion. Mr. C~\RTrn. In the very system which we created. or part of it iuullv. automatic 1)avmcnts for these doctors. now, who did the same work for charity years ago. have gotten them in a. position today where they really don't want to or don't have to do the work that von are talking about. It puts them in a l)el'iOd of affluence. If we had more physicians. I believe it would stimulate competition. and they will give that l)ati~m1t a little better care so that he will come Lack. Maybe I am wromlu. but I dont think so. i)r. ALTMAN. One of the pm'o1)1en~ we have seen. Dr. Carter, is that liv increasing the sup~)ly of ph sicians we do not increase the supply of the primaTE ca ic physicians where we are talking about the l.)Ilvsician's extenders. In the stud. as Dr. Cooper indicated, we find la rue numbers of surgeons operating at ~iO percemit of their capacity. while millions of voumg children do not receive prirnal'y care. So. the simple increase of pluysiciauis does not necessarily result iii more primary care being delivered. Mr. CArm:ri. i~eally. we dont know, because we have never reached ili~t level where we have enough. have we ? Dr. ALTMAN. I think we have in some specialties. Mr. C~uiTER. \Ve have enough now, is that right? T)r. Enwvims. We said we had enough at the moment. WTe have a Htumatirm where, in a certain attract ive-areas of the country we have suirucons making adequate incomes doing two and three ~perations per week. Yet. on the Indian icrervations that Mr. Buzzell's agency lullS, we have a backlou of suruerv of 3 and 4 `s-ears. - Mm'. CARTER. I thought that would be a good place for our health corps to put more of 0111' people. PAGENO="0329" 319 Dr. EDWARDS. It is. Mr. CARTER. Can we get enough of them in there to take care of these problems? Dr. EDWARDS. We are gaining on the problem, but it is a very difficult problem. Mr. CARTER. Maybe we will solve it by 1980 or 1985. I hope sooner. Dr. COOPER. Physician extenders can aid the quality of care even with a more adequate supply of physicians. The use of the extenders is not only to supplement the physicianS but to improve his capa- bilities. I don't think the two ideas are mutually exclusive. Just as the proper use. of a nurse or any other allied health professional improves the capability of the doctor, I think the extenders are compatible with reaching the objectives you say. I would like to have a doctor taking care of me, but I think, if he. has a full team with him, to improve the quality of the care that he can give, that is a completely acceptable concept for us to pui~sue. Mr. CARTER. As a country doctor, I always operate with a full team. Thank you. Thank you, Mr. Chairman. Mr. ROGERS. Mr. Secretary, I think we have many areas that we are. very close to on. I am particularly pleased to see some of the areas that are changing as you are beginning to stress them. I welcome this. I am particularly pleased to see you give added em- phasis to the. National Health Service Corps. I think this is a pro- gram that needs to be fully developed. I would, however, like to question some areas which I am concerned about. The primary concerns that you set forth in your statement are adequacy of supply. That is number one. I think the committee is concerned with that in writing the legislation over the years. This is w-hat we have been gearing up to. We need to get into some of the details on page 6 to see how we can accomplish this. Then, the geographic and speciaties distribution which is more difficult. We can hopefully offer some encouragement to that in a training bill. As to productivity, perhaps if we train properly, we could get. good pro- ductivity. Equity-I am not sure exactly as to what is meant, but let me ask you this now. One of the problems I am concerned with is. that we write a. law, the President signs it., the Department begins to administer it. Then, we come in and we change the signals. WTe do it right in the middle of a class that has been taken in based on the assumption that, if a medical college begins to gear itself to respond to the. national need that has been set forth and generally agreed upon. they cannot depend on what we are going to do. It seems to me, one of the greatest things we can do for medical education in the Nation is to give. it some stability, so that a dean and a faculty and a student. body will know what. they can depend upon. Now, let's consider this idea of letting every student, after letting him pick out. his school. have complete control of any capitation or loan funds that. lie is given. How much advance warning does that give to the school to be able to prepare for that student.? It. is a nice theory. but. what stability is there for medical education in the country if von are goin~ to allow these students to flit anywhere. and they will start to say. "Well, I will let. von know; you all come PAGENO="0330" 320 iii here. and we wifl ~et our faculty and if we can get more students, we will pay more to our faculty." I don't see this is very helpful in givin~ stab~litv. Suppose tl~e' second half of the sophomore class in a medical college decided they wanted to go somewhere else in their third year? What happens to that- I)i. EDw~~1~ns. First of all. that could not happen. Mr. Rooriis. I am not so sure of that. If you are going to give them the control of the funds. they will arrange some way to allow entry. I )r. EDWARDS. They could not do it this year. M~. T~oovr~. Not this year. but this is for 3 years. It won't be long. Di'. i':InVAiiDs. First of all. a~ medical school can take so many fresh- mcii. so n~anv sonliomoi'es and so many juniors. Mi'. Ro;nis. You will be surprised what they can do when support moiic~ is offered. In fact. that is the theory of your bill, incentives, isn't it Di'. EDWAnDS. Right. Mr. ROGERS. It is in ours too. but now, how can they plan? How con they sign up a l)rofessor and get him a good person to teach, to ~i ye quality education ? Dr. EDWARDS. The last. problem the medical schools in the United States has to(lay is stability in terms of the number of students they are goilur to have. They have more thaii an adequate number of students applying for the available positions. Mr. ifloc;rn~. Yes, sir. but they all don't have the money. I)i'. EDWARDS. ~O. Mr. ROGERS. What we are saying is-we are talking money now- why isn't it reasonable to determine what the capability of that school is? `ibis is what we have tried to do on a capitation award. Let. the school have it. and the student comes there and gets their funds. Do you really think it is practical to say, "We will let the si iident go an where lie wants" ? Dr. Euw~~nns. The student can go an where he wants now. Mr. ROGERS. ~o. lie can't. I)i'. Enw.~i~ns. Why can't. he ? If lie can get in. Mr. ROGERS. That is one. Secondly. because many of them simply do not have the capai)lhltv for getting in those schools now. Dr. EDWARDS. What capability, financial? Mr. ROGERS. Financial is one, spot is another. 1)1'. EiuvAiws. You mean the number of available spots? Mr. ROGERS yes, Sil'. T)r. EruvAriDs. There is no question about that. Mr. ROGERS. What. about the availability of the college to provide those spots. If the college cannot know what it is going to have, if you allow the students complete control of the financing coming into that college. I do not see how you can give any stability to the school over a long-i'ange period. Dr. Eow~~riDs. I guess I don't follow -von. First, each medical school takes so many in each of its classes. Now, this costs the medical school so much per student. That money can be paid in several dif- ferent. ways. `We can pay it all. The Federal Government could pay PAGENO="0331" 3~ 1 it all. or we emil (1 pay part of it and another part come from the State and another part come from tuition. Our particular position is. that the student, the medical student of to(tav is iii a position to pay more of his own way than he has l)een. That has nothing to (10 wjth stability per se. ~\rr. ROGERS. I (Tout agree with you. I )r. Enw~rms. If he cant, we have a scholarship and loan program. Mr. Roams. You know what the General Accounting Office says about that. When the report comes out tomorrow. I would commend it to your reading. if you have not. I)r. Eow~rins. I have read it at great length. Mr. Roomms. llie loan program von are proposing could be (us- astrous, because your interest rate now is what, 11~ ~ percent. arid the Secretary makes up to 10. TIe can go up. he has the right of three, and they are ~~iving seven. So. von are not even meetint~ the current market this veal. There is no tehin~ what it will be next year. So. how is that going to work? Furthermore, von are going to end up with students who have a lot of money. Now. how iuan~- medium ineome and lower are going out to borrow $~h000? Dr. Enw-~RDs. We are proposing to u~erease the Scholarship pro- gram to ~221~ million. ~\1r. RoemEs. You guarantee them to ~et a loan. but they won't be able, to because the bank won't make it if they can't. get the going interest. That is the situation today. Tt may change. Maybe the interest will cirol) all of a sudden. I don't know. but I question it. Now, it seems to me. here, we have set up the way students can check in with a. school they want to. give some Stal)ihtv to the school. The student knows lie goes to that school to get his loaii : they know who they can depend on, the type students they want. And I don't see what the real purpose is of ehan~~i~~g that function of having the student go to the school and the school making the loan of those f ii nds. 1)r. ALTMAN. Mr. Chairman, with respect to how universities in general tend to think of funds, not even thiou~h I am a real doctor and dont know evervthing that goes on in medical schools. I have looked at the funding activities in the social and physical sciences. Many schools tend to talk about hard money and soft money. hard money is money that comes from tuition and from students. They think they can depend upon it. They have a long history of recruiting students, and they know what their market is like. They tend to think of Government money, no matter which source it comes from, as soft money. Mr. ROGERS. We all think of it as that, I am sure. I)i'. ALTMAN. So, in general, schools tend to think of the stability of funds coming from their students as a lot more dependable and a lot stronger rock from which to build a 10-year faculty. Mr. ROGERS. Is that true in the State of California? Why they are proposing no tuition ? 1)r. ALTMAN. I was talking about a private school. Mr. CARTER. The average payment on in-State students is only $1.200. It costs about $12,000 a year to educate that student. That PAGENO="0332" 322 is just a drop in the bucket. lie would pay as tuition only one-sixth of what it would cost. Mr. 1~oGEm~. I (lout think that applies in the medical school. I )i. EDwARDS. That is what we are proposing. That it be more of a iO?I~. Mu. Poon~s. It has to he the Rock of Gibraltar from $1,200 to I )r. Eniv~ims. ~\0 one is su~gesting S12.000. \iu. Rooms. You cut Federal funds, in 3 years. they are out. I )u. l'Mw~AriDs. We have not suggested that. We said we are phasing it down. At tIle end of 3 years, we will take a new look. We said we ate phasing it down. Mi. lOnERS. That is not the way I read your statement. \Vhere is that statement I )i. EDWARDS. We are suggesting we phase out veterinary medi- runt-I think that is all. Mr. Roc;rrts. At the bottom of one of the pages-~ l)i. Enw-ARDS. In the case of medical school, dental school-"The (it e(ts of the plia~e down will be monitored closely, and at the end oF 3 years. we will reevaluate the need for continued capitation sup- pout. There. we ate talking about dentistry, medicine, and osteop- ;ithiv. In other wards, we are phasing down. but. not out, osteopathy, (lInt stiv. optometry. podiatry, and that is it. i\Ir. Ronrti~. I won't argue the point. I thought I saw that. I )u. Enw~ia~. I know exactly what you saw. and we said. ~WTe will 1 e phasing down or out.' l)ut we were talking about veterinary 11 ~P (Tj (` i n e. Mi. Id e;rn~. In any event, it goes down. have you seen the Institute of Me(LI(ines study ? l)i. EDw\lfl)s. ~es. sir. ~[i. harms. Wimit ~tudv do v~u base yours on that you want to I liOI5~ it out ? This is exactly contrary to the study made by the In- stit~ite of Medicine? I )i. EItW\ful>~. ~\ot eotitrarv-we are not suggesting that we do away \Vithi eap}tation. Mr. T~onrn.. You have reduced it. 1 )r. Erw~\m)s. We aie reducing capitation. Mr. Rooms. You reduced it below the level of support recom- mc u(ltd liv the Institute of Medicine, and that is a conservative report. I )r. AL'm'~r\x. ~o far a~ T know. Mi'. Chairman. the LEreat bulk of the Tnst i~ ide of ~\rcclieiuie's stiudv was a factual and well done 101) of tuv~n~ to estimate the cost of education. Mr. Returns. That is what capitation goes for, right? J) u, MAX. I am not sure about that. T\ fu. fd rmm~. `111ev testified today in their study it has been- ). Amnr~v. We (lilT au 111(lepeIl(lent study tr ing to figure out whl(~1' the money goes tirit we put into medical schools in general. Mr. Roorrus. I am not talking about in general. T)u'. Arr~riX. Ineluidintr capitation support. `We found that, based on this study and a lot of discussions with deans. they freely admitted that funds that flow in from one source often get used for another. PAGENO="0333" 323 ~. while in general they are plol)ahly right. the three studies we know of indicate the money tends to be used from research training to support education, and educatiomi to support research. Mi. C:~rm:ri. ~`. Chairman, lie made the very point I talked about a while ago; that time medical schools did not depend on capitation alone, but that the research money also went into it. I )r. EDWARDS. 1o11 are absolutely right. ~\h'. Chairman, the point l)i'. Altman is making is, that the Institute of Medicine was a study of medical school costs, not of revenues. Mi. ROGERS. \Vell. they also looked at revenues, hut it was mainly (O~~t5. I would agree. I )r. Ernv~~nDs. Time only place we differ with time Institute of Mcdi- ci1i(-it is not we (lout agree with capitation. but we believe that certain amounts they feel should be provided by capitation, we be- lieve, could be provided from tuition. That is the basic issue. We. think the study is an excellent study. We disagree only in terms of the level of capitation. Mm'. ROGERS. They recommend to this committee-and. I think, did so this morning-that we maintain capitation between 2S and 40 per- cent of the cost, and they have outlined the cost. These are educa- fional costs, and they have divorced those costs from research and till of these other things you are talking about. Dr. EDw~~ims. Did Ton ask them why? Mr. ROGERS. Because they analyzed it-they had people give their time sheets as to where they work each hour of the day. They ana- lvzed it, and tile testimony is here. The report is here, and the cx- trim eted educational work. I)r. EDWARDS. I)id von ask them how they came to the capitation figure ? \[r. IRO(;Erms. Yes. T ~i. Enw~~mms. how \ Er. Rooms. By dete rmi iii ng wi mat the ~enera 1 simpI )() It Ii as 1 )CCII. what the need is. and also the fact that the supuort that they may or univ not get from seimools, the amoimmit that generally has i)een gotten froiim States, what has been a historical 1)atterM. what they get from i~liihiiiit1iiopy or gifts. what they get from st iident fees, end what they get from the Federal Government. I )r. E1)wAIms. Ihat is right. In other words. it \V~S thmmi i' opinion. and we have aim 01)10 lOfl that Ol)v!OTIS1v differs. Mr. Runmims. \Vlwt did von do your study on I )i. EDWARDS. It is opinion, lust like tlmei ms is. Theirs iz 1 nO nem''ent oj)tion. It was not a s~udv of eal)itatlon versus t it~o~m. `iliei'~ is no stio lv there. They looked at oveial 1 costs and t hien------- 1'. T~ocn:mms. Then, what study have von mimade f)m'. EDw'~~rmDs. This is a ~udgmeutiml thin~r. There is no study ti mat von can show me or I rail show von. whirli will aive you liii' kind of information in terms of how von would conic up with (apitetion ver~ns tuition versus State support and so forth. This iS a ~iidg- merit aT thing. MI'. ROGERS. I guess everything is l1u(l(!mefltlll. hut I tlmiuik we have enouim'hi Supportive evidence to show exactl V whet we mu ex- pert of support. \Ve know what lma-z been time historical tradition, PAGENO="0334" 324 \Ve know wii~t Schools Love coiled for en the various sectors of Si ~l)OGI't. Y~e have this d0:ulflente(l. `o. I iii ik we. (10 know. ~\O\V. 5' l1)pOPe VOIi weee to SIIV. "~\e1I. we just (iecide(t that we ill ~t t o IL to ippi it it ~ 1 You could (~ ~li it too (`Oiil(tiIt on Di'. ALw\n\x. 1(~. 511. ii'. I h iou-. Xud von Love i niony programs, or ~Oil could say, "Lc~ ~lidcnthi'opliv do it." I )r. i'~ v\w)~. It not s~ur~restin~ that. ~h'. I ~orn~. I u 1~~'~tai~d. hut almost. Maybe. IJI'. I )iV\iIi iS. Die l1ietlical seh~ols could also say~ `\Ve wont caph tiitio~i to do it all," ii\1 i'. 1~o~:ioi. Thuy could Soy that. hut they have not. I )r. !~1)ivo1~! c. We ale not savin~~ r. I G1iiO. Xl uout pei'cent~ 1) i'. Eny~i~i's. We lot ye not ~a~d the other either. They have not said iuhl C01)ltOtiofl. i\Ii. kOG1TII~. ii\I~vLe the ai~~wer is somewilele in between w'iu~t von a ic bo~ Ii Say in~. II lug'i'(e. this committee wifi have to set a figure. but based on a snidy done for (Longiess on what tiie amount of CapitIltIoll sh1ould be hat has come from the Institute of Medieine-uwd it sir,'s betweeii ~5 and 4U percent. I fl. lnv~r,1)s. I I'esl)eetfullv disagree. It was not a study in terms of' what copitatloll should lie. It was a study to determine the cost 01 nielucai edlI(iitlOn. r. l~oorI~~. `\Vell. let nie iead von the tecommendation. I have it he lu somewlic IC. I )r. 1Lnvxrms. "The Stud Group is of the option that capitation giants.' "is of the opinion." "ranging between.' Also, if the report were 1 ;iISC(l on ii "Laid" study. thei'e would not be a wide range such as a ~5-4t) percent lange in terms of suggested Federal supl;ort. Mt. I~ooLiou. That is for us to make judgments, as von say, l)ecauSe the sellools iiiav ask for 40. You say maybe 5 01 10 peiciumit, anci they sitv a range of ~5 to 40. I )r. inv,~muus. But the study mcccl reflects the study groups op- 1111011. Mr. iloorilS. I guess the whole rel)O1t is an opimon. 1)r. ToI)WMII)s. Mi'. Chairman. I must disagi'ee. The whole 1el)ort is not an Opinioli. `I'he study does contain some hard cost figures. 1)i. ( oori:n. Would von think their opinion of 25 to 40 percent is based on the last dollar need that would be necessary to balance the books Mr. i~oGERS. Paidon 1)i. Coopru. Do von thiuik the 25 to 40 percent would be based on a last dollar concept of what would he needed to balance the books ? In other words. 25 to 40 percent is their estimate. or opinion, of how- Ifluch money would be necessary to provide last dollar costs. Iii other words. to balance their books so they don't run a deficit for medical education. If that were the case, then I think the source of the last dollar is what the difference of opinion is. PAGENO="0335" 325 Mr. T~uc;niis. It says it ~enc1oises capitation giants protriain of ~i- pIO1)iiate I~ederai undertaking to l)1~ovide a stable source of finan- cial Supl)ort for health profess~o~i~il schools. The Study Group is cf tIle opin~on'-aiicl this is in their financial summarized rccom- iiicndation. This is more than just an opinion, it iS a recornuen- d~~tion summarized. ~`The study group concludes that a range of (apitation between 25 and 40 p~ent of net education expendjtures liduid help assure the stability of both the 1)111)1 iC ~t~id 1)Iivate in- atitutions inul the maintenance of proportionate levels of State as- s~staiice. tuition and pililalltllrOpy. That is from the actual Iiìstitute program. l)r. l5inVAIa)S. We have it here. "The group is of the opinion." Mi. l~oG1:l~s. This sins. "concludes." This is on page 49 of their report. That is an extract that von are reading fiomn, of the official report. home is the l'e1)olt. Now, this report on page 49 says, "The study group concludes." Furthermore, it is listed as a recommendation. Of course, it is all un opinlon of this group that studied it. But they concluded it, and they recommended it. and I think it has some substance. Dr. ALTMAN. Mr. Chairman. we did not quite arbitrarily come up with the numbers. We were trying to balance the use of the Federal funds with respect to that last question of equity and as Dr. Cooper said we recognize that there was a need for say 25 percent addi- tional funds. But in an occupation such as medicine it seemed only reasonable that physicians should bear a larger percentage of the education costs. The I)1obleln we have, Mr. Chairman, is part of what we talked about earlier. There are different people who want to see the health system co~ ~rolled in a different sort of a way. They would like to design a Jystem where the total education was paid for by the Federal ~overnment and the total income was regulated by the Federal ~. ~overnment. I guess our feeling was that we did not want to go to that situation at the other end of totally regulating their income and therefore it was equitable that they be asked to pay a large percentage of their educational costs. Not so much that they would, in fact, not be able to go. In order to avoid that we would have the loan program and the special scholarship program for the disadvantaged. The problem we see down the road is as the Federal. Government picks up a larger aiid larger percentage of the educational costs, it is natural they are going to begin to ask for more and more of the education institutions and ultimately on total control of physicians' income. Mr. C~~wirri. Mr. Chairman, he makes a very important, Persuasive argument. I)r. (toorrri. At current capitation levels we are paying about ~2.0()0. nbc average cost is about S12.000. We are. therefore, below the 25 to 40 percent level. If the contention is that for stability we would have to come to the 25 to 40 percent level. that. would indicate that a large number of schools should be in financial distress. The number of schools that Dr. Endicott reports are in financial distress in tile past year does not support that conclusion. PAGENO="0336" 326 Mr. Bocuns. What is tile iS that many this year. 1 )r. LxDrcOrT. ~1es sir. 1~ received awards. i~l r. i~ocrus. how many applied i )r. .LNDI('uTr. rweiitv-eigl~t. Mi. I~oG1:Rs. Iwent -enrlit applied and that is even with capita- tiO~t 1)1. (~uw'Lri. ~es. Sir. hut as an avertuie. ~25 to 40 peiceiit would not e a reflect 0111 01 that level of support of disaster needs. lB i. lh(;FR~. itXVOl)t for the fact that also you have an inflationary factor iii VOill ~0.l1flOiS whii(h1 piobably even compound the probleni i~ioie. ~\ow, let me ask von tins. Before we passed capitation and gave thieiii sonic support that they could continue on about. what WOS tile ~)eict~11t~ige of schools ~n distress l)i. EYDICUT'r. ilefoie l9~i approximately half of the schools were ieceiviio~ money Oil the basis of financial distress. Mi. linGERs. iou ineaii they were awarded distress grants. J)r. ENDIUOTT. iliat is correct. Mi. liOGEIIS. Ho\V nlanv al)plied 1)i. LxI>IcuTT. i am sorry 1 do not recall how many applications we have but 1 do recall about half the schools were receiving finaii- cial distress support. Mr. floGrus. (if course this is exactly what I am talking about. The lack of stability of a Federal program where, if we recognize rhe~ e are some Federal responsibilities- Lii. (`norm. We do recognize Federal iesponsibilitv, Mr. Chair- man. ll~~t in reacllmg the study groups conclusion that 25 to It) pete(01t Is a net expenditure needed for stability, would it not be a~)pI0pIiate to get some figures on revenues to point, out the options that are available to oflset aganist cost. I thInk we I1~iVe not had au adequate study of tile data available to out ~nc that i~eu e has been a ieductioii iii financial distress under euiu'cnt capltatioll fioia ~O percent to 18 schools. Ten percent- ~\ji. I uu:iis. ~hiie iiuiiiber decreased from 115 in 19T1 to 18 in ~ 1)j. (Ia i'm. I th ni: there are other factors contributing to stabil- ulv. one of v:hi dhl is clinical Piactice income. `ihat is why I think we could le~~e~ir ib urn darn on total revenues as well as costs. Mr. lucius. l'hit what ale we talking about is ecTucation and edu- (`at1~a~ tifl'idtS. \ow. what (to von anticipate a student would have to I )Oii( )\V ioi h's enti ic nuedical education? I ) r. Li )W.\Iii ~. 1 t Iii ik it oh iv~o~islv would depend on the student. On: StIll ~cur wui~icI inive to bomiow it all. I think the next student would hive to boI-iow--(tepending on his resources. Mi. 1lia;i:mi~. ~-eui-eiv somebody has an idea how much they borrow. how mi~ucII they will have to. f)~. Ll)waaos. \~e raised that limit to ~25.000. So he has the op- p01-thu ltv_~~~_~_ lB i. lha~j:rn~. If he nas nuonev. If he has no money? I )i. Jb~vtnos. That w iight. F. ihacii~. Is that for 1 ear. 2 years. 4 years? PAGENO="0337" 327 l)r. EDwtm)s. Tlìat is for 4 years. I )r. Coori:i~. ~7.500 for a maximum i~ year for a 3 to 4 year period l)r. Eiw~Ri)s. Foui year total is ~i.0O0 with a ~TJ~00 annual ceil- ing. Mr. ROGERS. rut is what YOU p1'OpOse but I (lout think that has passed and there has been great controversy on that. Mr. EDwMu)s. rut iS what we are pI0p05111g. Mr. C~1~Ti:l~. ~\Vhat amount of money did VOU dIspense for distress giants last yeai Dr. ENDicoT'r. Last year about S0.2 million. This year $10 million is authorized for this 1)urpose. I would like to correct the figures. \Ve were giving you figures before for the total number of plo- fessional schools, not nle(lical schools. the number of medical schools which applied for financial (listless tIns ear was 12 and the num- l)er of schools recommended by the council for support was 6. That is a substantial drop as I am sure von are aware from the situation 3 years ago. Mr. ROGERS. No question about it. It has given some stability and I would think it is very difficult to be running a medical school when von have to worry about whether you can get enough mone to continue to operate. One of the reasons we passed this bill was to give some stability to medical education. Where they (lOn't have to go through the fiction, I)r. Altman, of research; of trying to get a research grant in order to come (lown to educate. rihiS was pait of the reason and that is why we recognize first of all medical schools as a national asset and I think no one really dis- agrees with that do they? l)r. ALTMAN. No. Mr. RoGERs. Secondly, we should support education if it is a na- tional asset to some degree for education sake, so we don't have to go through the fiction of having every professor come up and file a research grant amid try to do his teacl~mg out of research money. Dr. AL'r~IAx. We are in total agreement. Mr. Chairman. We recom- mend capitation be continued. The main difference is we are recoin- mending it at a lower level. I should add two thimigs. One. we are trying to use the medical schools in an way possible to help us address the specialty and geo- graphic distribution pioblenis. We are asking for more money to be channeled into special projects which could help us iii those areas. ~\lr. R0GI:rms. Except those in the project grants have to please who- evei is in the current office of hEW, and that does not provid~ very miiuch 5t~uI)ility. I found that there is some change amid that what one may Ike one year someone else comes in and they don't like it. As a result that school is out. They have put in mnone to get started on a piogram ~tii(l suddenly, their funding is cut. and they have to dis- miss their staff. \Ve tried through our I)1oPO5al to provide some stability. Dr. ALTMAN. I thank you, sir. That was the reason why I made the comments l)efole :uhioimt. hard money and soft money. When all PAGENO="0338" 328 ~ci tbe 1c~i!e4 money ~iill is i.roini.r to be the students be- er )t lp~)l~ce~It~ aiicl the need for physicians with 1 1 111 i o i~ of tuit'ou i~ the h~icle~t mone~ a (all ii~Ve. i tllC-V InVe a set agreed upon cap~tation figure in 1av. I )r. F; -ups T a~ tee with von, Mr. Chairman. in terms of the stal I tv hut I dent t~iiuuti ~flhi aIR going to come to an answer on the ~-tjbihitr i~si~e until vc~n 1-e(~uest the same kind of a cost study of ifl~t~1ll 1~l'Jl ~eve1niea. a:ns. We univ want to get that. But certainly the facts soe I Hut we breui~hit some stal)ihity to medical education in the uollltiv. and the on; reisities. I think, feel that. Di-. ItD\VARDS. \O (lilestioll about it. Mr. C~inn-;ru. I think that we finally arrived at the conclusion there a (I1,miiingling of funds for the Ijmiipose of medical education. Both (apltation and research. Does each medical school have an identifiable financial unit report- ing to the l)epartment of i-leahth. Education, and \Velfare on the use of funds. Dr. Em-avauDs. It varies all over the lot. Dr. Enclicott would have to answer that. 1)i. E:~m)n-oTT. Tn applying for capitation support each school must supply us with information on non-Federal revenues. The law re- quires that there be a maintenance of efforts in terms of continuing to obtain the same amount of non-Federal revenues as they obtained before. So we do get that report. Mr. (H\Jrrru. You (lout have an account on the Federal funds, on the us' of the Federal funds? Dr. Exi)IC0TT. On the use of- Mr. CARTER. Yes. you do not have a financial unit which reports how the funds von give the medical schools are used. Dr. LxDIco-rT. Yes, we do. Mr. CARTER. lou do have? T)r. Exeicorr. `ies, sir. Mr. (H~R'rI:R. What do you require of them in the way of specific accounting of capitation and other support funds? Di. ENn[ue'rT. Tn terms of capitation they must submit an annual report which indicates that they have spent the money for the pur- poses for which it was given-in this case for education- Mr. Cain'ER. Medical education. 1)r. ENnico'rr. For education. As provided in the medical schools. Mr. Caumru. You are certain then that all capitation funds are use(l oul to support education process, is that correct? 1)m. EDWARDS. No. T)r. ENDICorr. I am reasonably satisfied. However this I think is inherent in any situation in which you make grants for a specific plilpose. I think you can compel establishment of an accounting i~~- cedure which will assure you that those Particular dollars were spent for that purpose. However, it is not possible for that accounting system to require that they not redistribute other sources. And to this extent any grant PAGENO="0339" 329 support is sort of functionable. If they in the past, for example, had been spending 20 peicent of their money for research and 80 percent for education. theii you come along and make an agreement to sup- poi't education and require that they spend all of that money for educational purposes, the schools can certainly comply with that. however, they can withdraw 20 percent which they had been previ- ottslv spending for research and spend it for some other purpose. There is 110 way of preventing schools from doing that and in fact they do do that. Mr. CARTER. Dr. Edwards, do you agree with that? Dr. EDWARDS. Dr. Endicott has mole of the facts available to him. I am not. sure that I would be quite as enthusiastic about their spending it for education as he has indicated. Mr. CARTER. have you a compilation of the salaries of the ad- ministration and teaching staffs of the medical schools? Dr. EDWARDS. No AAMC has it but we do not. The Association of American Medical Colleges. Mr. CARTER. You are putting your money out but you don't know 110w much they are paying those people or where the money goes? Dr. ExDIcorr. We know how much of our money goes into their salaries but we don't know how much other money might. Mr. CARTER. Thank you very kindly. Mr. ROGERS. Now, let me ask a few questions. Dr. EDWARIS. May I interrupt? Again this is the issue of revenues and I think that is the next piece of this puzzle that needs to be addressed by you and by our- selves. Mr. ROGERS. Now, let me ask this. I think I have discussed the Institute of Medicine study which gives us some background on the stability from the distress. What about giving us precise budget figures under the proposed administration bill. In other words, how much would ou spend for capitation? How much for special projects, for health manpower educational initiative awards, for area health centers, for assistance to the disadvantaged program. Could you give us those figures? Dr. EDWARDS. Do you want those now or should we submit them for the record? Mr. ROGERS. I would like your capitation. Dr. EDWARDS. Capitation, $124,600,000-this is in the 1975 budget. Mr. ROGERS. That would be reduced to what? Dr. EDWARDS. For fiscal year 1976, capitation is estimated to be at a level of $101,100,000. For fiscal year 1977, no projections are pres- ently available. We have student assistance, special projects- Mr. ROGERS. How many for special projects? I)r. EDWARDS. Grand total of $63,983,000. We do have the figures for 1976 and 1977 but they are not broken down. For this year our total outlay would be $365 million. The outlay in 1976 would be $327 million. Mr. ROGERS. Is this for special projects? Dr. EDWARDS. Special projects. Mr. ROGERS. This is for the whole bill. 38-698-74-pt. 1-23 PAGENO="0340" ~30 Dr. EDWARDS. Yes, sir. 1977 would be $307 million. It gets to 1979 where the total would be $267 million. Mr. ROGERS. This is supporting how many medical schools? Dr. EDWARDS. This would be no new medical schools. Mr. ROGERS. The medical, dental, and osteopathy. The schools in that. category oniy? Dr. COOPER. ~\o. There would be other schools. For the first 3 years there would be the inclusion of veterinary, optometry, and podiatry. Mr. ROGERS. On page 35 I believe your statement devotes a little less than a page to H.R. 14721 and H.R. 14722; a little less than ~`* ~ to H.R. 14357. Let me just ask this now. On capitation we vary on the amount. You are not sayilig you would phase it out after 1977? 1)r. EDWARDS. I would want to make this point clear. In no way are we suggesting that we eliminate capitation in the schools of medicine dentistry and osteopathy. The only disagreement we have with you is time level of that capitation support. Mr. ROGERS. Now, what about for capitating schools public health? Dr. EDWARDS. We do not propose to capitate schools of public health, but wouki support these schools through special projects. Mr. ROGERS. Is there any reason why they could not be included along with the other schools there. Dr. EDWARDS. No. It was just a judgmental thing on our part. I think a good case can be made for schools of public health. Mr. ROGERS. In other words, if we are going to have any public health doctors in this Nation, we better make sure there is some stability to those schools as well. Dr. COOPER. Yes, sir, we recently have undertaken to get some bet- ter data on the current composition of this vital resource which is changing. Mr. ROGERS. I am encouraged by a change of attitude on the schools of public health; the Public Health Service Corps, and of course the National Health Service Corps. I commend you for that. Construction. Would you support any construction? Dr. EDWARDS. We are supporting renovation- Mr. ROGERS. How about grants, construction grants ? Dr. EDWARDS. No grants, loans and loan guarantees. Mr. ROGERS. Do you think it is feasible to have some grants? Dr. EDWARDS. Certainly it is feasible. Mr. ROGERS. I won't press you any further. In order to receive capitation. schools must agree to do one of several things in our proposed bill. Could you comment quickly on increased enrollment? Dr. EDWARDS. Again we would oppose increased enrollment. We believe that by maintaining current enrollment we can have ade- quate numbers by 1985. You propose to increase enrollment. Mr. ROGERS. Well, this would be an option that the school could use. It is not mandated in this proposal. Second, increase physician extenders. That is an option. Do you think that is a good option? Dr. EDWARDS. Absolutely. PAGENO="0341" 331 Mr. ROGERS. Enrollment of FMG's for remedial training in the third and fourth year. If they are American students. Dr. EDWARDS. That is an option. I would not have any problem with that. Mr. ROGERS. Apply for special projects and then have them ap- proved by the Secretary. As, for instance, is there any reason we could not work out special project programs where they have these alternatives to move into these programs. They get capitation even though they may not have to be funded. You have a special project provision. This might be able to be accomplished by the capitation award. Dr. EDWARDS. Our proposal relies solely on the special project au- thority. Mr. ROGERS. I presume you would agree with the program. Dr. Endicott, do you think it is possible to administer for instance- Dr. ENDIc0'rr. I think this might present some problems, but yes, 1 think it could be administered. Mr. ROGERS. For instance programs to select students from dis- advantaged backgrounds; programs to provide undergraduate train- ing in underserved areas; programs to provide residence training in underserved areas; programs to train physician extenders; dental programs to train auxiliary manpower-and so forth. I)r. ENDICOTT. Let me state the problem as we see it and I reviewed this one with my staff. It is a question of timing. Ordinarily schools would be applying for capitation at the same time they would be applying for special projects or they might have to wait until the last minute to find out whether they would be receiving support. Mr. ROGERS. Or they might have to apply a year before and plan a special project program. I presume they would, wouldn't they? Dr. ENDICOTT. This is from an administrative point of view, purely a question of timing. Mr. ROGERS. Wrhat about area health centers? I)r. EDWARDS. Yes, sir. Mr. ROGERS. I hope you will have an opportunity to look at what they are doing at North Carolina on this. This is a very impressive program. 1)r. EDWARDS. It is indeed. We definitely support it. i\Ir. ROGERS. Of course the continuation of grants for family prac- tice residencies. Dr. EDWARDS. Yes, sir. Mr. ROGERS. And continuation of grants for computer technology? Dr. EDWARDS. Yes, sir. Mr. ROGERS. Section 783, grants for the remedial education of U.S. citizens who are in the foreign medical schools. This is the third and fourth year. I think we went through that. I already asked that. The allied health sections. Dr. EDWARDS. Yes, sir. I)r. COOPER. We already do that. Mr. ROGERS. I just want to know whether you support this or not. The allied health sections of the bill, to train allied health personnel. Dr. EDWARDS. Yes, sir. PAGENO="0342" 332 \fr. R~n:r~. T]~e noise bill. do you basically support the nurse bill for muses trainin~r ? I )r. (~ooi'im. Capitat ion for nurses? M r. fl oI:iis. That is part of it. You dont support capitation I nil- clerstand. T)r. Ei vano~. I think you have some construction money iii your iliil~es prograiri whjeh we (lout. I )~. ( OOl'}Tii. We Sll~)pOIt 1h(~ Specittl projects. Mr. llnorin~. Tire Roy bill, do you support it? I )r. EI)wArro~. There ale a certain provisions that we support and certaIn features which we dorit. Mi. I ~rrrs. What about a l)ill extending the Soldier's and Sailor's (`i'il Relief Act to pul)lIc health officers? You're supportive of that 11 ~ J 0. Emvaims. The I)epaitnmnt is studying the bill and will be filing a r~ olt in tIle near future. Mt. Tlo;lTIu. ~\nw. in talking al)out residencies you say you want to hirive si)eciril viojects. I 0. Lowairos. We have special project money for the creation of family re~idencies. We have special project money for this, $2,000 per vemir for each student that goes in. Mr. ROGERs. As a graduate? l)i. EDWARDS. ~es, sir. Mr. ROGERs. How man family practice residencies need to be created? Dr. ENDTCOVF. It depends on what we would agree to as a desirable mix. At the present time there are about 1.200 field residencies and about twice that many applicants. That would be out of a graduating class of about 11.500. approximately 1 out of 10. If von were shooting for. let's say, 50 percent primary care then obviously you would have to create quite a large number of new training posts in this field. Mr. ROGERS. How many residencies are there in the Nations About 51.000? Dr. ENDICOTT. That is approximately correct. Total. Mr. ROGERS. I understand. These are places where they are ap- proved and need people. They are established ready to function if they can get someone there. Dr. EDWARDS. That is right. But that does not mean in looking at the new world that maybe all of those should be. Mr. ROGERS. I understand. You may want to change surgery some or classifications. Dr. ExDIco'rr. This basically is one of our problems. We have sub- stantially more approved residencies than we have graduates to fill them. So if the students continue to prefer certain specialties other thaim primary care and if we continue to have the present number of ap- proved residencies, obviously they can continue to go in fields other than primary care. Now our legislative proposal would not directly address the prob- lem of too many approved residencies at the present time. The sub- PAGENO="0343" 333 ject is more diiectlv addressed in Congressman Roy's bill, but not in 0111'S. Mr. ROGERS. What (10 you propose to do. Do you propose to have any residencjes in family practice? 1). Lxnu'o'r'i'. We are proposing to offer a carrot rather than use the stick. Mr. ROGERS. I understand. What I am trying to find out is what is your carrot? What is the amount of your carrot, how many new posi- tions? I presume you are going to fund them or help fund them. Dr. ExDrcOrr. We are. Our budget would provide $15 million for family piactice residencies. I)r. EDWARDS. And for primary care residencies, an additional $10 niillioii for a total of about $25 million. Mr. ROGERS. How many positions would that amount to as far as your support goes? How much would You fund it at generally each? I realize it may change some. But what. $2,000, $3,000? 1)r. DUNN. First of all approximately ~10 million of th~ money for family practice residencies ivould go for continuation of programs that are now ongoing. Thus far we have been funding about half the number of programs that have been started. The question about the future then is a question of whether or not currently funded programs could take over more of the cost so we could then fund additional programs. There would be at least $5 in ihhion fo i new programs. Mi. ROGERS. You are saving that most of this money is already taken 111) then? l)r. DUNN. A portion of it is. With the present arrangement for reimbursement. Mr. ROGERS. Of family practice? J)r. I)i~xx. Yes, sir. That is a major traction because as you know it is difficult to get these programs started since they are oriented to out patient care. And it is difficult to generate patient-income through ambulatory care centers with the current reimbursement. arrange- nient. I think this is the point Dr. Edwards may want to expand on as to what the future may hold for making a shift there. Mr. ROGERS. I won't get into that yet. J don't think you are going to have much support in the next. 3 years. What I want to know is what are you going to do to establish new residency family practices, are von going to do anything? T)i. COOPER. Yes, sir. Mi. RoorRs. How much do von project? T)r. COoPER. We are projecting to give the $2.4 million at $2,000 per graduate that enters into family practice resTdencv. Mr. ROGERS. I think you just said if he graduates from the college in family practice. l)i. COOPER. And enters a residency. Mr. RoGERs. He may be entering one that is already established. Dr. COOPER. Yes, sir. Mr. ROGERS. You are not. increasing- Dr. CoopER. No. but. we are a graduate program which would be designed to stimulate primary care activities not only in family medi- PAGENO="0344" 334 cine but also in internal medicine and pediatrics. I cannot give you a specific target figure at the moment but the primary objective of the incentive award would be to stimulate achieving the objective of the 50 percent in primary care through family practice. We will also seek modification of internal medicine and pediatrics programs by use of special projects. Mr. ROGERS But it looks to me like you're just continuing present support, you are taking $2 million to- Dr. COOPER. No. what we would like to do- Mr. ROGERS. They said maybe $5 million would go to new resi- dencies. I )r. CooI'l-:R. We would like to provide the capability including pos- siNe stipends to those institutions that will start new programs. Mr. ROGERS. That is what I want to get at. How many? Dr. COOPER. We want to make them competitive for the other es- tablished residencies. Mr. ROGERS. But how are you planning to establish? I want a fig- ure. and funding. 1)r. EDWARDS. This is a significant figure. Mr. ROGERS. I agree with the Secretary. Dr. EDWARDS. We are going from $5 million to $25 million. Mr. ROGERS. I did not get that. Dr. COOPER. We expect to have available $25 million for new pri- mary care programs. Mr. ROGERS. But that includes continuation of present supported programs, does it not? Dr. EDWARDS. A continuation of present programs pius new grants to pay part of the cost of planning. developing and operating for an initial period the programs of graduate or special education or training and family medicine, pediatrics, internal medicine, or other health care shortage fields. Mr. ROGERS. This is what I want to know. Dr. ENDTCOTT. At the risk of increasing confusion, may I offer some comment? The family medicine residency program is a new program. It is only 2 ears old so that at the time of the enactment of the current legislation this was something proposed for the future. Now, residencies have been established. Up to now we have pro- vided support for about half of the programs. Our current level of investment is, I believe. ~9.5 million, which supports about one-half of the residents in family medicine. MI~. ROGERS. You are going to put another $5 million? I)r. EXDTCOTT. We are proposing to put another $5 million into that, but we are proposing in addition a new program called primary care residencies over and above that. Mr. ROGERS. I-Tow much is that, 10- Dr. EXDTCOm This would be SlO million. Mr. ROGERS. Are you doing any present support in those fields? Dr. EDWARDS. In 1974 we are spending $9~500.000 for family medi- cine residencies. We are spending nothing in 1974 for primary care residencies, nothing. In 1975 we propose to spend $13 million instead of $9.5 million for PAGENO="0345" 335 family medicine. That is an increase of $5 million. Iii addition to that we expect to spend $10 million compared to nothing this year in pri- mary care residencies. Mr. ROGERS. Pediatrics, internal medicine? Dr. EDWARDS. Yes, sir. So that is a fourfold increase. Mr. ROGERS. How many will that provide? How many residencies will that provide? Dr. EDWARDS. 500. Mr. ROGERS. In total? Dr. DUNN. Only for family medicine. Mr. ROGERS. The total $15 million would provide- Dr. DUNN. Let me separate this if I may. Again hoping to avoid further confusion. Family medicine, we would hope to provide an additional 500 residency slots, of which about 300 would be first-year places and 200 second- or third-year places. Mr. ROGERS. How many are we presently supporting? Dr. DUNN. About 800. Mr. ROGERS. So that would give us 1,100 total? Dr. DUNN. Let me qualify this by saying when we say provide slots we are not paying the full cost of the stipend or for the resi- dencies. We are paying for a program which provides a slot for a resident. In fact, we are only paying about 25 percent of the funds that. are needed for stipends. Much of the cost is for full-time faculty to organize and start these programs. Mr. ROGERS. Then you are not really establishing a residency. You are just saying you are talking about programs. Dr. DUNN. We are supporting a portion of the costs for the total program. Mr. ROGERS. You are not going to pay a st.ipend. Dr. DUNN. The applicant indicates what cost they can in fact pro- vide funds for from other sources. Then we provide funds to meet their unmet cost~. It varies from program to program as to what the particular unmet cost happens to be. So that is why it is not a carte blanche. We do not automatically provide a stipend for every slot that we support. Some programs can support their residents but they may need help to get programs running. Mr. ROGERS. I would like some breakdown on this. ,I think this is pretty cloudy. What about the internists and pediatricians? I)r. EDWARDS. Why don't we give you a description of what this year's money is going for. Mr. ROGERS. I think we should. How much you are supporting and give us some examples because I had understood when we put this provision in the law before, setting up support for family practice residency, we anticipated von would give enough support to really get them and support them and give a stipend. Dr. EDWARDS. Where it has been needed it has been placed there. But in other hospitals it has been used for the support of faculty. Mr. ROGERS. Now what do you project the increase will be by 1977? This is what you are going to do in 1975. Dr. EDWARDS. I don't have that with me. Mr. ROGERS. Would anyone Imow. PAGENO="0346" 336 I)r. LNDICO'I'T. We have not made that projection. Dr. EDw,\RDS. `We have the total cost. i\ir. i~ouu~. Can you give us wliat you plan to spend in these areas? I)r. EDWARDS. No. I can give you the total health maiipower cost but I do not have the breakdown. Mr. ROGERS. If you could give us that breakdown. How many positions? J)r. EDWARDS. For family medicine programs the estimates are $25 million in 1976 for a total of 2.200 positions supported, of which L30() are estimated to be first-year places. and $35 million in 1977 for a total of 3.200 positions. of which 1.800 are estimated to be first-year 1)1 aces. Mr. ROGERS. As I understand we have about 10,000 residencies not now filled. Dr. ENDIC'OTT. That is about correct, yes, sir. Mr. Rooms. Approximately half of the residencies are filled by foreign medical graduates. Dr. ENDTCOTT. Yes, sir about one-third. Mr. ROGERS. I think it was half last year, wasn't it? Dr. Exoicorr. I am not sure. l)r. EDWARDS. I take the 10 unfilled off the top and that would give you-that would take care of the discrepancy between the third and the half. Mr. ROGERS. I think about half are filled as I understand it by foreign medical graduates. Dr. COOPER. Of those that are filled. Mr. ROGERS. 10.000 are not. filled. I won't argue that now. If you will provide that information it will be helpful, although I think we have the figures here which show that it is about half. Dr. COOPER. Tn 1972-73 there were approximately 45,000 filled posi- tions of which 14.400 were filled by foreign medical graduates. Mr. ROGERS. How many are coming in, about 9,000? Dr. EDWARDS. That is about right. Mr. ROGERS. How many graduating about 9 to 11? Di'. COOPER. That is about. right.. Mr. ROGERS. Now what happens if a trend starts within the next year where a nation says "We are not allowing our nationals, who have had training in our university medical schools to come to the United States." Dr. EDWARDS. You mean we would not allow- Mr. ROGERS. Not that we would not; they would not let them come. What does that do to our health manpower? Dr. ALTMAN. To the extent that the $2,000 per student going into family practice would encourage a greater percentage of the grad- tiates to go there, we would hope to see a continued increase in the number of family practice people. To the extent there is a reduction in the residencies being filled in surgery and the other specialties, that is much less of a problem. `We are trying to assure that these family practice residencies are filled along with tlìe other primary care residencies. Mr. ROGEEc. T don't think that responds to what I am saying. PAGENO="0347" 337 Dr. ENDIcorr. If the countries from which our foreign medical graduates have come were to prevent their coming in the future, clearly we would have a very substantial number of unfilled but ap- proved residencies. Since they are usually here for a residency which covers a period of 3 years, the impact would become progressively worse over a period of 3 years and we would end up then with approximately 15,000 unfilled residencies, which is the number of for- eign medical graduates now in residency. Dr. ALTMAN. But I think it is important to put on the record that it is not crucial that all the residencies now in existence be filled. Dr. EDWARDS. Many of them would be better off unfilled. Mr. ROGERS. Ten thousand of them are not. That is a pretty good number. T)r. EDWARDS. Most of those 10,000 probably are just as well un- filled. Mr. ROGERS. Isn't the theory that the economy will handle all these problems? Dr. ALTMAN. Yes, sir. Dr. EDWARDS. I don't follow you. Mr. ROGERS. If there is a demand, a real demand, it will be paid for. The position is paid for and there will l)e somebody to fill it. Dr. EDWARDS. A demand for residency. ~fr. ROGERS. Sure, if there is a demand then a hospital is not just going to spend the money for nothing. Dr. EDWARDS. But most of these residencies of that 10,000-most of that demand is filled by non-American students. Mr. ROGERS. They are the ones filling. I am talking about the hos- pitals that set~ them up. There is a~ demand. The economic handles it. Dr. EDWARDS. Not economic as much as it is frequently cheap labor. l)r. ALTMAN. In this industry the economics tend to generate resi- dencies and internships to fill up inexpensively the services that could be provided and maybe should be provided by house staff. Tn addition there are a number of cases where there is an oversup- ph- of residencies and interns in some of our bigger innercity hos- pitals as opposed to some of those 10,000 in primary care which are going unfilled. Mr. ROGERS. And some in surgery are going unfilled. I just visited one where they needed a surgeon badly. Dr. ALTMAN. That is true. Mr. ROGERS. So I am not sure that saying we should just do away with them solves the problem. 10~000 is a good cut. In other words, there must have been some demand. Ten thousand is a good demand. Dr. EDWARDS. A good surgeon in a nonteaching environment wants to set. up a residency. There need not be any demand. For per- sonal reasons he just wants to set up a residency. There are a lot of those, including internships. Mr. ROGERS. I would think they would not want to pay fees they have to pay now just to set them up if there was not some use for them, would they. As a general rule I would not think they would go to the added expense. Dr. EDWARDS. I would say there is not an economic reason for hos- pitals doing everything the doctors want them to do. PAGENO="0348" 338 Mr. ROGERS. I understand that but 10,000 are not being filled. Dr. ALTMAN. Many of these residencies were set up in the late 1960's when demand for hospital care accelerated rapidly with medicare and medicaid. Since that time as a result of reduction in length of stay and in changes in care pattern including a move away from outpatient care, we are finding that residencies which used to be needed continue to be funded in part because the hospital will get paid by the third party cost reimbursers even though those residents are not providing the same level of service that they did when they first were put into effect. So we have a situation where a number of residencies are now superfluous while others in primary care cannot. get started. Mr. RoGEI~s. I understand that and 10,000 are not filled. This could easily and quickly happen. I think, in India-you read about it in India-ancl Thailand and some of the other countries. Now. suppose this happened. What are we going to do. IVe have stopped encouraging additional training of personnel. If your bill passes~we don't want to increase any more. Dr. EDWARDS. Oni estimates were made on the basis of 50- to 80- percent reduction. I don't think there is much likelihood that over the next 5 years there is going to he more than 80 percent reduction in the number of foreign graduates. Mr. RoGi:ris. So, that is very significant. I would doubt it would be that. the way we are going. Dr. EDWARDS. Nevertheless our figures represent that kind of a re- cluction so we feel even with that- Mr. ROGERS. As of what time? l)r. EDWARDS. Between now and SO. Mr. ROGERS. 1980. Tn 5 years. Dr. EDWARDS. Yes. Mr. ROGERS. So you are still counting heavily on foreign medical graduates? Dr. EDWARDS. I think if they were all to stop tomorrow we still have a lot in the pipeline. Dr. ALTMAN. Another thing we might add is the number of grad- uates now is just beginning to catch up to the increased enrollment that resulted from the 1971. So that in 1672 we had 9.500 graduates. at the same time our first year places were up to 13,000 to 15.000. In the next couple of years, as the flow from that increased first year enrollment begins to come out. we will see, a 4.000 or 5.000 increase, almost 50 percent in the production of our medical schools. These should fill a sizable per- centage of either unfilled residencies or take the place if foreign grad- uates are cut back. Mr. ROGERS. I am afraid we are also going to see a shift mto de- mand for other kinds of residency. Dr. ArT~rAx. I think that is true. . Mr. ROGERS. I don't think an 1,100 increase in residencies is very significant, in family practice. l)r. ALTMAN. We are working extensively in trying to change that reimbursement policy. PAGENO="0349" 33~) Mr. ROGERS. I understand that. Dr. ALTMAN. I think we can do that short of national health in- surance I might add. Mr. ROGERS. I hope so because something needs to be done. I am concerned about your foreign medical graduates. I don't think that if we are to stay steady, without increasing personnel, that we are effectively planning for the future demand for medical per- sonnel in this Nation. Now, what will nationi health insurance, if it were to pass, do as far as demand? Dr. EDWARDS. We figure it is overall about a 10 percent increase in overall demands. Most of that would probably be in the ambula- tory areas. Mr. ROGERS. Only about 10 percent. Do you figure how many peo- ple really then are not getting medical care? Dr. EDWARDS. We figure there are about 25 million that have no form of financing. Mr. ROGERS. You figure about 20 million-about 25 million. Dr. ALTMAN. A lot of them are receiving care. They are receiving it out of the centers and the free care in a chaotic sort of situation. But. they are receiving care. We would like to stabilize that care in addition to providing more. The change in demands varies quite a bit. For example, hospital care would only increase by about 4-percent as a result of the plan. Where you get physicians it~ goes up to 10 percent and dentists 15 percent. Mr. ROGERS. have you figured in the 15-percent increase for the dental area? T)r. ALTMAN. Yes, sir. Mr. ROGERS. You would be producing enough you feel? Dr. ALTMAN. Dental is much closer to the borderline than the physician. I)r. EDWARDS. Here again I think one of the real secrets in being able to provide adequate dental care is the use of dental auxiliaries. Mi. ROGERS. How do you support dental auxiliaries? I did not think you were supporting allied health. l)r. EDWARDS. Special project money. Mi. ROGERS. Special project grants. Dr. EDWARDS. Yes, sir. And reimbursement too. The main thing- and this is critical-is that under the proposed national health in- surance we would reimburse for these kinds of services. Mr. ROGERS. If that provision passes. Dr. EDWARDS. That is very important in terms of looking at the demand and how to meet the demand. Mr. ROGERS. But what I am saying is to actually get the person trained. . 1)r. EDWARDS. Yes, sir and we are providing special project money for that purpose. Dr. ALTMAN. $8 million for physicians' assistants and dental as- sistants. Mr. ROGERS. Would you give us a breakdown on the record for th~if? How much do you anticipate this will produce? Dr. EDWARDS. I don't have those figures. PAGENO="0350" 340 Mi. ROGERS. I)oes anybody know? Any thought? Or just an $8 million figure. J)i. ALTMAN. A big problem is to get the dentists to make use of auxiliaries in a more constructive way. Mr. ROGERS. I understand. That does not answer my question thou~.rli. You are going to have a lot of problems getting all the allied health l)eople working. Dr. EDWARDS. To date we have trained over 600 expanded dental auxihlahies, over 600 physician assistants and 323 nurse practitioners. This is iii addition to those being trained in the current fiscal year. Mi. ROGERS. How many? I)r. EIIwARI)s. Close to ~h100 physicians' assistants are in training in fi~cal year 11)74. Four hundred ten nurse practitioners and 1,400 exparlde(l function dental auxiliaries. Mr. 1h~GERS. Now on the residencies. How do we gear what we are doing to the number of residencies that are needed, and how do we turn them out from schools to get them there. I don't see that an ade- qua~ e job has been done in determining what the need of the residency programs are. I)i'. Enw~&Rr)s. I think our basic premise is that about 50 percent of n~edieal graduates should be going into primary care. ~ I~UGERS. Now. I presume the medical colleges and AMIA could certainly be effective in this area, could they not? The American Ho~pitai Association. also. T)r. EDWARDS. You mean effective in what way? Mr. ROGERS. In training to determine actual residency needs and theii let us gear what we should be producing to fill those needs. T)r. LI)w-AIms. There is no question they could be helpful but they hay" to do more than just put out numbers. Mr. ROGEJe~. How can we begin to coordinate this? Have you called them iii and said "How many in each State, how many in each city." J)i'. EI)w~~nns. You better believe we have. We meet with them on a ii gular basis through the Coordinating Council on Medical Educa- tiomi of which I am a member. Mr. J~i;i:u~. Can they let us know the numbers of residencies by State. w~rit they should have and what is needed. 1 r. Einv~ims. They can help. Mr. i~oGE1~S. I)oes anybody know? J)r. EDWARDS. No. 1)1'. XE:FMAX. The problem we have in that respect is that resi- (lelli'ies after all provide services. Yet you want them as training for future physicians who may or may not be practicing in the area. I `p to now our residency clots have primarily been based on the need for the services produced by those people in those hospitals rather than the demand for the primary care physicians. 1)r. EDWARDS. That is the key to t~e whole thing. Many of the residencies we have in this country are based not on need but for services rendered. It is a service to the physicians as much as it is to the patient. \It. ROGERS. What you are saving is we do not need residencies. We need doctors to take their plac~ in the hospitals. Is that what you are saying? PAGENO="0351" 341 Dr. EDWARDS. That is part of the problem. Dr. COOPER. Some programs in the surgical area are beginning to address this problem. The surgeons, instead of having two house of- ficers standing by during an operation, uses a physician-extender and an assistant in a much more effifficient way than a surgical resident. A surgical resident can then be doing actual teaching and at the same time reduce the number needed for in-training at any one time. Mr. ROGERS. What about the theory where the man takes his resi- dency and has a tendency to stay in the location. Does that help? Dr. EDWARDS. It helps if you need more surgeons. Mr. ROGERS. Or a family physician. If you set up some family physi- cian residencies in the rural area. 1)r. ALTMAN. I know the study which Mr. Preyer was talking about. There is a bit of cause and effect problem which leads me to be a little concerned. If you have a choice of any place in the country to practice your residency you would likely take your residency in the area in which you ultimately want to practice. So it is not always the residency which changes your behavior pattern but you gear your geographics decision on where you ultimately waiit to stay. `While I think it is a good study I am leary about~ saying that is the total answer. Mr. ROGERS. What concerns me real]v as we don't seem to have tied together our proposal for a program as to what our basic needs are. I)i~. ALTMAN. WTe knew the directions we wanted to go. Frankly, I think it was the consensus of everyone working on this that we were not smart enough to correctly estimate the exact numbers. We knew we wanted to move toward more primary care. We knew we wanted more physician-extenders. It is a little difficult to be so accurate about whether we needed 5,000 or $8,000. Also the quickness with which we moved is a factor. Mr. ROGERS. What about the approval of residencies? Most of these residencies that are accredited are approved aren't they? l)r. EDWARDS. Yes, sir. There is a formal approval. Mr. ROGERS. AMA and AAMC. 1)r. EDWARDS. Right. Mr. ROGERS. Isn't that a pretty good control factor? Isn't that a good way to get knowledge~ of what we need to be doing? 1)i'. EDWARDS. I don't think that gives you any knowledge as to what we need to be doing. It gives you knowledge as to whether or not a particular hospital's training program meets minimal standards as far as they are concerned. Mr. ROGERS. Should residencies be, in effect, monitored or con- trolled by your medical centers, and/or colleges in that State? Dr. EDWARDS. Well, I think there needs to be a good deal more con- trol over them than we have now. I don't mean Federal Government control necessarily but in terms of total numbers. And I think this is exactly what some of the specialty organizations are beginning to look into now. I think many of them feel we have allowed too many residencies to be created. Mr. ROGERS. Is there any reason for the 11/2-year delay in the schol- arship program for the National Health Service Corps? PAGENO="0352" 342 Mr. BUZZELL. Yes, there is a reason but there is no excuse. Di. EDWARDS. Could I amplify on that? Mr. RoGERs. I could ask for the reason. Mr. BUZZELL. We have had a number of problems in terms of de- sign and clearance of regulation, to make sure they conform with the legislation and with the intent of the Department and others. The key point is of course that the regulations are now available and the program is now operating. Mr. ROGERS. What about the forgiveness? Mr. BUzZELL. The forgiveness program in respect to what? Mr. ROGERS. Retroactivity, year for year, year for 2 year. Mr. BUZZELL. I am pleased to report that we are now making the retroactive payments. Mr. ROGERS. I commend you. What about the requirement of 2-year service for one ? Or for a portion of a year you have to have whole veal's service. Mr. BUZZELL. That is not applicable to loan forgiveness, Mr. Chair- in an. Mr. ROGERS. What I am saying is, for service, as I recall, you were going to make them serve a whole year for that part of their education. Mr. BUZZELL. In order to obtain the loan forgiveness a NHSC assignee had to stay 2 years, which might put him beyond his initially planned date of service. Since we have fixed the retroactivity problem we no longer have that. problem. So in terms of loan forgiveness it is quite straightfor- ward. We have been able to make the retroactive payment and as a consequence they are going to be providing the agreed upon 2 years of service. Mr. ROGERS. So that 1 year service for 1 year of school- Mr. BUZZELL. Two years of service for 2 years of school. I think the question is more directly related to the scholarship program. Mr. ROGERS. When were the final regulations issued on the scholar- ship program? Dr. EDWARDS. That will be published the day after tomorrow, Wednesda. Mr. ROGERS. Now I understand that during the week March 4 to 8, the information bulletin on the public health Service School al- ready SHAPE program was sent to 700 to 750 tentatively selected students from about 1,600 applications. Mr. SMITH. Based on the anticipation of those regulations they were notified of potential selection. The regulations were approved to be committed to 400 based on our evaluation and funding capability through fiscal 1975. They would be funded as of the 15th of February, tuition and fees as well as their stipend for the remainder of the year. Mr. ROGERS. How many applications have you had, 1,600? Mr. SMITH. Almost 2,000. A good many of those are for funding in iiext fiscal year. Mr. ROGERS. You can tell them they are tentative. Mr. SMITH. We asked for proposed $22.5 million. PAGENO="0353" 343 1~1r. ROGERS. If you have that many people why don't you come in with a supplemental. Can you do that, Mr. Secretary? Mr. SMITH. The present legislation limit is the authorization. Mr. ROGERS. We will change that. Would you be supportive of that if we change it? Mr. SMITH. Our budget for fiscal 1975 contains a request for $22 million. Mr. BUZZELL. If I may make this comment. I think the Department would want to look carefully at whether or not they wanted more scholarships than that authorized by the $22 million. The National Health Service Corps may have too many applicants coming into the program. Dr. EDWARDS. They are going from $3 million to $22.5 million. Mr. ROGERS. In other words, you had 2,000 apply. You talk about taking 600, 500, is that right. Mr. SMITH. Yes, sir, the $22.5 million would provide 2,500 to 2,800 scholarships. This would also provide the opportunity to support scholarships in other disciplines other than medicine such as dentistry and so forth. Mr. BUZZELL. Thus a supplemental is not required. Mr. ROGERS. In other words you think it is sufficient. Mr. BUZZELL. I think so, yes, sir. The present budget request of $22 million if made available at the beginning of 1975 would be adequate. Mr. ROGERS. How many cities have applied? Mr. BUZZELL. Excuse me, Mr. Chairman. Back to National Health Service Corps now? Mr. ROGERS. Yes, sir. Mr. BUZZELL. It is based on the number of communities and we have- Dr. ROGERS. Either communities or counties or whatever. Mr. BUZZELL. Roughly 600. It, is more than we have approved. Mr. ROGERS. How many are presently being served? Mr. BUZZELL. 189. Mr. ROGERS. How many do you project to have in the field in 1975? Mr. BUZZELL. 300 and-how many communities approved and fully staffed? Mr. ROGERS. Yes, sir. Mr. BUZZELL. A year from July we will have 350 sites. Mr. ROGERS. By July 1975. Mr. BUZZELL. Approximately 13 months from now. Mr. ROGERS. You will have 300 communities fully staffed. Mr. BUZZELL. 350. We will come close to doubling the number of sites approved and staffed in the next year. Mr. ROGERS. So we have by a year from this July we will have taken care of about half the requests. Mr. BUZZELL. By a year from Juiy we will have taken care of slightly over half of the total scarcity area need out there which we estimate to be approximately 650 communities now, based on the criteria that we are now using in this program. Mr. Ro~s. But have any other areas asked for help even though you may have yet made the judgment it is a shortage area. PAGENO="0354" Mr. BUZZELL. Yes, sir, Mr. Chairman. Mr. ROGERS. How many of those? Mr. BUZZELL. Dr. Martin tells me it is roughly 80 to 90. Mr. ROGERS. And in addition to the 650 you have designated~ Mr. BUZZELL. No. We have 80 to 90 communities out there that have made application which we have not yet approved or disap- proved. Dr. EDWARDS. That is included in the 650 number. Mr. BUZZELL. Let me try to illuminate confusion. We, estimate in this Nation we have roughly 650 areas we would like to serve at the end of this 3-year program. Mr. ROGERS. You have made the judgment that those communities fit the criteria. Mr. BUZZELL. That is correct. Mr. ROGERS. 650? Mr. BUZZELL. `We made the judgment using these criteria that there are approximately that many communities out there-650. In addition to that we have already approved a number of communities and have application or expressions of interest on the part of many other communities who would like to be approved. Dr. Martin estimates that roughly 80 or 90 will have to be in- formed shortly. There are many others that have not yet applied and they are in that 650 number. The 650 number is in three parts. The group that is approved which will be approximately 350 within the next year. There are many communities out there that have ex- pressed interest but are not included in the 650 because they do not meet the criteria. Mr. ROGERS. How many have applied pver and above those areas included in your 650 designations? Mr. MARTIN. We have turned down 40 applications from corn- munities that (lid not meet the criteria. Mr. ROGERS. Have an more applied outside these 650 areas that you have. Mr. BUZZELL. That is the 40. Mr. ROGERS. What about this business of a 50-percent reimburse- ment. We had heard they were going to require 50-percent reim- bursement. the Corps put out word, and then Secretary Weinberger said they did not think the would. What is the true situation. Mr. Bl~zzELL. Mr. Chairman, we. do not mandate a percentage of reimburSement. We are proposing that we be given more flexibility so that the community for example in the first year of practice not be required to provide any reimbursement. If any of our e~ip1ovees have indicated 50-percent reimbursement or any other percentage. then that is a mistake that we would correct. If you on the committee know of any instances where the commu- nities have been misinformed, we would like to know that. Mr. ROGERS. What about if they set up a Health Service Corps delivery point in a community and it gets into debt? What happens when the debt. reaches $~0,000? Mr. BUZZELL. Currently or under the proposal? Mr. ROGERS. The current time and then what you propose. PAGENO="0355" 345 Mr. BUZZELL. At the current time nothing happens in the sense of punitive action on our part. Mr. ROGERS. What about the Justice Department? Mr. BUZZELL. Nothing to my knowledge. In the proposed legisla- tion once again-and in fact all of the proposals-would again not mandate that anything happen if they go in debt $20,000 or what- ever. What we prefer to see is the reverse-that is that the community not go in debt to us during that first year. This is a year in which, of course, their revenues are least likely to equal their expenses. We don't want the community indebted to the Federal Government. Mr. ROGERS. What about fees, must they charge fees to everybody? Mr. BUZZELL. No, sir. Mr. ROGERS. What is the statement on that? Mr. BUZZELL. The policy is they cannot deny service to anyone regardless of the ability of the people to pay. We have many sites by the way where the fee collections are very low for that very reason. Mr. ROGERS. Has HEW hired a consulting firm to advise health corps sites as to fee schedules? Mr. BtTZZELL. Yes. Mr. ROGERS. Is that problem oriented- Mr. BtTZZELL. POMI is the name. That is an acronym. Mr. ROGERS. What does that mean? Mr. BUZZELL. Problem oriented medical institute. In our proposed legislation we asked for the flexibility to use another option than the national contract option. Mr. ROGERS. How much is this contract for and how many cities is this firm advising? Mr. BUZZELL. We don't have it with us. We will have to supply it for the record. Mr. ROGERS. Would you know off hand? Dr. MARTIN. The contract is roughly $1 million and they are re- sponsible for all the sites. Mr. ROGERS. Would they also be. responsible for the 350? Mr. B'LTZZELL. No. The concept we propose to use as proposed in the legislation is one whereby we permit the local community to hire the technical assistance they require. Mr. ROGERS. It may be a good thing. I am not critical. I want.ed to find out about it. Mr. BUZZELL. I would prefer options. Mr. ROGERS. Are there any other contracts like that out? Mr. BUZZELL. Yes, sir, but not of that magnitude. Mr. ROGERS. What are they? Mr. BUZZELL. We have a contract with the American Medical As- sociation; and with the Students AMA. These have been contracts geared to helping us with the recruiting problem. Mr. ROGERS. How much for AMA and how much for students? Mr. BUZZELL. Currently AMA is $60,000, geared to the assistance we need to recruit midcareer physicians. Mr. ROGERS. Is that for a certain period of time? Is that the total contract? 38-698------74-pt. 1-24 PAGENO="0356" 346 Mr. BCZZELL. Two years. Mr. ROGERS. Is not $175,000. Dr. MARTIN. There is an additional contract to the American Medical Association for the payment of physicians who are willmg to cover solo sites. Mr. ROGERS. Would you please identify yourself. Dr. MARTIN. I am Dr. Edward Martin. Mr. ROGERS. Your position, Dr. Martin. Dr. MARTIN. I am Director of the National Health Service Corps. There are two contracts, one to recruit and the second contract pro- vides for the American Medical Association to recruit and place physicians for short periods of time to replace the physicians when they are forced to leave the site. That is the difference between the $170,000 and $60,000. Mr. BUZZELL. They help us recruit staff during these periods when the assigiiee is not at the site. Mr. ROGERS. Would you let us know how many have been used and for what periods of time and where. What about the student? Is that to encourage students to come in? Mr. BUZZELL. We were only able to direct our recruiting efforts to the young medical students and the Student American Medical As- sociation group is an excellent resource for that purpose. Mr. ROGERS. How much has been expended in contracts for the Corps, in contracts other than those for service? Mr. BUZZELL. Over the 2½ year period I would estimate roughly $3 million and we will correct that for the record. Mr. Roo~s. Would you give a breakdown of what those were? [The following material was received for the record:] NATIONAL HEALTH SERVICE CORPS CONTRACTS-FISCAL YEAR 1974 American Medical Association-$185,300. Locate civilian physicians, as requested by Regional Offices of the National Health Service Corps, to be placed for short intervals in shortage communities while the Corps assignees stationed there will be unavailable. Assist in publiciz- ing the program to the medical community by developing promotional articles and materials for distribution to physicians. Provide to the replacement physi- cian complete information concerning his responsibilities while on the NHSC site. Determine the factors and demographic characteristics which contribute to a physician's willingness to leave his current position and offer primary medical care in an underserved area and to cover costs for physicians serving as replacements. This contract has, since its start in January, 1974, placed 19 physIcians in these locations: January: Gallup, NM; Monterey, TN; Antonito, CO; Pagosa Springs, CO; Sa- guache, CO; Westcliffe, CO; Lusk, WY; Terry, MT; West Yellowstone, MT; La Moure. ND; Martin, SD; and Hoopa, CA. February: Hoopa/Livingston CA. March: Fossil/Condon, OR. May: McCormick, SC; Seattle, WA; Hoopa, CA; and Winona, MO. June: Cross City, FL. The contract also requires AMA to launch a recruitment campaign for mid- career physicians seeking to relocate their practices and families. Most of the NHSC effort is directed to the younger professional who is beginning his career but experience shows that a number of established physicians, each year, re- locate themselves. The AMA Is the logical source of assistance to this group and the efforts of AMA on behalf of NHSC will yield numerous assignees for the Corps. PAGENO="0357" 347 National Training Labs in ABS-$120,800. Continuation of activities supported in fiscal year 1973. Human Sciences Resources, Inc.-$21,286. Completion of activities supported in fiscal year 1973. Family Health Care, Inc.-$807,900. Continuation of activities supported in fiscal year 1973. Student American Medical Association Physicians National Hoissestaff Assooio,- tion-$163,500. Develop local physician advocates for the National Health Service Corps in 250 primary care residency training programs, development of network for the distribution of NHSC informational material and conduct of a series of regional meetings during the peak months of the NHSC recruitment effort for individuals who have indicated a high level for interest in the NHSC. Student National Medical Association-$6,500. Continuation of activities supported in fiscal year 1973. Student American Medical Association-$122,763. Identify 50 medical and osteopathic students who have completed ~ieir sopho- more or junior year and place them for a minimum of 8 weeks in National Health Service Corps communities to form the basis for future recruitment of these individuals to NHSC sites. Wichita State University-$36,740. Test and evaluate a series of measurable educational objectives that the Bu- reau of Community Health Services could apply nationally in the preparation, evaluation, standardization, and continuing education of rural nurse practitioner trainees. Joe Davis, Inc.-$242,501. The contractor will provide all necessary personnel, equipment, facilities and materials to execute a variety of National Health Service Corps recruitment aids including advertisements, brochures, slide series, posters and mailers. Among the services performed will be editorial, photographic, design, layout mechanicals executions, advertising placement and purchase of space. NATIONAL HEALTH SERVICE Cones CONTRACTS-FISCAL YEAR 1973 National Training Laboratory-$285,000. Provide assistance to NHSC RPCs in carrying out programs of pre-service orientation, in-service education and field support of assignees and their family in dealings with communities, i.e., cross-cultural adjustments, training of com- munity boards, problem solving in assignee-community problem areas and assist community with continuity planning in the event of NHSC termination. Family Health Care, Inc.-$496,600. Provide on-site request (technical) assistance in 120 field stations based on management analyses that were performed. An orientation In patient manage- ment practice for all newly assigned physicians, preoperatlonal management analysis of new NHSC field stations to build an ongoing viable and successful problem-oriented practice at Corps sites. Human Science Research, Inc.-$74,825. Develop a methodology (including plan for using information on assignees and sites) for predicting successful matches of health professionals with com- munities. The effectiveness of such matches will help to determine the effective- ness of NITSC in establishing on-going and viable practices. National Medical Assoeiatioiv-$88,000. Recruitment of minority physicians for assignment to NHSO sites, develop- ment of techniques for attracting minority physicians to careers in underserved areas, to familiarize minority professional groups with NHSO objectives and to encourage participation and support. PAGENO="0358" 348 Student American Medical Association-$40,883. Identify and locate physicians who have served at least one elective experi- ence as a student in a primary care experience sponsored by SAMA and screen the~e to determine who would be potential candidates for NHSC assignees. The predisposition of this group towards family practice proves to be a necessary factor in retention of assignees in NHSC areas. ~tudent Natioaal Medical .4s8ociation-$18,000. To support a National Preceptorship Program to recruit and place medical students in National Health Service Corps assignee sites that include exposure to health practitioners in solo and group practice settings, community hospitals and community health and preventive medicine programs, to encourage these students to consider NI-ISC assignments upon graduation. ~cettle In (lien Health Board-$90,240. Serve as catalyst for developing and establishing follow-up to patient referrals to area hospitals and O.P. Departments, assist Indian population toward greater utilization of services available, identify gaps in resources and to open areas to SIHB beneficiaries. JoJm a ~in a u.s Coin J)(ifl y-$3O.800. Development of journal publications, posters and recruitment materials for use in NHSC recruitment activities. Gale A.c~oeiutes, Inc.-$19,310. l'lanning and cotiducting a conference on recruitment. These two efforts, along with Corps staff, assisted in achievement of almost 100% of our recruitment goal. Mr. ROGERS. As I understand in a letter to one of the sites, the group's recommended levels for fees were above the prevailing rate. Can you give us an explanation of that? Mr. BUZZELL. First of all, as a general policy, that would not be tile situation but I will confirm that for the record. That is unusual. More typically tile problem is one of assuring the medical private sector that our fees are comparable with theirs. But there may well have been that kind of situation. Mr. ROGERS. I would like to have a breakdown on that because I cannot understand it. Mi'. BFzzELL. Stranger things have happened. Mr. ROGERS. Not many. Where the Government goes in and recom- mends highei' rates to the prevailing rates. Mr. BUZZELL. We do have some sites that are quite self-sufficient. Mr. ROGERS. This is the point. That is the point I was afraid of. It is not the intent of the legislation that the site must be self- sufficient. Mi'. BUZZELL. I agree. Mr. ROGERS. We hope that they can do well, but, that is not a criterion. I was afraid you were putting that out in your regulations. Mr. BIJZZELL. Tile pleasing thing is that rural America is willing to pay foi' its health care. Mi'. ROGERS. We all are. Mr. BUZZELL. Not all of us. Mr. ROGERS. We all are but why should they have to pay more than tile prevailing rate? Mr. BUZZELL. I don't think it is possible for rural America to pay more thait the prevailing rate. Mr. ROGERS. It is my understanding that at one of your sites they did and we have a letter but if you would check that out and let us imow that would be helpful. PAGENO="0359" 349 Mr. BtTZZELL. It would be helpful if we could have the specifics of that because generally speaking we do charge the prevailing rate. Mr. ROGERS. I think that they tried to say "They are people who are not paying; therefore you are going to make the people who do pay more to cover the people that don't pay." That is the theory of making itself sufficient. which was not the intent of the legislation. Previously someone did not understand that very clearly. Mr. BUZZELL. I think 99.9 percent of every single collection has been less than or equal to the prevailing rate. Mr. ROGERS. I would hope. Mr. BtTZZELL. 99.999 percent as a matter of fact. Mr. ROGERS. I might call your hand on that. What about con- sidering a sliding fee schedule to allow the poor individuals to pay to their ability? Mr. BtXZZELL. We have that now, Mr. Chairman. Mr. ROGERS. It is done? Mr. BUZZELL. Yes. sir. Could I make a one sentence statement, Mr. Chairman. I read quite carefully the National Health Service Corps proposed legislation on the. part of this committee and also on the part of t.he Senate. We have, as a team, in the executive branch worked on our proposed legislation. I think except for the two or three areas which are. program design areas we are in concurrence. I urge. however, that the committee look carefully at our technical recommendations because they provide better flexibility to achieve the committee's philosophy. Mr. ROGERS. I appreciate that. We will look carefully at our re- commendations. What. are you doing about nurses? Are you getting any further out there and how many? Pr. MARTIN. The.re are 62 nurse clinicians and nurse practitioners. There are additionally 20 nurse practitioners in training. We expect the full-time nurse staff by next year to be 95 t.o 100. Mr. ROGERS. What is the funding for recruitment for the Corps this year, last year. and projected for 1975. Mr. BUzzELL. It is ~284,0O0 for fiscal year 1975. Mr. ROGEIIS. What response are you getting from young doctors? Do von think you can fill the slots? Mr. BTJZZELL. Mr. Chairman. by the first of July, one month from today, we will in fact have every single slot filled and by July next year we are projecting we will have three to four applicants for every spot.. Mr. ROGERS. That is encouraging. Have any of the people at this table ha.d an opportunity to be at a college and make a speech on this to t.he students? Mr. P~TzzELL. I have. Mr Chairman. Mr. ROGERS. Ha.ve von. Mr. Secretary? Dr. EDWARDS. No. I have not. Mr. ROGERS. Did von get. good response? Mr. BUZZELL. The response is outstanding. Heretofore some of the quastions they ask were very hard to answer. For example, they ask why do you expect. me to take this opportunity at $16,000 a year when in fact I can earn S46.000 a year. Actually facts are that we have, not been competitive. The question is very difficult. PAGENO="0360" 350 Mr. Roo~s. I presume the hold-up in this program is over at 0MB. Mr. BUZZELL. No. The hold-up is in terms of what we propose to do. In my judgment it was a new program and second, it was a small program. I don't think we collectively had a good program designed. There has been absolutely no problem with the Office of the Secretary or the Office of Assistant Secretary or with the Office of Management and Budget in connection with what we are pro- posing. Mr. ROGERS. I have heard from some students, who are interested in the program. that they have no way of being sure where they will be under the loans and scholarships assigiied. In other words they could be assigned to work in prisons although they really may have a preference for some other area. Is there any way to allow- students to indicate a preference and then to fill that if possible? Mr. BUZZELL. Yes, sir. Mr. Chairman. We stop short and will con- tinue to stop short of providing a guarantee, but we are in fact now not on1y guaranteeing the students joining the program that they are going into National Health Service Corps, but we are giving them a community selection opportunity through the matching process. We can assure the students with a high degree of probability they will be. able to pursue the National Health Service Corps or the Indian Health Service. That. is our other major need. Mr. ROGERS. I know it is. You are not just confining your scholar- ship program to medical students only are you? Mr. BUZZELL. Yes, we are now. Mr. ROGERS. Why? When you need nurses and when you need dentists? Mr. BUZZELL. Tn the National Health Service Corps program we are placing our highest priorities on physicians. Said differently it would be my desire at the present time to fill every single slot in- chiding the national office slots and regional office slots with practic- ing physicians. So it is really a question of priority as to need. Mr. ROGERS. I think you should come in and give us some recom- mendations during the consideration of this. If you need an increase in authorization you better do it now so we can get it written into the legislation. Mr. Samuels maybe you could help us on that. Dr. BUZZELL. I want to make sure I point out that the Office of Management and Budget has asked for the increase on the scholar- ship program. The National Health Service Corps program we are proposing would in fact require a higher level of authorization. Mr. ROGERS. Please let us have those figures right away, because I understand Senator Beilmon of Oklahoma put into the record a list- ing of counties where they simply have neither physicians, dentists or nurses; 964 counties, which is far above the 650. Eight hundred thirty-three counties needing dentists and 817 counties needing nurses. Mr. BUZZELL. Not all in Oklahoma~. Mr. ROGERS. No. Less for Oklahoma. But he has a good vantage point there of the whole United States. PAGENO="0361" 351 Now in conclusion-and I appreciate your patience-I think it would be helpful for us to have your response to the General Ac- counting Office report which will be out, I think, tomorrow and any recommendations you have as to legislation as a result of that report. I think that would be helpful. Also, I would like to have any recommendations you have regard- ing controlling the number and types of residences through legisla- tion that should be considered. I do have some questions I am going to ask be answered for the record. I am hopeful the committee will be able to finish this legislation, write it, have it passed in sufficient time to meet the deadline of June 30 so we will try to see if we cannot get it through the Congress before the deadline. We may have to call on you to give us specific help and specific language. Are there any other questions? Thank you so much for being here. The testimony was most help- ful. I want to say I think we are beginning to see some move and change in the Department. I commend you for it. I am pleased to see some activity there. Thank you so much. The committee stands adjourned until 1:30 p.m. tomorrow after- noon. [Whereupon at 6:15 p.m. the subcommittee adjourned, to reconvene at 1:30 p.m., Tuesday, May 21, 1974.] PAGENO="0362" PAGENO="0363" HEALTH MANPOWER AND NURSE TRAINING-1974 TUESDAY, MAY 21, 1974 HOUSE OF REPRESENTATIVES, SUBCOMMIrI'EE ON Puimic HEALTH AND ENVIRONMENT, COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE, Washington, D.C. The subcommittee met at 2 p.m., pursuant to notice, in room 2322, Rayburn House Office Building, Hon. Paul G. Rogers, chairman, presiding. Mr. ROGERS. The subcommittee will come to order. 1\Te are continuing our hearings on manpower legislation, medical manpower; there are a number of bills. This afternoon our first witness is an old friend of the committee who has rendered distinguished service in government as Assistant Secretary of HEW [Health] and is now professor of social medicine and director of the health policy program, School of Medicine, IJni- versity of California, San Francisco-Dr. Philip R. Lee. The committee welcomes you, Dr. Lee. Your statement will be made a part of the record and you may proceed in any manner in which you desire. STATEMENT OP PHILIP R. LEE, M.D., PROFESSOR OF SOCIAL MEDI- CINE ARD DIRECTOR, W1~AT~TH POLICY PROGRAM, SCHOOL OP MEDICINE, UNIVERSITY OP CALIFORNIA, SAR FRANCISCO Dr. LEE. Thank you very much, Mr. Chairman and Mr. Roy. It is a pleasure to respond to this committee's request to discuss some of the major health manpower policy issues facing this com- mittee and the Congress. I have been asked by the staff to comment particularly on geographic maldistribution of physicians and other health professionals, maldistribution by specialty, and foreign medi- cal graduates. I hope that my remarks will serve as an introduction to the com- ments to be made by the panelists who will discuss these issues in more detail. Before discussing these three topics, however, I want to comment on the question of how many physicians or other health professionals is enough and the need as a matter of national policy to provide equal educational opportunities in health professions education. It has been pointed out in the past by my colleague. Dr. Edwin Rosinski, that the 1968 Health Manpower Act made it clear that health manpower policy was no longer merely a numbers game. As time has passed. that has become increasingly clear. (353) PAGENO="0364" 3.54 Health manpower policies cannot be separated from policies re- lating to the organization, delivery, and financing of health care, particularly the manner in which physicians and other health pro- fessionals and hospitals and other institutions are reimbursed for their services. This committee. in examining the key issues as they relate to national health insuranceS has made it clear that it understands the interrelationships between these and that it appreciates the com- plexity of the problem. There are at least four key questions related to national health insurance that will influence health manpower requirements and strategies: 1. What percentage of the Gross National Product will be put into health services? 2. `What services are to be produced? 3. `Who will receive these services? 4. Who will pay and how will they pay? How we answer these questions will significantly affect the demand for physicians' services and for the services of other health pro- fessionals, as well as the demand for hospital and other institutional services. In attempting to discuss the need for physicians and other health professionals it is necessary to use numbers and ratios that seem to confuse rather than illuminate the issues. A variety of figures may be used because studies were done in different years. Some of the ratios that I will discuss and others will discuss were based on total physicians to population. other ratios include those physicians in office- or hospital-based practice whose principal activity is patient care. while other ratios will refer only to those physicians involved in providing primary medical care. We ~ow the ratios of physicians to population do not reflect available services because they do not reflect the number of physi- cians available and providing primary care nor do they reflect the number who provide only specialty or consulting services. These ratios also do not show that. doctors in areas with fewer physicians work longer hours, employ more paramedical or auxiliary personnel, see more patients per hour and more patients per year than doctors in areas where the supply of physicians is greater. It. seems clear as we approach that national health insurance will result in an increased demand for physician services. This in turn will require more physicians and health personnel to provide the services required. The problems are: How many, what kinds, and where? It is surprising in view of the imminence of national health in- surance that very few studies have been done on the anticipated increase in demand for physician services as a result of national health insurance. Depending on the type of program enacted, phy- sician requirements may range from as few as 400,000 (an increase of approximately 50.000) to as many as 500,000 (an increase of ap- proximately 150.000) physicians by 1980. Recently Dr. Henry Simmons, Deput.y Assistant Secretary, Depart- ment of Health. Education, and Welfare, and yesterday Dr. Ed- wards, said that the Department anticipates the physician require- PAGENO="0365" nient by 1980 would be between 400,000 and 450,000. The Depart- ment projects that the supply will be between 430,000 and 450,000 by that time. The ratio of physicians to population will raise from the 1970 level of 158 physicians/100.000 population to ~07-to-212/ 100.000 by 1985, acording to Dr. Simmons. and I think also ac- cording to Dr. Edwards' testimony yesterday. Earlier projections by Dr. Mark Blumberg for the Carnegie Com- mission on Higher Education, based on assumptions that are different from those of the Department of Health, Education, and Welfare, indicate significantly lower physician to population ratios than those projected by DHEW. Dr. Blumberg projected ratios of 169.5 to 190.4 physicians per 100,000 population by 1987. Dr. Blumberg based his projections on the assumption that immigration of foreign medical graduates would decline to 0 by, I believe, 1978; and DHEW projections continued immigration at continued high levels. My comments on the number and projected physician supply re- flect my view that national health insurance cannot be ignored as a factor in future demand projections and that the capacity and out- put of American medical schools should not be reduced, indeed it should continue to expand at a modest rate to meet future increases in demand generated by population growth, national health insur- aiice, technological progress, higher levels of education and income, a greater number of aged, and other factors. At the present time it appears to most observers that the present number of physicians is adequate to meet the Nation's current needs. Geographic and specialty maldistribution of physicians are the major problems and must be dealt with effectively. This is particu- larly true with respect to primary medical care. SPECIALTY MALDISTRIBUTION The problems of specialty maldistribution and geographic mal- distribution are linked, but the solution of one problem will not necessarily solve the others. No Western industrialized country has solved the problem of the relative shortage of physic.ians in rural areas. These problems have not been solved by different systems of health care, even in the Soviet Union and Israel. where the physi- cian to population ratio is high. I believe we must understand the problems before we can hegiiì to find solutions. The problem of specialty maldistribution basically relates to a lack of primary medical care. The deficiency began to appear decades ago, as more physicians engaged in specialties and fewer in general practice. A few figures illustrate the problem. In 1931, there were 90 general practitioners per 100,000 population in the United States. Thirty years later this ratio had declined to 37 per 100,000. In 1931, general practitioners constituted over 70 percent of the Nation's practicing physicians; in 1961. it was less than 25 percent, and it is still lower today. What is sometimes overlooked in these figures is that primary care is not the sole responsibility of the general practitioner. It is also provided by internists, pediatricians, and obstetrician-gyne- cologists. Indeed, in many over-doctored urban areas general PAGENO="0366" 356 surgeons. dermatologists. and many other specialists provide primary medical care. A recent study by Dr. Robert Huntlev of Georgetown University School of Medicine indicated that in 1970 there were 41.2 office-based patient care physicians for every 100,000 population whose practices were devoted largely to primary medical care. If we add surgeons, psychiatrists, and obstetrician-gynecologists to the list, the ratio rises to only 61.8 physicians per 100,000 population. It is little wonder that people perceive there is a shortage of physicians. The extent of maldistribution is evident when one examines esti- mates of the number of physicians needed to provide good primary medical care. The best estimates were made by Schonfeld, Heston, and Falk of Yale ~ in 1972. They estimated that 133 phy- sicians per 100.000 persons were required for good primary care. To achieve this ratio would take about 266.000 physicians would be needed. Taking the most optimistic approach to our current need for pri- mary medical care by including all physicians who are involved in patient care in our estimates, the maximum number that might be involved in primary care in 181.156. This figure would include general surgeons. psychiatrists. obstetrician-gynecologists, pedi a- tricians. internists, and general practitioners. This figure is surely high. Dr. Gerald Weber of the University of California, Berkeley, has done an excellent review of the distribution among specialists. He used only general practitioners. internists, and pediatricians in his estimates of primary care providers and he noted that these pro- viders increased from 103.000 to 104.000 in the two decades between 1950 and 1970. There was an increase of only 12.000 in other medical specialists as compared to increases of 56.000 in other specialties such as laboratory medicine, pathology. and radiology. He also found that there had been an increase of 41,000 on the various sur~zical specialties during the same period. Mr. ROGERS May I interrupt at this point? There is a call on the floor for a vote. We will be back as soon as the vote is made. The committee stands in recess for 5 minutes. I Brief recess.] Mr. HASTINGS Ipresiding]. Mr. Rogers was inadvertently detained but will be here shortly. If you would care to proceed at this point. Dr. LEE. The trend of the 1950's to 1970's in terms of excess pro- duction of specialists, particularly surgeons, and an inadequate output of primary care physicians is evident in future projections based on residency training, Professor Weber observed that if the average physician practices 30 years. it will require 3.5 residents in training to eventually replace every 100 physicians in a particular specialty. In 1970. general surgery had 12.2 new trainees for each 100 physicians. while the combined primary care specialties of general practice, internal medicine, and pediatrics had only 4.5 physicians in training for every 100 in practice. At the present time, approximately 35 percent of all residencies that are filled are in the primary care specialties. including general practice. pediatrics, internal medicine, and obstetrics and gynecology. PAGENO="0367" 357 These residencies currently number about 16,000. The. American Medical Association has recommended an increase to 50 percent of all residencies in these fields. I fully support the recommendation. This shift. cannot. occur overnight, but in view of the fact that there has been an increase of 10.000 in the total inimber of residencies available in t.he past 5 years. it should be possible to increase primary care residencies by at least 5,000 in the next 5 years while reducing surgical residencies by an equal amount or more. RECOMMENI)ATIONS Special incentives should be given to medical schools and teaching hospitals to develop undergraduate and graduate programs i~ medical education that will result. in the PrOduCtiOn of adequate numbers of primary care specialists. Programs should include family medicine and family practice, internal medicine, pediatrics, and ob- stetrics-gynecology. The Congress should also provide incentives for the development of nurse practitioner, physician's assistant., and other intermediate health practitioner programs. rfhere should be developed in conjunc- tion with training programs for primary care physicians so that the. scope of their services can be expanded and the number of patients served efficiently and effectively can be increased. It will make little sense to train these health professionals in new or ex- panded roles, however, unless restrictive State licensure laws are changed and unless reimbursement for t.he services they provide in associatioii with physicians is adequate to get physicians to bring them into their primary care practices. Congress should recommend to the Americaii Medical Associa- tion, the specialty societies and spe~ciaJty boards, the Coordinating Council on Medical Education, the Liaison Committee on Graduate Medical Education and others concerned with graduate medical education, the immediate elimination of the 6,000 unfilled residency positions, except those positions in primary care fields. Congress should also suggest an nnmediate reduction in the excess number, in relation to national need, of the surgical residency positions. The reduction in presently approved residencies should be accom- panied by a re-evaluation of need and the development of a sig- nifioaaitly increased number of family practice, internal medicine, pediatric residencies, and obstetrics-gynecology residencies in geo- graphic areas more appropriate to the need for primary care. The number of residencies should be roughly equal to the undergraduate enrollment and first-year residencies should be equal to the number of graduates of U.S. medical schools plus 10 percent to provide train- ing opportunities for the limited number of foreign medical graduates wishing to obtain advanced training in the United States. GEOGRAPHIC MALDISTRIBtITIOX Geographic maldistribution of physicians can cause problems similar to those of the specialty maldistribution, particularly a shortage of primary care. People can travel for specialty consulta- tions and, when required, hospitalization and surgery. Institutions PAGENO="0368" 358 such as the Mayo Clinic have long served such needs. It is interesting, though, that the Mayo Clinic, although international in its reputa- tion, draws most of its patients from an area. within 200 miles of Rochester, Mimi. In a study prepared by John McFarland of the AMA's Center for Health Service Research and Development, five major categories of influences on physician location decision were: Environmental factors (quality of life in the community, nonprofessional attrac- tions); prior exposure; professional relationship; economic factors; and demand determinants. In considering these influences it is evident that some, such as the climate in a given location, are not amenable to public policy ~mathpulation, while others, such as prior exposure, professional relationships, and economic factors, may, in part at least, be influ- ènced by Federal policies. The problem of geographic maldistribution is familiar to most of you. It is long-standing and, as time passes, the differentials be- tween urban and rtrral areas and between areas of relative scarcity and surplus increase. In other words, the problem gets worse. The ratios of physicians with patient care as their primary activity per 100,000 population illustrate the geographic maldistribution problem only in very gross terms. Whether on a regional basis or statewide basis, we see great differences. A study several years ago by Haug, Roback, and Martin, of the American Medical Association, revealed that the national average was 125/100,000 population while. ten Mid-Atlantic States had 161/100,000. The East-South Central regions had only about 90/100,000. Individual States varied from a high of 193/100,000 in New York to less tha.n 75/100,000 in North Dakota, Mississippi, and Arkansas. Professor Reinhardt of Princeton University re- ported ratios of 161/100.000 in New England; 115/100,000 in the East-North Central Division; and 95/100,000 in the East-South Central Division. These figures do not reveal the maldistribution between urban and rural areas in almost every State. California is a good example. In 1971, there were 36,329 physicians practicing in California, or a ratio of 178.1 physicians/100,000 population. The ratios ranged from 194.5/100,000 in the major metropolitan areas to 88.2/100,000 in the isolated rural areas. The variation between counties is even more extreme, from an absurd 513.4 physicians/100,000 population in San Francisco to 70.8/100.000 in rural Siskiyou County with 24 physicians serving a population of 33,900. This degree of geographic maldistribution would be intolerable if it were not for the fact that the variation in ratios of primary care physicians to the population is not nearly as great. The range appears to be from 62 primary care physicians per 100,000 popu- lation in t.he Pacific Region to 40 in the East-South Central Region. General practitioners, fortunately. are better distributed in relation to this populatio~i in the rural areas and small towns than they are in the urban or metropolitan areas. Two other factors need to be examined before we can reach any conclusion about the possible impact of Federal policies on geo- graphic maldistribution. When we look at what happens in areas PAGENO="0369" 359 that have shortages of physicians, we find that the physicians work longer hours than their urban colleagues; they empioy more auxil- iary personnel; they see more patients per hour and they see more patients annually. According to Professor Reinhardt's data, the average physician in New England has 4,808 patient visits annually while a physician practicing in the East-South Central Region has 8,408 patient visits amiually. This greater patient load can do a lot to make up for the shortage. However, the extra workload, longer hours, relative isolation and inadequate facilities drive many general practitioners from rural practices to specialties and a life in the city or the suburbs. In the city a similar problem is occurring. Many neighborhoods in Chicago, Boston, Detroit, and other major cities that were for- merly well supplied with physicians are now virtually without them. This shift has occurred as blacks, Puerto Ricans, and Mexican- Americans have moved into these cities and the white residents, except for the aged and the poor, have moved to the suburbs, taking physicians and other health professionals with them. One of the major purposes of the Office of Economic Opportunity's Neighbor- hood Health Centers and the Children's Bureau's Maternal and Infant Care and Child and Youth projects was to bring medical services to the underserved areas. What can be done to deal with the problem of geographic mal- distribution, which has been growing worse for certainly the last 20 or 30 years? RECOMMENDATIONS Congress should: First, encourage and give specific incentives for medical and health professions schools to admit students from rural areas and from socioeconomically disadvantaged groups whose medical care needs have not been adequately met by those tradition- ally admitted. This would mean the admission of more women, minority, and rural students. Second, encourage and provide support for a rapid expansion of family practice residencies, particularly in areas where physicians will be needed in this function. This can be done best through the support of these training programs and the development and expan- sion of Area Health Education Centers. Third, encourage and provide support for the expansion of the other primary care residencies, particularly in areas of need, follow- ing a strategy similar to that adopted for family practice. Fourth. encourage and provide incentives for the development or expansion of physician assistant and nurse practitioner programs, and I would include the niii~e-midwife program. These should be constructed in conjunction with the primary care training programs in order that the students learn how to function effectively as mem- bers of an interdisciplinary health team before they go into practice. Fifth, expand and strengthen the National Health Service Corps, particularly through the development of a scholarship program that leads from medical school and residency training into the National Health Service Corps with service for extended period in under- served areas and meeting the needs of population groups whose needs are underserved. PAGENO="0370" 360 Finally, develop an adequate system of evaluation to determine how effective the response of the Nation's medical schools is in meet- ing the Nation's needs for physicians of the right kind, in the right place. at the right time. FOREIGN MEDICAL GRADUATES Some have looked on the immigration of foreign medical graduates as an important source to meet health care needs in the United States. I think that facts show differently, and I encourage you to look at the data and then decide on a course of action far more appro- priate than that. advocated liv Secretary Weinberger and his asso- elates in the. Department. of Health, Education, and Welfare. Before discussing some of these facts, it is important to look at the history. The history is ilmiportant because it indicates, to some extent at east, why we are where we are, and it suggests what can be done. Piiei to the Second World War there were few graduates of !`on~:gii nieWcal schools taking advanced training in the United Stares. In 194(S Senator Fuibright introduced amendments to the Surlitis Piopertv ~ct of 1~}44 that. provided for an international edu- cational exchange, including support for foreign students to come to the United States to study. In 148 the United States Information and Education Exchange Act [Smith-Mtmdt Act] was enacted, authorizing a fuller exchange program and creating the exchange visitor [J Visa] immigration category. This did not have much im- pact on medical school admissions, but it did bring an increasing number of foreign medical graduates into internship and residency programs which began to expand rapidly. I have. provided the members of the committee some charts which list tIle internships and residencies filled by foreign medical gradu- ates and nonmedical graduates. (See p. 369.) The first of these, the 1)ercemlt filled, and on the side of that I have indicated when the Smit]i-Mundt Act. was passed and certain amendments which were important took place. It was originally assumed that tile students or trainees who came into the United States under exchange visitor programs would all be part of Government-sponsored programs. Gradually the boundar- ies of eligible programs expanded until any sponsor could apply to the Secretary of State to obtain exchange visitor program status. Tile program was based on the premise that persons would come to the United States for training and then return to their homelands. They would not be brought in to meet U.S. health care needs. House staff foreign medical graduates fell under the exchange visitor program because: They were not considered to be coming to an established institu- tion of learning-even if their program was affiliated-and therefore were not eligible for a student visa. They did not fall under the H visa category which applied to persons with ability to perform a needed service in the United States. Tile. SpOnsoring institutions made the selection of exchange visi- tors in their programs. This became a popular vehicle for hospitals PAGENO="0371" 361 to bring in foreign medical graduates. By 1961 there were 2,735 ex- change visitor programs and 1,300 of them were sponsored by hospi- tals. Many hospitals had previously expanded their capacity to pro- vide training for physicians who were returning from World War JJ* ~ the veteran population declined, the hospitals needed a new source of trainees-and this was to be the foreign medical gradu- ate. The number of foreign medical graduates doubled between 1950 and 1952. It doubled again by 1958 and again by 1967 to fill the ex- panding number of approved interships and residencies. The Educational council for Foreign Medical Graduates was es- tablished in 1957 to certify the basic qualification of foreign medical graduates to enter training. The ECFMG was not officially recognized by the Immigration and Naturalization Service and physicians could still enter the country without holding the minimal criteria of adequacy as defined by the American Medical Profession. By 1960 the concerns of the Nation regarding exchange visitor pro- grams turned from national security to U.S. manpower shortages and the "Brain Drain" from foreign countries. The guidelines for admitting foreign medical graduates were often changing and were very flexible so that waivers to the law were con- sidered more the rule than the exception. 1 9(5 AMENI)MEXT To TIlE IMMIGRATION ACT OF 1 9i2 Before 1965, immigrating physicians were included in the U.S. quota for total immigration from their home country. The exchange visitor program was not subject to national quotas and was thus used as a vehicle for many foreign medical graduates to come into the United States. The 1965 act abolished the system of quotas based upon national origin-in a transitional process which would last 21/2 years. By 1968. the quotas were distributed on a first-come, first- served basis with special preference and nonpre ference categories. Foreign physicians fell under two of the preference categories: Members of professions or persons with exceptional abilities in sci- ence and art; and persons with skills which are in short supply in the JJi~ited States. Under this new system, the allocation of immigrants from Asian countries was enlarged from what it had been under national quotas. The mix of immigrants was changed both nationally and for foreign medical graduates. In the tables, if you look at the shift in percentages of physicians coming from different, areas of the world, you will see this shift.. In 1965, the Labor Department determined that there was a physician shortage in the United States. thus easing entry of foreign medical graduates into t.his country. This determination allowed physicians to apply to the Immigration and Naturalization Service for a visa without first applying for Labor Department clearance. The. change in the Immigration Law in 1965 had allowed those foreign medical graduates entering the United States for training to obtain an immigrant visa rather than an exchange. visitor visa, thus leaving them a. broader spectrum of options when their training is completed. 38-68 6) - 64 - 28 (1 `. 1) PAGENO="0372" 362 For foreign medical graduates the distinction between immigrant status and exchange visitor status has been so blurred by waivers and exceptions that it is very easy for the foreign medical graduate to switch from one category to the other if forced to enter the United States as an exchange visitor. The programs to recruit graduates of foreign medical schools for internship and residency positions began after the Smith-Mundt Act in 1948 and the creation of the exchange visitor (J visa) immigration cat egorv. By 1950, 722 graduates of foreign medical schools filled F) j)eIeent of th e available internships :111(1 1.250 filed 9 l)erceflt of the available residencies. By 1952, the number of both interns and resi- dents who were graduates of foreign medical sehools~ doubled; and, as a percentage of the available positions, their numbers rose to about 20-25 percent of the total, where it was to remain stable until 1965. While the percentage of internship and residency positions filled by foreign medical graduates remained relatively stable, the numbers increased steadily, rising from 1,116 interns and 2.233 residents in 1951-52 to 2.821 interns and 8.153 residents in 1964-65. The great majority of these residents entered as exchange visitors (J visas) rather than as immigrants. Between 1962 and 1965, 17,285 foreign medical graduates entered as visitors and 8,151 entered as immigrants. Also in 1965. the same veal' the Department of Labor determined that there was a j)lIvsicialI shortage and eased the entry of foreign medical graduates into the United States. medicare and medicaid were formulated. Medicare and medicaid increased the demand for services and also guaranteed hospitals reimbursement for the costs of interns and residents' services provided to medicare and medicaid be i w fi cia ries. Following these events, the number of residency positions offered rose from 38.750 in 196-1---G5 to 51,658 in 1972-73. Of the 51,658 positions available now, only 45.081 are filled. The number filled in that period by foreign medical graduates rose from 8,153 to 14,471. The increase of 6.300 in 8 veai's was more than double the increase in the preceeding 8 years. Foreign medical graduates represented ~ ~ of all residents in 1972-73. In 1967. for the first t.ime, the uiuiiiber of foreign medical graduates entering the United States ex- ceeded the number of graduates of U.S. medical schools. It was not until 1971. however, that the number entering as immigrants exceeded tl ie number entering as exchange visitors. Several forces were at work: hospitals increasing the number of residency positions because payment for their services was assured; the Department of Labor declaring a shortage because of the unfilled position and increasing numbers of foreign medical graduates coming into those positions because the positions are available a.nd they were permitted to come either as immigrants or under special J visas. Another important development is the shift. in the countries of origin of foreign medical graduates entering the United States. Be- tween 1965 and 1971. among the ph~'sicians and surgeons admitted to the United States as immigrants the percentage entering from Asian countries increased from 10 peicent to 66 percent. The students were largely from India. Thailand. Korea, and the Philippeans. PAGENO="0373" l)uring this period the per~'entages from South American countries declined. The numbers froni the Enited Kingdom. most European countries and ( `anada renlai ned nj proxiliiately the same. Most of the foreign medical graduates in residency training they seem to be (listrilifited flUiCil as the American medical school gradii- ates' residencies ale distrilnited. Moie jrnportant. when it comes to practice, where do they go Well, they largely practice where the graduates of American medical schools practice. They largely prac- tice in the States with the highest l)Iiysicia! to-POPI1 ti0n ratjo. For instance, the 10 States with the largest number of foreign medi- cal graduates in practice have 1 3~M phivsiciaiis Per 1( )0,000 popul a- tion in office-based practice while the 10 States with the lowest num- ber of foreign medical graduates have only 86.1 per 100,000 popula- tion. The national average was 12~ in 1970, the year this data was gathered. -~ For the United States as a whole. 14.9 j)ercent of practicing physi- cians were foreign medical graduates in 196~. In nonmetropolitan areas the percentage was ft6 and in metropolitan areas it. was 16.1 percent. In other words, the foreign medical graduates don't contrib- ute to a solution of the maldistrihution problem. An examination of specialty choices by foreign medical graduates is also of interest. In some specialties, such as physical medicine, anesthesiology, and pathology, the percentage of foreign medical graduates exceeds the average, for U.S. graduates. The primary care specialties have about one-third of the residency positions filled by foreign medical graduates. This percentage is similar to the number occupied by U.S. graduates. There are. two other problenis : 1) the unl iceflse(i foreign medical graduates. now estimated to l)C 10.000, practicing in the T.Tnited States in a variety of settings: and (~) the quality of medical care provided by the interns and residents from foreign medical schools which have educational standards in both the basic sciences and clinical fields that do not meet U.S. minimunis. This is a serious problem but no one yet. knows how serious. Finally, there is the growing number of U.S. citizens who have not gained admission to medical school in the United States, and have entered foreign medical schools. The numbers have increased from 1.731) in l954-5~ to 3.308 in 1969-70, and I am sure the figure is higher today. Many of the students meet the admission require- nients for IT.S. medical schools but were not admitted because of insufficient nuiii'bers of places. In man schools these students are receiving a less adequate education than they would obtain at any U.S. medical school. There are others, however, where the quality of medical education is as good or better than in most U.S. schools. One of the. problems is lumping the graduates of the good and the bad schools together. RECOMMENDATIONS My recommendations in this area are as follows. The problems are not easily solved. but. I believe Congress should begin with a multi- pronged program. Some of t lie recom mend at. ions made in previous sections also apply to the foreign medical graduate problem and I wont repeat them here. PAGENO="0374" 364 First. detcinì~in \vlietlici or not a health manpower shortage, spe- fical lv a i~ii~~iciait slioita~e. still exists in the United States. If Vail believe, as I do. that a national shortage does not exist, then iiialc that a hnding iii enacting the Health Manpower Act of 1974. ~c('o11d. (`ol1~lcss should set as a specific goal that the LTnited States will meet its own physician and other health manpower needs from its ow ii i'CSOU i('es by 1 Tlii 1(1. sl1h)l~)l't the developimieiit of programs in U.S. medical ~.`}iools to loll!! it I'.~. stiideiits who are studying medicine abroad to tiaiister Ilit() I .S. Schools in the third or fourth year of medical s(hiOOl. Illey iliaV be. in fact, graduates of a foreign schools but they shiotiki enter a LS. school in their third or fourth year. This has iiieii an all too brief introcluctioii to a very complex sub- ject. I will sul)niit for the record my spechc comments on T-1.R. 14721 tiitrod~ic'ecl by the (listlIh1'uishe(l chairman of this subcommittee, Mr. i~ogeI's. and II.R. 143~T introduced by the distinguished Congress- ii a ii Itoin hansas. 1I)r. by. I appreciate the opportunity to discuss these critical manpower issues and 1 will be pleased to allS\vcl' questions. I regret. with the adininistratioti only introducing their bill yes- ti i'dav at noon. there las not been time to conduct a serious evalua- tion of their proposals. but 1 hope to submit an analysis of that for lie ucco id I c to ic vol ci ose tiie icco i'd on these hearings. .\Ir. bi ou~s. Thank von. We would like to have comments for the iccotol Ofl tile aduiiiiii4ration proposal. A summary of test iniouiv and recommendations, the comments on II . b. I 4T2 I, a suninia iv of the foreign medical graduate situation, i ad the analysis of the administration bill follow :] STM MARY OF TESTIMONY AND RECOMMENDATIONS There is no longer a national physician shortage. ~. There are serious pI-ollenis of specialty and geographic maldistribution which limit the access to and quality of primary medical care available to many. and impose a severe burden of overwork on physicians practicing in many uiiderserved areas. 3. The great influx of foreign medical graduates has done little to correct the specialty an(l geographic maldistribution of l)hysiciaflS or the shortage of primary o'are PhYsicians. RECOM MENI)ATIONS 1. (`on gress should find an(l declare that there is no longer a national physi- cian shortage and that tli~ availability of unfilled residency positions does not constitute evidence of unmet need. ~ Congress should set as a specific goal that the Fnited States will meet its own physician and other health manpower needs from its own resources by 1975. It will not depend n the graduates of foreign medical schools to achieve this objective. ~. Special incentives should he given to medical schools and teaching hos- totals. including AHEC'S. to provide the country with adequate numbers of primary care physicians, nurse practitiners. nurse midwives, physician assistants. and tiler intermediate health practitioners who can hell) meet the nation's need for primary medical care. This should be (lone through both undergraduate and graduate programs. 4. Congress should recominenol to tile American Medical Association, the specialty societies and specialty hoards, and the liaison and coordinating com- mittees concerned with graduate medical education, the immediate elimination of the currently unfilled residency positions. except those positions in the PAGENO="0375" 36.~ primary care field. Congress should also suggest an immediate reduction in the excess number. in relation to national need, of the surgical residency positions. The national goal, to be achieved by 197~, should be a number of residency positions equal to the total enrollment in United States medical schools with the first-year residencies not exceeding the number of U.S. graduates annually by more than 1O~i~. It should be the intent of the expanded residency program to meet the national needs in primary care specialties, particularly in under- served areas. 5 Congress should give special incentives to medical and other health pro- fessions schools to admit students from rural areas, from socioeconomically disadvantaged groups, and women. 6. Congress should strengthen and expand the National Health Service Corps, providing greater incentives for students to enter while undergraduate students~ 7. An adequate system should be developed to evaluate the effectiveness of the medical and other health professions schools in meeting the needs for phymcians and other health professionals of the right kind, in the right place, at the right time. COMMENTS ON TIlE HEALTH MANPOWER TRAINING ACT OF 1974-HR. 14721 (By Philip R. Lee, M.D.) I am pleased to be able to offer my comments on the "Health Manpower Act of 1974" introduced by Congressman Rogers. Since the enactment of the Comprehensive Health Manpower Training Act of 1971 there has been a re-examination of issues relating health professions education to the nation's health manpower needs. The "Health Manpower Act of 1974" addresses the major issues in health manpower training which have arisen from this re-examination: the need for an increased number of primary care providers, geographic and specialty maldistribution, and foreign medical graduates. I strongly support the general approach of the bill, and most of the provisions of the bill in detail. There are. however, additions and suggestions for strengthening several provisions which I feel are appropriate and necessary in order to respond to the nation~s health manpower needs. Although the bill focuses on the need for schools of medicine and osteopathy to respond to local manpower needs, it should 1* stressed that this requirement applies to all health professions. The interrelationship of medicine and nursing in the delivery of health services necessitates some comments on nursing. The contribution of nursing to primary care is to expand the SCO~C of health services as well as to extend medical care. For this reason the training of nurse practitioners, public health nurses. and nurse midwives must be pursued co- operatively in both schools of medicine and nursing. Maximum utilization of nurse practitioners and nurse midwives will be facilitated by joint training and work experiences. The need for more accurate information to provide the basis for the rational develol)ment of policies concerning health manpower is beyond question. The recent study by the Institute of Medicine (in the Costs of Education, of the health Professions is an excellent example of the type of studies which should 1)0 mandate(1 by Congress. It is my l)OsitiOfl that the studies required by the new legislation in the section concerning the National Health Service Corps and under Title VII are essential to the body of knowledge needed to make responsive and appropriate policy decisions. SPECIFIC COMMENTS ON THE `HEALTIT MANPOWER ACT OF 1974" The fohlow-ing comments are arranged to conform with the relevant sections of the legislation. For the sake of clarity. some sections of the Committee's summary of the bill are incorporated verbatim in the comments. TITLE iv GRANTS FOR HEALTh PROFESSION SCHOOL Section 401 The formula for determining the level of capitation payments is appropriate and should he supported l.)y Congress. It resl)on(15 to the recommendation of the Institute of Medicine's study on the Costs of Education in the Health PAGENO="0376" 366 Professions. The study is excellent and it should form the basis for capitation L~rants under this section. ~S'ect ion. 402 Several modifications are suggested for this section both in the number of projects required of the schools and the options available to the schools. As ~vell as maintaining enrollment at existing levels an(l maintaining existing levels of non-Federal funds expended, schools of medicine and osteopathy should be required to do at least two of the following 1) Increase enrollment by ten percent if their class size is 100 or less or by five percent or ten. whichever is greater, if their clas,s size is over 100. `l'hrough either the :i(lfluission of additional first year students or admission to the third and fourth year classes of students transferring from two-year medical schools or United States citizens transferring from schools located outside of the United States. (2) Increasc their enrollment of physician extenders (physicians' associates, nurse practitioners) by twenty-five percent. (3) Submit evidence demonstrating the schools commitment to equal educa- tiorial opportunity, particularly enrolling adequate numbers of socio~conomicaJ- ly disadvantaged students. as well as women and students from rural areas. (4) Accept at the level of five percent of first year enrollment. students wh~ would agree in advance to practice in designated under-served areas for a mini- mum of two years. (,5) Apply for and have recommended for approval a special project grant to: (a) Identify. cnn ill and graduate students with rural backgrounds, and from minority or low income groups. (l~ Develop or substantially expand programs to train undergraduate students and physician extenders in niedically ünderserved areas geo- graphically remote from the main teaching site. (c) I)evelop the proper specialty balance in residency programs with a minimum of sixty lercent of the residencies in primary care (family prac- tice. general internal niedicine. pediatrics, obstetrics and gynecology) through such mechanisms as: Establishing new or expanding existing divisions or departments of family medicine to include both undergraduate and residency training programs. Establishing new or expanding existing residency training programs in the primary care specialties which emphasize ambulatory care in medically underserved areas geographically remote from the main teaching site. dl Establish cooperative interdisciplinary training among schools of medicine, dentistry. osteopathy. optometry, podiatry, pharmacy, nursing, public health and allied health, including emphasizing training in the team approach to the jrovisi n of health services. Ic) Establish and operate programs to train for new roles, types or levels of health personnel including Physicians' assistants, physicians' as- Soci:ites. nursc practitioners and other categories of physician exteiiders. The secretary if the Department of Health. Education and Welfare should be required to report to Congress the extent to which schools are meeting the requirements for receiving their capitation grants. yeetion 406 A subparagraph (a) (~ I should be added to Section 770 which reads "To properly evaluate the effectiveness of these alternative approaches in alleviating shortages and improving the quality, utilization, and efficiency of resources in the health services delivery system iii the designated area." TITlE V ASSISTANCE FOR SPECIALIZED TRAncING .s'ection .501 Grants for the development of training programs in family medicine and the provision of financial assistance to students and 1)hysicians participating in such programs should be authorized for group practice clinics as well as hospitals. PAGENO="0377" 367 Section 503 The following wording should be added to Section 783(a) (z) concerning the education of United States students returning from foreign medical schools: and specialized training designed to prepare such students for success- ful completion of The Curriculum in .lmerican Medical Schools and licensure examinations." TITLE VI PUBLIC AND ALLIED HEALTH PERSONNEL Subpart 2-Section 792 Section 792(a) (5) should he expanded to read as follows: "New types of roles and uses for allied health personnel including projectR to develop and implement innovative programs to expose allied health trainees to a working environment with other categories of health professionals, in- cluding programs for training in the interdisciplinary team approach to health care delivery." TITLE vii MISCELLANEOUS Under this Title, technical amendment.s should appear under Section 706. Section 704 should require the Department of Health, Education and Welfare to request an outside study to be conducted which would develop projections of the demand for health manpower created by the passage of National Health Insurance. The findings of the study should he reported to the Congress within eighteen months of enactment of the new Act. Section 705 would require the Department of Health. Education and Welfare to examine distribution of physicians by specialty and subspecialty in the United States. Analysis should include consideration of range of professional activities for each specialty area. Many fully trained specialists and sub- specialists are possibly spending much of their time managing primary care level medical problems. The current National Aml)ulatory Medical Care Survey explores the variety and types of prol)lems for which patients seek medical care. Answers to these questions, the description of primary care medical problems and the physicians' activities in resolving these prol)lems will provide valuable data in assessing the ability of a group of physicians to meet the health care needs of a geographic iopulation. Section 706 would consist of technical amendments. ADDITIONAL COMMENTS FOREIGN MEDICAL GRADUATES In the health manpower training act passed this year. the Congress should state the need for the country to be meeting its health manpower needs with its own resources by 1978. The flow of foreign medical graduates into the United States has gone far beyond the intent of Congressional legislation which provided the opportunity for citizens of foreign nations to receive specialized training in the United States in order to provide more adequate services to their fellow citizens upon their return home. As Senator Taft indicated in his submission to the April 25. 1974 Congressional Record, the Administration policy of basing the nation's health manpower needs on the current flow of foreign medical graduates is unwise and should not be supported by Congress. There are several mandates which would have a significant impact on the entry of foreign medical graduates into the United States, and they should appear in the legislation: (1) Congress should declare that there is IIO longer a shortage of physicians in the United States. The fact that not all approved residency ~rogramns offered each year are filled is not an indication of an undersupply of physicians. (2) The Department of Labor should he urged to re-examine the health manpower situation to declare that~ there is no longer a physician shortage in order that the T)epartment of State will no longer be able to authorize visas of foreign medical graduates without Department of Lals r It':t ra mae. (3) The 1965 Amendment to the Immigration Act of 1~)52 should l~ amended to assure that foreign medical gra(lUates whose primary activity is office or hospital based patient care no longer he given preferenti;il immigration status under the two preference categories: Members of professions or persons with exceptional abilities in science and art Persons with skills w-hich are in short supply in the United States PAGENO="0378" 368 The type of proviso m rec~ nlmen(led here w mid c ~ntinue to give entry prefer- ence to physicians engaged in needed biomedical research hut it would limit the ability of foreign medical graduates to enter the United States in numbers which are in excess of the nations needs or demands. If the Congress is concerned about taking this direct action, it is reconi- mended that the Congress request a study to be conducted by such a group as the Institute f Medicine, the National Commission for Manpower Policy (created by the Comprehensive Employment, and Training Act of 1973) or the Coniniission on tIme Future of Physicians ( Macy Foundation). The findings of the study should be reported to the Congress within eighteen months after enactment of the legislation, with specific recommendations for amendment of the Immigration Act of 1952 and Department of Labor policy. SUMMARY OF THE FOREIGN MEDICAL GRADUATE SITUA'rIoN IN THE UNITED STATES The attached charts provide a fairly complete numerical summary of the Foreign Medical Graduate situation in the United States. They are divided into five sections which address the following questions (1) What have the trends been in the number of students admitted to medical school, the number of intern and residency positions offered and the number of these positions which were filled by Foreign Medical Graduates? (Tables A-i to A-3.) (2) Where do FMG's comime from? (Tables B-i and B-2.) (3) Where in the ~1flite(1 states do FMG's go for m~esidences or for practice? (Tables C-i to C-4.) (4) What is the distribution of FMG's among the major professional activi- ties of physicians? Table 1)-i. (5) What is the status of American students studying in foreign medical schools? (Tables E-i to E-3.) PAGENO="0379" > ~ c~ 3 3~ 31 - - II 10 O~C) H H 01 01 01 01~ cC,: cC, 0 PAGENO="0380" Table A-2 STATUS or INTERNSIIII' AND RESIDI:NCY PROGRAMS TN THE UNITED STATES - 45000 45,000 ________________________________ STATUS OF INT100SHtP I AND OUSIUL NCY PUOUTAMS IN SAL U.S.A. - 40005 - F:. G4:~: .__-_---,-----------,~- -~--- *~_~__~__ - - 4D,000 05 0 fl 1 1 - = 35000 50000 UI Fl ~ ~_`~_ - - L j~ 20000 -~---~-- 29,000 INS ES N 500 IFS ~ SOS ~_-_------~ :: ____ __________ Sourcc: Gr~di~Ic McJIc~I Educ~tIon,' Journal of S/lO ~ ~n el-Icon 4/ed/cal ,losOcIaSIOn, 218 (1971), 1245 PAGENO="0381" 371 7.8 10.2 12.9 18.9 6.2 10.0 10.0 ;. 7 4.3 5.5 .5 ii. .~ 17.3 7.1 7.3 20.9 o. 7 9.9 6 100.0 1C~. 2 2,012.0 0. 75:.. 0 FABLE A-3.-COMPARISON OF FOREIGN PHYSICIANS ADMITTED TO THE UNITED STATES WITH NUMBER OF U.S MEDICAL GRADUATES, 1962-71 Foreign physicians Exchange u.s. Year ending June 30 Immigrants visitors Total graduates 1962 1.797 3,970 5,767 7,168 1963 2,093 4,637 6,730 7,264 1964 2,249 4,518 6,767 7,336 1965 2,012 4,160 6,172 7,409 1966 2,552 4,370 6,922 7,574 19671 3.326 5.204 8,530 7,743 1968 3,128 5,701 8.829 7,973 1969 2.756 4,460 7,216 8,059 1970 3,158 5,008 8.166 8,367 1971 5,756 4,784 10,540 8.974 Total . . 28,827 46,812 75,639 77,867 First year in which the number of FMG's entering the United Stotes exceeded the number of U.S.MG's. Source: Figures on immigrants and exchange visitors are from the U.S. Deoartmest of Justice, Immigration and NaturaIl~ Zation Service. Figures of U.S. graduates from `Medical Education in the Un'ted States,'' Journal of the American Medical Association, 218 (1971), 1221. TABLE B-i-PHYSICIANS AND SURGEONS ADMITTED TO THE UNITED STATES AS IMMIGRANTS BY COUNTRY OR REGION OF LAST PERMANENT RESIDENCE. FISCAL YEARS 1953-71 United Other South Fiscal year Kingdom Europe Canada Mexico Cuba America Asia Other Total 1953 1954 1955.. 1956 1957 1958 1959 1960 1961 1962 i963 1964... 1965 1966 1967 1968 1969 1970 1971 66 299 130 40 58 66 373 116 60 90 62 417 128 63 92 76 513 151 93 112 142 729 256 95 199 228 189 592 218 57 86 285 147 579 210 44 77 227 125 425 245 96 94 256 140 ~13 287 64 94 208 119 383 380 70 120 298 154 421 467 97 156 327 155 053 440 77 229 454 147 421 380 110 701 3~8 187 483 393 119 150 350 206 596 449 86 162 358 185 481 314 55 215 345 140 426 236 32 53 172 192 436 240 29 52 161 268 461 474 28 95 269 155 316 207 244 29 205 260 004 205 583 1, 175 1, 277 1,448 1. 744 3. 836 252 845 335 1,040 284 1.046 443 1.388 186 1.990 191 1.934 139 1 630 11° 1,524 208 1.583 263 1 211 7 :00 223 2~s9 200 7 n.: 25b 3. 123 248 2. ~ 304 3. 15 325 ~, 758 Source. U.S. Deportment of Justice, Immigration and Naturalization Service. TABLE 0-2--PERCENT DISTRIBUTiON OF PHYSICIANS AND SURGEONS ADMITTRD TO THE UNITED STTTES AS IMMGRANTS BY COUNTRY OR REGION OF LAST PERMANENT RESIDENCE, 1957, 1965, AND 1971 F:~caI yvor-- Country or region ` 1957 1305 Asia Canada Cuba Mexico South America United Kingdom OtherEuropv Other Total Nimber 36. iS 100' 5 1,990.0 Source: Table 01. PAGENO="0382" TABLE C-1.--NIJMBER OF RESIDENC'ES, Be C[NS(IS REGION AND STATE Northeast: New England: Connecticut Maine Msssachusetts New Hampshire Rhode Island -- Vermont Middle Atlantic: New Jersey New York Pennsylvania North Central: East North Central: Illinois Indiana Michigan Ohio Wisconsin Norrrber of residents on duty Number of residencies .-. ..-.---.~------ Graduates United Percentage Tot~I Positions States and Foreign foreign residence vacant Canada graduates graduates positions Sept. 1, Percentage Sept. 1, Sept. I, iii filled offered t97? tilled 1972 1972 positions 19/4-75 32 93 973 879 94 90 479 400 46 1, 033 3 12 62 48 14 77 44 4 8 68 87 182 2054 1944 ito 95 1,320 624 32 2,208 4 15 103 100 3 97 87 13 13 134 13 22 198 178 20 90 82 96 54 267 2 14 113 109 4 96 101 8 7 171 245 92 2,113 1,145 36 3,827 74 244 2,790 2,529 261 91 1,187 1,342 21 54 621 476 145 77 401 75 73 198 2,304 1,945 359 84 1,091 854 82 257 2,724 2,352 372 86 1,327 1,025 27 78 781 683 98 87 516 167 7,985 1,235 87 4,522 3,463 Census division, region, and Stale Tn; 1 a I positions Number of oflened Number ot approved Sept. 1, hospitals programs 1972 Total positions tilled Sept. 1, 1972 Total 141 338 3,503 3,258 Total 363 1,192 13,057 11,882 9 54 130 1,034 922 112 89 201 721 202 697 8,657 8,065 592 93 3, 864 4, 201 107 365 3,366 2,895 471 86 1,982 913 1, 175 91 6, 047 5,835 49 14, 279 78 1, 251 52 9, 308 32 3, 720 53 3, 150 16 680 44 2, 435 44 2, 987 24 885 Total 2/7 631 9, 220 43 10, 137 PAGENO="0383" 373 - ~ - ~ J~H! ~ ~o~*~aO~j ~ PAGENO="0384" TAGLI. C I. NUMBEII lit RESUlt NCIIS, laY CLNSUSRLGION ANt) STA1~ Cor roses N umber of resid~ots on duty Numnljr'r of resmrteocirs -- Grad nit lotal Total U ruted N' rrrrritage total positions positions Positrons Slates arid Foreign foreign residency Number of offered filled v.ic,irit Caniata giaduates graduotes positrons Number of approveit Sept. 1 .Sopf. 1, Sept. I, Percentage Sept. t. Sept. I, ri tttenl otteiert Cenrsos itivisien, region, arid State hospirals progranis 1972 972 197? tilted 191? 19/? positions 1974 lb Went: Moo ntai Arinonra 18 29 278 224 54 81 149 75 33 371 Cotoiailo . 20 64 723 685 38 95 651 34 5 749 Nevaila I I 4 1 3 25 1 100 4 NewMexico . 9 1/ 183 t75 8 96 162 13 1 2111 Utah . . 12 30 266 253 13 95 237 16 6 308 Total -. 60 141 1.454 1,338 116 92 1,199 139 101,591 Pacitic: Alaska . . . . 1 - - Caliternia 131 450 5,259 4, 704 555 89 4, 365 339 7 5,793 Hawaii 11 21 206 196 10 95 157 39 20 219 Oregon . 9 37 358 312 46 87 290 22 7 393 Washington 18 53 585 527 58 90 478 49 9 611 Total .. 169 561 6,408 5,739 669 90 5, 290 449 8 7,016 Possessions: Territories and possessions: Canal Zone 1 8 36 31 5 85 17 14 45 36 Puerto Rico 15 42 494 365 129 74 128 237 65 525 Total 16 50 530 396 134 75 145 251 63 561 Grand total 1,562 4,607 51, 115 44.858 6,257 88 30, 418 14, 440 ~ ~ ~`55,90~ PAGENO="0385" -4 CO CO -4 C -4 a -4 -4 CD C" -< --4 ~0> -4 0 0 0 0 0 o -4 0 0 -4 0 >>ccCOCO000zzzzzz~a~at0100000>>>> (02 ` 9'5 ~ ~ ~ g~oo-'5- ~ ~ -,,aa~o - ~ ~ ~ ~-° 3° ~=-~ 9.ro'<~ - o-~ - F' ``:`~":: ``:::::: a, 5 . , 3, p ;, .,, ~, `::`.~~~ p'° , ``I. , , 0 2 2' B PAGENO="0386" 376 TABLE C-3.-GRADUATES OF FOREIGN MEDICAL SCHOOLS AS PERCENTAGE OF ALL PHYSICIANS IN SELECTED SMSA's 1, Dec. 31, 1967 Location Total physicians Graduates ot foreign medical schools Percentage of total who are graduates of FMS Totol United Staten 306, 970 45, 816 14.9 Nonmetropolitan Metropolitan Akron, Ohio 47,859 259,111 849 4,100 41,716 191 8.6 16.1 22.5 Albany, N.Y Atlantic City, N.J Baltimore. Md Binghamton, N.Y Bridgeport, Conn Buffalo, N.Y Canton,Ohio 1,425 265 4,817 406 1,370 2,397 386 365 75 1,317 116 347 548 83 25.6 28.3 27.3 28.6 25.3 22.9 21.5 Chicago, Ill Cleveland, Ohio Danville, Ill 11,987 4,121 103 3,266 1,185 23 27.2 28.8 22.3 Detroit Flint, Mich 5,850 487 1,366 108 23.4 22.2 Galenburg,lll Jersey City, NJ 76 842 16 324 21.1 38.5 Kankakee, ill 113 51 45. Laredo, len 49 20 40.8 Lewiston, Maine 113 24 21. Long Branch, N.J 556 118 21. Lorain, Ohio Miami, Fla Middietown, Coon 245 2,834 165 94 715 52 38.4 25. 31.5 Newark,NJ Newbargh,N.J 3,470 325 857 97 27. 29.8 New Brunswick, N.J 773 271 35. Now York City Paterson, NJ Pittsfield, Mans 31,458 1,875 239 10,999 464 51 35.0 24. 21. Providence, R.l Steobenville, Ohio 1,408 120 389 26 27.6 21. Toledo, Ohio 912 234 25.7 Trenton, NJ 618 154 24.9 Utica, N.Y 438 105 24.0 Wilmington, Del 694 157 22.6 Yonngstown, Otis 653 221 33.8 i Inclades son-Federal and Federal physicians. Snsrce: C. N. Theodore, J. N. Haag, "Selected Characteristics of the Physician Population 1963 and 1967," American Medical Association, Chicago, 1968, Table 32. PAGENO="0387" 377 TABLE C-4.--LICENSING OF FOREIGN MEDICAL GRADUATES BY STATE, 1970 Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Diotrict of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachasefts Michigan Minnesota Mississippi Missouri Montana Nebrauka Nevada New Hampshire New Jeraey New Mexico New York Norht Carolina North Dakofa Ohio Oklahoma Oregon Pennsylvania Rhode Island Sooth Carolina Sooth Dakota Tenneusee Texas Utah Vermont Virginia Wanhingfon West Virginia Wisconsin Wyoming Total 4.6 0 0 1 1.2 0 0 0 2 16.6 35.8 52 34.8 26 47.2 4.3 0 0 0 0 29.5 205 58.1 94 8.2 4.2 9 11.1 2 2.0 40.0 34 41.2 14 10.2 37.5 29 41.4 16 89.0 0 0 0 150 76.5 24.9 681 39.5 138 40.2 1 32 6.3 16 8.6 0 12 0 4 14.8 0 0 0 0 0 46.1 357 60.8 107 30.8 33.6 206 65.0 100 32.7 0 47 0 13 10.0 5.0 44 11.4 18 15.2 6.6 67 29.9 34 15.9 7.9 45 13.3 7 3.3 40.0 218 39.9 110 88.7 34.2 227 37.0 140 37.7 43.4 193 40.4 47 14.5 13.0 85 15.3 72 16.8 21.6 48 43.8 21 7.2 L9 11 9.1 5 5.1 4.7 224 12.1 176 43.7 0 19 0 17 70.8 0 0 0 4 3.7 33.3 0 0 0 0 29.8 36 30.6 26 59.0 40.2 693 40.7 368 77.6 34.1 39 38.5 16 48.4 59.7 712 60.5 204 16.6 18.1 55 55.7 10 6.8 13.6 18 16.7 15 75.0 23.8 51 92.2 11 3.5 17.3 0 0 4 4.5 0 0 0 3 7.7 4.7 809 4.8 550 54.9 23.8 21 23.8 18 50.0 0 0 0 1 5.5 4.2 11 9.1 5 27.7 0 0 0 3 1.6 8.7 169 18.3 80 17.5 4.5 0 0 5 10.4 41.8 166 47.6 96 53.0 30.5 214 54.7 64 20.1 27.6 139 28.1 97 41.6 50.4 114 57.9 38 56.7 7.9 32 12.5 23 22.8 0 0 0 0 0 12, 087 23.5 6, 124 37.9 2,971 27. 1 Note.-This table excludes Guam, Poerto Rico, and Virgin Islands. The totals are thus nut exactly comparable to Tables C7 and Cli. Source: "Medical Licensure Statistics, 1970," Journal ol the American Medical Association, 216 (1971), 1788, 1797, 1808-15, 1842-43. Total physicians examined State of license for license Percent failed FMG's examined for license Percent failed Additions to the profession who were FMG's FMG's ax percent of all additions fo medical profession 28 67 92 441 24 40 32 2,345 314 5~ 483 411 306 139 319 264 220 357 205 100 97 101 675 58 19 37 702 44 771 216 22 269 110 847 21 24 179 572 22 194 409 145 131 65 33-698 0 - 74 - 25 (PL 1) PAGENO="0388" 3~S TABLE 0-1--FOREIGN MEDICAL GRADUATES IN COMPARISON WITH ALL PHYSICIANS IN THE UNITED STATES BY MAJOR PROFESSIONAL ACTIVITY, DEC. 31, 1970 . Foreign medical Major professional activities graduates 1 All physicians Foreign medical graduates as percent of all physicians Patientcare 48,191 278,535 17.3 Office-based practice 20,980 192,439 Hosoital-based practice 27, 211 86, 096 10.9 31.6 Interns 3,050 11,449 Residents 13,598 39,779 Full-time staff 10, 563 34, 868 26.6 34.2 30.3 Medical teaching 1,006 5,588 Administration 1,194 12, 158 Research 3,285 11,929 Other 466 2,635 Inactive, unknown 3,075 23,183 18.0 9.8 27.5 17.7 13.3 Total physicians 57,217 334,028 17.1 1 Excludes graduates of Canadian schools; includes American graduates of foreign schools. Source: J. N. Haug, B.C. Martin, Foreign Medical Graduates in the United Staten, 1970," p. 18. TABLE E-1.--INTERNATIONAL EXCHANGE IN MEDICAL EDUCATION, 1954-55 THROUGH 1969-70 Number of U.S. Students Studying Year Abroad Number of Foreign Students in U.S. Schools 1954 to 1955 1,730 1955 to 1956 2,056 195 to 1957 NA 1957to 1958 NA 1958to 1959 NA 1959 to 1960 2,896 1960 to 1961 2,832 1961 to 1962 2,097 1962tu 1963 1,929 1963to 1964 1,872 1964to 1965 2,215 1965to1966 2,377 1966 to 1967 2,325 1967tu 1968 2,626 1968 to 1969 3,022 1969to 1970 3,368 619 760 1,087 985 1,154 1,048 1,196 1,033 1,208 1,376 1,223 667 1,136 999 951 1,134 Source: Institute of International Educatiun. PAGENO="0389" 379 TABLE E-2.-ESTIMATED NUMBER OF AMERICANS ENROLLEO IN 16 MEDICAL SCHOOLS IN MEXICO AND EUROPE, OCTOBER 1969 Students in admitting class Americans is alt medical Graduates 1969 Americann Americans Country Schooln Total only schosls Total only Menicoa Spain1 Italy Switzerland 1 4 3 S 1,030 270 1,695 170 3,317 175 3823 29 572 486 821 210 158 1,016 946 775 11 14 86 30 Belgium Total 3 1,502 99 254 445 19 16 9,367 743 2,343 3,130 162 Does not include at least 500 Puerto Ricano attending Menican and especially Spanish schools. 3 Because of manser in which Swins schools keep records, this is not the entering class, hut class completing the anatomy-physiology course sequence (i.e., equivalent to sophomore claoo in U.S. schools). Source: Henry R. Mason, "Foreign Medical Schools as a Reoource for Americans," Jouroul ot the National Association ot College Admissions Counselors, 15(1970), No. 3. TABLE E-3.---NUMBER OF STUDENTS TRANSFERRING FROM FOREIGN TO U.S. MEDICAL SCHOOLS, 1960-70 Number of studentn transferring Academic year: 1960-61 30 1961-62 41 1962-63 1963-64 36 1964-65 31 1965-66 24 1966-67 23 1967-68 33 1968-69 40 1969-70 76 1970-71 139 Total 516 STUDENTS TRANSFERRING FROM FOREIGN TO U.S. MEDICAL SCHOOLS BY YEAR OF CLASS Year 1968-69 1969-70 1970-71 2dyear 3d year 4thyear 20 20 0 26 49 1 29 108 2 Total 40 76 139 Source: "Medical Education in the United States," Journal of the American Medical A ssociatiun , 218( 1971), 1219, 1220 PAGENO="0390" 380 Mr. ROGERS. I see we have a vote. I am afraid this is going to be a difficult afternoon. We will recess for 5 minutes and then con- tinue first with the panel on geographic ma.ld.istribution: Dr. Donald l)ewev. Professor of Geography. l)ePaul University; Pierre de Vise. College of Urban Sciences. University of Illinois; Dr. Donald L. Madison, Department of Family Medicine, School of Medicine, Univei~ity of North Carolina; and Dr. E. Leon Cooper, Executive Director, National Medical Association. [Brief recess.] Mr. Roy [presiding]. We have a distinguished panel. I will ask each panelist to identify himself. Who will testify first? STATEMENTS OF A PANEL ON G~EOGRAPHIC NALDISTRIBUTION, CONSISTING OF PIERRE DE VISE, COLLEGE OF URBAN SCIENCES, UNIVERSITY OF ILLINOIS AT CHICAGO CIRCLE; DONALD R. DEWEY, PH. D., PROFESSOR OF GEOGRAPHY, DePAUL UNIVER- SITY, CHICAGO, ILL.; DONALD L. MADISON, M.D., ASSOCIATE PRO- FESSOR OF MEDICAL CARE ORGANIZATION, SCIHOOL OF MEDICINE AND ASSOCIATE PROFESSOR OF HEALTH ADMINISTRATION, SCHOOL OF PUBLIC HEALTH, UNIVERSITY OP NORTH CAROLINA AT CHAPEL HILL; AND E. LEON COOPER, M.D., ACTING EXECUTIVE DIRECTOR, NATIONAL MEDICAL ASSOCIATION, WASHINGTON, D.C. Mr. DE VISE. Mr. Chairman, my name is Pierre de Vise. There is a basic assumption behind almost every criticism of the Nation's health delivery system: There aren't enough doctors to go around. But t.he problem is actually more. complicated, because. the doctors we have don't. locate where they are. needed most, in doctor- poor States, which t.hey are currently avoiding in droves. An analysis of the Nation's physician distribution reveals that despite vastly increase.d health expenditures over the last 6 or 7 years, doctor-poor areas are getting poorer and doctor-rich areas richer. The trend seems to be that of doctors `abandoning Midwest- `~rn industria.l States. rural areas, and urba.n gheit.tos for practices in middle- and upper-income a.reas in coastal cities and surround- in~ bedroom suburbs. Multibillion-doflar Federal Medicare, Medi- caid and OEO programs have failed to stem the doctor exodus and have actually worsened the situation by creating a disproportionate demand for services in coastal cities. The cosmopolitan and good climate centers of Boston, New York City, and San Francisco and the States of New York, Massachusetts, and California have half again as many doctors per population as Chicago and Illinois, my home city and State, and two to three times as many doctors per population as other doctor-poor citie.s and States. If physicia.ns depended entirely on private patients for their liveli- hood, those in doctor-rich cities could double their income by moving to doctor-poor cities. In fact, however, as was pointed out before, physicians can make as much or more in Boston and Los Angeles as in Chicago and Detroit. because they can e.~p1oit Federal programs to make up for a saturated private-patient market. PAGENO="0391" 381 The Federal Govermnent now pays a fourth of all physician bills, compared to 6 percent of all hills before the advent of medicaid and medicare in 1966, and these Federal dollars flow much more freely to doctor-rich States than to doctor-poor States. As a result, the three States with the highest physician-population ratios-New York, Massachusetts. and California-with less thaii a fifth of t.he Nation's population, capture half of all medicaid funds and over a fourth of all medicare dollars and medical school ~rarits. Fnt.il the Federal Government revei~e.s this indirect, and unintended subsidy of doctors migrating t.o good-climate and cosmopolitan areas, attempts by States like Illinois-~in fact. most of the States repre- sented by the members of this committee-to ease local shortages are doomed to failure. More Illinois-trained doctors go to California than stay in Illinois, not only because of the attractions of climate and glamour but also because California gets three times more Federal aid per graduate than Illinois, two and a half times as much medicaid money, and a. third more medicare money. As a re- sult, California imported 509 graduates last. veai while Illinois exported 310, making these two States far and away the major importing and exporting States respeutive.Tv. California educates half as many doctors per capita. as Illinois but. receives twice as many hospital~based interns, residents, and licensed practitioners. Illinois, on the other hand, educates two to three times as many American doctors as it receives. I am submitting t.o the subcommittee in my testimony three reports on physicians distribution. The first is an article in t.he February 1973 issue of the Journal of Medical Education that outlines t.he effects of new Federal health spending programs on State-by-State. distribution of physicians. The second is an article in the fall 1971 issue of Health Planning in Ilflnois that traces the growing maidistribut.ion of physicians among Illinois counties since 1950. The last is a Chicago Regional Hospital Study Working Paper prepared in April 1974 that discusses the. effect of undergraduate and graduate education and of migration on the supply of physicians in California. Illinois, New York, and Ohio. Between 1960 and 1972. physician population ratios climbed 30 percent in New York and 37 percent in California. but only 17 percent and 18 percent respectively in Illinois and Ohio. The two coastal States had close to 40 percent more physicians per population than Illinois and Ohio in 1960. By 1972. they had almost 60 perCe1~t more physicians per population than Illinois and Ohio. In Califor- nia, both metropolitan and non-metropolitan counties enjoyed simi- larly high growth rates, but. in the. three. other States. t.he metro- politan areas registered gains of between 20 and 31 percent. whereas the non-metropolitan areas show-ed losses ranging between 5 and 8 percent. Some States are exerting a much greater effort. than other St.ates in producing physicians, but there is little connection between the effort and the reward in terms of licensees. Looking at the four largest urban States, New- York is a large supplier and recipient: California is a low supplier but. a large recipient.; Illinois is a large supplier but a low recipient; and Ohio is mediocre both as a sup- pler and as a recipient of doctors. In all four States, local medical school graduates supply a minor fraction of the doctors who locate PAGENO="0392" 382 their practice in the State. Local graduates made up in 1972 but 30 to 33 percent of the new practitioners in New York, Ohio, and California, and 6 percent in Illinois. That same year, foreign medical graduates supplied slightly over half of New York's and Ohio's interns, residents, and licentiates, and two-thirds of the interns and three-fourt;hs of the. licentiates in Illinois. They now account for 40 percent of all physicians in New York and are projected to exceed 50 percent before 1980. Without any additional increases in enrollment. beyond those al- ready in the works, the supply of physicians is projected to grow by 92 percent in New York, 87 percent in CalifoTnia, 73 percent in Illinois, 70 percent in Ohio, and 74 percent in the Nation between 1970 and 1990. By 1990. New York will have a projected ratio of 3.80 physicians per 1.000 population, 83 percent above the Nation's projected ratio of 2.24 and 91 percent above the ratio of 1.99 projected for my State of Illinois. It is also projected that the non- metropolitan counties in these four States will continue to lose physicians as they ha.ve in the past. In conclusion. t.he maldistribution of physicians in the four States and the Nation is not likely to be reduced, in my opinion, by further increases in the number of medical school graduates or by any of the efforts made so far to induce physicians to practice where they are needed. Solutions to maldistribution go hand-in-hand with solutions to the equally vexing problems of unregulated medical care organiza- tion and skyrocketing costs-a transformation in health insurapee, mode of delivery, and method of reimbursement that is probably too drastic to be politically feasible before 1980. I would like to add one comment on the distribution of foreign medical graduates. it is true, as Dr. Lee says, that they tend to locate in urban areas, but their distribution patterns are very different within these urban areas. They tend to fill a stopgap, they tend to locate in poverty communities or middle-income suburbs not attractive to U.S. graduates. In the Chicago area, for example, FMG's provide three-fourths of the doctors for medicaid patients. They made up over three-fourths of our new licentiates last year. States like Illinois and cities like Chicago are absolutely dependent on FMG's. [The three reports referred to, follow:] PAGENO="0393" 383 Ph~~iciaii Migration from Iiilatnl to Coa-~tal State~: Antipodal Example- of Illinoi~ and California Pierr(' d' ! Reprinted from the Journal o~ Medical Education Volume 48, No. 2, February 1973 Reprint Series I. 6 Chicago Regional Hospital Study 122 South Michigan Avenue Chicago, Illinois 60603 PAGENO="0394" 3S4 Phv~iciaii Migration from Inland to Coastal States: Antipodal Examples of Illinois and California Pierre d(' I i.S(' Some states and urban areas in this country have two to three times as many physicians per 1.000 population as other states and urban areas. Results of a recent unpublished study by the author resealed that the gap betv~een doctor-rich and doctor-poor states has greatly wid- ened since 1960, with Chicago and Illinois joining the ranks of doctor-poor com- munities and states that are rapidly losing ground to more glamorous centers on the East and West coasts. These huge dif- ferences in physician distribution are most commonly explained by local dif- ferences in population density. affluence, and medical school production of new doctors (1. 2). Indeed, the nations 300 metropolitan areas. the dense. affluent population centers in which most medical schools are located, have a physician population ratio more than twice that of nonmetro- politan areas. In 1970 the ratio of physi- cians to 1,000 population in metropolitan areas was 1.73: for nonmetropolitan areas it was .80: and lor the nation as a whole, it was 1.48. Yet when the physi- cian population ratios of the nation's 20 largest metropolitan areas are compared. This article is based in part on a paper presented at the Congressional Black Caucus Forum on Health Care, Harvard Univer~tt~, April 7. 1972. Mr. de Vi',e is a','~istant director. ll1tnoi~ Re- gional NI edical Program, Chicago. it becomes apparent that disparities even larger than those found among the states exist and that there is practically no as- sociation between physician numbers and population density and affluence. Table I shows that nine of the 10 cities with the highest physician/population ratios are located on the East and West coasts, with the cosmopolitan centers of Boston. New York, and San Francisco leading the way. Nine of the 10 lowest ranking cities are inland, with Chicago's industrial neighbors, Detroit and Mil- waukee. at the bottom of the list. Boston, which ranks first in physician/population ratio, ranks eighth in population size and ninth in average family income, while Detroit, ranking 20th in physician population ratio, ranks fifth in popula- tion size and third in average family in- come. Cleveland and Anaheim, the excep- tions in the list, are parts of larger metro- politan regions. Cleveland provides health care for 11 counties and four metropoli- tan areas (Cleveland-Akron-Canton- Youngstown) whose aggregate ratio is 1.44 physicians per 1,000 population, s~hile Anaheim falls within the shadow of Los Angeles. An examination of the 10 states with the highest physician-population ratios confirms the strong attraction that East and ~Vest coast centers of glamour and good climate exert on physicians (Table 2). PAGENO="0395" 385 TABLE I 20 LARGEST METROPOLITAN AREAS IN THE UNITED STATES RANKED BY NUMBER OF PHYSICIANS PER 1,000 POPULATION* (1970) Average Family Population Income Area Ratio Rank Rank 3.21 8 9 2.79 1 12 2.63 6 6 2.32 11 16 2.14 12 10 2.03 17 8 2.02 2 13 2.02 4 14 1.96 7 1 1.91 14 5 1.71 15 7 1.70 3 4 1.62 20 15 1.59 10 17 1.59 18 2 1.56 16 18 1.52 13 19 1.49 9 20 1.49 19 11 1.39 5 3 * Sources are Distribution of Physicians in tire United States 1970, Chicago: American Medical Association, 1971; and the 1970 U.S. Census of Population. LocationaJ Preferences Traditional explanations of physician location were probably too simple- minded even for the more free enterprise locational forces of the early 1960s. They are certainly inadequate explanations of present-day locational forces, particu- lary those operating among large urban centers. The analytical complexities are of two orders--the partially inconsistent eco- nomic and social goals which motivate physician location and the mixed private- public market for physician services which reduces traditional dependence on a geographic private office practice. We can identify four types of life-style goals capable of motivating physicians to locate in certain states and urban centers (interstate choices) and in certain com- munities within a state or urban center (Intrastate choices): 1. Income-maximizing goals which stress consumption aspirations, or lo- cating a practice to get the most material benefits out of one's medical skills. These goals would favor intrastate locations that are accessible to affluent patients, that minimize distances to the hospitals they use, and that are not overly satu- rated with competing physicians. Inter- state locations are more dependent on the total physician supply of these larger areas and should result in approximately equal physician-population ratios among urban centers of equal per capita income. 2. Family-oriented goals stressing the best environment for bringing up children and satisfying the social daytime needs of the mother. Intrastate locations would favor cOmmunities of single-family hous- ing with good schools and an active com- munity life. Newer affluent dormitory suburbs are targets for this kind of mover. Interstate locations would favor good climate states with year-round outdoor recreation. 3. Social prestige goals stressing a life style and envirOnment consistent with TABLE 2 10 STATES WITH THE HIGHEST NUMBER OF PHYSICIANS PER 1,000 POPULATION (1970) 5tate Ratio Boston New York City San Francisco Baltimore Cleveland Seattle Los Angeles Philadelphia Washington Newark Minneapolis Chicago Atlanta St. Louis Anaheim Dallas Houston Pittsburgh Milwaukee Detroit New York Massachusetts Ca Ii for n i a Con nec tic Ut Vermt Maryland Colorado Rhode Island Florida Penns~ Ivania 2.36 1 .96 1.91 1 .91 1.90 1.81 1.75 1.55 1 .54 1.52 PAGENO="0396" 386 the social status of physicians. Since ph'. sicians are `.~ elI near the top of the social status ladder in the United States. these goals would result in intrastate loca- tions in the traditional affluent. social register communities. with a preference for those that cater to executives and protessional workers who commute down- town as opposed to country-club or fox- hunting t\ pes of suburbs for the idle rich. Interstate locations would favor cosmo- politan centers of intellectual and aca- demic excellence, with a preference for European and Asiatic-oriented centers on the East and West Coasts as opposed to Middle American provincial capitals. 4. Professional interaction goals stress- ing professional and social interaction among people sharing common skills. al ties. and interests. Physicians. for e\Jmple. `.~ould tend to maximize inter- specialty contacts at the professional level and intraspecialtv contact~s at the social Ic'. ci. These goals partly overlap with income maximizing and social prestige goals hut also reflect the special social- ps\chological needs of an elite steeped in arcane skills and `.ocabulary that cannot easily he shared with members of other elite groups. These goals favor intrastate locations accessible to the concentrations o~ specialists offices downtown and in the large university medical centers. I nterstate locations would fa'. or regional centers \vith the largest number of spe- cia lists and the largest and most prestigi- Otis medical schools and basic science schools. These four goals are somewhat over- lapping and somewhat conflicting. The hrst coals would tend to equalize physi- cian- ponulation ratios among states and conimuyities. hut the second. third. and ourth goals `could tend to generate gravitation to large existing centers of lence. The principle of cumulative ad- vantages of large medical concentrations is somewhat similar to the phenomena of retail gravitation evident in the regional location of large department stores and of the very large scale economies found in basic steel production and automobile assembly. There is an important differ- ence in terms of the public or consumer interest, however. Consumers get con- siderable benefits from commercial and industrial concentrations in the form of better accessibility and lower prices. But the public or consumer interest is very poorly served by medical gravitation which is motivated by provider prefer- ences for amenity locations and which results in poor accessibility and high prices in doctor-poor areas. The continu- ing shifts of physicians at both intrastate and interstate scales from doctor-poor to doctor-rich areas suggest a weakening of the constraint of* income-maximizing goals. permitting trade-offs from the physician-population equalizing goals to the gravitational goals either because of a shift in goal preferences or because of a substantial increase in economic demand. It is hypothesized that the tremendous increase since 1965 in public payments for physician services has in effect raised the potential economic demand for medical services of most communities and states by about a fourth. In the absence of a corresponding increase in medical man- power. physicians find their locational options greatly increased by being able to move to amenity locations at least until full saturation of the potential new market. If this did in fact happen, we would expect to find that these shifts were made without the expected result of lowering medical price levels in the re- ceiving amenity areas and we would ex- pect to find considerable geographic disparities in physician participation in anlenii\ social. and professional excel- PAGENO="0397" new public programs corresponding to the traditional locational preferences of physicians. Income Fein's (3) economic diagnosis of the physician shortage has led some to con- sider local variations in physician earnings as a reason for the wide variations in physician-population ratios (4). Yet the play of the private market should actually help prevent the uneven geographic dis- tribution of physicians; that is, given reciprocal licensure and free physician movement among states, huge disparities in physician population between states of similar population density and income would not develop. Otherwise, doctors in states with lower ratios would be able to earn more money than those in states with high ratios. For example, with minor regional variations, American communities spent last year an average of S90 per person for physicians' services, yielding an average gross income of S60,000 per physician. If physicians were dependent on private patients only for their practice, average physician income in Boston, New York City, and San Francisco would be about half of what physicians could earn in Detroit, Milwaukee, and Pittsburgh. Actual average physician income was estimated by state and region by project- ing 1966 data based on random samples of physician income tax returns (5). These projections were compared with 1969 and 1970 data from the Medical Economics continuing survey (6, 7). The projections revealed a slight tendency for average physician income to vary in- versely with the physician/population ratios of the nation's major regions (Table 3). The Northeast and West regions rank highest in physician- population ratios and lowest in average physician income. Howe~er, while the Northeast region's physician population ratio is 45 percent abo~e that of the North Central region, its a~erage physician income is onl~ 15 percent below that region. Before 1965. differences in regional and state physician population ratios were narrower, and average physician income was much more closely related to the supply of physicians. In . 1960. t'or exatiiple. the physician population ratio in Massa- chusetts and California was about a third higher than in Illinois, and as erage physician income was correspondingly lower. But in 1970 the physician popula- tion ratio in the two coastal states was 50 percent higher than in Illinois and their average physician income substantially exceeded that of Illinois. Medicaid and Medicare There is considerable esidcnce pointing to the huge federal subsidies of Medicaid and Medicare as the reason for the widening disparities in the distribution of physicians throughout the nation. Government spending increased from 7 percent of all physician payments in 966 to 25 percent in 1970. Public funds pa~ an even higher share of hospital costs~ half of the hospital care bill is noss paid by government compared with 36 per- 387 TABLE 3 NUMBER OF PBY5iCIANs PER 1,1)00 POPULATION AND MEDIAN PFn'stcis\ INCOME BY REGION AND MAJOR METROI'OLttAN .AR~ I97() Rngion and .\rca Rain, tn ``mc Northeast New York Cd~ North Central C h c ago South Atlanta West Los Angeles United States I 88 S4O,(M~) 2.79 38,7011) 1 29 46.1(k) .70 41.600 1.21 45.51)0 1.62 41.001) 1.66 42,601) 2.02 47,100 I 48 42.8(k) PAGENO="0398" :38s cent of the bill in 1966 (Si. In the first four years of Medicare and Medicaid. which together account for about half of all public medical care dollars, the govern- ment paid Out S36.7 billion to hospitals and doctors (9, 10. Applying a method of cost-benefit analysis developed by Stuart (lh. the author found that of this four-year out- la~, slightly more than half went for actual medical services for recipients and the rest to pay for the inflation in hos- pital costs and medical fees brought on largely by the vastly expanded federal spending. During these Iou:' years, doc- tors benefited by both additional chents and higher fees to the tune of between S 13,500 and S18,500 on the average. This boost in income alone did much to in- crease the mobility of physicians. But beyond that, doctors who gravitated to coastal centers made a much greater de- mand on Medicaid and Medicare dollars than their colleagues in doctor-short states. Medicaid and Medicare payments are disproportionately high for states with a physician surplus and disproportionately low for states short of physicians. New York. Massachusetts. and California- the three states with the highest physi- cian population ratios-receive half of all the nation's Medicaid funds and al- most a third of all Medicare monies even though less than a fifth of the nation's Medicaid and Medicare eligibles reside in these three states. Medicaid payments per capita are two-and-one-half times higher in California than in Illinois (9). and Medicare payments per enrollee are one-third higher (10). Table 4 contains a comparison of Medicaid payments per capita and Medi- care payments per enrollee for the three states having the highest physician pop- TABLE 4 MEDICAID PAYMENTS PER INHABITANT AND MEDICARE PAYMENTS PER ENROLLEE FOR SELECTED STATE.S RANKED BY RATiO OF PHYSICIANS PER 1,000 POPULATION (1970) Medicaid \Iedicare Stale Ratio Payments Payments Highest ratios New York Massachusetts California Lowest ratios Mississippi South Dakota Alaska Illinois United States ulation ratios, the three states having the lowest ratios, and Illinois. The average physician; population ra- tio for the 10 states with the highest per capita Medicaid payments is 1.91; this is 90 percent higher than that of the 10 states with the lowest payments. This ra- tio for the 10 states with the highest average Medicare payments is 1.79, which is 80 percent higher than that of the 10 states with the lowest Medicare payments. Medicaid payments to Illi- nois are about one-third of those for the three top states and are four-fifths of those for the nation. Medicare payments to Illinois are about one-fifth lower than those for the three top states and 1 per- cent above the national average. Federal Grants Research grants to medical schools con- stitute another important federal subsidy to doctors. In 1970 the federal govern- ment gave a billion dollars to medical and other health professional schools, or an average of close to S84000 per medi- cal school graduate (12). This program too favors the doctor-rich states. Six of the 12 medical schools receiving the larg- est total federal grants are located in 2.36 S66 S414 1.96 47 415 1.91 50 478 .83 4 251 .80 13 278 .68 9 246 1.37 19 348 1.48 24 344 PAGENO="0399" :389 New York. Massachusetts, and Cali- fornia. The University of Illinois Medi- cal School, which ranks third in the na- tion in nuniber of medical students, ranks 45th in federal grant dollars. Other good amenity states, such as Washington. Florida. Connecticut, Colorado, and Utah. round out the top 10 states, while mid-continental and southern states join Illinois in the bottom 10 category The 10 states having the highest amount of funds in federal grants to medical schools per graduate have a combined physician population ratio of 1.6.. almost 50 percent higher than that of the lowest 10 states. In 1970 grants to the top 10 schools averaged S208.000 per graduate compared with an average of S56.000 per graduate for the bottom 10 schools. Migration from Illinois Not only does California receive three times more federal aid per graduate than Illinois, two-and-a-half times as much Medicaid money. and a third more Medi- care money. but also it is the residence of more Illinois medical school graduates than is Illinois. In fact. California im- ported 509 graduates in 1970, while Illi- nois exported 310, making these two states far and away the major importing and exporting states respectively. Befitting these roles, of all of the states California ranks sixth from last in producing medical school graduates per inhabitant but 10th highest in receiving new medical practitioners, while Illinois ranks 14th highest in the production of doctors per inhabitant and 16th lowest in receiving new medical practitioners. Table 5. based on data given in the 1970 Education Number of the Journal of the American Medical Association 13) and the 1971 Directort' oJ Approved Intern- ships and Residencies (14). gives a year- TABLE 5 A\lERis.s\ MIDI(.\L STUDEN IS, GRADUATES, TRAINEES. AND LICENSEES: RATIOS BY 100,000 POPULVI ION FOR CALIFORNIA AND ILLiNOIS (1970) First-sear medical students bs slate of residence Frst-sear medical students b3 state of school Medical school graduates Interns First - sear resi- ,tifo;n,a I \ urnC,~r R,,ti~, Nurnb,'r Rati,) dents Licensees .056 5.4 238 2.1 by-year account of the physician migra- tion from Illinois to California, Accord. ing to these figures. Illinois educates two to three times as mar'.y American doctors as it receives as hospital-based interns and residents and as licensed practi- tioners. California. on the other hand, educates half as many doctors per in- habitant us Illinots hut receives twice as mans interns, residents, and practi- tIC) n e rs. New and Expanded Schools What can be done to retain Illinois na- Uses and graduates in the state? In a 1968 report Dr. James A. Campbell of Presbyterian-St. Luke's Hospital in Chi- cago and his colleagues stated that the growing shortage of practitioners over- shadowed all other health care problems in that area, including the rapidly in- creasing cost of care ( l5. In response to the recommendations contained in the Campbell report. the Illinois Board of Higher Education unseiled in 1970 a 10- year plan designed to double the num- ber of medical schools in the state from six to 12 and to double the number of graduates from 550 to 1.100 (16). Both 737 3.7 558 5.0 593 3.0 644 5.8 488 2.4 548 4.9 1.229 6.2 350 3.1 1,153 5.8 354 3.1 PAGENO="0400" 390 public and pri~ate medical schools will be subsidized under this plan. In the public sector four ne~~ three-year schools are to be built in downstate Illinois. one each in Rockford. Peoria. Springfield. and Carbondale. and the number of students is to be increased two-and-a- half times from 2.900 in 1970 to 7,500 by 1980. The total costs of the expanded public facilities are expected to exceed s150 million. Educational costs of the 10-year plan hate not yet been deter- mined but may be estimated. It costs about S72.000 to train a doctor. with about S50.000 provided by the state and the balance from the students, the fed- eral government, and other sources. As mentioned above, the annual number of graduates would increase from 550 to 1.100 over the 10-year period. Assuming an annual average of about 300 addi- tional graduates. this expansion would require an outlay of about S150 million during the decade. State support to existing pri~ate medi- cal schools will include construction as well as educational subsidies. A Sl2 mil- lion grant (half from the state and half from the federal government) will per- mit the Chicago Medical School to re- locate from the congested West Side Medical Center to the northwest suburbs. State educational support to private schools will include S6.000 a year for each new medical student. co~ering about a third of the total cost. California, on the other hand has no plans for expanding existing medical schools or building new ones, even though it is among the bottom 10 states in the production of doctors per in- habitant. It is apparent ~hy California will not expand its medical schools as long as it can attract more doctors than it can use from states such as Illinois. It is less apparent why Illinois views the doubling of its medical schools and graduates in the next 10 years at the cost of perhaps half-a-billion dollars as any- thing less than a subsidy for California- bound physicians attracted by the lures of climate, glamour. and federal dollars. House Staff Places Campbell (15) foresaw the danger that new medical graduates would continue to gravitate to California. In his report he noted the high correlation between location of practice and location of in- ternship and residency: 42 percent of Illinois graduates practice in the same state in which they took their internship and 46 percent practice in the same state in which they took their residency. In order to retain medical graduates, Camp- bell recommended 200 new first-year in- tern positions and the expansion of resi- dency programs in "environments of actual and potential excellence, particularly the new clinical centers for undergraduate medical education which will encourage the new graduate to take his internship and residency training in Illinois." There are two assumptions underlying this proposition that are unwarranted: (a) that new internship and residency positions would automatically be filled by Illinois or even American graduates and (h) that graduates choose internship and residency locations without refer- ence to their eventual office location preferences. The lie is given to both of those as- sumptions by the present attraction rates of California and Illinois internship and residency programs. In 1970 Illinois filled only 34 percent of its 1,026 intern- ships and 44 percent of its 2.587 resi- dencies with American graduates. In contrast. American graduates filled 85 percent of California's 1,443 internships and 84 percent of its 4,407 residencies. PAGENO="0401" 391 (In Illinois 27 percent of internships and 14 percent of residencies were not filled; for California the figures were 12 per- cent and 10 percent; total U.S. figures were 25 percent and 15 percent.) This would indicate that the problem of attracting and retaining American graduates to serve in internships and res- idencies and the problem of attracting doctors to establish a practice are one and the same; that is, that most gradu- ates choose their internships and resi- dencies with an eye to future office loca- tion rather than on the basis of availabil- ity or quality of postgraduate training programs. The problem of Illinois hospitals at- tracting American interns and residents was probably worse in 1972 than in 1970. As an example, Cook County Hospital, with the largest number of internships in the state, had only two American gradu- ates to fill the 130 positions offered for 1972-73. Medical Student Recruitment The intensive recruitment of rural and minority medical students has often been urged, most recently by the Association of American Medical Colleges' Task Force on the Health Manpower Short- age, as a solution to more severe short- ages of physicians in rural and minority communities (17). This solution is pred- icated on the assumption that rural and minority communities are underserved by doctors in part because rural and minority populations are underrepre- sented in medical schools, that such students are more likely to return to serve the population from which they stern, and that by increasing the enroll- ment of such students, the number of doctors who serve these communities can be increased. The attraction of rural students is a major reason for the establishment of the new downstate Illinois schools men- tioned pre~iously and for the schools that will eventually be built in the Rock Island- Moline, Decatur, and Champaign- Urbana areas. In Chicago the Office of Economic Opportunity is supporting `Project 75," an effort by the local black medical society, the Cook County Physi- cians Association, to plan the enroll- ment of a minimum of 12 percent minor- ity students in American medical schools by 1975 (18). Past experience, however, is that medi- cal students of all cultural and economic backgrounds gravitate to large urban centers after graduation. When we look at medical graduates by state of origin, four of the five states with the highest ratios per 100,000 population are agri- cultural states: Nebraska, North Dakota, Vermont, and Kansas. But in physician population ratio, three of these states are in the bottom half of state rankings- Kansas is ranked 28th, Nebraska, 30th, and North Dakota, 44th. Black physicians shun Chicago and its ghettos almost as much as their white colleagues. In the nation blacks consti- tute 11 percent of the population and only 2.2 percent of the physicians. In Chicago blacks make up a third of the population and 5.8 percent of the physi- cians. Thus, Chicago's black physician' population ratio is 12 percent below the national average. Of the 100 physicians who see most of Chicago's 440,000 welfare and Medicaid patients, 56 are foreign-born--38 from Latin America, 9 from Asia, and 7 from Europe. Of the 44 American physicians who specialize in welfaie patients. 32 are white and 12 are black. Even Chi- cago's black hospital's staff, whose sup- porters have called the city's compre- hensi'~e health planning agency racist, do PAGENO="0402" 392 not see welfare patients except as emer- gency cases. Where do black physicians set up practice, then, if not in inner-city ghettos? Even more than their white colleagues, they harken to California's state song, "California, Here I Come." Fifteen per- cent of the graduates of Meharry and Howard, the nation's two black medical schools, practice in California, com- pared with 4 percent who practice in illinois (19). Physicians from rural and minority communities do not and ought not to have any more obligation than the rest of us to return to serve the population from which they stem. We ought to train more physicians from rural and minority communities because they deserve the public subsidy and the opportunity to become physicians just as the rest of us do. Policy Implications In the previously mentioned unpub- lished study by the author, it was shown how federal programs like Hill-Burton, Medicaid, and Medicare. designed to rectify shortages in hospital-short and doctor-short communities, not only had failed their objectives in Illinois com- munities but also had actually aggra- vated the maldistribution of physicians by unintentionally subsidizing the sub- urbanization of physicians and hospitals. In the 25 years since Hill-Burton was en- acted, for example. not a single Chicago inner city community hospital was helped while two dozen outlying and suburban hospitals were able to build new or to expand with federal subsidies. In the five years of Medicaid and Medicare, only 20 physicians were added to the active roll of welfare physicians while hundreds of outlying and suburban physicians were subsidized by these pro- grams, contributing to the unprecedented flight of physicians from the inner city in these five years. A similar perverse effect of federal programs on the interstate distribution of physicians has been traced in this paper. In the interstate as well as in the intrastate relocation of physicians, the federal purse has apparently helped fi- nance the further gravitation of physi- cians to states and communities tradi- tionally favored for reasons largely of amenity, social, and psychological satis- factions for a profession not particularly deprived in these satisfactions. In both papers the author showed that other public programs designed to rectify the physician shortage for deprived pop- ulations like neighborhood health cen- ters, medical school expansion, and minority medical student recruitment held little promise in view of the eventual gravitation of this subsidized medical manpower to doctor-rich areas. The OEO Neighborhood Health Cen- ter model of the l960s has given way to the health maintenance organization model of the 1970s as the panacea for improv- ing primary medical services. But HMO will do no better than OEO unless this health delivery model can keep Chicago graduates in Illinois and unless it can attract these graduates to practice in communities with the greatest need rather than in communities with the greatest wealth. Unless there are controls on the geo- graphic allocation of HMO subsidies, these too will gravitate to doctor-rich states. Signs of this can be read in the hearings on the Health Maintenance Orga- nization Assistance Act of 1971 (S1182). Of the 106 profit groups which had sent the Department of Health, Education, and Welfare a letter of intent to form an HMO. 21 were from California, 11 from PAGENO="0403" 393 New England. 10 from New York, and two from Illinois (20. 01 the 86 HMO grants made through March 1972, nine went to California, eight to New Eng- land, seven to New York, and three to Illinois (21). In both papers the author recommends that the government check the un- intended effect of these programs by establishing an area's physician-popula- tion ratio as a criterion of priority for federal subsidies under these programs. Summary If physicians depended entirely on pri- ~ate patients for their livelihood, those in doctor-rich cities could double their income by moving to cities with half as many physicians per population. Yet we find that physicians in Boston and Los Angeles make as much as or more than doctors do in Chicago and Detroit. It is hypothesized that discriminatory federal spending helps explain why local physician surpluses and shortages are not reflected by corresponding differ- ences in average physician income and contributes to widening disparities of physician ~population ratios among ma- jor metropolitan areas and states. It is shown that federal dollars, which now pay a fourth of all physician bills compared with seven percent in 1966, flow more freely to doctor-rich states than to doctor-poor states. New York, Massa- chusetts, and California, with less than a fifth of the nation's population, capture half of all Medicaid funds and over a fourth of all Medicare payments and medical school grants. It is contended that until the federal government re~erses this indirect and un- intended subsidy of doctors migrating to good climate and cosmopolitan areas, attempts by states like Illinois to erase local shortages are doomed to failure. More Illinois-trained doctors go to Cali- fornia than stay in Illinois, not only be- cause of the attraction of climate and glamour but also because California gets three times more federal aid per gradu- ate than Illinois, two-and-a-half times as much Medicaid money, and a third more Medicare money. Illinois educates two to three times as many American doctors as it receives as hospital-based interns and residents and as licensed practi- tioners. California, on the other hand, educates half as many doctors per capita as Illinois but receives twice as many in- terns, residents, and practitioners. It is predicted that the plan to expand internships and residencies in Illinois hospitals as a way of attracting future practitioners has little chance of success as long as Illinois hospitals cannot fill more than a third of the present. open- ings with American doctors. More in- tensive recruitment of medical students from rural and minority communities is a worthwhile goal in itself, but it will not result in more doctors for these doctor- poorest communities. Doctors from rural and minority communities shun indus- trial cities like Chicago and agricultural states like Illinois just as much as the rest of the doctors. References 1. J0R0FF, S., and NAVARRO, V. Medical Manpower: a Muhi-Variate Analysis of the Distribution of Physicians in Urban United States. Medical Care, 9:428-438, 1971. 2. SCHEFFLER, R. The Relationship Between Medical Education and the Statewide Per Capita Distribution of Physicians. J. Med. Educ., 46:995-998, 1971. 3. FEIN, R. The Doctor Shortage: An Eco- nomic Diagnosis. Washington, D.C.: The Brookings Institution, 1967. 4. SCHAFFNER, R., and BUTTER, I. Geographic Mobility of Foreign Medical Graduates 38-6~3 0 - 74 - 7 (Pt. 1) PAGENO="0404" 394 and the Doctor Shortage. Inquiry, 9:24- 33, 1972. 5. REED, L. Studies of the Incomes of Pity- sicians and Dentists. U.S. Department of Health, Education, and Welfare. Wash- ington, D.C.: U.S. Government Printing Office, 1968, P. 96. 6. OWENS, A. Inflation Closes in on Phy- sicians' Earnings. Medical Economics. 63-71, December 21, 1970. 7. OWENS, A. Physicians' Earnings: Leveling Off. Medical Economics: 203-211, Octo- ber 11, 1971. 8. The Size and Shape of the Medical Care Dollar: C/tart Book/1970. U.S. Depart- ment of Health, Education and Welfare Social Security Administration, Office of Research and Statistics. Washington, D.C.: U.S. Government Printing Office, pp. 24-27, 1971. 9. Medicaid and Other Medical Care Financed From Public Assistance Funds, Fiscal Year 1970, Report No. B-S FY70, U.S. Department of Health, Education, and Welfare, Social and Rehabilitation Service, Program Statistics and Data Systems. Washington, D.C.: U.S. Government Printing Office, 1972. 10. Medicare, Fiscal Years 1967-1970, Se- lected State Data. U.S. Department of Health, Education, and Welfare. Social Security Administration, Office of Re- search and Statistics, Publication No. 72-117501. Washington, D.C.: U.S. Gov- ernment Printing Office, 1972. 11. STUART, B. Who Gains from Public Health Programs? Annals of the American ,lcadem'i a! Political and Social Scier~ce, 399:145-iSO, 1972. 12. DHEW Obligations to Health Professional Schools, Fiscal Year 1970. (Volume 3.) U.S. Department of Health, Education, and Welfare. Office of the Secretary for Health and Scientific Affairs. Washington, D C.: U S. Governnient Printing Office, 1971. 13. Council on Medical Education of the American Medical Association. Medical Education in the United States. J.A.M.4. 214:1483-1581, 1970. 14. Direcrir: at .4pproved Interns/tips and Rc3 idenc,c.s. 1971-72, Annual Report on Graduate Medical Education in the United States. Chicago: American Medical Asso- ciation, 1971. 15. CAMPBELL, J., TUCKER, W., and TURNER, I. Education in the Health Fields for State of Illinois. Chicago: Board of Higher Education, State of Illinois, 1968. 16. Medical Education in Illinois. Health Planning in Illinois, 1:1-11, 1970. 17. Task Force Report to the Inter-Association Conintittee on Expanding Educational op- portunities in Medicine. Washington, D.C.: - Association of American Medical Col- leges, 1970. 18. THOMAS, A. Project 75: A Program to Increase the Number of Minority Medical Students in U.S. Medical Schools. J.A.M.A., 218:1816-1818, 1971. 19. THEODORE, C., SUT-TER, G., and HAUG, J. Medical School Alumni, 1967. Chicago: American Medical Association, 1968. 20. United States Senate, Committee on Labor and Public Welfare, Subcommittee on Health. Hearings on S. 935, S. 703, S. 837, S. 1182, S. 1301, July 20 and 21, 1971, Part I. Washington, D.C.: U.S. Government Printing Office, 1971, pp. 138- 141. 21. Listing of Health Maintenance Organiza- tion Grants. News, Information, Data (Volume 6, No. 65.) U.S. Department of Health, Education, and Welfare, Public Health Service Regional Medical Program Service. PAGENO="0405" ~r~fl L ~ `~L~J rmri ~) U `~ tn~~ ri r'-~ (rSl b UCULJUU~ftJ 0 395 PHYSICIAN NEEDS FOR ILLINOIS IN THE 1970'S It is generally conceded that the United States, ranking tenth highest among the worlds nations in physicians per population, suffers not so much from a shortage of physicians as from a rnal- distribution of physicians. No one can really tell how many phy- sicians per population we need any more than one can tell how many hos- pital beds per population are needed. Actual use of physician and hospital services, regardless of a real need, gen- erally determines norms such as physi- cian and hospital bed-population ratios. Yet, when we witness huge disparities in physician population rotios of com- munities, of the order of 10 to 1 in metropolitan Chicago for example, it is hard not to conclude that some com- munities in the State of Illinois enjoy large surpluses of physicians while other communities suffer from dangerously low numbers of physicians. When we look for explanations for these huge differences in community physician-populotion ratios, bvo, and only two, variables stand out-average personal income and populotion density -both correlating positively with phy- sician-population ratios. Hospital beds, contrary to conventional wisdom bear no perceptible relation to physician- population ratios. In fact, the states poorest communities hove a somewhat higher hospital bed-populatii--n rotio than the richest communities. The some relationships prevail when we expand the total study area to the en'ire nation and the sub-units to the nations counties. The tenth of Americans living in the 1,805 counties of lowest population density-per capita income have nine percent of the nations hos- pital beds but less than four percent of the doctors. On the other hand, the 20 million Americans living in the 12 counties of hghest population density-per capita income have nine percent of the hospital beds and 16 percent of the nations doc- tors. Thus these two extreme deciles of counties have identical hospital bed- population ratios but a disparity of 4 to 1 in physician-population ratios. The nations 300 metropolitan areas encompass the most densely populated and affluent counties, and their physi- cian-population ratio is more than twice that of non-metropolitan areas. These metropolitan areas contain 73 percent of the nations people, 74 percent of the hospital beds, 86 percent of all physi- cians, and 93 percent of all hospital- based physicians. Hospital and physi- cian-population ratios for metropolitan and non-metropolitan areas are given below: or pita I Beds! 1000 pop. Metropolitan Areas 4.2 Non-Metropolitan Areas 4.0 United States 4.1 Doctors can exercise considerable lat- itude in where they locate because they operate in a sellers market. In addition to a penchant for large and affluent communities, doctors also tend to prefer regions with a reputation for gocd cli- by Pierre de Vise ______ Mr. d. Vise, a noted urban spe- cialist, Is IRMP'e Assistant Di- rector for Health Information. H. woe formerly assistant direc- tor for research at the Hospital Planning Councit for Metropoli- tan Chicago and project director for tic. Chicago Regional Hoe- pital Study. MD's! 1000 pop. 1.73 .80 1.48 ILLINOIS REGIONAL MEDICAL PROGRAM FALL 1971 Volume II Number 3 PAGENO="0406" 396 mate, intellectual as weT as mereoro. logical. Thus, New York City, New Engiand and the Wes' Coos' have pky. 5~c'an-populat on raos ~wo to three times bic~er `Han `~`ose of less well en' dowed recons. Aco ~, it is p~sician- population ratios rather than bed- population ratios that are affected by regional onenNes. A breakdown of the two ra'ios by each of the four ~aar regions of the nation in 1970 make this aoundcntly clear; NON-FEDERAL PHYSICIAN-POPULATION RATIOS: 1970 and 1960 Percent of Nation Census Reqion Population Hospital Beds M.D's Beds! 1000 ~gp, MD's! 1000 ~Q2,_ Northeatt 24.1 24.6 31.2 North Central 27.7 30.0 23.8 South 31.2 29.2 24.9 West 17.0 15.4 19.2 United States 100.0 100.0 100.0 4.2 4.5 3.9 3.8 4.1 1.88 1.29 1.21 1.66 1.48 This understanding of locational pref. government spending in health core in erences of physicians helps explain some the lost ten years. remarkable things that have happened Vastly increased federal spending has to the physician population of Illinois no doubt contributed greatly to the 38 in the last decade. As we may see in percent increase in the nation's physi. Table i, even though Illinois gained can population since 1960-directly almost 3,000 physicians since 1960, the through subsidies to medical education gain was confined almost entirely to and indirectly by adding to demand for non-office practitioners in metropolitan medical serviees and with consequent Chicago. inflationary effects on physician income. There were absolute losses of private However, this greatly increased eco- practitioners for both metropolitan Chi- nomic demand for the services of physi. cago and downstate and the gain of cians has further reinforced their free- fewer than a hundred total physicians dam of choice of where to locate. They downstate did not keep up with residen- have exercised this greater freedom by tial population growth. The states ratio further concentrating in urban centers of private practitioners per population that are mast desirable in terms of the fell by 10 percent in the decade. In all three attractions of affluence, density three physician-population ratios_office and amenities. practice, patient care and all physicians Thus the centers of the East and West -Illinois stood sIghtly higher than the Coast, that were already endowed with nation in 1960, but fell considerably be- two to three times the physician pops- low nationai norm in 1970. lation ratios of less attractive centers, Even though Illinois ranks fourth simply increased their advantage. highest among `states in per capita in- In the 1960 decade, the physician- come and sixth highest in proportion of population ratio grew by 34 percent urban population, these advantages points for the five states with the highest have been partially erased because of ratios, compared to a nine percent point more rapid urbanization and income gain for the five states with the lowest growth in the South, Southwest and ratios in 1960, as witness the following West, and because of the trebling of figures: Five Highest Ratios State Ratios 1970 1969 1970 ~ 0.56 NewYork 2.33 1.87 Alaska 0.71 0.71 Massachusetts 2.12 1,71 South Dakota 0.78 Connecticut 1.91 1,57 Alabama 0.85 California' Colorado 1.90 1.47 1.84 1.44 South Carohna Mississippi 0.87 0.79 0.76 5-State Total 2.00 1.66 5-State Total 0.83 0.74 PAGENO="0407" 397 Off ire-Based Peavtixe GePeartive Hosp~lai-BaxeiI Peactire Total Pit Case Other Avt9ity Total PhysearA F çiaas pee 1,000 Pop, UNITED STATES ILLINOIS METRO CHICAGO EIOiONSTATE 1970 1960 1970 1960 1970 1900 1970 960 9.487 9560 6,681 6709 2,806 2.881 2,802 3,76.8 1,700 2,402 1.102 .204 8,685 5.614 4,501 4,227 1704 587 3,965 1.856 3,405 1,655 290 190 13,182 11,436 10.006 8,375 3,096 3,071 1,261 336 1,134 758 127 78 837 700 620 561 217 144 15,299 12,477 11,040 9,094 3,459 3,383 Olive Peartire All Patiext Care All Physix,at-is .93 .90 .86 .98 96 1.08 .69 .75 1.26 1.08 1.19 1.13 1.45 1 35 .75 .813 1.48 1.23 1.37 1.24 1.70 1.46 .84 .88 SOURCES: Aerevcao Medical Association, Distnbxtiott of Physicians the Uoitexf States U. S. Bxeeata of the Cetteas, Censtas of Poptalatiost Even though Illinois already ranks high in urban population and affluence and contributes itt share to the produc- tion of new physicians, it cannot com- pete with the superior reputed amenities of East and West Coast centers. ri fact, California and New York have become the main beneficiaries of the increased production of physicians by Illinois medical schools. As many Illi- nois medical school graduates gravitate to California as to metropolitan Chica- go. As many gravitate to New York as to downstate Illinois. Many more Illinois graduates are practicing in the states of California, New York, Florida, Arizona, Colorado and Washington than are practicing in Illinois. Location of Practice of Ittinois Graduates California Metropolitan Chicago Downstate Itlinois New York Florida Arizona Cotorado Washington Greater physician mobility has hurt Illinois not only by shortchanging its share of the nations physicians, but also by greatly aggravating the maldistribu- tion of physicians within the state. Even in the gross bipartite divisIon of Illinois mode in Table 1, we observe that metropolitan Chicago increased its p'ny- siciart-population ratio from 1.46 to 1.70, twice the downstate ratio, down from .88 to .84 between 1960 and 1970. l's Table 2, we have arrayed 1960 and 1970 physicians and population ratios for each of the stale s seven planning regions, seParating the urban counties of 100,000 or more peopie) from the rural counties that make up the balance of the regions. Wilts few eecept~ons, the urban coun- ties have much higher physician-popula- lion ratios in both 1960 and 1970, and increased their ratios during the decode, while the rural counties have generally had their ratios reduced. The state's 17 urban counties gained a little over 3.000 physIcians since 1960, from 10,770 to 13,762, while the state's rural counties lost 200 physicians, from 1,700 down to 1,514. The physicianpopcilation ratio of the 17 urban counties taken together climbed from 1.35 to 1.57, while that of the rural counties fell from 0 77 to 0.66. A useful measure of the increasing 22% concentration of the slate's physicians in 21% the urban counhes is the disparity index. 7% This index measures the percent of the 6% state's physicians that would have to 2% move if we were to redistribute them so 2% that each county would have iden'ical physician-population ratios-these cor- responding to the statewide ratios of 1.37 physicians per 1,000 in 1970 and 1.24 physicians per 1,000 in 1960. In this theoletical exercise, 2,858, or 18.7 per. cent, of the state's physicians in 1970 would have hod to relocate, compared to 1,829, or 14.7 percent, of the .hysi- clans in 1960. The physician.populotion ratio is ad- mittedly an inadequate measure o~ phy- sician services inasmuch as it does not precisely measure physicians' services. Both Tables 1 and 2 hove ide.n1f:ed TABLE I Non-Fedetal Pliysiviarts, by Type xl Peavtice, United Slates, Sines, and Cxrnponevt PeN 1970 a-il 1950 102,924 50,016 130,100 85,103 255,027 25,317 19,021 301.323 161.293 82,237 70,056 31,723 193,015 10,012 16,420 219. 4-48 Total Pop. fl,000'tI 203,185 178,464 11,114 10.082 6.979 8,221 4.135 3.881 PAGENO="0408" I~J.,L2_ Non.Fedgral Physlcieas Population for Counties of 100,000 or more People and PlannIng Regions In Illinois: 1970 and 1960 General Region Total - - - Prgctitioners OTHERS ALL M.D'S PHYSICIANS PER 1,000 PERSONS Prioate PructAonors MO~_ i9~Q !~P 1~1I~ i~P t~ 191P i~P t919 t~P i~LO1.~0 1970 ~9GO Counties Renon 7 Cook Du P.oje Lake McFl.~nry 8611 Other Counties f3eg:on3A Sans mon Other Counties Reqiun 3B 391 4~1 142 266 249 155 168 164 27 79 141 223 257 116 187 108 79 66 503 487 .73 .83 .87 .96 48 35 286 241 .96 .99 1.16 1.15 31 31 217 746 .56 .73 .66 .83 _____________ .78 .92 .93 50 320 257 110 1.10 1.64 1.36 20 157 137 76 .71 .94 .91 7 61 56 .44 .49 .51 56 12 95 100 .75 .79 .85 :10 39 237 282 .54 71 .117 .83 SOURCES: American Medical Association, Distribution of Physicians in the U. S. PRIVATE PRACTITIONERS 421 . . 139 237 285 184 Wiueebego 238 206 45 76 193 130 Other 186 215 94 161 92 54 CountIes c:io:i..ift........_.._..._.,.669 693 259 452 410 251 202 128870832 .70 Peo,o 214 207 44 83 170 124 106 Rrok Island 127 107 31 59 96 58 30 52 49 33 44 19 5 9 LaC,ille 83 88 38 70 45 18 12 Othr~ 193 242 113 196 80 46 45 5708 2411 _,,,jJ9]3_,,,,__~?p2 _J~j~*l5 5490 5911 1385 2964 4105 2947 4840 2238 10330 11149 1.00 1.15 1.lIB 1.59 432 207 103 128 329 79 132 39 564 246 .88 .66 1.15 .78 220 201 59 108 181 93 56 37 276 238 .88 .97 1.10 1.14 323 201 74 109 249 92 93 44 416 245 .84 .68 1.09 .83 56 58 30 47 26 11 11 5 67 63 .50 .69 .60 .75 160 131 411 73 111 58 27 22 187 153 .64 .68 .75 .80 84 82 33 58 61 24 49 26 133 108 .56 .62 81 .82 91 60 482 481 .73 .81 .90 .93 85 47 27 215 191 1.04 1.12 1:13 1.30 70 44 33 267 290 .60 .69 .72 .78 576 564 219 358 357 206 88 140 664 704 .75 .80 .87 1.00 Champaign 173 92 38 43 135 49 26 62 199 154 1.06 .69 1.22 1.16 McLean 77 83 22 41 55 42 13 13 90 96 .74 .99 .86 1.15 Macon 118 106 23 46 95 60 15 27 133 133 .94 .90 1.06 1.13 Other 208 283 136 228 72 55 34 38 242 321 .56 .77 .65 .87 Counties Regipn4 348 346 149 231 199 115 65 27 413 373 .52 .57 .62 .61_ Madison 136 137 53 84 83 53 32 12 168 149 .54 .61 .67 .66 St. COir 170 158 56 97 114 61 28 11 198 169 .60 .60 .69 .64 Other 42 51 40 50 2 1 5 4 47 55 .31 .42 .35 .45 Cuunties Re3yun5 ,..- 312 345 162 277 150 68 59 53 371 398 .61 .68 .73 .78 All Counties 312 345 162 277 150 68 59 53 371 398 .61 .68 .73 .78 U. S. Bureau of the Census, Census ol Population PAGENO="0409" 399 three separate components and ratios in an attempt to more specifically define physicians in private practice, in hospi- tal-based practice, and in education, research and administration. The private physician-population ratio has gone down for all but eight of the states counties (all urban) since 1960. Metropolitan Ch:cago's gain of 2,000 hospital-based physicians accounts for over two-thirds of the states gain of 2,900 physicians during the decade. It is difficult af course to translate this gain in terms of primary physician services, olthough the state's large increase in out-patient and emergency department utilization no doubt reflects substantial substitution of private practice by hos- pital-based practice for primary care services. There is some evidence, however, that for a forge number of Chicago residents, dependence on hospital out-patient and emergency services for primary medical core leaves something to be desired in matters like travel distance, waiting time, appropriate personnel, sufficient facilities and financial solvability, Even the counts and ratios of private practitioners by specialty are subject to cautious interpretation because they treat all physicians In general or special- ty practice as equal. Yet, for purposes of evaluating the disparities in geographic distribution any bias in age and quality distribution of physicians would likely reinforce the disparities reflected by gross physician- population ratios. However, ocr attempt is made in Tables 3 and 4 to differenti- ate age, practice and specialty charac- teristics of physicians for each of the state's seven planning regions. As one would expect, the major dif- ferences are between Metropolitan Chi- cago (Region 2) and the six other re- gions. The Chicago region snot only has twice as high a physician-population ratio as the downstate regions, it also has a much lower proportion of pfcysi- cians in private practice (57 versus 84 percent), a physician age dist'ibution six years younger (46.5 versus 52.7 median age), a much lower proporrion of pri- vate practitioners in general practice 19 versus 36 percent) and a higher propor- t~on in family practice spcrvia~ties (22 versus 14 percent) arid in psychiatry (6.4 versus 4.0 percent) The hospital-based specialties, as one might expect, are relatively equally distributed in all re- gions but the Carbondale (Region 5), which has but four anesthesiologists, six pathologists and eleven radiologists for its 27 counties. The distribution of the more rarefied specialties is another story, however, The Chicago region captures 93 percent of the state's allergists, 98 percent of the cardiologists, 88 percent of the neurolo- gists, 89 percent of the neurosurgeons, 84 percent of the physiatrists, 87 percent of the plastic surgeons, and 78 percent of the thorocic surgeons )see Table 5). The largest disparity is to be found be- tween Chicago's 130 and downstate's three cardiologists. Only one other re- giorc-Rockford--has all severs special- ties represented, and one region-Car- bondale-counts but one specialty rep- resented-by one specialist. The projection of 1980 physician needs for Illinois is complex, indeed, when we examine the consequences of the state's gain af 2,900 physicians in the 1960's. More physicians have meant fewer private practitioners for the state, and fewer physicians of any kind for all but a handful of the state's communities. One might be tempted to urge fewer physicians for 1980 if indeed the trends of urbanization and shift away from primary care practice might thereby be reversed. Even if we were to agree on say, the national norm of 1,48 physicians per 1000, as the statewide goal, we would have to find a way to implement this goal. TABLE 3 The increased importation of foreign Otiaractei'istixu of Ptiysiriaos, By Piaon,m Region in iilioois: 1970 M.D. `s per % of Prvate Lf~icLunu~ Practctixrcers Median %60t'ears nerd Oidr, 52,5 30.1 51.9 255 46.5 21.5 53.6 30.0 52.6 26.8 51.0 ` 20.2 53.8 32.8 48.2 SSat. Planning ~.gions Re~9ni IA Rockloed .87 ,84 lB Peoria .92 .77 2 Chicagn 1.68 ,5-, 3A Speiogfield .90 81 38 Champaign .87 ,87 4 E,St. Lxxis .62 64 5 Caeboodate - .73 .84 ILLINOiS 1.37 62 230 PAGENO="0410" 1A R~okfnrd lB Pi~'i4 2 Ch.n~g~ 3A S,ygl..id 38 Cp~ 4 ~ 5 C.-bni99~ ILLINOIS 400 TAnLE 4 Chtv~iv~y' Ph'r~-~~ 8y P i-vi~~~~g Rr8y,, ,~ iiL,iy~ 1970 ~MD. TABLE 5 N-F,dyy4 P5y~n.~n. En, S~in,8d Sn,nitn~ By Pi~wng R.çin, iiiin,i~ 1970 graduates was the main source of ph>'- sician growth in Illinois in the 1960's. The number of graduotes of Illinois med. cal schools, which has increased but slightly in the 1 960's-from 516 in 1960 to 550 in 1970--is expected to go up to 830 by 1975. On the other hand, the retention rote of Ihinois graduates is going down, In 1960, about twa-thirds of the state physicians were Illinois graduates. By 1970, the latter made up but half of the state's total. On the other hand, the proportion of foreign graduates among Illinois practitioners more than doubled -from one-tenth in 1960 to one-fourth in 1970. The proportion of foreign hos- pital-based phys'ciars rose trom one- fourth to one-ira~f In contrast, only three percent of California's hospita-based phys~cians are foreig-' grcduates. Unless the trend of retention losses con be reversed, and some way found for Illincis to success1uily compete against superior climate amenit,es, gains in local medical school production will benefit California n-ore than she Chi- cago metsopoliton area, and will benefit almost any of the other good clirncte states more than downstate ~ili~ois. In fact, Illinois might decide that ne best investment irs medical education in cost-benefit terms would be to under- write a few scholarships in the Philip- pines, Pakistan, India and other under- developed nations, insofar as medical graduates from these parIs make up the molar sources of the state's new physi- cians. This assumes, of course, that these physicians are more needed in Illinois than in their homelands. If we should be successful in raising the number of physicians to match the national norms, there would then remain tire goals of redressing the geographic maldistribution of physicians and of making better use of hospital-based practitioners for delivering primary care services. There are, unfortunately, few good models to guide us in these tasks. The Office of Economic Opportunity (OEO) Neighborhood Health Center model of the 1960s has given way to Health Maintenance Organization (HMO) model of the 1970's as the pana- cea for improving health delivery ser- vices. But HMO will do no better than CEO unless this health delivery model can keep Illinois graduates in Illinois, and unless it can attract these graduates to practice in communities with the greatest need, rather than in commu- n'ties with the greatest wealth. G,,wyi OmyrO i-yymnJ OR & P~di. Prvrtl,- A,ynyhn. P~tt~. ROd.. twac ~L~y Mw~y 9~. w~ yi~ 83633 A Rwklyd 339 150 9.6 6.3 43 4 5 3.3 3.9 3.7 18 Prvy,~ 38.3 10.5 6.3 53 24 60 3.4 3.7 4.0 2 C1',~~ `9.2 95 5.5 6.0 6.2 6.4 3.5 4.2 4.0 3,1, Si~'i~gt.yi3 38 CT~-np~.~ 4 6. 5,. Ly,,,~ 36.2 35.8 37 7 0.8 8.7 85 10.6 11.0 97 5.8 5.9 77 3.6 50 4.5 4.2 4.3 3.7 1.6 2.0 3.7 2.4 3.4 2.2 3.8 3.9 3.7 C4,w,,cni, 32.8 12.6 75 4.9 3.0 2.5 1.1 1.6 3.0 iLLilOiS 732 9.6 142 6.0 5.7 6.0 3.3 3.9 3.9 SOURCE Ayn,,n~, M~thii4I A~ininBny P169i4 Thn~n, ~ttor Cai7piyy03 f~tro!cetse ~ EsitioSst~ ~i6~0r9 ~r~ce 3 1 1 4 2 3 3 1 5 3 2 7 2 5 51 130 lEA 97 69 60 74 0 0 1 5 2 0 3 0 0 4 2 2 1 3 O 5 6 0 `0 3 7 0 1 0 0 0 0 0 55 133 120 110 82 69 95 PAGENO="0411" 401 THE CHANGING SUPPLY OF PHYSICIANS IN CALIFORNIA, ILLINOIS, NEW YORK, AND OHIO: REDISTRIBUTION OF PHYSICIANS SINCE 1960 AND PROJECTIONS TO 1990 (By Pierre de Vise, College of Urban Sciences, University of Illinois at Chicago Circle) INTRODUCTION AND SUMMARY Both New York State and The United States enjoyed a gain of almost 50 percent in physicians between 1960 and 1972. New York State remained number one among the states in physicians per population, with a ratio, in 1972, of 2.44 physicians per 1,000 people, 55 percent above the national ratio of 1.57 physicians/1,000. New York City and New York County (Manhattan) regis- tered ratios of 3.12 and 7.98 physicians/1,000 in 1972, twice and five times, respectively, the national ratio. Manhattan is presently suffering signs of physician surplus, reflected by an average physician income one-fifth below the national norm, and by large numbers of physicians who cannot get hospital appointments, including half of its general practitioners, a tenth of its internists and pediatricians, and 6 percent of its surgeons and obstetricians. Projections of U.S. and foreign physicians presently in the pipeline of medical education and graduate training point to an additional physician in- crease of 42 percent in New York and 32 percent in the nation by 1980. By that time, not just New York City, but many other urban areas on the east and west coasts will be facing a physician glut, while many other communities will endure worsening shortages of physicians. Not just New York City, but also most other urban areas that were already well endowed with physicians in 1960 were the main beneficiaries of the nation's additional 100,000 physicians. On the other hand, most communities that suffered a physician shortage in 1960 w-ere not able to attract the new physicians, and had even fewer physicians serving them in 1972. New York State, with the nation's highest physician-population ratio, was not spared from the effects of worsening physician maldistribution. New York City's physician ratio was 50 percent higher than Upstate New York's ratio in 1960; and 71 percent higher in 1972. Six Upstate counties, with an average ratio of .76 physicians/1,000 in 1960, slipped down to .56 physicians/1,000 in 1972. New York's metropolitan counties saw their physician population ratio grow by about a fourth since 1960, while the state's non-metropolitan counties suf- fered a drop of 10 percent in their physician ratio. It is perhaps the continuing deterioration of I)hysical manpower in many recommend, in its 1972 Statewide Plan for Higher Education, that medical sc-hools move "as expeditiously as possible to double the total number of medical students in New York State."The implementation of this recommenda- tion is not likely to help doctor-short communities in Upstate New York as much as it would further accelerate the present and projected physician glut in New York City. The purpose of this paper is to compare the growth in physician numbers and their redistribution since 1960 in New York State and three other large urban states-California, Illinois, and Ohio. and to trace the role of medical education and graduate training efforts by these states in current and pro- jected increases in medical practitioners for these states. The major findings are that New York State is exerting a much greater effort than other states in predncing physicians, and is receiving much more than its share of the nation's physicians, hut that there is little connection between the effort and the reward. Even if it were to reduce its production of physicians by half, New Yoi4k State would probably retain its top ranking in physicians per population in the indefinite future. The maldistribution of physicians in New York State and the nation is not likely to he redressed by further increases in medical school graduates or by any of the efforts made so far to induce physicians to practice where they are needed. Solutions to the problems of physician maldistrihution go hand in hand with solutions to the equally vexing problems of unregulated medical cai~e organiRation and skyrocketing costs-a transformation in health insurance. mode of delivery and methods of reimbursement that is too drastic to be politically feasible before 1980. New York is a large supplier and recipient. California is a low supplier hut a large recipient. Illinois is a large suppliei~ hut a low recipient, and Ohio is both a mediocre supplier and recipent of doctors. Iii all four sthtes. local medical graduates supply a minor fraction of the doctors who lucate PAGENO="0412" 402 their practice in the state. Local graduates comprised in 1972 but 30 to 33 percent of the new practitioners in New York, Ohio and California, and 6 percent in Illinois. That same year, foreign medical graduates (FMG's) supplied slightly over half of New lurks interns, residents and licentiates. }`MG's now comprise 40 percent of all physicians in New York and are pro- jected to exceed 50 percent before 1980. Without any additional increases in enrollment beyond those already in the works, the supply of physicians is projected to grow by 92 percent in New York, 87 percent in California, 73 percent in Illinois, 70 percent in Ohio and 74 percent in the nation between 1970 and 1990. By 1900, New York will have a physician ier 1,000 population ratio of 3.80, 83 percent above the nations projected ratio of 2.24, and 91 percent above the ratio of 1.99 pro- jected for Illinois. The assumptions underlying these projections are that the government will not try to increase enrollments beyond those now in the works, that the Asso- ciation of American Medical Colleges will impose a single high standard of graduate training for both foreign and F. S. trained graduates, and that inter- state migration patterns of physicians will revert to the pre-Medicaid period of 1950 to 1967. THE GRAVITATION OF PHYSICIANS TO URBAN AREAS ON THE TWO COASTS Tenth highest among the world's nations in physicians per population, the United States suffers not from a shortage of physicians, but from a mal- distribution of physicians. No one can really tell how many physicians per population we need, any more than one can tell how many hospital services, regardless of real need. generally determines norms such as physician and hospital bed-populaton ratios. Yet, when we witness huge disparities in physician-population ratios of communities, of the order of 15 to 1 among New York counties, for example, it is hard not to conclude that some com- munities enjoy large surpluses of physicians, while other communities suffer from dangerously low numbers of physicians. When we look for explanations for these huge differences in state and county physician-population ratios, two variables stand out-population density and regional location. Hospital beds. contrary to conventional wisdom, bear no perceptible relationship to physician-population ratios. In 1972, the tenth of Americans living in t.he 1.805 counties of lowest popu- lation density-per capita income had 9 percent of the nation's hospital beds, but less than 4 percent of the doctors. On the other hand, the 20 milliio'n Americans living in the 12 counties of highest population density-per capita income had 9 percent of the hospital beds and 16 percent of the na~on's doctors. Thus, these two extreme deciles of counties have identical hospital bed-population ratios hut a disparity of 4 to 1 in physician-population ratios. The nation's 300 metropolitan areas encompass the most densely populated and affluent counties, and their physician-population ratio is more than twice that of non-metropolitan areas. These metropolitan areas contain 73 percent of the nation's people. 74 percent of the hospital beds, 86 percent of all physicians, and 93 pero~nt of all hospital-based physicians. Tn 1972, the ratio of physicians per 1,000 population in metropolitan areas was 1.84; for non- metropolitan areas, it was .82. Doctors can exercise considerable latitude when choosing a location because they operate in a seller's market. In addition to a penchant for large and affluent communities. doctors show a preference for regions with a reputation for a good climate and cultural amenities. Attractions of this nature explain why New York City, New England. and the West Coast have physician- population ratios two to three times higher than those of less well-endowed regions. Physician-population ratios in the largest urban areas are affected by regional amenities as well. Looking at the two most populous coastal states and mid-continental states. we find that the ratios of physicians per 1.000 persons in 11172 were 2.44 in New Yni'k. 2.02 in California, 1.45 in Illinois and 1.37 in Ohio. Moreover, metropolitan-non-metropolitan and regional differences have widened since 1960 in snite of the addition of 106.400 physicians to the supply of P.S. physicians. The physician-population ratio in metropolitan areas grew by 30 percent between 1960 and 1972. hut only by 9 percent in non-metropolitan areas. The ratio was 89 Percent higher in metropolitan areas than in non-metropolitan areas in 1960: it was 105 nercent higher in 1965. 116 percent higher in 1970 and 124 percent higher in 1972 (Table 1). PAGENO="0413" 403 Physician-population ratios climbed 30 percent in New 1rk and 37 per- cent in California. but only 17 percent. and iS 1)erceiit respectively in Illinois and Ohio. The two coastal states had close to 40 percent more physrcians per Population than Illinois and Ohio in 1960. By 1972. they had almost 60 per- cent more physicians per population than illinois and ohm (Table 1). In California, both metropolitan and non-nlctrop)l itan counties enjoyed similarly high growth rates, but in the three other states, the metropolitan areas regis- tered gains of between 20 and 31 percent. whereas the non-metropolitan areas showed losses ranging between 5 and 8peNeult (Table 1). The importance of population density in attracting paysicians is clearly illustrated in Table 2, which divides the four states and the United States Into 5 groups of metropolitan counties and 4 groups of non-metropolitan counties according to population size. Witb the exception of Los Angeles and San Francisco, we find that phvsncian-population ratios vary positively with population size for each rung of the ladder. For the United States, the ratio is 4 times higher in the largest metropolitan areas than it is in counties of under 25.000 people. We also note in Table 2 that ratios have gone up more since 1970 in the larger county groups than in the smaller county groups. Finally, we may see in Table 2 that for given population densities, physi- cian-population ratios are consistently higher in New York and California and consistently lower in Illinois and Ohio than national norms. All 9 county groups in California have higher ratios than all but the three largest county groups in Illinois and Ohio. The physician-population ratio does not directly measure physicians' serv- ices. In Table 3. we have identified three distinct types of physician services- private office practice, hospital-based practice. and education, research and administration. Since 1960, private physicians have gained the least-23 percent in number and 11 percent in population ratio. Hospital-based physicians have increased by 121 percent in number and 94 percent in population ratio. Depend- ing on how we apportion the time of hos'pital-hased physicians for patient care, the gain in patient care physicians icr population since 1960 is somewhere between 14 and 16 percent, or about half of the 28 percent gain in the overall physician-population ratio. MEDICAL MANPOWER SINCE I 950 Back in 1960, 17 percent of tht' new licentiates, 19 percent of the interns, and 29 percent of the residents were foreign aiedical graduates. By 1972, 46 percent of the new licentiates, :i.T oerceal of the iiiteriis md 32 percent of the residents were foreign graduates. ir the entire 12-year period. 25 percent of the ne~v licentiates, 27 percent of the intm'riis and ~2 per('ent of the residents were foreign graduates. Thus, in the 1960's, FMG's male up about a fourth of the nation's new physicians. but current levels of FMG trainees and licen- tiates indicate that they will constitute about. a third of the new physicians In the 1970's. The contributions of undergraduate education, graduate training and migration to the pool of practicing physicians are more difficult to ascertain at the state level. But certain indicators are available that suggest huge dis- parities among states in medical educational efforts and records. and sug- gest that there is little connection between a state's efforts in educating physicians and its supply of medical practitioners. Our four large urban states proi-icle examples of these di-sparities. Let us first look at the production and supply of `U.S. medical graduates since 1960. Table 4 gives us the annual progressior. through the stages of first-year students. and graduates of ITS. medical schoolF. of interns. first-year residents, and all graduate trainees, and finally of licentiates that are P.S. graduates. If through the 12 years. all first-year students graduated in four years and all took one year of internship and three years of residency training, and all applied for and received their license, the tw-o four-year cycles of undergraduate and graduate training would exhibit a consistent progression. increases in first- year enrollments would show corresponding increases in graduates, interns, residents and licentiates four, five. eighl and nine years later. But variable proportions of students drop out, graduate in three. five or more years, go di- rectly into residency, and apply for and receive licer,ses. Perhaps the most significant changes in the 12-year period occurred since 1967. with the adop- tion of many three-year undergrsduate programs, the recruitment of minority students, the elimination or optional bypassing of internships in primary care PAGENO="0414" 404 specialties, and the adoption by most states of the FLEX licensure examina- tion In 19430, minority students comprised 3 percent of all medical students; by 1972 they comprised 10 percent of total enrollment Currently, about 12 per- cent of minority students repeat the first year (coiiipared to one percent of white Students) and 11 percent drop out before graduation (compared to 3 percent of white students) In 1960, all graduates had to take a year of internship. In 1972, 1,593 U.S. graduates (17 percent of graduates in 1971 went directly into residency pro- grams primarily in psychiatry, family practice, general surgery, internal medicine, and obstetrics-gynecology. This accounts for the disparity between a 2 percent decrease in interlis and a 53 percent increase in residents between 1960 and 1972. In 1972, 33,400 licenses were issued by state examining boards-12,869 by examination and 20,531 by reciprocity or endorsement This represented a 20 and 10 percent increase, respectively, over 1971. Of these 33,400 licentiates, 14,476 received initial licenses (an 18 percent gain), representing net addi- tions to medical practices. These large increases are due in part to the adop- tion by all states but Delaware, Florida and Texas of the uniform FLEX examination. The components of gains since 1960 in U.S. trained medical manpower are given for the four large urban states in Table 5. Both absolute numbers and ratios per 100,000 residential population are show-n in the table. There are a number of w-ays to interpret these figures in terms of medical educational efforts and rewards of the states. First, we may compare the efforts and rewards of the state relative to other states and the nation using population ratios. In 1972, New York's con- tribution as state of residence of medical students was 45 percent higher than the nation's ratio. New York educates slightly fewer than the number of stu- dents who originate from New York. The state's ratios of first-year students and graduates are 24 and 34 percent above the nation's ratio. New York trains slightly more graduates than undergraduates. Its ratios of interns and resi- dents are 49 and 42 percent respectively above the nation's. New York's share of licentiates conforms closely to its gra(luate training effort. Its ratio of licentlates is 46 percent above the nation's. An alternative way of assessing New- York's efforts and rewards In the production of doctors is to express its numbei~ of U.S. trainees as a percentage of national totals. The six significant percentages can he written as follows: In 1972, New York comprised 8.9 percent of the nation's ispulation, 12.9 per- cent of first-year medical students by place of residence. 10.9 percent of first- year students by place of school, 11.8 percent of the medical school graduates, 12.9 percent of U.S. interns. 12.7 percent of U.S. residents, and 13.0 percent of U.S. licentiates. For New York State, at least, there appears to be a solid relationship between effort and reward in the production of doetor's-w-ith shares of be- tween 11 and 13 percent of the nation's trainees and licensed doctors. But New York is about the only state for w'hich this relationship holds. Compare, for example, the 6 percentages in 1972 for California, Illinois and Ohio. California has 9.8 percent of the nation's population. 6.9 percent of first-year students by state of residence, 6.6 percent of first-year students by state of schools, 6.9 percent of the graduates. 17.2 percent of TJ.S. interns, 14.4 percent of U.S. residents, and 15.6 percent of the ITS. licentiates. The corresponding per- centages for Illinois are-5.4. 6.0. 6.2. 6.3, 3.9, and 2.4 percent. The figures for Ohio are 5.2. 4.3, 3.3. 5.6. 4.4, 4.4 and 4.0 percent. New York Is in the exceptional position among the states of being attractive to doctors and a big producer of doctors. In 1972. New York ranked among the top 10 states in the population ratio of medical students by residence (2nd), graduates (R), interns (5th). and licentiates (8th). But the ranking of the three other states show an entirely different pattern. Among the states, California ranks ninth from last as state of residence of first-year students and sixth from last in producing medical school graduates per inhabitant, hut ranks 10th hIghest in receiving new medical practitioners, while Illinois ranks 5th highest as state of residence of first-year students. and 14th highest in the production of doctors per inhabitant. hut ranks 13th lowest in receiving new medical practitioners. Illinois educates two to four times as many American doctors as it receives as hospital-based interns and residents and PAGENO="0415" 405 as licensed practitioners. California, on the other hand, educates half as many doctors per inhabitant as Illinois but receives twice as many interns, residents, and practitioners. Ohio had a dispr'oportionately high number of graduates in 1972 because of the coincidence of 3-year and 4-year graduates. Using 1971 data, Ohio ranked 35th as state of residence of first-year students, 31st in the production of doctors, and 30th in receiving new practitioners. Thus, Ohio has a relatively balanced position as mediocre supplier and recipient of doctors; Illinois is a big supplier but poor r'ecipient of doctors; California is a Ioor supplier but a heavy recipient; and New York is both a heavy supplier and heavy recipient of doctors. A somewhat mare accurate pattern of the importation and exportation of doctors among the states emerges if we allow for the eight-year pipeline of medical training by comparing 1972 licentiates with 1968 graduates and the entering class of 1965 (Table 6). As states of residence, New York and Ohio are moderate exporters of doctors, but receive about as many doctors as they educate. In contrast, among the 50 states, California and Illinois are by far arid away the major importing and exporting staj~s. In 1972, California Imported 725 graduates and Illinois exported 352 graduates, based on state of gi~duation. Based on the *state of original residence, California imported 622 graduates and Illinois exported 297 graduates. The equity in numbers of graduates and licentiates shown by New York and Ohio does not mean that all New York and Ohio graduates choose to locate their practice in the same area In 1972, 58 percent of New York graduates located in New York; 13 percent went to California, and 1 percent went to Ohio. The distribution of Ohio gr~aduates w-as 74 percent in Ohio, 6 percent in California and 6 percent in New York. Only 29 percent of Illinois graduates located in Illinois, 26 percent went to California: 11 percent to New York, and 2 percent to Ohio. California graduates showed the highest retention rate among the four states-82 percent remained in California; 4 per~cent went to New York, and 1 percent w-ent to Ohio. The above figures show initial migration of graduates of the four states in terms of first licenses obtained in 1972. We also have information on the present~ state of practice for all graduates from these states. For New Yoi'k graduates, 49 percent are in New York, 9 percent in California, 7 percent In New Jersey and 3 percent. each, in Connecticut, Massachusetts and Florida. From the perspective of U.S. graduates pr~icticing in New York. 58 percent are graduates of schools in New York, and 5 percent, each, come from schools In the District of Columbia, Illinois, Massachusetts and Pennsylvania. Thus. New York gets back as ITS. licentiates about the same number of doc- tors as it graduates by having about. half of its graduates remaining in New York and depending on out-of-state schools for the other half. So far in this section, we have dealt only with U.S. ti~ained doctors. We did note earlier the large inroads made since 1960 by foreign graduates in supplying the nation's interns, residents and licentiates. New York and Illinois stand out among the 50 states in dependence on foreign graduates. Curi~ntly, slightly over half of New York's interns, residents and licentiates are FMG's. Illinois has even higher proportion of FMG's among its new doctor~. In 1972, two- thirds of its interns, half of its residents, and three-fourths of its new licentiates were FMG's (Table 71. Ohio. too, depends heavily on FMG's. who make up about half of that state's new- trainees and practitioners. In con- trast, FMG's comprised but 4 percent of California's interns, 20 percent of its residents and 9 percent of its new licentiates. THE FMG INVASION OF THE ITNFrED STATPS In 1972, FMG's comprised 13 percent of all practitioners in the United States. 35 percent of the interns and residents. 32 percent of the full-time hospital staff. 12 percent of all physicians in administration, 20 percent of those In teaching, and 30 percent of those in research. The sharp increase in the proportion of FMG licentiates between 1970 and 1972-from 27 to 46 percent in the P.S.. 17 to 52 percent in New York and 31 to 77 percent in Illinois-is due in large part to legislation in 1970 (P.L. 92-2251 relaxing immigration restrictions for FM(~'s. Before 1970, it was estimated that about 2.04)4) FMG's returned home each year. The current esti- mate is that only about 300 return home each year. About 60 percent of the PTsIG's may now enter the United States directly as immigrants, and n~rnut 89 percent enter as exchange visitors and later apply for immigrant status. PAGENO="0416" 406 The developing nations of Asia are the major sources of FMG's. In 1972, India, the Philippines, Korea and Taiwan supplied a third of all FMG licen- tiates. FMG's gravitate to large urban areas even more than American physi- cians. I~ss than 10 percent of all FMG's are located in metropolitan areas. FMG's favor New York City, Washington, Chicago and other large mid- continental urban centers. in addition to New York, Illinois and Ohio, the states receiving the largest infusions of FMG licentiates in 1972 were Michi- gan (71 percent), Virginia ~68 percent). I'ennsylvania (67 percent) and Missouri (60 percent). T~rhan centers on the east and west coasts that are highly attractive to U.S. doctors tend to draw fewer FMG's. Only a tenth of California's licentiates, and a third of the licentiates in Massachusetts and Maryland were FMG's in 1972. FMG's comprised about 38 percent of New York's physicians in 1972. If FMG's continue to capture half of all new licenses in New York, their pro- portion of the state's medical manpower will exceed 50 percent before 1980. (See Table 8). Already. FMGs outnumber American doctors in many hos- pitals and poverty communities in New York City. Concern over the prolifera~on of FMG's in the nation's large cities Is no doubt a factor in the desire of some peoJ)le to increase U.S. medical school enrollments, as exemplified by the recommendation in the 1972 Plan of the New York State Board of Regents to (b)ul)le that state's enrollm.ent. This con- cern is apparently more than xenophobic bias. What few measures of perform- ance are available indicate generally that F'MGs are less competent than U.S. medical graduates. In the last ten years. the licensure examination failure rate was 36 percent for FMG's arid 6 percent for USMG's. A second measure of performance is the exaniination for certification by the Educational Council For Medical Graduates (ECFMG). In 1972, 60 per- cent of FMG applicants failed this examination, compared with 1 percent of U.S. graduates. Lack of fluency in English is no doubt a factor in the high failure rate of FMG's. However. 64 percent of American-born FMG's failed the ECFMG examination in 1972. Also, the major supplying nations are either English-speaking or have an English-speaking upper class. Specialty board certification is a third measure of competence. Of those eligible for l)oard certification, 23 I~ercent of the FMG~s and 43 percent of the USMG's were certified in 1972. Two-third of the FMG's failed their first specialty boards in 1972. compared with 27 percent of the USMG's. The last and perhaps least meaningful measure of performance is income from medical practice. According to the AMA's Periedic Survey of Physi- cian's median income in 1972 was $50300 for U.S.-horn-U.S.-trained physi= clans, 849.900 for foreign-horn-U.S. trained physicians. 845.100 for U.S.-born- foreign-trained physicians, and 832.100 for foreign-born-foreign-trained physi- cians. The impact of FMG~s has been the most severe in hospitals where house staff are needed to give patient care and in public institutions like mental and county hospitals where salary levels canot attract U.S. graduates. A less direct effect of the large numbers of FMG's in graduate training positions has been to take the pressure off U.S. medical schools to increase enrollment. The institutions that stand to gain from a supply of physicians willing to work for less-salaries un(ler $25000 a yea r~--and of physicians willing to practice in urban communities foresak-en by F. S. doctors were behind the 1970 legislation relaxing inimigratin controls. Perhaps the medical schools too benefited from the respite during the eight-year lag in converting ex- panded medical enrollments into pPacticing doctors. Even organized medicine foresaw some advantages in having FMG's fill the void left by U.S. physicians in these institutions and communities. The major beneficiaries are the FMG's themselves who can earn three to ten times more in the United States than in their homeland. Another benefit. stressed in an October 22, 1973 JIMA editorial, is that FMG's come for graduate training in the United States to learn skills not taught in their home- land, and stay here because the facilities and illnesses are more apnropriate to their training.' Both hypotheses of higher income and better training are supported by the evidence that two-thirds of FMG's are from underdeveloped countries. There are many more FMG's eking out a living at $15,000 a year as unlicensed practitioners in American public hospitals than FMG's earning between $100,000 and $500,000 a year. But it is well publicized stories of the 1 `Physician migration: Brain drain or overflow." (editorial) J.A.M.A., 228 :714, 1973. PAGENO="0417" 407 hundreds of FMG's who make big money from Medicaid that get back to the countries where these FMG's originate. In New York City, Chicago and Los Angeles alone, there are several hundred part-time FMGs that earn over ~100,00O a year from Medicaid, comprising two-thirds of all physicians in that income bracket. In what other nation and what other profession can someone two to three years out of school earn that kind of money? Perhaps hardest to understand is the willingness of underdeveloped na- tions short of both capital and doctors to train doctors at ~10,000 per head for exportation to the United States. The most plausible explanation for the toleration of this dollar and brain drain is the large influence wielded on government by the aristocratic families whose children want to make their future in the United States. The 50 percent increase in U.S. medical school enrollments during the late 1960's will be felt in corresponding increases in U.S. licentiates in. the late 1970's. FMG's will be more expendable in the years ahead, and pressure Is mounting for curtailing their influx. In a November 20, 1972 editorial, the AMA asked: "Isn't there something awry when the United States must depend on the immigration of FMG's for its supJ)Iy of physicians, while at the same time United States schools are forced to turn away qua~1fled applicants"? 2 One answer is the plan of the Association of American Medical Colleges to limit future internship and residency positions to 125 percent of curr'ent graduating clas.ses. If this idali should be accepted and Imple- mented, it would mean that the proportion of FMG's in graduate training positions would drop from its present third to a fifth. But unless state quotas are assigned, It would entail even greater FMG gravitation to the large urban states where they are presently gravitate. Even though FMG's are even more attracted to metropolitan areas than FSMG's, at least they tend to go Into urban communities, institutions, and programs neglected i)y American graduates. Is It certain that new gains in USMG's will filter down to these places If the FMG influx Is curtailed? EXPANDED MEDICAL SCHOOL ENROLLMENTS AND FUTTRE MANPOWER PROPOSALS All four large uitan states expanded places in existing schools and built new schools to greatly expand medical school enrollments between 1960 and 1972. In these 12 years. entering classes increased 46 percent in New York, 124 percent in California. 51 percent in Illinois. and 33 percent in Ohio. Graduating classes increased 32 percent in New York. 113 percent in California, 44 percent in Illinois. and 33 percent in Ohio. The new schools are Mount Sinai and Stony Brook in Xew York. Irvine. Davis and San Diego in California. Rush, Southern Illinois, and the Peoria. Rockford and Urbana- Champaign branches of the University of Illinois College of Medicine in Illinois, and Toledo in Ohio. A larger supply of local doctors u-as the avowed goal of these ambitious and costly school expansions. Yet, because of the migration of USMG's and the immigration of FMG's reported caner, local graduates in 1972 com- prised but 30 percent of the new licent.iates in New York: 6 percent in Illinois. 32 percent in California. and 33 percent in Ohio. Thus. in terms of direct cost-benefit, Illinois get-s hack (3 cents. and California. New York and Ohio get back between 30 and 33 cents for every educational dollar it. ~ New York and California attPact s many out-of-state VS~[G's and FMG's and Illinois retains so few of its rradnates that these three states could shut down their medical schools next year with few. if any, deleterious effects on their supply of doctors in the years to come. Indeed, such action might mitigate the physician surplus crisis that will confront New York and California If present migration trends continue unchecked. Only Ohio among the four states would suffer from a shutdown of its medical schools. Illinois w-ould suffer wit.h or without it. Such drastic surgery is purely hypothetical. of course. The pressure from universities, communities and state legislatures for new medical schools will probably continue, the dangers of physician overflow notwithstanding. In New York alone, there are eleven proposals for new schools in varying stnge~ of consideration. S3-rnptonlatic of the new medical school syridromo is the recent call by the New York Board of Regents to doubt medical school enrollments. `"Too many modh'al school npplli'ants" (editorial) ,T.A IrA., 222 :1 O51-52, 1072. PAGENO="0418" 408 In its 1972 Plan Fer Higher Education, the Board of Regents of New York recommended that medical schools move as "expeditiously as possible to double the total number of medical students in New Yor'k State." The Asso- ciated Medical Schools of New York and New Jersey disagreed with the Regents' recommendations citing recent radical growth in the medical schools in the State, arguing that deficiencies in the health care system derived not from absolute numerical shortages, but from specialty and geographic cluster patterns that did not mirror needs for service, and noting that the issues raised had national implicã~tions. Many of the new schools being proposed in New York and other states are away from existing medical centers in large cities. Several `states are consider- ing legislation that would authorize the construction of new schools in con- junction with existing hospitals in medium-sized cities. Some states are also studying the Illinois and Indiana models of downstate branches and sub- divisions of the state university medical school. The Illinois and Indiana plans have the dual objectives of increasing re- cruitment of downstate students and of establishing regional medical centers that will attract new practitioners. Under the Illinois plan, first-year basic science schools in Chicago and Urbana feed second-year students to three- year clinical schools in Chicago. Peoria. Rockford. Springfield and Carbondale. It will take a decade or more to evaluate the impact of these dispersed medical campuses on recruitment and on the distribution of practitioners in downstate Illinois and Indiana. The first years of the Illinois plan have not been accompanied so far by any significant increase in recruitment of down- state Illinois students. Only 31 percent of the students in the 1973 classes originated from downstate. This is about the same proportion as when t1~e University of Illinois Medical School had its only campus in Chicago. In the past, only 7 percent of flhinois graduates located their practice downstate. It will be six years before the fir~t graduates of the dispersed campuses will he able to improve on that statistic. In the meantime, few states are expected t.o emulate the examples of Illinois and Indiana. These models are bucking too many trends in medical education-larger enrollments under one roof, closer ties with basic science departments and major universities, and more integration with large urban teaching and research hospitals for undergraduate and graduate training. PROJECTS OF MEDICAL MANPOWER TO 1990 Pressure for more medical schools should let up when the full effect of the 1966-72 expansion in school enrollments and of the 1970-72 upsurge in F~MG's begin to be felt in the late 1970's. The elements for projecting the active physician supply in future years are: (1) the existing pool of U.S-trained physicians less annual losses by retire- ment and death. (2) the new graduates from U.S. medical schools less normal losses by retirement and death, (3) the existing pool of FMG's less losses through emigration, retirement and death and, (4) new FMG immigrants less losses through emigration, retirement and death. The Bureau of Health Manpower Education of the National Institutes of Health has developed methodologies to project under a variety of assumptions the total supply of physicians for the years 1975. 1980. 1985 and 1990.~ For simplicity's sake, we may reduce the controlling variables to three-the future level of federal support of medical education for projecting the output of 1TISMG's. the future policy of the United States with regard to the entry of FMG's as permanent residents and the filture policy of the AAMC with respect to restricting training positions available to FMG's. The Health Professions Educational Assistance Act of 1963 resulted In a large increase in federal support of medical education, and was responsible. in large part, for increasing the number of medical schools from 87 to 108 and entering classes from 8.722 to 13.726 between 1963 and 1972. The pro- portion of medical school expenditures covered by federal funds went up The Supply of Health Manpower. 1979 Profiles and Projections to 1990. Interim Report No. 73-44. t~.S. Department of Health. Education. and Welfare, National Insti- tutes of Health, Bureau of Health Manpower Education, February 1973. PAGENO="0419" 409 from one third in the early 1900's to slightly over half in the late 1960's. Construction of new schools and expansion of existing schools with the help of federal construction and capitation grants appear to have been the major determinants of enrollment gains in this period. The institutional formula grants available under the HPEA Act of 1963 were replaced by capitation grant.s in the Comprehensive Health Manpower Training Act of 1971 (P.L. 92-157,), with incentives to shorten curricula, promote assistants' training, and increase enrollment. It is expected that after the expiration of this Act, state and federal fundhlg will maintain enrollments at the existing levels. Federal construction funds and new student capitation funds are not expected to be continued. Federal support will probably match state support 50-50, and would be aimed at maintaining the higher enrollments spurred by the 1963 and 1971 legislation. On this assumption, annual enrollirient increases of 1.3 percent were pro- jected for the period 1975-1990, a rate of growth similar to that of the period 1952-1966, before the effects of the HPEA Act. The number of graduates is expected to rise from 8,979 in 1970 to 15,920 in 1990, an increase of 77 percent (versus a 28 percent increase in 1960-70). Adding the graduates to the existing pool of physicians, after deducting losses due to retirement and death, the supply of U.S-trained physicians would grow to 398,400 by 1980, or 50 percent above the 1970 supply. The annual growth rate of active physicians is expected to rise from 1.6 percent in 1960-70 to 1.7 and 2.4 percent in 1970-80 and 1980-90. The physicians per 1,000 population ratio is projected to rise from 1.25 in 1960 and 1.29 in 1970 to 1.38 in 1980 and 1.59 in 1990. By coinci- dence, the projected ratio of 1.59 U.S-trained physicians per 1,000 population Is identical to the ratio of all physicians in 1970. (Table 8) Many more variables will affect the future entry and training of FMG's. But future policies of the government and of the AAMC are the only ones considered in projecting FMG inputs to the physician supply. It is predicted that the federal government will modify its present permissive immigration policies by allowing only those FMG's who can obtain a license to remain. The AAMC and the AMA will probably join forces in implementing a national quota on FMG trainees. The attrition of internships and the affiliation with medical schools of all hospitals with training programs are other policy trends that will tend to squeeze out the FMG's by raising admission and training standards to the leve.l of school-affiliated residency programs. In the decade before the 1970 legislatIon, there was an annual increase of 3,800 FMG's. In 1971, the net increment rose to 5.200. In the absence of restrictive policies by the AAMC and the AMA, permissive Immigration laws might Induct an annual Increase of 6.600 FMG's. It is predicted that AAMC- AMA restrictions will be mitigated by relaxation of citizenship and licensure standards In and for states, Institutions and communities that will continue to depend on FMG's because of the unwillingness of USMG's to serve. The prediction Is that the Inflow of FMG's will continue at the annual rate of the 1960's. but that their retention will be at the 1971 figure, resulting In a net annual Increment of 5,200. FMG's accounted for most of the 25 percent gain In the physician-population ratio between 1960 and 1972. The above projection would increase the FMG supply from 60.000 to 162.000 and the ratio from 0.20 to 0.65 between 1970 and 1990. The proportion of all physicians that are FMG's is expected to rise from one-fifth In 1970 to one-third In 1990. Adding together projections of IJSMG's and FMG's. the number of all active physicians in the United States Is expected to rise by 95.000 (32 percent) In 1970-SO and by 132.000 (32 percent) In 1980-90. This compares with a gain of 89.000 (44 percent) In 1960-70. Total numbers of physicians would c1im~ from 222.000 in 1960 and 311.000 In 1970 to 408.700 in 1980 and 541,000 in 1990. The overall physician-population ratio Is expected to climb from 1.59 in 1970 to 1.87 in 1950 and 2.24 in 1990. (Compare New York State's ratio of 1.87 in 1960 and 2.35 in 1~70). Projections of the nation's supply of physicians In 1950 and 1990 may he allocated to states by projecting migration natterns by state of graduation of USMG's and state of training of FMfl's. Migration from Inland to coastal states was sharply increased by Medicaid and Medicare. `Rut it Is exyiected that these flows will not he maintained because of the saturation of the Me'~1- caid and Medicare markets In the coastal states ~nd because of utilization controls that will he developed by Professional Standards Review Or'ganiza- 33-698 0 - 74 - 28 (Pt. 1) PAGENO="0420" 410 tions (PSRO's) as required by the Social Security Amendments of 1972. Thus. it was assumed that the locational liatterns in 1967, on the eve of Medi- caid and Medicare, of the 1950-54 and of the 1900-64 classes provided the best approximations of the locational latterns of future USMG's. Unfortunately, longitudinal migration data are lacidng for FMG's and the projection of recent migration patterns of FMG-'s resulted in overwhelming majorities of FMGs in large urban states like New York and Illinois. Instead, the total supply of FMG's projected for the nation was allocated on the basis of their 1970 distribution. This is probably too conservative an assumption, hut no good alternative projection could be constructed because of the lack of longitudinal data. The supply of U.S-trained and foreign-trained physicians projected for' New York. California, Illinois and Ohio is shown for the years 1970 to 1990 In Table 13. During this 20-year period, the number of active physicians Is expected to grow by 92 percent in New York, 87 percent in California, 73 percent in Illinois and TO percent in Ohio. The physician-population ratio will climb from 2.33 to 3.80 in New York, from 1.93 to 2.50 in California, from 1.39 to 1.99 in Illinois, and from 1.31 to 1.22 in Ohio. Disparities in r~.tios between New York and the nation will continue to increase. New York's ratio, 55 percent above the national ratio in 1970, will be 83 percent above the national ration in 1990. New York's ratio superiority over the Illinois ratio will rise from 68 percent. in 1970 to 91 percent in 1990. By 1990, FMG's will comprise 56 percent of all New Yor'k physicians, 48 percent of all California physicians. Illinois and Ohio will continue to be shunned by U.S-trained physicians, and their' USMG ratios will show little gain in the 20 years. Disparities in the ratios of the nation's four regions will accelerate. Ratios In the Northeast and West regions will climb 50 to 45 percent by 1990, while ratios in the Sout.h and North Central regions will rise by merely 36 and 39 percent. New York's ratio will be 4.3 times the ratio of Nevada and Idaho, the states with the lowest ratios in 1990, compared to a 2.3 to 1 differential In 1970. DISCUSSION As stated at the outset, the problem of physician supply is not an absolute shortage of physicians, but one of maldistribution of physicians. Unless we find ways of erasing existing trends of maldistrihution, more money and more doctors will likely reinforce trends as they have in the recent past. Any incr'ease in New York medical school enrollments will simply reinforce the position of New York as the most doctored state in the union and of New York City as the nation's prime medical mecca. Most of the state's and na- tion's communities will remain undeserved no matter what existing solutions are followed. One of the avowed goals of the Social Security Amendments of 1965 was to underwrite physician services in communities that lacked the income base to attract and support physicians. But the contrary and unintended effect of Medicaid and Medicare legislation was to help finance the ftrther gravitation of physicians to states and communities traditionally favored for reasons of amenity, social, and psychological satisfactions for a profession not particu- larly deprived In these satisfactions.4 Other public programs designed to rectify the physician shortage for deprived populations like neighhor'hood health centers, the dispersion of medical school campuses, minority medical student recruit- ment, and the National Health Service Corps hcid little promise in view of the eventual gravitation of this subsidized medical manpower to doctor-rich areas. The Intensive recruitment of rural and minor'ity medical students has often been urged as a solution to more severe shortages of phy~ieians in rural and minority communities. This solution is predicated on the assump- ilon that rural and minority communities are undeserved by doctors in part because rural and minority populations are under-represented in medical schools, that such students are more likely to return to serve the ~opulat1on from which they stem, and that by increasinr the enrollment of such students. the number of doctors who serve these communities can he increased. Past experience, however, is that medical students of all cultural, racial and eco- nomic backgrounds gravitate to large urban centers after graduation. `d~Vtse. P. "Phvai~!nn mirratlon from mm nil to con atal stnt~s: Anttnodal exampleR of Illmnob~ and Caitfornia." Journal of ifMical FMueafion. 48 :141-151, 1978. PAGENO="0421" 411 Programs of forgiveness loans to medical students who agree to serve two to three years in designated underdoctored areas have had a spctty record. Thirty to forty percent of the doctors pay off the loans before completing their service In most of the programs. Although 5t will be a few years before a proper time base is available, it is unlikely that more than a small fraction of thcae doctors will stay on long after they have served their time. A bill Introduced March 16, 1974 in the house of Representatives hy Congressman Roy revises the National Health Service Corps by requiring that doctors who renege on their pledge to serve two years in a doctor-short area pay hack twice the amount of medical education subsidies received. This may increase the retention rate of doctors in the program, hut it will not induce them to stay beyond the two years of service. CONCLU510N5 In light of the Kennedy-Mills compromise of March 1974, it does not ap- pear that any of the major National Health Insurance bills have the potential to improve the distribution of physicians. The disastrous experience of the 1965 health legislation package of Medicaid, Medicare, Comprehensive Health Planning and Regional Medical Program Service has demonstrated that na- tional health subsidy programs that rely on voluntary pluralism without effective public accountability and control do not work. New forms of de- ilvering health care, reimbursement, and controls of utilization, quality and cost ea~visaged in Health Maintenance Organizations. and Professional Stand- ards Review Organizations will, in all likelihood, he preempted by national and local medical, hospital, and third-party payer organizations who will fight each other for the spoils. w'ith government and consumers the hapless and helpless victims. Solutions to the problems of physician maldistrihution are inseparable from solutions to the problems of unregulated medical cave organization and skyrocketing cost~s-a transformation in health insurance. mode of delivery and methods of reimbursement that is too drastic to he politically feasible before 1980. TABLE 1.-PHYSICIANS PER 1,000 POPULATION IN NEW YORK, CALIFORNIA, ILLINOIS, OHIO, AND THE UNITED STATES: 1960, 1965, 1970, AND 1972 Percent County group 1960 1965 1970 1972 change 1960-72 New York: Metropolitan Nonmetropolitan All countien 2.00 1.33 1.87 2.30 1.15 2.15 2.50 1.23 2.36 2.61 1.23 2.44 31 -8 30 California: Metropolitan Nonmetropolitan All countien 1.52 .86 1.47 1.80 1.16 1.71 1.97 1.23 1.90 2.08 1.16 2.02 37 35 37 lllinoin Metropolitan Nonmetropolitan All countien 1.36 .76 1.24 1.48 .78 1.34 1.54 .72 1.37 1.63 .71 1.45 20 -7 17 Ohio: Metropolitan Nonmetrnpolitan 1.26 .73 1.45 .70 1.49 .69 1.57 .69 25 -5 All coutien 1.16 1.26 1.32 1.37 18 United Staten: Metropolitan Nonmetropolitan All counties 1.42 .75 1.23 1.60 .78 1.37 1.73 .80 1.48 1.84 .82 1.57 30 9 28 Note-Excludes physicians in Federal service. Sources: American Medical Association, U.S. Bureau of the Census. PAGENO="0422" Metropolitan counties: Over 5000,000 1000,000 to 5,000,000. - - 500,000 to 1,000,000 100,000 to 500,000 50,000 to 10,000 Nonmetropolitan counties: Over 50,000 25,000 to 50,000 10,000 to 25,000 Under 10,000 All counties 1.04 1.05 1. 19 1,21 .74 ,78 .95 .98 .56 .56 .79 .73 .47 .48 1.48 1.57 2.35 2.44 Note-Excludes physicians in Federal service. Source: American Medical Association, U.S. Bureau of Census. TABLE 3.-PHYSICIANS, BY TYPE OF PRACTICE, UNITED STATES: 1960, 1970, AND 1972 Percent gain Physicians 1960 1970 1972 1960-72 Patient care 193, 016 255, 027 269, 095 39 Office-based practice 161, 293 188,924 198, 974 23 Hospital-based practice 31, 723 66,103 70, 121 Other professional activity 10, 012 26, 317 24, 228 142 Unclassified and inactive 16, 143 19, 979 32, 466 101 All physicians 219, 448 301,323 325, 789 48 Physicians per 1,000 Population: Patient care 1.08 1.26 1.35 25 Office-based practice .90 1.00 11 Hospital- based practice - 18 .32 .35 94 All physicians 1.23 1.48 1.57 28 Note-Excludes physicians in Federal service. Sources: American Medical Association, U.S. Bureau of Census. TABLE 4.-STUDENTS, GRADUATES, INTERNS, RESIDENTS, AND LICENTIATES TRAINED IN AMERICAN MEDICAL SCHOOLS: 1960 TO 1972 All United United States in- l'nited 1st-year States 1st-year terns and States Year students Graduates interns residents residents Iicentiates 1960 8,298 6,994 7,362 7,395 27, 627 6,611 1961 8,483 7,168 6,900 7,889 28,814 6,443 1962 8,642 7,264 7, 136 7,984 29, 313 6,648 1963 8, 772 7, 336 7, 070 8, 076 29, 503 6, 832 1964 8,856 7, 409 7,276 8,227 30, 128 6,605 1965 8, 759 7, 574 7, 309 8, 195 30, 074 7,619 1966 8,964 7,743 7,573 8,117 30,121 7,217 1967 9, 479 7,973 7, 506 8, 480 30, 622 7,343 1968 9, 863 8,059 7, 194 8, 573 31, 010 7,581 1969 10, 401 8,367 7,869 9,250 33, 380 7,671 1970 11,348 8,974 8,213 10,199 34,726 8,016 1971 12,361 9,551 8,120 10,306 36,893 7,943 1972 13,726 10,391 7,239 11,317 37,849 7,815 rercent change: 1960 to 1972 65. 4 48.6 53.0 37.0 18.2 1960 to 1966 8. 1 7. 0 2. 9 9. 8 9. 0 9. 1 1966 to 1972 53. 1 34.2 -4.4 39.4 25.6 8.3 Source: American Medical Association, 412 TABLE 2.-PHYSICIANS PER 1,000 POPULATION BY DEMOGRAPHIC COUNTY GROUP: 1970 AND 1972 United States New York California Illinois Ohio County group by - _____________ ______________ _____________ _______________ population size 1970 1972 1970 1972 1970 1972 1970 1972 1970 1972 2.26 2.38 2.74 2.87 2.01 2.13 1.70 1.80 1.90 2.01 1. 81 1.94 2. 13 2.25 1.92 2.04 1.58 1.65 2.00 2. 12 1.69 1.83 1.35 1.41 1.31 1.44 1.42 1.53 1.42 1.52 1.11 1. 17 .90 .95 1.23 1.26 1.14 1.18 1.02 1.05 .76 .82 1.26 1.22 .81 .82 .76 .77 .95 1.07 .67 .71 .63 .58 .88 1.03 .58 .56 .44 .51 .85 .85 .43 .36 1.90 2.02 1.37 1.45 1.37 1.37 PAGENO="0423" 413 TABLE 5.-STUDENTS, GRADUATES, INTERNS, RESIDENTS, AND LICENTIATES TRAINED IN AMERICAN MEDICAL SCHOOLS, NUMBERS AND RATIOS BY 100,000 POPULATION: 1960 TO 1972 U.S. trainees and year New Number York California Illinois Ohio Ratio Number Ratio Number Ratio Number Ratio United States Number Ratio 1st-year meoical students by State ot residence: 1960 1965 1970 1971 1972 1st-year medical studests by school location 1960 1965 1970 1971 1972 Medical school graduates: 1960 1965 1970 1971 1972 Interns: 1960 1965 1970 1971 1972 1st-year residents: 1960 1965 1970 1971 1972 Licentiates: 1960 1965 1970 1971 1972 1,077 1,327 1,474 1598 1,774 1,025 1,091 1,275 1,469 1,502 930 964 1,179 1,230 1,231 940 1,019 1,111 1,095 936 1,103 1,244 1,391 1,347 1,437 8l7 890 1,009 957 996 6.4 7.3 8.1 8.7 9.6 6.1 6.2 7,0 8.0 8.2 5.5 54 6.4 6.6 6.7 5.6 5.7 6.1 6.0 5.2 6.6 7.0 7.6 7.3 7.8 4.8 5.0 5.5 5.2 5.4 472 576 857 853 947 406 497 638 709 909 336 463 545 619 716 857 990 1,229 1,308 1,242 814 1,030 1431 1,403 1,624 580 1,011 1,056 1,166 1198 3.0 3.1 4.3 4.2 4.6 2.6 2.7 3.2 3.6 4.5 2.1 2.5 2.7 3.1 3.5 5.4 5.3 6.2 6.6 6.1 5.1 5.5 7.2 7.0 8.0 3.6 5.4 5.3 5.8 5.9 435 485 594 748 830 568 565 682 780 855 456 516 579 600 659 277 418 350 302 280 335 359 439 441 442 250 292 238 284 188 4.4 4.5 5.3 6.7 7A 5.6 53 6.1 7.0 7.6 4.5 4.8 5.2 5.4 5.9 2.7 3.9 3.1 2.7 2.5 3.3 7.4 3.9 3.9 3.9 2.5 2.7 2.1 2.5 1.7 439 389 531 531 589 336 338 445 501 448 336 228 352 364 577 328 379 352 345 316 393 395 435 439 494 375 413 296 322 310 4.5 3.8 4.9 4.9 5.4 3.5 3.3 4.2 4.6 4.1 3.5 2.2 3.3 3.4 6.4 3.4 3.7 3.3 3.2 2.9 4.0 3.9 4.1 4.1 4.6 3.3 4.0 2.8 3.0 2.0 8,298 8,759 11,348 12,361 13, 726 8,298 8,759 11,348 12,361 13,726 6,994 7,574 8,974 9,551 10,391 7,362 7.309 8,213 8,120 7,239 7,395 8,195 10,199 10,306 11,317 6,681 7,619 7,815 7,950 7,671 4.6 4.5 5.6 6.0 6.6 4.6 4.5 5.6 6.0 6.6 3.9 19 4.4 4.6 5.0 4.1 3.8 4.0 3.9 3.5 4.1 4.2 5.0 5.0 5.5 3.7 3.9 3,8 3.8 3.7 Source: American Medical Association. 1965 entering clasn by State at residence Imports (1-) sr espurts ~-) 1972 U.S. based on State of- lice ntiates Residence GRduatisn NewYurk Califurnia Illinois Ohio 993 996 -331 +3 473 1, 198 +622 +725 540 188 -297 -352 320 310 -79 -80 TABLE 6-1ST-YEAR MEDICAL STUDENTS BY STATE LICENTIATES, 1972 Stale OF RESIDENCE, 1965; MEDICAL O~RADUOTES. 1958: IS 1968 graduating class by Stste of grad uation 1, 327 576 485 389 PAGENO="0424" 414 T.005 7--NUMBER AND PERCENT OF INTERNS, RESIDENTS, AND LICENTIATES WHO ARE FOREIGN MEOICAL GRADUATES: 1960 TO 1972 Year New York California Illinois Ohio United States Per- Per- Per- Per- Per- Nomber cent Number cent Number cent Number cent Number cent FlOG otoror: 1961 552 34 590 37 27 3 162 41 4 243 27 37 201 191 28 34 1,753 2,361 19 24 906 45 r~7l 919 46 1005 52 3 399 57 4 502 51 4 511 53 62 65 259 341 321 41 50 50 3,339 3,946 3,924 29 33 35 F -year res~7ents - 113* 648 34 25 3 197 27 250 28 2,950 29 *35 93 44 1370 1,439 52 1271 1,436 52 1072 1,554 52 ~ conflates: 35 3 238 99 7 400 94 6 422 125 20 497 40 49 51 53 275 366 362 379 41 47 45 44 3,291 4,994 4,852 5,350 29 33 32 32 1167 222 21 1965 302 34 1870 204 17 1371 486 34 1972 1,115 52 72 11 112 34 3 92 94 8 107 104 8 169 129 9 632 31 32 38 60 77 103 43 ii 198 414 22 10 4 53 57 1,419 1,528 3,016 4,314 6,661 18 17 27 35 46 Guurce: American Medical Association. TABLE 8.--PROJECIED SUPPLY OF U.S-TRAINED AND FO REIGN-TRAINED ACTIV E PH YSICIAN 5, AN 0 PHYSICIANS PER 1,000 POPULATION RATIOS: 1970 TO 1990 New York California United Illinois Ohio States 11u':'r;,'r of chyscranc: iJ.S.-t'aired pliysiciaa&: 1970 1985 1090 ~- Foreign-trained physciar.s: 1970 1975 1980 1935 1990 To*i pnysicians 1970 1975 1980 1985 1983 26. 180 34, 240 10, 930 10, 360 251, 240 26,910 38.380 11,040 10,540 264,290 29,480 45,270 11,850 11,400 296,710 32, 610 53. 120 12, 880 12, 480 334, 970 36,100 61,620 14,050 13,690 377,150 16, 380 3, 850 4, 560 3. 660 59,970 23, 640 5. 300 6, 600 3, 227 65, 970 30,890 6.760 8,650 6,910 111,970 38, 150 8,220 10,700 8,530 137,960 45, 400 9, 670 12, 750 10, 160 161, 970 42,560 38,090 15,490 14,020 311,200 50. 550 43, 680 17, 640 15, 820 350. 250 60. 380 52, 030 20, 510 18, 310 408, 680 70,760 61,330 25,580 21,010 472,940 81,510 71,290 26,800 23,850 541,110 P6~sicians per 1,000 papi1af on: U.S-trained physicrans: 1977 1980 1990 Eorejga-traisod physicians: 1977 1993 1990 1 usa plysrc:0nS. 1970 - 1800 0100 1.43 1.74 .98 .97 1.21 1.49 1.87 .97 .98 1.27 1.68 2.16 1,04 1.08 1.45 .90 .19 .41 .34 .29 1.56 .28 .70 .59 .48 2.12 .34 .95 .80 .63 2.33 1.93 1.39 1.31 1.50 3.05 2.15 1.67 1.57 1.75 3.80 2.50 1.99 1.88 2.08 Source: Bureau of Health Manpowr Edacatioa, National Institutes of Health. PAGENO="0425" 415 Mr. Roy. Thank you very much for a very excellent statement. Mr. ROGERS. There is a conference I have to attend. I will try to get back as soon as possible, and I am grateful to Dr. Roy for chairing the subconunittee. Mr. Roy. Thank you, Mr. Rogers. Dr. Dewey. STATEMENT OP DONALD R. DEWEY, PH. B. Mr. DEWEY. The studies summarized in this report provide ample evidence of an increasing maldistribution of private practice physi- cians' offices in Metropolitan Chicago. The studies I refer to are: "Where the Doctors Have Gone," and the statement, "More Money, More Doctors, Less Care," and "The Changing Age Distribution of Doctors." Mr. Roy. Without objective they will be made a part of the record. Mr. DEWEY. The primary factors contributing to this maldistribu- tion are: (1) *the flight of doctors from the metropolitan area, (2) the suburban flight of doctors, (3) variation in the socioeconomic status of an area, (4) the proportion of blacks living in a community, and (5) the availability of large regional shopping centers in an area. The impact of these shifts in physician office location can be sum- marized by comparing their distribution at three levels of geographic detail: (1) the city and suburbs, (2) *by concentric rings encircling the city's core, and (3) individual municipalities and "community areas." CITY AND SUBURBS Between 1950 and 1970 the city of Chicago lost 2,000 private physicians. Chicago's current physician-population ratio is the lowest in the city's history and is expected to establish new record lows every year for the next 20 years. Chicago had almost two doctors for every 1,000 people between 1840 and 1930. Since that time this ratio gradually slipped to 1.1/1,000 in 1970. Chicago today has half as many doctors per capita as it had in the 1~)th and early 20th century. The suburbs, on the other hand, gained over 1,900 doctors' offices, just about what the city lost, and increased their physician~popula- tion ratio from .91/1,000 to .94/1,003 in the same 20-year period. CONCENTRIC RINGS The Loop, inner city and outer city all lost offices with a resulting decline in the physician-population ratio. The Loop lost over 650 offi- ces and its ratio fell from 18.47/1.000 to 15.36/1,00ft The ratios of the inner and outer city fell from 1.11/1,000 to .75/1,000 and 1.17/1,000 to .87/1,000 respectively. The physician-population ratio of the inner suburbs rose from .94/1,000 to 1.23/1,000 during the same period. The middle suburban ring experienced a decline in its ratio between 1950 and 1960, but gain in that ratio between 1960 and 1970. What this is all saying is that there has been ~ continuous outward shift of doctor's offices. The outward shift was not evenly distributed PAGENO="0426" 416 in each ring, nor was the flight from the city evenly vacated in each ring. Suburban areas of high socioeconomic status gain a dispro- portionately high share of the shifting doctors, while the poor and black areas of the city lost more than their share of doctors' offices. This can best be illustrated by comparing suburban municipalities with community areas of the city. SUBUIIBAN MFNI( IPALITIF~ ANI) (`( )Mi~IFXI'FY AREAS OF TIlE CITY Between 1950 and 1970 the physician-population ratio of the 10 most impoverished community areas of the city dropped from about one doctor per 1,000 population to a little more than one-fourth doc- tor per 1,000. The 10 most affluent suburban municipalities, however, inflated their ratio from 1.78 per 1,000 to 2.1 per 1,000 in the same period. The impact this can have on an area is best illustrated by compar- ing West Garfield Park, a community on Chicago's West Side, with the affluent suburb of Oak Park, located about 2 miles further west. Garfield Park changed from zero percent black population in 1950 to 96.8 percent black in 1970. The racial structure of Oak Park-less than 1 percent black-hardly changed in the same period. These two communities are about the same size and in the same general area. In 1950, there were 161 physicians in West Garfield Park, but in 1970, only 13. Oak Park, on the other hand, had only 73 doctors in 11950 but the number rose to 276 by 1970. West Garfield Park's doctor-to-population ratio fell from 3.5 per 1,000 to about .25 per 1,000 or from one doctor for every 300 people to one doctor for every 3,700 `people, while Oak Park rose from 1.15 per 1,000 to 4.42 per 1,000 or from one doctor for very 870 people to one doctor for every 225. This means there are over 16 times as many people for each doctor in West Garfield Park as in Oak Park. Thus, one finds a situation where more doctors are found in the afflu- ent white suburb of Evanston, Ill., than in all of south Cook County; there are more in rich Wilmette than in all of southwest Cook County; and more are in the tiny affluent suburb of Winnetka than in all of Will County. Such disparity in the distribution of doctors in the Chicago area makes it difficult not to conclude that some communities enjoy large surpluses of physicians while other communities suffer from dan- gerously low numbers of physicians. [The three studies referred to, follow:] PAGENO="0427" 417 WhERE uHF I)O(i~fORS H%~E (;o\E 0 The Changing Distribution of Private Practice Physicians in the Chicago Metropolitan Area, 1950-1970 PAGENO="0428" 418 Where The Doctors Have Gone The Changing Distribution of Private Practice Physicians in the Chicago Metropolitan Area. 1950-1970 Donald Dewey, Ph. D. t)PauI I niv~r.itv IILI~.4 )J'~ REGI( ~\ %I. MF;DI(;4I~ PROGRAM (UI( AGO RE{;I~ r~ u~ IIOSI'ITAL ST~D'~ RE~IAI{(iI I'AI'ER 1973 PAGENO="0429" 419 Copyright 1973 by Donald Dewey Published 1973 by the Chicago Regional Hospital Study illinois Regional Medical Program Research Paoers Phinois Regional Medical Program Chicago Regional Hospital Study 122 S. Michigan Avenue Chicago fl1~nns 60603 PAGENO="0430" 420 ACKNOWLEDGEMENTS There is no way I can fully show my appreciation to all those who contributed to to the completion of this study. However, even though it may be only token payment, I wish to extend my sincerest thanks to everyone who assisted. Especially, I want to ac- knowledge my appreciation to the following persons and agencies. Professor Dean Rugg, my Advisor, who set a standard and example of excel- lence combined with pertinent tactful direction which inspired me to seek a higher quality in my work than I had previously achieved. Pierre de Vise, Director of Research for the illinois Regional Medical Program, who from the inception of the idea to the concluded study used his extensive background and insight to give timely, relevant counsel. Professor Robert Nichols, a real friend and a true scholar, who acted as a sounding board to help me formulate and conceptualize many of the basic ideas of the study. His mastery of scholarly writing techniques was also exceedingly helpful. Brent Tolman, who provided technical computational skills. The long, late nights and very early mornings he spent with me at the Computation Center programming and debugging the programs used in this study will never be forgotten. Stan Grzeda, who used his talented hands to perform the small miracles of translating vague sketches into meaningful maps and diagrams. Bryan Lovelace, Deputy Director of the Illinois Regional Medical Program, who helped obtain critically-needed data and financial support for the study. Betty Kazmarz. Secretary at DePaul University, who typed the rough draft of several chapters: Fay Orchard, who edited the manuscript and typed the final draft; Ruth M. T. Ramirez. Planning Assistant at the illinois Regional Medical Program, who edited the final copy; and Martha Latko, [RMP Secretary. who typed the final copy. Wayne Dust, Vicki Dewey, and Sue James, who all spent many hours compiling the seemingly endless pile of data which was necessary for the analyses made in the study. Other staff members of the illinois Regional Medical Program, who were very helpful in many ways, particularly John Denne and Gerald Falk. The many agencies, both public and private, which contributed to the study. Particularly the illinois Regional Medical Program which assisted in the research by pro- viding data and part of the necessary funding through Grant # 3G02 RM00061-03A1. (The conclusions of this study, however, do not necessarily reflect the views of the Illinois Regional Medical Program.) Finally, and most importantly, I am ever grateful to my wife Pat who labored diligently into many long nights and yet still kept our household running smoothly, and to our daughters, Vicki, Jana, ,Julie, and Jenny, who all did without so many things that I might accomplish this work. 1-li PAGENO="0431" 421 PREFACE by Morton C. Creditor, M.D. Executive Director illinois Regional Medical Program This study describes and analyzes the changing distribution of all private practice physicians' and specialists' offices in the Chicago Metropolitan Area between 1950 and 1970. It focuses on the most significant locational factors influencing the shifts of these doctors' offices during the study period. The investigation begins with a brief survey of the historical distributional patterns of both all private practice physicians' and specialists' offices in the Metro- politan Area. The distribution of hypothesized locational factors is then described for the study period at several levels of geographic detail, i.e., the Metropolitan Area, Central City versus Suburbs, concentric zonal and radial sectora.l divisions of the Metropolitan Area and by "Community Areas" of the City and Municipalities of the Suburbs. Next, the distribution of all private practice physicians' and board-certified specialists' offices is described. The distribution of these doctors' offices is then compared in various ways with the distribution of locational factors. First, the mean centers of these distributions are compared. Next, their dispersals are compared through the use of ~Standard Distances. The shapes of the distributions are then compared via "Sectorgrams." Analysis of the relationships of the distribution of doctors' offices and the locational factors is then made at the Metropolitan Area level. Comparisons of the distribution of physicians' offices and the locational factors by more detailed geographic units follows. A chapter is devoted to comparison and analysis of the office distribution of each board-certified specialty type with the locational factors. The final chapter summarizes the findings of the study, indicates the con- clusions drawn, and makes general recommendations for attaining a more desirable distribution of physicians' offices in the future. The findings of this study indicate that physicians' offices are decentralizing -- shifting from the Loop and Inner City locations to the Suburbs -- at a faster rate than the population. The data further indicates that the suburban shift of physicians' offices is not uniform in all directions from the Loop. The decentralization is strongly attracted to areas of high socioeconomic status while areas undergoing a change in racial structure -- from predcnninantly white to predominantly black popu- lations --and/or decline in socioeconomic status are experiencing large declines in the number of physicians' offices. Regional shopping centers appear to be secondary locational factors as are medical clinics and the rise of group practices. Hospitals -- contrary to popular belief -- are established where physicians' offices are concentrated rather than being primary attractive forces in physician office PAGENO="0432" 422 cation. Tit~ changing hoaat~on ol speciat~sts' offices reflects the same pattern as all hvsicians' ohlieen, aol; ittire intensively, That is, specialists' offices are even more concentrated in affloent areas and he~s evident in poverty and black areas of the Metro- 1 ita n A rca tha n~.hi iitvi, ie ions' ofhiccs. [ne hino;iritr in the amount ol ohysiefans' offices in affluent areas as to 0 ic ct; .ini loam portions of the Mctropohitan Area is of thc ordcr of 10 to nit ialane~ in cx~ ected ti get worse as thc proportion of specialists increases rd itodoal care costs risc. Prograots aimed at reversing this trend appear to have ad little iuciess tho s Ia r. The Illinois Regional lilcifieal Program is pleased to have aided the research ci iiita t~ted in this ioonogra~ibt antI to make the findings available to the field. i. i PAGENO="0433" 423 TABLE OF CONTENTS Page ACKNOWLEDGMENTS in PREFACE v LISTOFTABLES x LIST OF ILLUSTRATIONS xiii Chapter INTRODUCTION Problem Working Hypotheses Study Area Time Period Scope of Chapters II. HISTORICAL GEOGRAPHIC PATTERNS OF POPULATION AND PHYSICIANS' OFFICES IN THE CHICAGO SMSA 12 Growth and Distribution of Population in the Chicago SMSA, 1830-1950 Growth and Distribution of All Private Practice Physicians' Offices in the Chicago SMSA, 1830-1950 The Growth of Physicians' Offices, 1830-1950 Growth Patterns 1830-1900 Growth Patterns 1900-1950 The Changing Distribution of Physicians' Offices, 1830-1980 Changing Distribution 1830-1900 Changing Distribution 1900-1950 The Rise of Specialization in the Chicago SMSA The Beginnings of Specialization Specialization in the 20th Century Specialization Prior to 1930 Specialization 1930-1950 Ill. GROWTH AND CHANGING DISTRIBUTION OF SELECTED SOCIO- ECONOMIC AND DEMOGRAPHIC CHARACTERISTICS RELATED TO PHYSICIANS' OFFICE DISTRIBUTION IN THE CHICAGO SMSA, 1950-1970 27 Population Growth and Racial Structure of Various Geographic Areas of the Chicago SMSA 1950-19 70 Metropolitan Area Total Population Negro Population Central City versus Suburbs Total Population Negro Population Concentric Zones Total Population Negro Population General Distribution of Population, Socioeconomic Status, Retail Shopping Centers, and Hospital Facilities in the Chicago SMSA, 1950-1970 vii PAGENO="0434" 424 Chapter Pa~e Mean Center of Distribution Centrographic Technique Relative Disuersion from Mean Center Standard Distance Shape of Distribution Sects rgram S Detailed Distributional Patterns of Selected Socioeconomic and Dernogranhic Characteristics of the Chicago SMSA, 1950-1970 Population Retail Sales Hospital Beds Socioeconomic Status IV. DESCRIPTION OF THE CHANGING DISTRIBUTION OF ALL PRIVATE PRACTICE IN PHYSICIANS' AND SPECIALISTS' OFFICES IN METRO- POLITAN CHICAGO, 1950-1970 70 Comparison of Chicago Metropolitan Area and National Growth lkittern of All Private Practice Physicians' and Specialists' Offices (1950-1970) All Private Practice Physicians' Offices Specialists' Offices Description ~f Chan~ing General Distribution of All Private Practice Physicians' md Specialists' Offices in Chicago SMSA (195~)_l97iJl Mean Centers of Distribution (Centrographic Technique~ All Physicians' Offices Specialists' Offices Distjersal (Standard Distancet Physicians' and Specialists' Offices Shape~ f Distribution (Seciorgram All Physicians' Oftices Specialists' (Jffices Proportional Distribution of Private Practice Physicians' and Specialists' Offices be Sector All Physicians' Office~, Specialists' Office- Description if Chatiginc. F~~tail~l ieee ilutin I All Petit Practice Physicians' and S;nci:iliete' li ` C Chtcag~ SSISA (ISiS-I ITs Cite vii' sus Scisils Al I Pbs -ic liii (III C S;cciali'ts' Cfice- Encentric Zn's arid Sect','~ All Physicians' Bide Suec~alists' Offices ~ ANAlySIS )~ Ri:LAl'loNsltIp 131:] WREN CIIANGIN( tiff, FION OF l~ttYSlC'IANS' ANI) SPECIALISTS' OFFICES IN iii! CltICA~O SMSA AND FACTORS (1950-1970) Fxolanation of General Distribution of Private Practice Physicians' and Diplomate Specialists' Offices as Compared Ia Locative Factors Comparison of Mean Centers Comparison of Dispersals Comparison of Shapes of Distribution Analysis of Detailed Distribution of Private Practice Phy- sicians' Offices as Compared to Locative Factors Population City versus Suburbs Concentric Zones viii PAGENO="0435" 425 Chapter Page Sectors The Loop Community and Health Care Areas Racial Structure Socioeconomic Status Hospital Beds Retail Sales and Services Other Pertinent Locative Factors Explanation of Detailed Distribution of Private Practice Diplomate Specialists Offices as Compared to Locative Factors Population and Specialistst Office Location City versus Suburbs Concentric Zones and Sectors Community and Health Care Areas Racial Structure Socioeconomic Status Hospital Facilities Retail Sales VI. DESCRIPTION AND ANALYSIS OF THE GROWTFI AND CHANGING DISTRIBUTIONAL PATTERNS OF DIPLOMATE SPECIALISTS' BY SPECIALTY (1950-1970) ~ 130 Description of the Changing Growth and Distribution of Private Practice Diplomate Specialists' Offices by Specialty in the Chicago SMSA (1950-1970) Growth Patterns (1950-1970) Distribution of Specialists' Offices by Specialty (1950-1970) Distribution and Classification of Specialties Specialty Types 1950 Specialty Types 1960 Specialty Types 1970 Concentric Zonal and Sectoral Distribution of Specialists by Specialty (1950-1970) Concentric Zones, 1950 Concentric Zones, 1970 Sectors Community and Health Care Areas Influence of Locative Factors on the Distribution of Specialists' Offices by Specialty VII. SUMMARY AND CONCLUSIONS 146 Trends in the Redistribution of Physicians in Metro- politan Chicago (1950-1970) Examination of the Trends in the Redistribution of Physicians' Offices in Metropolitan Chicago Factors and Forces Behind the Trends Conclusions Recommendations Appendices LIST OF COMMUNITY AREAS AND MUNICIPALITIES ON MAP 1-1 154 H. LIST OF HEALTH CARE AREAS ON MAP 1-2 156 SELECTED BIBLIOGRAPHY 157 ix 38-698 0 - 74 - 29 (Pt. 1) PAGENO="0436" 426 TA BLES Table Page 2-1 Growth of Population, Physicians, and Physician/Populatiob Ratios in Chicago (1844-1900) 16 2-2 Total Physicians in Chicago (1900-1950) 17 2-3 Phvsicians~ 1,000 Population in Chicago (1900-1930) 17 2-4 Percent of Physicians' Offices Located in Chicago's Loop (1844-19001 IS 2-5 Number and Percete of Physicians' Offices Within and Outside Chicago's Loop (1900-1930) 19 2-6 Distribution of Specialists in the Loop, City Outside the Loop, and the Total City (1914 and 1929) 24 3-1 Population of the Chicago SMSA, Central City and SMSA Outside the Central City 1950, 1960 and 1970) 29 3-2 Population of Metropolitan Chicago by Percentage in Concentric Zones (1950. 1960 and 1970) 31 3-3 Population of Metropolitan Chicago by Percentage in Study Sectors (1950, 1960 and 1970) 32 3-4 Population of Chicago SMSA by Concentric Zones and Sectors (1950, 1960 and 1970) 33 3-5 Increases in Negro Population in the City of Chicago by Con- centric Zones and Sectors (1930, 1960 and 1970) 34 3-6 Location of Mean Centers of Population, Retail Sales, Hosoital Beds and Socioeconomic Status Relative to Chicago's Loop (1950, 1960 and 1970) 36 3-7 Standard Distances of Population, Retail Sales, Hosoital Beds and Socioeconomic Status from the Mean Center in Miles (1950, 1960 and 1970) 38 3-8 Standard Distance of Selected Socioeconomic and Demographic Characteristics from the Loop in Miles (1950, 1960 and 1970) 41 3-9 The Average Socioeconomic Ranking and Perceutage of the Pop- ulation Retail Sales Volume and Hospital Beds by Sectoral Divisions of the Chicago SMSA (1950, 1960 and 1970) 44 3-10 The Distribution of Retail Sales in the Chicago SMSA by City and Suburbs (1950, 1960 and 1970) 51 3-11 Percent of Metropolitan Chicago's Retail Sales in City and Suburbs (1950, 1960 and 1970) 51 x PAGENO="0437" 427 Table Page 3-12 G-A-F Retail Sales - Years 1963 and 1967 Compared 52 3-13 The Distribution of Hospital Beds in the Chicago SMSA by City and Suburbs (1950, 1960 and 1970) 56 4-1 Physician and Physician/Population Ratios in the United States and Chicago Metropolitan Area (1950, 1960 and 1970) 71 4-2 Location of the Mean Centers of All Physicians' and Specialists' Offices Relative to the Chicago Loop (1950, 1960 and 1970) 73 4-3 Standard Distances of All Physicians' and Specialists' Offices from the Loop (1950, 1960 and 1970) 75 4-4 Standard Distances of All Physicians' and Specialists' Offices from the Loop in Miles by Sector (1950, 1960 and 1970) 77 4-5 The Numbers and Percentages of All Physicians' Offices in the Chicago SMSA by Sector (1950, 1960 and 1970) 78 4-6 Number and Percent of Specialists' Offices in the Chicago SMSA Outside the Loop by Sectors (1950, 1960 and 1970) 79 4-7 Number and Percent of Private Practice Physicians' Offices in the Chicago SMSA by Chicago and Suburbs (1950, 1960 and 1970) 80 4-8 Number and Percent of Diplomate Specialists' Offices in the Chicago SMSA by Chicago, Loop and Suburbs (1950, 1960 and 1970) 80 4-9 Percent of All Physicians' Offices in the Chicago SMSA by Con- centric Zones and Sectors (1950, 1960 and 1970) 81 4-10 Percent of Specialists' Offices by Concentric Zone (1950, 1960 and 1970) 82 4-11 Percent of Specialists' Offices in the Chicago SMSA by Concen- tric Zones and Sectors (1950, 1960 and 1970) 84 5-1 Physicians Per Thousand Population in the Chicago SMSA by City and Suburbs, with the Loop Included and Excluded (1950, 1960 and 1970) 92 5-2 Physicians Per Thousand Population by Rings and Sectors (1950, 1960 and 1970) 93 5-3 Top 25 Health Care Areas (Rated by Physicians Per Thousand Population) (1950, 1960 and 1970) 101 5-4 Top 25 Health Care Areas Showing Increases and Decreases in Physicians Per Thousand Population (1950-1970) 106 5-5 Physicians/Population Ratios in the Ten Highest and Ten Lowest Communities in Socioeconomic Status in the Chicago SMSA, 1970 113 5-6 Physicians' Offices/Population Ratios and Hospital Bed/Population Ratios for Metropolitan Chicago by Sector (1950, 1960 and 1970) 114 xi PAGENO="0438" 428 Table Page 5-7 Specialists Per Thousand Population in the Chicago SMSA by City and Suburbs (1950, 1960 and 1970) 118 5-8 Specialists Per Thousand Population in the Chicago SMSA by Concentric Zones and Sectors (1950, 1960 and 1970) 119 6-1 Diplomate Specialists Ranked by Number of Specialists (1950, 1960 and 1970) 131 6-2 Percent of Total Specialists in Each Specialty (1950, 1960 and 1970) 133 6-3 Distributional Classification of Specialists (1950, 1960 and 1970) 135 6-4 Percent of Specialists in Loop, City Outside of Loop and Suburbs (1950, 1960 and 1970) 136 6-5 Percent of Specialists of a Specialty in Community or Health Care Areas with 1~ or Less (Two or Fewer) Specialists 137 6-6 Percent of Board-Certified Specialists by Concentric Zone (1950, 1960 and 1970) 140 6-7 percent of Board-Certified Specialists by Sector (1950, 1960 and 1970) 142 xii PAGENO="0439" 429 ILLUSTRATIONS Figure Page 1-1 Community Areas and Municipalities of the Chicago SMSA with 2,500 or More Population in 1960 7 1-2 Health Care Areas of the Chicago SMSA 8 1-3 Concentric Zones and Sectors of the Chicago SMSA 9 2-1 Metropolitan Growth 1860-1960 13 3-1 Mean Centers of Population, Retail Sales, Hospital Facilities and Socioeconomic Status in 1950 35 3-2 Mean Centers of Population, Retail Sales, Hospital Facilities and Socioeconomic Status in 1960 35 3-3 Mean Centers of Population, Retail Sales, Hospital Facilities and Socioeconomic Status in 1970 37 3-4 Sectorgrams of Population, Retail Sales, Hospital Facilities and Socioeconomic Status in 1950 40 3-5 Sectorgrams of Population, Retail Sales, Hospital Facilities and Socioeconomic Status in 1960 40 3-6 Sectorgrams of Population, Hospital Facilities and Socio- economic Status in 1970 40 3-7 Concentration of Negro Population in the Chicago SMSA, 1950 47 3-8 ConcentratIon of Negro Population in the Chicago SMSA, 1960 48 3-9 Concentration of Negro Population in the Chicago SMSA, 1970 49 3-10 Highest 25 CA's and Municipalities in Retail Sales Volume in the Chicago SMSA, 1950 53 3-11 Highest 25 CA's and Municipalities in Retail Sales Volume in the Chicago SMSA, 1960 54 3-12 Highest 25 CA's and Municipalities In Retail Sales Volume in the Chicago SMSA, 1967 55 3-13 Changes in Rank in Retail Sales Volume of the Highest 25 CA's and Municipalities in the Chicago SMSA, 19 50-1960 57 3-14 Changes in Rank in Retail Sales Volume of the Highest 25 CAts and Municipalities in the Chicago SMSA, 1960-1967 58 3-15 CA's in which the Top 50% of the Hospital Beds of the Chicago SMSA were Located in 1950 60 3-16 CA's in which the Top 50% of the Hospital Beds of the Chicago SMSA were Located in 1960 61 xlii PAGENO="0440" 430 Figure Page 3-17 CA's in which the Top 501~ of the Hospital Beds of the Chicago SMSA Were Located in 1970 62 3-18 Highest 25 CA's and Municipalities in Hospital Beds in the Chicago SMSA, 1950 63 3-19 Highest 25 CA's and Municipalities in Hospital Beds in the Chicago SMSA, 1960 64 3-20 Highest 25 CA's and Municipalities in Hospital Beds in the Chicago SMSA, 1970 65 3-21 Highest 25 and Lowest 25 CA's and Municipalities in Socio- economic Rank in the Chicago SMSA, 1950 66 3-22 Highest 25 and Lowest 25 CA's and Municipalities in Socio- economic Rank in the Chicago SMSA, 1960 67 3-23 Highest 25 and Lowest 25 CA's and Municipalities in Socio- economic Rank in the Chicago SMSA, 1970 68 4-1 Mean Centers of All Physicians' and Specialists' Offices, 1950, 1960 and 1970 74 4-2 Sectorgrams of All Physicians' and Specialists' Offices in 1950 76 4-3 Sectorgrams of All Physicians' and Specialists' Offices in 1960 76 4-4 Sectorgrams of All Physicians' and Specialists' Offices in 1970 76 5-1 Mean Centers of Population, Retail Sales, Hospital Beds, Socio- economic Status, All Physicians' and Specialists' Offices in the Chicago SMSA, 1950 87 5-2 Mean Centers of Population, Retail Sales, Hospital Beds, Socio- economic Status, All Physicians' and Specialists' Offices in the Chicago SMSA, 1960 89 5-3 Mean Centers of Population, Retail Sales, Hospital Beds, Socio- economic Status, All Physicians' and Specialists' Offices in the Chicago SMSA, 1970 89 5-4 Distribution of All Physicians' Offices/1,000 Population by Concentric Zones, 1950 94 5-5 Distribution of All Physicians' Offices/1,000 Population by Concentric Zones, 1960 95 5-6 Distribution of All Physicians' Offices/i ,000 Population by Concentric Zones, 1970 97 5-7 Distribution of All Physicians' Offices/1,000 Population by Quintile Rank by Concentric Zones and Sectors, 1950, 1960 and 1970 98 5-8 Highest 25 HCA's in All Physicians' Offices/1,000 Population in the Chicago SMSA, 1950 102 xiv PAGENO="0441" 431 Figure Page 5-9 Highest 25 RCA's in All Physicians' Offices/i 001) Population in the Chicago SMSA, 1960 105 3-10 highest 25 RCA's in All Physicians' Offices / 1 OH) Population in the Chicago SMSA, 1970 104 5-11 highest 23 IICA's in Increase and Decrease oh All Phvsiciaii~' Offices/1,000 Population in the Chicago SSISA, 1930-1960 107 5-12 highest 23 RCA's in Increase and Decrease if All Physicians' Offices/I 000 Population in the Chicago SSISA 1960-1170 10~ 5-13 Highest 23 hhCA's in Increase and Decrease ot All Physicians' Offices/i ,000 Population in the Chicago SMSA, 1930-l97i) 109 5-14 IICA's in the Chicago SMSA Which Underwent a Change in Their Racial Structure, 1930-1960 110 3-13 1ICA's in the Chicago SSISA \Vhich Underwent a Change in Their Racial Structure, 1960-1970 111 5-16 CA's and Mui~icipalities in the Chicago SIISA with a Major Retail Shopping Center or CIII), 1967 116 3-17 highest 23 lhCA's in Special sts' Offices 1,01)1) Population in Chicago SMSA, 113)) 122 3-18 Ihighest 23 IICA's in Specialists' Offices 1,1)01) Population in Chicago SSISA, 1960 l2~i 5-19 Ihighest 23 RCA's in Specialists' Offices/i ,000 Population in Chicago SMSA, 1970 124 3-20 hhighest 23 RCA's in Increase and Decrease oh Specialists' Offices/i 000 Population in the Chicago SMSA, 1930-196° 123 3-21 highest 23 1ICA's in Increase and Decrease oh Specialisis' Offices/I 1)00 Population in the Chicago SSISA , 19)50-I 910 126 3-22 highest 23 RCA's in Increase and Decrease oh Specialism' Offices/l 000 Population in the Chicago SIISA , 19.SiI-l)lii 127 XV PAGENO="0442" 432 CHAPTER 1 INTRODUC TlO~ Since Malcolm Proudfoot's classification of retail shopping areas in 1937, many studies examining the commercial structure of large American cities have been published. The majority of these studies, however, focused on only one aspect of the commercial structure -- retailing -- while the service sector has been virtually ignored. Much of the information we do have about the internal structure of the ser- vice sector came simply as a by-product of studies examining the retail structure of cities. For example. James Vance's study, examining the effects of post-World War II decentralization on commercial structure focused primarily on retailing, but did give some passing attention to changes in the service sector. 2 After pointing up the decline of retailing in the Central Business District (CBD), Vance indicated that he felt the COD was only "changing rather than decaying" and that the result of these changes would he that the CBD would become "a place of offices rather than large stores." In Vance's study, as in most of the other studies of commercial structure, the term office is used as a common denominator for all nonretailing commercial activity in the city. This suggests that there is little variation in the locational factors of nonretailing commercial activity. In reality, however, the service sector of the commercial activity of cities is equally as complex as the retail structure and needs the same detailed classification. The need is particularly acute in times such as the present, when questions are being asked about the availability of goods and services to all inhabitants of metropolitan areas. One service for which data have scarcely been gathered, much less analyzed, is health care delivery -- or, more specifically, the distribution of physicians' offices. Pierre de Vise clearly identified this specific need in his study delimiting hospital study districts for metropolitan Chicago in which he stated: The changing locational trends of physicians offices are not a matter of indifference to those concerned with the provision of adequate medical care to the city's poor and with the future of central city hospitals. Cursory `Malcolm J. Proudfoot. "City Retail Structure," Economic Geography (1537. \`ol. 13. pp. 425-428. Raymond Vernon. The Changing Economic Function of the Central City, (New York: Metropolitan Region Study. 1959). James E. Vance. Jr. . "Emerging Patterns of Commercial Structure in American Cities," proceedings of the IGU Symposium in Urban Geography, Lund, 1960, Lund Studies in Geography (Series B, Human Geography; Lund, Sweden: Royal University of Lund. 1962) pp. 485-518. Robert C. Weaver. "Emerging Patterns, " Our Changing Cities, (J. B. Tucker edition, \Vashington. D.C.: Public Affairs Press, 1960). Vance, 1960, Op. cit. PAGENO="0443" 433 2 studies in Chicago, Cincinnati and Cedar Rapids suggest significant decentralization of physician's offices out of downtown and neighborhood locations in the central city to the greener pastures of medical buildings and group clinics in new suburban developments. The paucity of market knowledge about medical organization is hard to reconcile with our large social and economic investment in health care and with our high levels of achievement in medical knowledge -- especially when contrasted against the vast literature extant on changing locational trends of, for exan~0e, the fruit and vegetable markets in American cities. To date, little has been written about the distribution of physicians' offices. There has been some interest by governmental agencies, including some preliminary work done by the Hospital Planning Councils for the Chicago and Cincinnati Metropolitan Areas.4 There also have been several studies of the national distribution of physicians,5 as well as studies on state-wide distributions by several rural sociologists, in which their chief interest was availability of doctors to rural populations.6 3Pierre de Vise, "Hospital Study Districts for Metropolitan Chicago: A Geographic Analysis and Methodology," Technical Report, No. ? (Hospital Planning Council for Metropolitan Chicago, 1966) p. 19. 4(a) Philip Rees, "Movement and Distribution of Physicians in Metropolitan Chicago," Working Paper #1.12, (Chicago Regional Hospital Study, 1967) pp. 20; (b) Philip Rees, "Numbers and Movement of Physicians in Southeast Chicago: 1953-1965," Working Paper #1.13, (Chicago Regional Hospital Study, 1968) p. 17; (c) Movement of Doctor's Place of Practice, (Greater Cincinnati Hospital Council, 1962). Statistics of this study were updated in 1964. 5Bureau of Medical Economics, "Distribution of Physicians by Medical Service Areas, 1954," AMA Bulletin #94, (Chicago: American Medical Association, 1954); Frank G. Dickinson, "Distribution of Medical School Alumni in the U.S., 1953," Research Bulletin #101 , a report prepared by the Bureau of Medical Economics, (Chicago: American Medical Association, 1956); Rashi Fein, ~Studies of Physician Supply and Distribution," American Journal of Public Health, (1954) Voi. 44, pp. 611- 624; J. N. Haug, "Distribution of Physicians, Hospitals and Hospital Beds in the U.S., 1967: Regional State, County and Metropolitan Area, " a report prepared by the Department of Survey Research (Chicago: American Medical Association, 1968). 6John C. Beicher, "The Changing Distribution of Medical Doctors in Oklahoma, " Agricultural Experiment Station Bulletin B-459 (Oklahoma A & M College, 1955); Selz Mayo and C. Horace, "Distribution and Characteristics of Physicians and Other Health Personnel in North Carolina, " ~pgress Report R.S.38, a progress report prepared by the Department of Rural Sociology of North Carolina State College (Agricultural Experiment Station, North Carolina State College, Raleigh: 1960); L. Nelson, "Rural-Urban Distribution of Hospital Facilities and Physicians in Upstate New York, " Agricultural Experiment Station Bulletin 432, (University of Minnesota); Milton Terris, "Recent Trends in the Distribution of Physicians in Upstate New York, American Journal of Health (1956) Vol. 46, pp. 585-591. PAGENO="0444" 434 Indeed, the question of distribution of physicians' offices enters into a number of studies indirectly, but few studies have been found which deal directly with this topic. However, one investigation which did deal directly with this topic was a thesis b~' Earl Johnson which traced the distribution of physicians' offices and the ratio of physicians to population in Chicago between l~75 and 1930.8 Much of Johnson's analysis was sociologically oriented, hut he did include certain geographic aspects of the problem. For example, he noted not only a close relationship between the distribution of physicians' offices and retail stores in Chicago, hut also reported a close correspondence between the shift of the center of concentration of these offices in the Loop and the shift of the center of retail concentration. Using land values for linear measures of distances, Johnson found that the location of specialists? offices had a significantly close relationship to areas of relatively lower land values (away from the CBD). He also indicated that the pattern of distribution was subject to change "through the operatiol of certain definite processes such as concentration, centralization (both decentralization and recentralization), specializa- tion and segregation." Johnson's thesis was completed before suhurbanization drastically altered the structure of metropolitan areas in the United States and before the impact of wide- spread automobile use was felt, The study did, however, recognize the beginnings of these changes. Brian J. L. Berry, The Changiqg Retail Structure of Northeastern Illinois (Chicago: Northeastern Illinois Planning Commission, 1965); Richard L. Morrill and Philip Roes, "Influences of the Physician on Patient to Hospital Distance," Working Paper 1.16 (Chicago Regional Hospital Study, 1968); Loris Brown, "Doctors' Offices in Hosoitals, A New Trend," (Unpublished Master's Dissertation, Washington University, St. Lxuis, Missouri: 1950); Stanley Liberson, "Ethnic Groups and ~Iedicine," (Unpublished Master's Dissertation, Department of Sociology, University of Chicago: 1958); Charles Welch, "The Trend Toward Physicians' Offices in Hospital-Owned Buildings," (Unpublished Master's Thesis, State University of Iowa: 1959); Thomas C. Mitchell, "A Survey of Health FRcilities and Needs in South Cook County, Illinois" (Chicago: Developmental Program for Comprehensive Health Planning, 1969). 8Earl Sheppard Johnson, "A Studs' in the Ecology of the Physician" (Unpublished Master's Dissertation, Department of Sociology, University of Chicago: 1932). 9lbid, p. 62. Johnson substituted land values for distance because "Urban land values are highest at the market centers, for here is the place of greatest competi- tion for site use. (Witness in Chicago the $22 per front foot value on State from Washington to Monroe, and the high values at such business centers as Uptown, West Garfield Park and Woodlawn.) As one moves away from the center he finds values falling." PAGENO="0445" 435 4 A more recent study made by Rees in 1967 analyzed the movements of physicians in the Chicago metropolitan region for the years 1956, 1961, and 1965.1° ~ this study a one-in-eight sample of doctors' names taken from American Medical Direc- tories was used to represent the physicians of the Metropolitan Area. The city and suburbs were divided into five zones (based on Postal Zones) arranged concentrically about the Loop: Loop, Inner City, Outer City, Inner Suburbs, and Outer Suburbs, Rees' study was admittedly cursory; however, he was able to point out general trends in the movements of physicians In the years studied. He cited the absolute gains and losses of physicians in each study zone and then stated the following: these absolute gains and losses led to a relative redistribution of physicians between the zones. The Loop and Outer City zones became relatively less important; the signif- icance of the Inner City zone increased and then decreased; both suburban zones increased in importance throughout the study period It can be said therefore that there was a net shift in physicians' distribution within the Chicago Metropolitan Area from the Loop to the Outer Suburbs.~ Rees recognized that "this analysis did not pretend to look at the various factors that explain locational changes of physicians." He recommended that a "more refined analysis in terms of finer geographic detail, age of physicians, type of prac- tice, origin and destination of medical interns and residents, and other factors is needed, ,j2 further revealing the general paucity and superficial nature of existing data pertinent to health care delivery. The following study expands our limited knowledge of the health care delivery system in the United States by describing the changing patterns of private practice physicians' offices in the Chicago Metropolitan Area between 1950 and 1970, identifying and analyzing the significant locational factors in these changing patterns. It thus identifies significant elements which have led to changes in the structure of large American cities and reveals certain effects that decentralization has had on part of the service structure, specifically, the professional service sector. Problem According to the previously cited studies, the general trend of office dis- tribution in Metropolitan Areas of the United States today is toward a greater relative concentration in the CBD, while at the same time certain types of offices are decen- tralizing. Doctors' offices, according to Rees and others, appear to be among those which are decentralizing. The problem, therefore is: 10Rees, 1967, Op. cit. p. 18. l2thjd, p. 19. PAGENO="0446" 436 (1) to determine what changes have taken place in the distribution of physicians' offices in the Chicago Metropolitan Region in the past two decades, and (2) to identify the locational factors in these changes and their relative importance on present and future distribution of doctors' offices. Working Hypotheses The shifts in physician office location in the Chicago Standard Metropolitan Statistical Area (SMSA) have not been totally unobserved. The cursory studies which have been discussed and preliminary investigations of the author have led to the formu- lation of a number of hypotheses regarding physician office distribution and the factors affecting it. The verification of these hypotheses forms the basis of this study: (1) The pattern of office distribution of physicians in private practice is shifting away from the Loop and Inner City into the Suburbs. More particularly, the shift has been away from areas which are changing from high to low socioeconomic status. (2) The shift of physicians' offices out of city neighborhoods which have changed from predominantly "white inhabitants" to predominantly "black inhabitants" is larger than shifts out of other areas of the city. (3) New planned retail shopping centers in suburban areas are `~ttractive forces' in the relocation of private practice physicians' offices. (4) The type of specialized medicine practiced by a physician influences office location. (5) The bed capacity and the quantity and type of medical services provided in the regional hospitals of the city also influence the location of doctors' offices in that community. Since the Chicago Metropolitan Area is an ambiguous term having a wide variety of connotations, it is necessary to more precisely delimit the study area. For the purposes of this study the Chicago Metropolitan Area will mean the six-county area delineated by the United States Bureau of the Census as the Chicago SMSA. The basic areal units used in this study are the 75 contiguous "Community Areas" (CA's) into which the city was divided by Edwin Burgess in 192013 and the 147 suburban municipalities 131n 1920 E. W. Burgess divided the city of Chicago into seventy-five geographical units called Community Areas. The geographic delimitation of these regions is based upon their relative internal homogeneity in regards to selected socioeconomic and demographic characteristics at that time and census tract boundaries. Since 1920 a large amount of statistical data have been accumulated and recorded for these Community Areas. PAGENO="0447" 437 6 of 2,500 or more population designated in the 1960 Suburban Fact Book 14 (See Figure 1-i). The suburban municipalities are not contiguous; therefore certain portions of the six county area are not included in parts of this study. Other areal units used to display data are Health Care Areas (HCA's). These units are contiguous and cover the entire SMSA (See Figure 1-2). Health Care Areas were defined by de Vise in 1966~1j Although CA's and HCA's are the basic areal units of this study, much of the study will utilize a larger geographic area formed by grouping these basic units. This large geographic area will reflect the concentric ring and radial sector patterns which characterize the SMSA. In other words, the Metropolitan Area has been divided into seven concentric zones focused on the Loop as well as five wedge-shaped sectors reflecting compass direction from the Loop. The concentric zones are termed: The Loop; Inner and Outer City; Inner, Middle, and Outer Suburbs; and Satellites. The satellite ring is not a continuous zone but is made up of five separate cities located in a semicircle about Chicago. These cities -- Waukegan, Elgin, Aurora, Joliet, and Chicago Heights -- are industrial satellites which developed very early as individual central cities apart from, but with some dependence on, Chicago. The five wedge- shaped sectors are names North, Northwest, West, Southwest, and South (See Figure 1-3). The intersection of the lines demarking the concentric zones and sectoral wedges form 31 cells, viz., the Inner City North, Outer Suburbs West, etc. These cells give both the concentric zonal and sectoral location of a phenomenon. They are thus important in describing the distributional patterns discussed in this study. Since statistics for the rings and sectors will be based on data gathered by the HCA's, they will reflect the SMSA totals rather than just the part found in municipali- ties of 2,500 or more population. For example, the number of physicians and popula- tion used in ascertaining physician-population ratios must include the entire population and total number of doctors located in the SMSA and cannot be limited to those in municipalities of 2,500 or more population. Population residing outside of the six- county area are not included in the study, however, even though some of them may visit doctors located within the SMSA. Time Period The time period for this study was selected after consideration was given to several factors. In looking at the changing patterns it soon became apparent that it would be necessary to go back far enough in time for changes to be evident but not so far back that the number of changes would make the earliest pattern irrelevant. `4Northeastern Illinois Planning Commission, Suburban Factbook (Chicago, fllinois: Northeastern Illinois Planning Commission, 1960,) Since that time, NIPC has produced a 1970 version. 15de Vise, 1966, Op. cit. PAGENO="0448" 438 Figure 1-1 COMMUNITY AREAS AND MUNICIPALITIES OF THE CHICAGO SMSA WITH 2,500 OR MORE POPULATION IN 1960 PAGENO="0449" 439 Figure 1-2 HEALTH CARE AREAS OF THE CHICAGO SMSA 0 5 0 5 MILES PAGENO="0450" 440 9 ~lR" 1-3 CONCENTRIC ZONES AND SECTORS Of THE CHICAGO SMSA ICR. !NNER* CITY NORTH ICNW~ INNER CITY NORTHWEST ICW INNER CITY WEST COW INNER CITY SOUTHWEST CS INNER CITY SOUTH OCR OUTER CITY NORTH OCNW OUTER CITT NORTHWEST OCW~ OUTER CITY WEST OCSW - OUTER CITY SOUTHWEST OCS OUTER CITY SOUTH ISNW - lINER SUBURBS NORTHWEST SRN - SATELLITE RING NORTH SRW SATELLITE RING WEST SRSW SATELLITE RING SOUTHWEST SRS SATELLITE RING SOUTH PAGENO="0451" 441 1) To begin with, the years 1930, 1940, and 1950 were alternatively considered as the starting year for this study. First, 1930 was rejected because so many changes have taken place since then that the relevancy of the pattern at that time to today's pat- tern is questionable. Next, 1940 was discarded because the 1940 pattern was not dif- ferent enough from the 1950 pattern to warrant studying both years~ (The great sinli- larity of the 1940 and 1950 pattern is due to the fact that little change occured during the 1940's because of World War II. Doctors who were approaching retirement age in 1940 remained in practice through the early 1950's or until the post war medical students graduated and were ready to assume the practices of the doctors who desired to retire.) Cn~z 1950 was selected as a possible initial year, a comparison was made with later years. A one-percent random sample of physicians was extracted from both the 1950 and 056 Medical Directories, Examination revealed that 33 of the doctors of the 1950 sample were sixty ~`ears of age or older, Six years later 35 of the original sample were no longer listed in the Directory; by 1961 over 50 were out of practice; and in 1965 more than 66 of the doctors of the 1950 sample were no longer practicing medicine. In contrast, examination of the 1956 sample showed that only 20 were sixty or older. In addition, five years later only 15 of these doctors had gone out of practice and by 1965 only 35 were no longer listed in the Directory. This comparison indicated that a relatively higher number of older doctors were practicing in 1950 than in 1956, and that shortly after 1950 many of these older doctors retired. For these reasons 1950 was selected as the initial year for the study~ Scope of the Chapters Chapter One provides a general introduction to the study; establishes its purpose, need, and place in recent geographic literature: defines and delimits the problem; and explains the working hypotheses, time period, and study area. Chapter Two includes a review of the growth and distribution of both popu- lation and the private practice physicians' offices in the Chicago area and also sum- inarizes the significant events from the beginnings of specialization UI) to 1950. The historical distribution of physicians' offices is based on a study by Eric Johnson in 193216 and, owing to the nature of the data, is very general. Examination of the begin- nings of specialized medical practice is necessary since its phenomenal rise has re- sulted in one of the most significant developments in the structure of the medical pro- fession in the last two decades. Chapter Three includes a discussion of the changing distribuCon of selected socioeconomic and demographic characteristics of phenomena which have hypothesized spatial relationships with physician office distribution. The phenomena discussed are: `6Johnson, 1937, Op. cit. 38-6C3 0 - 74 - )O (Pt. 1) PAGENO="0452" 442 11 (1) population, both total and Negro, (2) socioeconomic status (SES), (3) retail sales, and (4) hospital facilities. The growth and geographic distribution of each of these phenomena are examined at various levels of geographic detail, viz., the entire metro- politan region, the central city versus the suburbs, concentric zones and radial sectors, and finally, by selected Health Care Areas. It is necessary to become familiar with each of these distributions to deter- mine what relationship exists between them and physician office distribution and to test the study hypotheses. Chapter Four is an in-depth examination of the growth and distributional patterns of private physicians' and specialists' offices in the Chicago SMSA between 1950 and 1970. Description of these distributions employs the same increasingly smaller geographic areas used in describing the socioeconomic and demographic phenomena discussed in Chapter Three. In the fifth chapter the changing distributional pattern of these offices will be compared with the shifts in the socioeconomic and demographic phenomena to ascer- tain how important each phenomenon is as a locational factor in the changing distribu- tion of physicians' offices. This is accomplished by comparing the distribution of total physicians' and specialists' offices with the hypothesized locational factors in the following ways: (1) a comparison will be made between the movements of the mean centers of dDctors' offices and those centers of each of the locational factors between 1950 and 1970; (2) the dispersal of physicians' offices from the Loop, measured by Standard Distances, will be compared to the dispersal of each locational factor from the Loop: (3) the shifts from Central City to Sulxirbs of both doctors' offices and loca- tional factors will be compared; (4) the distribution of physicians and each locational factor will be compared by concentric zones and sectors; and finally (5) the changing distribution of doctors' offices and each locational factor will be compared by community and health care areas. Chapter Six includes an examination of the growth and changing distribution of the offices of each specialty separately at various levels of geographic detail. The pattern of the distribution of the offices of each specialty are then classified according to the degree to which they are dispersed from the thcp, i.e., Loop concentrated, dispersed, nucleated-dispersed, etc. The changes in the proportion of offices of each specialty in each category of the classification system during the study period summarizes the shifts in the distribution of offices and is an important indication of future distribution pattern. Analysis of this data completes the chapter. The seventh chapter is a summary of the study's findings and states the conclusions which may be drawn from them, In addition, some recommendations are presented suggesting ways to stimulate physicians to locate their offices in a manner which would yield a more optimum accessibility pattern for the entire population of the Chicago Metropolitan Area. PAGENO="0453" 443 CHAPTER II HISTORICAL GEOGRAPHIC PATTERNS OF POPULATION AND PHYSICIANS' OFFICES IN THE CHICAGO SMSA Growth and Distribution of Population in the Chicago SMSA (1830-1950) The region in which Chicago is located became a part of the United States in 1783, but little active settlement occurred in the Chicago area before the mid-nine- teerith century. In a period of only one hundred and twenty years (1840-1960), Chicago grew from a small village to a metropolitan area with over five million inhabitants. In 1830 as few as seventy people dwelt along the muddy flat where the Chicago River empties into the southern end of Lake Michigan,' while a short seven years later Chicago was incorporated as a city encompassing an area of about ten and one-half square miles and a population of about 4,000. Moreover, in the next third of a century Chicago trebled its area and grew to a city of 300,000 population. Unfortunately, then came the tragic year, 1871, when a third of the city was reduced to ashes, two hundred lives were lost, and over two hundred million dollars worth of property was destroyed in one of history's greatest conflagrations -- the Chicago Fire. Yet, in less than a decade Chicago rose out of those ashes to become the second largest city in the United States with half a million inhabitants, and it took only one more decade to double its population to one million. This phenomenal growth continued unabated until by 1930 there were over three million people in Chicago, and by mid-century the population of the metropolitan area surpassed five million. Generally speaking, Chicago's tremendous growth can be attributed to both natural increase and the avalanche of immigration -- first from Europe and then from rural areas of the United States. The European immigrants expanded into the western Great Lakes region about the middle of the nineteenth century and continued for more than one hundred years. The rural-urban migration began in the mid-1800' s and has continued until the present time. The distribution of Chicago's rapidly growing population was greatly influ- enced by the mode of transportation available at the time. Discussion of Chicago's growth, therefore, necessitates a division into various `Transportation Eras. 2 During the first era through 1859, travel was mostly by foot or by horse, and was very slow and arduous. D.iring this early period the population of Chicago was concentrated in a tight core about the commercial center of the city (See Figure 2-1). `Pierre de Vise, "Chicago's Widening Color Gap, " R~port No. 2, (Inter- university Social Research Committee, Chicago: 1967) p. 3. 2The Chicago Area Transportation ~ Vol. I, p. 24 cites five transpor- tation eras in the development of Chicago. 12 PAGENO="0454" 444 13 Figure 2-1 METROPOLITAN GROWTH 1860-1960 - /4 ~ :~ k I ~ ~. `:~~I~ 44~ vie S *, ~ 1860 1900 I 1930 PAGENO="0455" 445 14 The second era (between 1860 arid 1892) was characterized by the develop- ment of horse-drawn street cars which somewhat increased the population mobility and enabled the nucleus to expand outward from the core. A flood of immigrants, primarily from northwestern Europe, poured into Chicago during this period and settled along the outer edges of the city, i.e. , the periphery of the area now called the Inner City. This early outward expansion was still not very great in distance since the new mode of transportation was too slow to permit expansive development from the city center. The third era began with the introduction of cable cars in 1880 which afforded a slightly faster mode of travel than the horse cars. Their utilization, however, was limited in time by the rapid development of electric streetcars near the turn of the century. By 1910 cable cars were obsolete. Greater sneeds introduced by the develop- ment of electric streetcars and interurban railways in the early l900's enabled Chicagoans to settle at greater distances from the downtown area and yet have ready access to the Central Thjsiness District. It was in this period (19lJ0-1~20 that expansive urban growth really began. The wealthy began to vacate the innermost parts of the city and move into suburban villages along the interurban rail lines. Secomi-generation Inner City immi- grants moved out along these lines, but remained primarily within the city limits.3 The space vacated by the decentralization of these two groups was rapidly filled to capacity by new migrants coming from Europe. The new settlers, were predominantly from southern and eastern Europe -- Italians, Greeks, Poles, Czechs, etc. Hence, no~ only the city's form changed at this time, hut also its socioeconomic makeup. Chicago's areal pattern changed from a compacted nucleated pattern to one with a dense core surrounded by radial spokes of considerably less density During the fourth era (1920-1950), the decentralization of the population was given further impetus by the development of the automobile. The increased mobil- ity and shortened travel time derived from this mode of transportation enabled second- and-third-generation descendants of the early immigrants to move out to the edges of the city and into the inner suburbs. This expansion was still concentrated in the rail- oriented settlements established during the preceding period. Again the vacancies created by this movement were more than filled by the continuing flood of migrants to the city. Although legislation had closed the floodgates to European immigrants, migration to the city continued through an intensification of the rural-urban shift of population within the United States. Deplorable conditions in the South, caused by the economic collapse of the plantation system following the Civil War and culminating in the plight of bankrupt "Croppers, " provided a vast resource of unemployed manpower. In the early l930's, therefore , the northern industrial centers beckoned and the poverty-ridden (and mostly black) southerns responded. Consequently, the stream of migration from southern Ibid, p. 26 PAGENO="0456" 446 15 farms to northern cities, including Chicago, rose dramatically. These migrants, as others before them, entered the city and settled in the areas where housing costs were lowest. Decentralization of the second and succeeding generations of this migrant group, unlike their predecessors, was limited to the periphery of the existing ghetto and escape to suburbia" was impossible. This had considerable effect upon the ethnic structure of the city, the two most prominent resulting patterns being: (1) the concen- tration of black people in the Inner City ghettos; and (2) the marked lack of blacks in most suburbs. It is important to emphasize this contrast for it affected socioeconomic con- ditions in the city. The inability of second-generation blacks to decentralize, except on a block-by-block basis, meant that later waves 01 migrants litsrally piled in upon thos2 already there. Population densities, therefore, rose sharply in those areas without any increase in services or facilities. In fact, as the non-white population of an area rose, many services vital to the effective functioning of that area moved out, thus further d~e- creasing the amount of services available. The result was a rapidly increasing decay of areas which were in fact already slums. The urban structure of Chicago remained at a status quo during the war years of the 1940's because economic conditions dicated holding residential growth to a mini- mum. In the postwar period, however, Chicago turned to slum clearance and new housing for the decaying inner portions of their city. This set the stage for massive residential building in the suburbs and urban renewal in the city, programs which characterized urban growth within the Chicago SMSA in the 1950's. Growth and Distribution of All Private Practice Physicians' Offices in the Chicago SMSA (1830-19501 The Growth of Physicians' Offices (_1830-195O~ The very early practitioner made his rounds on foot or horseback, braving the rigors of winter in a bear-fur suit, cap and moccasins. He carried his medicine in a fur sack or wrap- ped in a cloth and stewed it in a corner of his saddle bags, usually his bills were paid in trade ... Lxiring the early days the doctor had only a limited number of diseases to treat and these he cured (or failed to cure) with an even more limited supply of medicine, which he ad- ministered in `heroic' doses. Quinine, jalap and calomel with the possible addition of opium were his usual stock in trade.4 The practice of medicine in 19th century Chicago has little similarity to modern medical practice. Gone is the image of the doctor travelling about the town and countryside in a horsedraWn buggy calling on the sick in their homes. Also relegated to memory are the little black instrument satchels, the dimly-lit cluttered offices, and 4pJ4~21sMe~cal~!2!i!i~i, (Oak Park, illinois: May 1940) Vol. 77, No. 5, p. 39. PAGENO="0457" 447 16 the broad list of sometimes helpful, sometimes harmful, but usually ineffectual, paraphernalia and `cures.' Although a relatively large number of medical histories exist -- of which most are biographical in nature or deal with medical technology -- the literature on geographic distributions of physicians is more limited. The American Medical Assoc- iation has published a medical directory since 1906 which contains the most complete listing of licensed medical doctors in the United States, with biographical information about each. Prior to 1906 similar data about physicians was published in a variety of directories. These earlier sources pose a problem for researchers since the data re- ported in one are not always consistent with earlier or later directories. There seems to be little agreement in these sources as to the definition of a medical doctor. The physician's name, address, and age are about the only data commonly found in director- ies. Therefore, the portion of this chapter describing the early growth patterns of physicians will be brief and general. Growth Patterns, 1830 to 1900. The earliest medical aid available in the area which was to become Chicago was by military doctors at Fort Dearborn. Civilian doctors, however, moved into the area very early. In fact, they came as soon as the population outside the garrison grew large enough to support a physician in private practice.6 In general, the early increases in the total number of physicians in Chicago closely paralleled the growth trend of the general population, although periodic dis- crepancies occurred. Table 2-1 shows the relationship between physician and popula- tion growth between 1844 and 1900. TABLE 2-1 Growth in Population, Physicians and ~ppi~tion Ratios in Chica_g~j~44 -1900 Year ~pulation Pj~y~(cians Physicians/1,000 Population 1844 8,000 23 2.88 1850 28,269 57 2.02 1861 123,696 216 1.75 1870 306,605 472 1.54 1880 491,516 853 1.74 1890 1,099,850 1,820 1.65 1900 1,698,575 3,305 1.95 Source: Adapted from Earl Sheppard Johnson's ~ clyjn the Ecology of the Physician, p. 13. 5The information supplied for each physician has changed slightly through the years; however, the physician's name, address, age, specialty, medical education, year of graduation and licensing have been reported since 1906. 6(Alexander Wolcott was the first resident physician in the area; he arrived 1818.) Chicago Medical Society, History of Medicine and Surgery and Physicians and Surgeons of Chicago (Biographical Publishing Corporation, Chicago; 1922) p. 22. PAGENO="0458" 448 From 1844 to 1570 the physician/population ratio declined sharply-- espe- ciallv between 1544 and 15.30 -- indicating that the rise in the number of doctors did not keep pace with the dramatic increase in population. Population growth continued un- abated between 1870 and 1900, yet the ratio of doctors to population nearly returned to the 1850 level by the year 1900. This indicates that it took about a quarter century for the medical profession to respond to the dramatic growth of population, and another quarter century to regain the ground lost in the interim. It also indicates that physicians were moving into the city at about the same overall rate as the population. Growth I~tterns, 1900-1950. The steady increase in the number of physi- cians' offices in Chicago which began in the early 1800's continued through the first three decades of the twentieth century (See Table 2-2). Actually, the number of doctors' offices in Chicago nearly doubled between 1900 and 1930, rising from a little over 3,300 to over 6,300 in this thirty-year period, Overall the number of physicians in the city increased b'. 2, ~33 in the thirty vesrs preceding 1900, and by 2,869 in the thirty years following (See Tables 2-1 and 2-li. Thus, Chicago added about the same TABLE 2-2 Total_PhvsiciansinChic~g~00-1950) Year City of Chicago Year ç~~ç~icao 1900 3,305 1930 6,374 1910 4,141 1940 5,942k 1920 3,436 1930 5,791 * Estimated Source: 1900-1930 Johnson, Op. cit. p~ 43 number of doctors in both three-decade periods. However, the year 1930 was the high- water mark of physicians' offices in Chicago: between 1930 and 1950 there was a steady decline. Statistics show that the number of doctors' offices in Chicago was reduced by nearly 600 during this twenty-year period, while the population of the city continued to grow. The physician-population ratio, therefore, reversed its earlier trend and declined steadily after 192 (See Table 2-3, TABLE 2-3 Physician/I ,000 Population ~ Year /1009 Year M.D. /1,000 1900 1.95 1929 1.86 1909 1.94 1940 1.75 1921 1.96 1951 1.63 PAGENO="0459" 449 18 The decline in ratio was due to the fact that the nation failed to produce physicians at a rate comparable to its spectacular growth in population. This effect is corroborated by Johnson, who states: It appears that for the past twenty years (1910 to 1930) the whole population increased at a rate a trifle greater than twice that of physi- cians, namely a rate of 33.4 compared to a rate of 16.3. Furthermore, the whole popu- lation showed a faster rate of increase between 1920 and 1930 (1910-1920, 14.9 1920-1930, 16.1) than it did in the preceding decade, while the physician rate of increase showed just the reverse (1910-1920, 8.1 1920-1930, 7.5~,' The same trend continued throughout the rest of the first half of the century so that by 1950 the physician/population ratio for Chicago was down to 1.65. ~ Chan~ngDistribotion,H30to 1900. The changing distribution of physicians within Chicago during the nineteenth century j~ also noteworthy, for although the princi- pal rovement of physicians in th~ nation as a whole was one of centralization (the rural- urban shift), the trend of physicians within the city was decentralization. During the initial growth stages of the city, doctors were concentrated in th~ commercial center, or business district. In 1844. br example, nine of ten doctors in Chicago were located in the j,oop (See Table 2-4). As the city grew, an increasing number of pvsicians began to locate their offices away from "downtown' Chicago, although this dispersion was not great in distance since the city was still quite compact, TABLE 2-4 Percent (if Physicians' Offices L'anChij~544-1900) Year Percent Year Percent 1s44 91.3 1875 19.1 issO 61.4 1550 2-1~0 1a61 58.7 1890 23,5 1865 61.2 1900 23.4 1x70 42.3 Source: Adapted from Johnson, Op. cit. , P. 45 Conversely, there were periods of relatively high rates of dispersal and periods when only limited numbers left the Loop. For instance, during the six years `Earl Sheppard Johnson, ~`inthcolo~J~~an (Unpub- lished Master's Thesis, Department of Sociology, University of Chicago: 1932). PAGENO="0460" 450 19 from 1844 to 0150, the percent of doctors offices in the Lo.p declined sharply from over 907 to just over 6O~7, while in the next fifteen years hardly any change occurred. Another sharp decrease in the proportion of physicians offices located in the Loop occurred between 186:1 and 1870. During this five-year period the Loop's share of Chicago's physicians' offices declined from 61.2 to 42.3 , so that the number of offices located outside the Loop for the first time exceeded those located within, Then, between 1170 and 1875, a precipitous drop in the percent of physicians' offices located in the Loop was recorded-- from 42,3 to 19.1 . This drop reflects the devastating effect of the Chicago Fire on the downtown area and is not truly repre- sentative of the period. The Loop recovered from the fire by lhSO and although the per- centage of offices in this area rose again to nearly 25 -- nowhere near the pre-fire proportion--the'. never reached that level again throughoul the remainder of the century. Chai4g~Distribution,1900-195O The number and percentage of physi- cians' offices located within and outside Chicago's Loo) between 1900 and 1950 are arrayed in Table 2-5. TABLE 2-3 Number and Percent of Physicians' Offices_Within and_th1tsideCh~~s~J~U0_19~ Year WithIn the~p Outside the Looj3 1900 765 23 2,54(1 77 191)) 1,130 27 :1,011 73 1920 1,446 26 3,999 74 1330 1 ,4~4 24 4,790 76 1940 1,4S7* 25 1,453* 73 1950 1.490 23 4,301 75 * Estimated Source: Adapted from Earl S. Johnson's The Ec~l2~yoL Ph- sicians, p. 43, and The American Medical Dir- ect~y, 1951. The decentralization of offices outside the Loop, which proceeded so rapidly in the nineteenth century, leveled off in the first half of the twentieth century. In fact, in 1901) the proportion of physicians' offices located in the Loop was approximately twenty- five percent (25 and remained about the same throughout the next fifty years. Between 1900 and 1950 the number of offices outside the Loop increased by 1 .761 while those inside the Loop increased by only 725. Doctors' offices outside the Loop, however, were not dispersed randomly but reflected a pattern which Johnson termed "recentralization. " One of Johnson's theses was that the medical service function is sufficiently similar to the retail func- tion of cities that the same locational factors are important to both activities. One of the factors paramount to the location of both functions is accessibility. Both, there- fore, are usually located close to points of great accessibility; hence, they are usually PAGENO="0461" 451 20 found in proximity to one another. To put it another way, the compact settlement of early Chicago was focused on a single business nucleus and therefore dictated the concentration of physicians in that area. Later, as the city grew and the population became more dispersed, certain activities -- including retailing -- began to move closer to the population they served. Johnson found that the particular relocation of these activities was at points of con- vergence of transportation routes. Hence, l)hYsiciafls, like retailers, began to relocate outside the Loop near major intersections of the transportation network. The dispersion from the Loop, therefore, "recentralized" in a pattern of dispersed nodes or clusters about thc city. In summary, the distribution of doctors' offices in the first half of the twentieth century was characterized by a leveling off of decentralization from the Loop to the rest of the city. The location of doctors' offices outiade thc Loop were concen- trated in dispersed clusters at points of convergence of major transportation arteries. The Rise of Specialization in the Chicago SMSA The Be~inin~soLSj~ecializatioo The spectacular rise in the number of hoard-certified specialists between 1900 and 197') is one of the most significant changes that occur `ed in he structure of tne Aine rican rectical profess n Tb,: roots oi this change go back to the late nineteenth and early twenlieth centuries. The oegree of specialization in the American medical profession in the nine- teenth century is not knoan. Formal certification in a recognized arcs of medical specialization by an ,iutho rized body is 1 devel opmeni of the twentieth century. Iloweve r no official record of certified specialists was kept before 1939. There was very early interest in cc rlsin aspects of medicine which have since become recognized medical specialities. hut before 1920 few doctors limited their practice solely to one area of medicine. SpecializatIon in the nineteenth century generally meant that a general practitioner was interested in the diagnosis and treatment of a particular type of affliction, as in toe medical care of expectant niothers , etc. lIe devoted time outside of his regular practice to study, attend meetings, and do research in the area of his SThe AMA Directory of Medical Specialists, t939, was the first directory that listed tiplomates of all specialty beards (if the American board of Medical Spe- cialties although sonic of the individual hoards issued directories of their members is early as 1927. The A0L~ Medical Directory, t9t4, reported data, on specialists also, but the determunation of who was a ,pecialist was made i~ the physician himself and no formal training or eertilicatioi of competence in the specialty was required. Certification of speeiaiist~ `lid net begin before lol 7 -- the ear of incorporation of the first specialty hoard (American Board 01 Ophthalmology) of the American Board of \Ie,lical Specialties. It was not until seven years later that the second board (Otolar- vngologyi was incorporated, and over half of the specialty boards date from the 1930's. The American Board of Family Practice was instituted as recently as 1969, and others may vet follow, PAGENO="0462" 452 special interest. Usually those so inclined also joined specialty societies or associa- tions which enabled physicians to share knowledge of developments in that part of the profession. Therefore. one measure that can be made of the amount of interest in specialized medicine at this time is to determine the number of members in special medical societies. It was not until the second half of the nineteenth century that specialty societies began to be established in the United States. The Medical and Surgical Dir- ectorvot the United States, published in 1886 by H. L. Polk, indicates that the first specialty society was the American Opthalmological Society, organized in 1864.~ The first specialty society organized in Chicago was the Chicago Pathological Society of H Jo l~92 beth the Chicago Ophthalmoiogical and Otological Societies were estab- lished: Societies for Internal Medicine, Orthopedics, Dermatology, and Neurology all followed around the turn of the century. However, the 1914 AMA Medical Directogy was the first one in which mem- bers of various specialty socieies or associations were listed. In that year only 11~ of Chicago's doctors were listed as belonging to a medical specialty society or assoc- iation. Prohably only a minor portion of those were actively pursuing intensive study in their chosen areas of special interest. Keeping in mind, therefore, the weak defini- Hon of a specialist, it can be estimated that the percentage of specialists in Chicago in the late nineteenth centurY was quite low, prohably under ten percent. In summary, the role of specialization in the American medical profession in the nineteenth century was insignificant, even though specialty societies were estab- lished and medical schools were teaching topics of specialized medicine in the latter parts of the century. It is noteworthy, however, that most of the physicians who ob- tained fame or distinctio~ during this time were specialists, and that most of the med- ical progress of that time flowed from their work. t2 All of these things were of con- sielerable importance to the rise of medical specialization in the twentieth century. 91'he 1914 A~lA ~IedicalDirect~g~ also reported the following other assoc- iations and societies organized between 1864 arid 1886; American Otological Society, H68: American Neurological Associatimi l57~; American Dermatological Associatioo and American Gynecological Societies, H76: American I~rynogo1ogical Association, H7n; American Surgical Association. 1880: and the American Paednlogical Society, 1 ~6. ~Thomas Neville Bonner, Me ineiicl850-195O (The American llistorv Hesearch Center, Madison, Wisconsin: 1957) p. 77. ~Ibid, p;a. 77-78, tdlbid, Chapters III and VI. A r.iore detailed account of the rising impor- tance of 5;)OCialists and their contributions to the development of medicine and Chicago as a medical center of the world. PAGENO="0463" 453 22 ~j~1i~tion in the Twentieth Century In 193() Johnson stated "One may say confidently that the predominant characteristic of present day medicine, everywhere, is specialization and about it almost no end of comment has been forthcoming for the past several years. The literature describing changing events in the medical profession in the early decades of the twentieth century all emphasize a substantial, if not phenonierial, rise in specialized medical practice. Yet, as late as 1950, only about ten percent of the private practice physicians in Chicago were listed as board-certified s:jacialists by the American Board of Medical Specialties. The discrepancy, of course, is in the word `board-certified." Soecialization in the first three decades of the new century was determined by the doctor's own designation and was qualified by the amount of time he limited to that particular area of medicine, e.g. , "full" or `~art time' sue- c ialists. The idea of certifying a physician as to competency in his chosen area of special interest -- and often his limited area of practice -- was objectionable to a relatively large minority of physicians as late as 1912. In that year, Dr. Franklin Martin proposed the establishment of the American College of Surgeons, the aims of which included the following goals: 1. A standard of professional, ethical and moral requirements for every authorized graduate in medicine who practices general surgery or any of its specialties, insofar as feasible along the lines of the Royal College of Surgeons in England, Iceland and Scotland. 2. A supplementary degree for oper- atirig Surgeons. 3. Special letters to indicate fellow- ship in the College. 4. A published list of members of the College. 14 Dr. Martin's proposal encountered immediate, strong opoosition from with- in the profession. Referring to this, Bonner states: Many feared that his program would produce a European type aristocracy of surgeons, some thought the whole plan uinecessarv, while still others deplored the professional dis- tinctioii inherent in setting up a special college for surgeo.~s. A branch of the Chicago Medical Society branded Martin's 13Johnson, Op. cit., p. 47. `4F'ranklin Martin, ~~of Life (Doubleday, Doran and Cooipany, Garden City, New York: 1933) VOi. II, p. 410. PAGENO="0464" 454 23 idea as `un-American' and `un-democratic,' declaring its belief that the founders of the College were simply appointing themselves judges of who was to practice surgery. 1) Dr. Martin's proposal succeeded in suite of these obstacles, and in 1913 the American College of Surgeons was organized and formal specialization was off to a somewhat shaky start. In 1917 the American Board of Ophthalmology was incorporated as the first board of what was to become the American Board A Medical Soecialties. The American Board of Ototaryngology followed in 1924, and in the 1930's a whole host of new hoards were incorporated, and certified specialists began to appear. Thus, the rise of formal soecialization did not happen overnight, although when it finally did begin the change came swiftly. The remainder of this discussioo, therefore, will be divided into two parts: siecialization prior to 1933 and after 1933. The d.scussion of specialization prior to 1930 will necessarily depend oo the looser defin1tion if a spe- cialist, i.e., individual physician-designated, while that of the post-1930 period will use the formal definition of a specialist, i.e., board-certified. There exists a statis- tical `fault-line' between the two periods and figures, for the former will not be com- parable to those of the latter. However, the trends in specialization will be apparent. Specialization Prior to 1930 . As mentiooed previously, the earliest record which identified physicians as specialists is the 1914 AMA Medical Directory. The spe- cialists recognized in this volume were: OALR (Ophthalmology, Otology, Laryngology and Rhinologv), Surgery, Obstetrics, Gynecology, Internal Med1cine, Urotogy, Neuro- logy, Psychiatry, Pediatrics, ~ermatologv, Orthopcd~cs, Clinical Pathology, Roent- genology, Pulmonary Diseases, Proctoiogv, Anaesthesis, Public Health, Industrial Surgery and Bacteriology. Specia1 practice was further siibd~ridei I ito "!imi,ol" or "spiei " If a oh"a:min Ii,' iir.l ~ ii y'~elized practice "limited' he practiced his specialty exclusively, and if he iernied i t"specia'" he gave sgecial, but not exclusive attention to his specialty. The form~ is room `1 - ` ferr ~d I a~; `full-time" and ,he latter as "part-time' special practice. Table 2-6, constructed from statistics eoiipfled by Johriso'i, reveals the gro~h and ,Lstributional pattern of specialists in Chicago in the early period 16 Fhe total number ,f spocLilists in Chicago between 1914 and 1929 increased rum I ,032 to 2,168 (110 increascl. This breaks down to a 56.3 gain to: full-time sr?ctalists (increasing Ii' m 713 to 1,113 physiciansi and a 225~ gain for part-timt~ sgecialists (increasing from 332 to 1,058 phvsiciansi. Thus, in this fifteen-year period tor which accurate records existed the number of physicians who practiced specialized ined~cine more than doubled, with the part-time specia1ists accounting br the larges' share of the growth. `°Bonner, Op. cit., p. 97. `6johusoii's study dealt with the rise of specia1ization between 1914 and 1929 in considerable detail. The discussion of pre-1930 special practice relies heavily o-i his study. PAGENO="0465" 455 24 Conversely, when the city is subdivided into (1) the Loop, and (2) the re- mainder of the city, an important deviation from the general pattern stated above becomes apparent. The number of full-time specialists ~eLo2~ more than doubled (1l8~) between 1914 and 1929, while part-time specialists increased only 1.7~ in that area. In contrast, part-time specialists outside the Leo increased an amazing 770~, while full-time specialists gained only a modest 10 in that same area. In other words, the concentration of full-time specialists in the Looj~ and part-time specialists outside the Lo~p became ol)vious. TABLE 2-6 Distri betion~~pecialists i n the Loop~ç~y Outside of the Loop, and the Total City ~d19~ Loop Outside Loop Total City Full Time Specialists 1914 304 406 710 1929 644 446 1,110 Increase T9iT~~ 118.4 9.8 56.3 ~rt Time ~cialists 1914 227 95 332 1929 231 827 1,058 % Increase 1914-1929 1.7 770.5 218.7 Total Specialists 1914 531 501 1,032 1929 895 1,273 2,273 Increase 68.5 154.1 110.1 As for the dispersion of doctors by specialty, Johnson reported that intern- ists, psychiatrist-neurologists, and dermatologists were concentrated in the Loop. Johnson further stated: Eye, ear, nose and throat (combined), surgery and obstetrics and gynecology (paired) maintained their rank as the three leading specialties throughout the city, except the Loop . . . and industrial surgery ranked highest for specialties with the greatest percentage of out of the Loop offices in 1929.17 Specialization, 1930-1950. The rising interest and increased participation 17 Johnson, Op. cit. , p. 91. PAGENO="0466" 456 25 in specialized medicine soon led to the formation of specialty boards whose primary objectives were: to provide comprehensive quaVying examinations for physicians who fulfill requirements and to certify those who are successful. In this manner an attempt is made to insure the public, both lay and medical, that physicians professing to be specialists possess proper capabilities. 18 There is considerable correlation between first specialty boards, the first specialty societies. and the areas of medicine for which special training was first avail- able. For example. the earliest courses dealing with a specialized area of medicine taught in the United States were in Ophthalmology -- taught at Harvard in 1850; in 1864 the American Ophthalmological Society was the first specialty society organized in the United States; the first department of Ophthalmology in Chicago was established at Rush Medical School in l~69: finally, in 1917 Ophthalmology became the first specialty board of what later became the American Board of Medical Specialties. In a similar fashion, Otolarvngolog\ followed all three stages of development and Obstetrics and Gynecology came right behind, each step of the way. By 1930. these three specialty boards had been established, two of them having been in ope ration for some time. 19 The direc- tories of the two boards operating prior to 1930 reveal that there were only 139 board- certified specialists in Chicago -- a handful of those claiming to be specialists in that year. By 194(11. little had changed except the number of specialists and specialty beards. In that year there were twelve boards recognized by the American Board of Medical Specialties, and the number of specialists in Chicago had increased substan- tially to SS9. 20 However, this still represented only about 13'~ of the estimated total number of physicians in the Metropolitan Area at that time. In reviewing the office distribution of these specialists in 1940, it was deter- mined that 61 of the specialists' offices were located in the Lonp, another 27C were located in the city outside of the Loop. and only 12d were in the Metropolitan Area out- side of the city. 20 Office location in the city outside of the Loop was concentrated near the four largest and most important hospital complexes in Chicago at that time -- (1) Conk County-University of Illinois-Presbyterian; (2) Northwestern Medical School- Wesley- Passavant; (3) Michael Reese and (4) University of Chicago Hosoitals and Clinics. `American Board of Medical Specialties, Directory of Medical Specialists (Marquis' \~`ho's Who. Inc. . Chicago; 1970-71) p. xvii. t9Obstetrics Gynecology was just organized in 1930 so in that year only two biards -- Ophthalmology and Otolaryngologv -- were actually in operation with a number of certified specialists. °0 - American Board of Medical Specialties~ Directory of Medical Specialists, 1940. PAGENO="0467" 457 26 Outside the city, the industrial satellites -- Wau.~egan, Elgin, Aurora. and Joliet -- were important centers for specialists, as were the residential suhurds of Lvanston and Berwy a. The leading specialties of this period were internal medicine otolarvngology, pediatrics, ophthalmology, and obstetrics/gynecology, in that order. 01 these five, internal medicine was most concentrated in the Loop with t3ree of four internists located there. Pediatrians --- the least concentrated: only one of five was located in the Loop. Obstetricians gynecologists, ophthalmologists, and otolarvngologists averaged about two of three offices located in the 1.001). All other specialties, though havin~ a limited membership. had a high proporfoon of their offices located in the 1.oop . with the excep- tion of radiologists (only one in three) who acre usually located near one ol lhe larger hospitals. The early distribution of board-certified specialists, therefore, was con- centrated in the Loop. with the exception of pediatricians and radiologists, who tended to be concentrated near either hospital or major retail centers outside the Loop. However, the patterns of specialists locations for the decade between 194)) and 1950 did not conform to the foregoing. The typical situation of that period resulted fiom the interruption caused by World War II and the post-war period of adjustment, which carried through to 1950. Because of the irregular circumstances which charac- terized that period this section will not deal with it. Looking at the patterns of population and physician specialiv.ation in the first half of the twentieth century in summary, several factors appear pertinent. t. The physician/population ratio failed to keel) pace with population growth and dropped to its lowest level (1.63/1 000) since the in- corporation of the city. 2. Doctors' offices decentralized into the outlying shopping centers of the city at points of convergence of transportation. 3. Specialization began in the early 1900's with specialty hoards being established after 1930. 4. Most board-certified specialists we ic concentrated in the l.o p prior to 1950. Exceptions were pediatricians and radiologists. who located near hospitals or in major retail centers outside Ito loop. 38-698 0 - 74 - 31 (Pt. 1) PAGENO="0468" 458 CHAPTER III GROWTH AND CHANCING DISTRIBUTION OF SELECTED SOCIO- ECONOMIC AND DEMOGRAPHIC CIIARACTFHISTICS BEIATGD TO PhYSICIANSt OFFICE DISTRIBUTION [N TIlE CHICAGO SMSA (1950-19701 Four socioeconomic and demographic characteristics -- population growth and racial structure, socioeconomic status, retail shopping, and hospital facilities -- were previously hypothesized as significantly influencing the location of physicians' offices in the Chicago SMSA. In order to test their hypothesized relationship to the changing distribution of doctors offices in the twenty years between 1950 and t970, it is necessarY to examine the geographic patterns of each of these locational factors. Therefore, this chapter is structured to accomplish the following: (li Examine the groaah of Chicago' oj~,~ion, both total and Negro, using Ihe various geographic subdivisions outlined earlier, i.e. , Metropolitan Area, Central City vs. Sutairbs. and Concentric Zones and Sectors: (2 Describe the geriei'al distribution of all four locative factors bvide ntifving three basic statistical attributes cI spatial phenomena: (a the mean center or most central )oint ti distribution; (hi the relative disper- sion from mean center: and (ci the shape of distri- bution as determined by axial distance and cli rection from the center: and Pb Describe the detailed distribution of all four of the above- stated locative factors at the previously indicated geocraphic levels. Starling at the general distribution level, several techniques or methods are cnuioved to identity the three basic statistical attributes of spatial phenomena. First. the Cent roe raphic Technique is utilized to determine the mean center of each distribution studi iii. tThe Centrographic Technique was developed over a long period of time throigh the tvor~ of such agencies as the U. S. Bureau of Census, the former Slendeleev Centrographic t,aboratorv in Leningrad, U.S.S.R. , and recently revived by Roberto llachi. The following are a few examoles of the abundance of literature available con- cerning centrographv: a An exhaustive bibliography and histoi'ical account of the development of the technique is contained in the appendix of an article by U. E. Swiatlovski and \\ . C. Wells. "The Centrographic Method and Regional Analysis," Geographical Revie~ (1937 \`oi. 27. pp. 250-254. (hi Some of the fundamentals and a laborous mechanical method for obtaining the mean and median centers and the point of minimum aggregate travel (PMATi of a distribution appear in: John Fraser Hart, "Central Tendency in Area Distribution," Economic Geography (19541 \`ol. 30, (ci A detailed explanation of the calculation of a mean center is given in the appendix of an unpublished "preliminary report" whose " . . . major purpose is to provoke comment on our research approach. " This report is: "A New Approach to the Delineation of Hospital Service Areas. " Discussion Paper Series No. 16, August 1967, by H. D. Cherniack and J, B. Schneider. PAGENO="0469" 459 28 Another statistical measure called "Standard Distance, also explicitly described by Bachi, 2 is used to define the dispersion of the distribution from the mean center. The "Sectorgram, " a technique developed by H. D. Cherniak and J. B. Schneider of the Regional Science Research Institute3 is used to describe the shape of each distribution. Later, at the detailed descriptive level, maps and tables are used to portray the distributional patterns by succeedingly smaller geographic areas. Population Growth and Racial Structure of Var ious Geographic Areas of the Chicago SMSA (1950-19 70) Metr~~tan Area Total Population. The population of the Chicago SMSA increased over 35% between 1950 and 1970~ (See Table 3-1). However, the major portion of that growth came in the first decade, since the growth rate of the 1960's was only about half that of the 1950's. Statistics from the United States Census show that the population of the Chicago SMSA increased 20% between 1950 and 1960, but only 12% in the next decade. During the overall period the population growth rate of the Chicago SMSA was above the national average in the 1950's, but below that average in the 1960's. This deceleration indicates that some of the factors related to the phenomenal growth of the immediate post-war period were leveling off. Particularly noteworthy are some of the economic factors related to the basic industrial growth patterns of the region and, hence, affecting Chicago's attractiveness to migrants. Negro Population. Contrary to general population patterns, the growth of the Negro population in Chicago continued unabated, rising from about 550,000 in 1950 to over 1.2 million in the next twenty years (See Table 3-1). The l22ç increase in Negro population, as with the total population, was also much greater in the first decade. Growth in the sixties reflects natural increase more than migration since the influx of blacks dropped from "15,700 per year in the 1950's to 1,200 annually since 1960. `~ 2Roberto Bachi's works and reference to his papers on Standard Distance appear in many journals. (a) "Standard Measures and Related Methods for Spatial Analysis, "~gionai Science Association: Papers and Proceedings (Tenth Zurich Congress: 1962). (b) 0. D. Duncan, et al. Statistical Geography (Glencoe, illinois: Glencoe Press, 1961) pp. 90-93. (c) Roberto Bachi (Brian J. L. Berry and Duane Marble, eds.) "Statistical Analysis of Geographical Series," in~~tial_Analysis: A Statistical Header (Prentiss Hall, Englewood Cliffs, N.J.: 1968). 3J. B. Schneider, "The Spatial Structure of the Medical Care Process," Discussion Paper Series No. 14 (July 1967). The Sectorgram approach to the descrip- tion of a distribution is also described in detail in the article by Cherniack and Schneider cited in Footnote 1. 4'rotal population in this section is based on the entire population of the SMSA. 5Pierre de Vise, "Chicago's Widening Color Gap," Report No. 2, (Chicago: Interuniversity Soáial Research Committee, December, 1967). PAGENO="0470" 460 29 TABLE 3-1 Population of the Chicago SMSA, Central City and SMSA Outside the Central City (1950, 1960 and 1970) 7. Total SMSA Outside 7. Total SMSA Central City SMSA Central City SMSA 1950 Total Population White Negro 7. of Negro 1960 Total Population "2. increase 50-60 White 7. increase 50-60 Negro 7. increase 50-60 7. Negro 1970 Total Population 7. increase 60-70 ~ increase 50-70 357. White 5,748,028 7, increase 60-70 87, ~ increase 50-70 247. Negro 1,230,919 7, increase 60-70 387. 7. increase 50-70 1227, 7, Negro 187, 337, Sources: U. S. Census of Population, 1950. 1960 and 1970: 5,177,868 4,623,836 554,032 10.77. 3,620,962 3,128,511 492,451 13.67. 707, 687, 907. 1,556,906 1,495,325 61,581 47. 307, 327. 107, 6,220,913 3,550,404 587, 2,670,509 427, 207. 5,330,759 -27. 2,737,767 517, 717. 2,592,992 497. 15'2. 890,154 -137. 812,637 917, 747, 77,517 97, 617. 147, 657. 237, 267, 37, 6,978,947 3,329,090 487, 3,649,857 527, 127, -67, 377, 2,226,470 397, 3,521,558 617, -187, 367. 1,102,620 907. 128,299 107, 367. 657, 1. 087, 3.57. Illinois; General P'pulation Characteristics and Donald Bogue, The lopulation of the United ~tates (Glencoe, Illinois: 1959) PAGENO="0471" 461 30 Central City versus Suburbs Tot l~2p14_a~ion. The growth of population in the Ceotral City reached its apex by 1950. The two decennial censuses since then recorded absolute declines in the City's population with the rate of decline increasing from 2~'~ in the fifties to 6' in the sixties (See Table 3-1). However, it is highly unlikely that this trend will continue in the next decade as most estimates indicate a stabilization of the population of Chicago in the 19701s. The Suburbs, on the other hand, experienced continuous rapid growth. The population of the Suburbs increased 71~ during the 1930's and 37(' in the 1960's, rising from 1.5 million in 1950 to over 3.6 million by 1970. This doubling of the population in the Suburbs in less than twenty years was much higher than the national population growth rate. It is expected that the major share of the anticipated population growth of the next three decades will also be in the suburbs. This would result in that area accruing a population three times as large as the present city population. ~ Population. Citing the slight decline in the total population of the Central City and continuous growth in the Suburbs, however, does not really depict the changes that occurred in the population growth in these two areas in the last twenty years. To simply state that during the 1950's the Central City had a net population loss of approximately 70,000 hides the fact that over 390,000 whites abandoned the City while approximately 320,000 Negroes moved in (See Table 3-1). Also, the 6 net loss of population in the 1960's does not indicate that another 500,000 whites fled the City while the black population of the City increased over 300,000 in that decade. The result of these shifts was that the Negro population of the Central City increased from just under 500,000 in 1950 to over 1.1 million by 1970. The white population of the City, on the other hand, decreased over 900,000 during the same period of time. The ratio of blacks in the Central City, therefore, rose from l3.6~( in 1950 to 33 in 1970. In contrast, the Suburbs have remained lily white." The addition of over two million to the population of that area between 1950 and 1970 included only 66, 71S blacks(3. 5). The racial structure of the Suburbs, therefore, did not change appreciably in the past two docades (See Table 3-1). In 1950. only 10' of the SMSA's Negroes lived outside the Central City, in spite of the fact that the population of the Suburbs increased 125;, and the Central City lost 8~ of its 1930 population. In summary, the population of the Central City of Chicago declined slightly between 1930 and 1970 while the Suburhan population grew rapidly. The slight decline in the Central City's population obscures the fact that 900,000 whites left the Central City while the same area gained over 600,000 blacks. The great growth of the Suburbs, however, was virtually all white. Although these figures clearly point out the dichotomous nature of the Metro- politan Area, the Central City and Suburbs should not be thought of as representing two divaricated but internally homogeneous areas, for in some instances the variance within these two areas is greater than between them. In other words, the pattern of population growth sometimes differs as much between certain parts of the Central City as between PAGENO="0472" 462 31 the Central City and the Suburbs. It is necessary therefore, to look at the SMSA in finer geographic detail in order to more fully describe population growth in this region. Concentric Zones Total Population. To begin with, the population of the Metropolitan Area was separated into concentric zones and sectors, as outlined in Chapter One. Table 3-2 records the percent of the population found in each zone. Analysis of this table reveals TABLE 3-2 Population of Met~politanCh,~~obv Percentage in Concentric_Zone~J~0,1960,& 1970) Zone 1950 1960 1970 l~op 2' Inner City 43 33 26' Outer City 25 23 21', Total Central City 70 37T 4~, Inner Suburbs 13 19 21 Middle Suburbs 13' 19' Satellite Ring 5 3 5', Outer Suburbs 4 6 7' Total Suburbs 30 43~ 52' Metropolitan Area Total l00' ioo'; 100'; Source: U.S._Census of Population: Detailed Characteristics of~~2~al~ion (1950, 1960 and 1970). relative losses in population in the zones within the Central City during the twenty years shown, while the zones in the Suburbs had relative gains (with the exception of the Satellite Cities, which maintained 57 of the total population in 1950, 1960, and 1970). Table 3-3 arranges the same data by sectors. Looking at the Metropolitan Area as a whole, the South Sector had the largest relative losses while the Northwest Sector had the largest gains over the twenty-year period. The difference between them, however, was slight. yet, when the sectors are divided into City and Suburbs, the sectoral pat- terns become more distinctive. The Southern and \Vestern Sectors in the Central City had significant population decreases, while there were large increases in the Western and Northwestern Sectors of the Suburbs (See Table 3-3). Another, more important. fact is revealed by referring to Tabie 3-4. here it becomes apparent that the Inner City recorded absolute losses in population in each sector The Southern and Western Sectors had the most significant declines; these losses were primarily the result of the elimination of several large residential areas through urban renewal. The Outer City, however, actually gained in absolute popula- tion in all sectors, except the West. On the other hand, the growth of population in all PAGENO="0473" Sector North Northwest West Southwest South Sector North Northwest West Southwest South Sector North Northwest West Southwest South Me tropolitan Area 1950 1960 1970 20% 13% 28% 17% 20% 19% 14% 29% 18% 19% 19% 16% 29% 19% 16% 1950 City 1960 1970 14% 10% 14% 12% 18% 11% 8% 12% 11% 15% 10% 7% 9% 11% 11% Suburbs 1950 1960 1970 6% 8% 9% 3% 6% 9% 14% 17% 20% 5% 7% 8% 2% 47 5% Source: U.S. Census of Population: Detailed Charac teristics of the Population. (1950, 1960, i~pj zones and sectors of the Suburbs, show great absolute gains. The Inner and Middle Sub- urbs.however, far exceed the rest of the suburbs. No inner or middle suburban cell had less than a 100% increase in population with the exception of the Inner Suburbs West, which began the period with a large population. In summary, population moved out of the Inner City into the Inner and Middle Suburbs during the study period. Nqgro Population. Examination of the zonal and sectoral growth of the black population of the SMSA can be limited to the Western and Southern Sectors of the zones within the Central City. This is possible because over 90% of the SMSA's increase in black population was concentrated in those areas (See Table 3-5). The growth of Negro population in the 1950's was most marked in the Southern Sector of the Inner City and the Western Sector of the Outer City. Over 90% of the City's black population increase in this period was in these two areas. Between 1960 and 1970 the Western, Southwestern, and Southern Sectors of the Outer City accounted for 84% of the black population increase. The result of this was a distinct concentration of Negroes in two sectors of the Central City -- the Western and Southern Sectors. In summary then, not only was the growth of the Negro population in Chicago primarily confined to the Central City but it was also restricted to only limited parts of 463 32 TABLE 3-3 ~ Percentage inStudLSectors 1950, 1960 and 1970 PAGENO="0474" TABLE 3-4 Population of the Chicago SMSAj~y_concentric Zones and Sectors, 1950, 1960 & 1970 R1fl2 Inner Outer Inner Middle Satellite Outer Total Sector Year ~ Suburbs Suburbs Ring Suburb Sector Central 1950 96,214 1960 79,846 1970 72,200 North 1950 275,007 441,903 157,484 60,276 60,064 30,678 1,025,412 1960 251,477 443,146 257,830 97,841 92,794 53,769 1,196,857 1970 218,671 445,885 301,670 128,975 121,220 72,499 1,288,920 Northwest 1950 412,700 3b2,056 35,183 31,791 -- 80,700 1,130,678 1960 367,242 386,384 87,938 138,070 -- 142,044 1,130,678 1970 335,696 385,701 130,712 295,94~i -- 187,005 1,335,063 West 1950 214,353 286,000 376,645 159,302 108,229 42,l~9 1,186,688 1960 175,058 298,359 512,939 335,422 134,073 74,173 1,530,024 1970 122,534 284,518 545,055 565,706 153,210 96,426 1,767,499 Southweat 1950 325,347 179,809 63,022 40,000 76,696 17,787 777,488 1960 302,022 263,684 148,966 61,877 94,116 26,741 897,406 1970 282,186 297,083 220,474 103,235 94,596 42,134 1,039,708 South 1950 694,849 332,823 107,321 36,799 24,551 8,622 1,204,965 1960 609,858 351,369 196,896 9S,451 34,331 27,115 1,315,020 1970 507,324 376,194 274,1)39 129,857 39,931 33,030 1,360,375 Total 1950 1,922,256 1,602,591 739,655 328,168 269,540 179,946 1960 1,705,657 1,742,942 1,204,569 728,661 355,314 323,842 1910 1,466,411 1,789,381 1,471,950 1,223,722 408,957 431,094 Source: U.S. Census of Population, Detailed Characteristics of the Population, 1950, 1960, and 1970. PAGENO="0475" 465 34 that area, viz., the Western and Southern Sectors of the Outer arid Inner Cities, respec- tively. TABLE 3-5 Increases in N~gro Population in the City of Chica~g~ by Concentric Zones and Sectors 1950, 1960 and 1970 % of Total % of Total Increase. Increase Increases Increase 1950-60 1950-60 1960-70 1960-70 5,473 1.7% 3,094 1% Inner~ North 1,105 .3% 4,362 1% Northwest 620 .2% 16,922 5% West 2,984 .9% -10,786 - Southwest 3,143 1.0% 25,066 8% South 149,539 46.7% -19,643 - Outer City North -269 - 3,663 1% Northwest -195 - 311 - West 139,489 43.4% 71,628 22% Southwest 6,020 1.9% 72,174 23% South 12,463 3.9% 122, 334 39% Total Increase 320,836 100.0% 319,554 100% Source: Chicago Inventory, Community Area Fact Book, 1950, 1960. Ceneral Distrilaition of Population, Socioeconomic Status, Retail Shopping Centers, and Hospital Facilities in the Chicago SMSA, (1950-l9~ Mean Center of Distribution _ç~t~g~phic Technique. In 1950, the mean center of population was located at the western edge of the city, over six miles from the Loop. The centers of retail sales and hospital beds, the surrogates of retail shopping centers and short-term general hospital facilities, were in close proximity to the center of population, but slightly closer to the Loop. Re~il sales were also centered slightly north of the centers of pop- ulation and hospital beds (See Table 3-6 and Figure 3-1). However, the mean center of communities ranked by socioeconomic status, located approximately nine miles north- west of the Loop near the western side of ths suburb of C~k Park, was much further from the Loop than the other three centers. The location of these centers indicates that in 1950: (1) retail shopping and hospital facilities were more concentrated in the Loop than the population, and (2) socioeconomic status was morö concentrated in the Northern Suburbs than the population. PAGENO="0476" 466 Jo Figure 3-1 MEAN CENTERS OF POPULATION, RETAIL SALES, HOSPITAL FACILITIES AND SOCIOECONOMIC STATUS, 1950 Figure 3-2 MEAN CENTERS OF POPULATION, RETAIL SALES, HOSPITAL FACILITIES AND SOCIOECON0~IIC STATUS, 1960 PAGENO="0477" 467 36 TABLE 3-6 Location of Mean Centers of Population~ Retail Sales, Ho~pita1 Beds and Socioeconomic Status Relative toChicago's LoopJ~.9502 1960 and 1970) Retail Hospital Population Sales Beds SES 1950 Distance from Loop in miles 6.3 5.4 5.6 9.0 Azimuthal bearing from the Loop 260° 271° 263° 274° 1960 Distance from Loop in miles 7.8 6.9 5.7 11.5 Azimuthal bearing from the Loop 263° 269° 268° 275° 1970 Distance from Loop in miles 9.0 NA 6.3 10.8 Azimuthal bearing from the Loop 267° NA 271° 277° NA Data not available By 1960 the center of population had shifted a mile and a half westward. The center of retail sales did likewise and remained about a mile from the center of popula- tion (See Table 3-6 and Figure 3-2). The mean center of hospital beds, however, shifted almost straight northward and remained about the same distance from the Loop. The center of hospital facilities, therefore, shifted away from the centers of population and retail sales during this period. Socioeconomic status shifted over a mile to the northwest and remained northwest of the other three centers in 1960. The decentralization of all centers except hospital facilities is obvious. The straight northerly shift of the mean center of hospital facilities indicates that the Loop concentration continued to be strong but that expansion of facilities in the north was greater than to the south or west. Between 1960 and 1970 the population center shifted another mile and a half westward, placing it nine miles west of the Loop (See Table 3-6 and Figure 3-3). Data on retail sales for 1970 were not available; however, estimates made in 1967 indicate that there was little change in the trends of the preceding decade. Therefore, the center of retail sales was probably still close to the population center. The center of SF8 was still northwest of the Loop, but slightly farther away. The mean center of hospital beds shifted to the northwest, moving away from the center of population and retail sales and toward the mean center of high socioeconomic status. In summary, the mean centers of these phenomena shifted away from the Loop during the twenty-year study period (19 50-1970). The centers of retail sales fol- lowed the shifting population centers westward away from the Loop; the mean centers of PAGENO="0478" Figure 3-3 MEAN CENTERS OF POPULATION, RETAIL SALES, HOSPITAL FACILITIES AND SOCIOECONOMIC STATUS IN 1970 00 PAGENO="0479" 469 38 socioeconomic status moved northwestward into the Suburbs; and the mean centers of hospital beds shifted northward in the fifties and northwestward in the sixties. Relative Dispers on FropLM~n_Center Standard Distance. The mean center of a distribution gives some indication of changes within it, but it is of equal importance to know how widely dispersed a phenomenon is from that center. Standard Distance is a means of stating in comparable terms how dispersed or concentrated a distribution is. Briefly states, Standard distance appears to he the simplest measure of geographical dispersion to be assoc- iated with the center (considered as an index of location of the phenomenon studied). It enables one, inter alia, to describe synthetically the actual dispersion of a phenomenon, to compare it with the dispersion to be expected under cer- tain hypotheses. to appraise its change over time, and to compare it with the dispersion of other phenomena. 6 Standard Distances in miles from the Loop were generated for each of the four distributions discussed above for 1950, 1960, and 1970 (See Table 3-7). This data is for the Metropolitan Area and reflects a very overgeneralized and simplified pattern of the dispersion of these distributions. TABLE 3-7 Standard Distances of Population, Retail Sales, Hospital Beds and Socioeconomic Status from the Mean Center in Miles, 1950, 1960 and 1970 1950 1960 1970 Population 16.0 17.8 19.4 Retail Sales 15.1 17.0 NI) Hospital Beds 13.2 14.0 15,2 Socioeconomic Status 17.1 21.4 20.2 ND = No data available Socioeconomic status had the greatest dispersal in Standard Distance from the Loop for all three years shown in Table 3-7, even though its Standard Distance de- creased between 1960 and 1970. This apparently indicates the great suhurbanization of affluence. Population had the second highest Standard Distance for all three years and exhibited an increase not only between 1950 and 1960 hut also between 1960 and 1970, Therefore, the Standard Distance between SES and population closed during the last decade, a phenomenon indicating that population also experienced a great suburbaniza- tion. The Standard Distance of retail sales was nearly as great as population, since its rate increase between 1950 and 1960 was about the same as population. Op. cit. , p. 103. PAGENO="0480" 470 39 The comparatively steady growth rates and standard Distances separating population and retail sales was used to determine the time lag between population e~'pan- sion and retail center establishment in an area. It was estimated that during the 1950's retail center decentralization lagged approximately five years behind population. Hospital bed distribution was the most concentrated of these four over the two decades. Furthermore, its rate of increase was far less than the other three dis- tributions. Thus, the relative decentralization of hospital beds was much less than any of the others in the s-ears 1950-1970. This contrast reflects the concentration of hospitals in the City and the relative immobility of these institutions. Summarizing the dispersal of these phenomena as measured by Standard Distances it was found that socioeconomic status has the greatest dispersal or is the most suburbanized of the locational factors while hospitals are the least dispersed or most concentrated in the Central City. Population has become more suburbanized with a Standard Distance nearly as great as that of SES. The dispersal of retail sales appar- entlv approximates that of the population with a lag of about five years. Shape of Distribution Sectorgrams. As stated previously, the use of Standard Distances for measuring dispersal at the Metropolitan Area level generalizes and smoothes the pat- tern of dispersion within the region and therefore does not describe the disparity within that region. In order to measure such disparity within a region Cherniack and Schneider developed the Sectorgram. This device divides the study region into an arbitrarily chosen number of equiang'uiar sectors centering on the mean center of distribution. The Standard Distance of each sector is computed separately, utilizing only those points located within that sector. This yields a more detailed display of a distribution when plotted on a map (See Figure 3-4o However, comparison throueh time of sectorgrams constructed in this manner is difficult due to the fact that the mean center of each distribution in each time period is a different point. Thus, corresponding sectors do not include the same area. For example. the mean center of population in 1970 is west of the center of that dis- tribotion in l95~. Thus, some of the communities found in the Western Sector in 1950 will be in the Eastern Sector in 19T'~: hence, the Standard Distances of those sectors are incomparable. However, since Standard Distance 15 not uniquely associated with the mean center, it can be measured from any point. So for the purposes of this part of the sujdy, the Loop was desienated as the center from which Standard Distances for all distribu- tions were measured in each time period. Hence, the area encompassed by corresponding sectors was held constant and more comparable shanes were obtained for contrasting the changing distribution of each phenomenun during the study period. ~ta f',r the Loop area itsef were eliminated ~cause they could be arbitrarily placed in any sector desired and thus affect the Standard Distance of that sector. PAGENO="0481" 471 Figure 3-4 SECTORGRAMS OF POPULATION. RETAIL SALES, HOSPITAL BEDS AND SOCIOECONOMIC STATUS IN 1950 Population Retail Sales Socioeconomic ~ Hospital Beds Figure 3-5 SECTORGRAMS OF POPULATION, RETAIL SALES, HOSPITAL BEDS AND SOCIOECONOMIC STATUS IN 1960 Population Retail Sales Retail Sales Figure 3-6 SECTORGRAMS OF POPULATION, RETAIL SALES, HOSPITAL BEDS AND SOCIO- ECONOMIC STATUS IN 1970 40 Socioeconomic Hospital Beds Popul ation Socioeco~c'mic Hospital Beds PAGENO="0482" 472 41 To begin with, the 360 degrees encircling the Loop were divided into eight sectors. each 43 degrees in width, oriented to eight principal compass directiens. Since the phenomena of this stodv are involved with only five of the compass directions, C Standard Distances were calcolatod only in the Northern, Northwestern, \\estern, South- western and Soothern Sectors for the four distriuutions presently under discussion. These data were then plotted on the base reaps used to show the shapes of distributions. T5e Seem rc"ams displavinc the various shapes of the distribution of all four loca- ttonai factors for 1030 are shown in Figure 3-4. The Standard Distances of each sector ate displayed it Table 3-m A study of the Figures and Table show that the patterns of tonulation and retail sales are very similar, both in shape and the Standard Distance of each sector from the i.ooo. Disnersion is greater to the west, southwest, and north- west than to toe no"th or south, the Southern Sector being particularly limited in its disnersa Iront the Loop. On the other hand, socioeconomic status is more evenly dis- tributed about the SIISA. with the greatest dispersal to the northwest and least dispersal to the southwest. The ranco between them, however, was not great. Hospital beds dis- played the most uneven and extreme pattern of the four dtstributions in 1950; the North- western and Southwestern Sectors had the most extreme dispersal. while the Northern, Southern and Western Sectors had the most limited expansion from the Loop. TADLF 3-~ Standard Distance of Selected Socioeconomic and Demo g,f~3hic Characteristics from the Loop in Miles 1L930196° and t970) Retail Socioeconomic Huspital Population Sales Status Beds 1950 Sector North iOU 13.1 18.1 12.5 Northwest tm9 t7. 7 18.7 19.3 West 10,0 17.2 17.5 11.9 Southwest ln.0 17.0 13.7 21.0 Sooth 11.4 11.0 14.7 8.9 t960 North 17.4 13.5 19.5 13.7 Northwest 2t.4 20.0 26.6 21.7 West 17.5 16,7 19.7 11.6 Seuthwest tm3 17.4 18.7 18.7 South 13.3 13.7 18.0 10.3 1970 ________ North 19.4 18.8 14.6 Northwest 22.8 NO 24.6 22.5 West 19.2 19.3 12.1 Soothwesl 19.2 DATA 15.4 18.1 Sooth 14.4 17.3 11.7 PAGENO="0483" 473 42 Between 1950 and 1960 there were only minor changes in the sectoral pat- terns of the four distributions (See Table 3-8 and Figure 3-5). Decentralization was common to most sectors, although the Standard Distances of the Western Sector of retail sales and the Western and Southwestern Sectors of hospital beds decreased. The most noticeable change, however, was the great dispersal to the northwest in all four distributions. This change was most marked in the pattern of SES. The Southern Sector increased significantly in each distribution, hut was still much less dispersed than any of the other sectors in population, retail sales and hospital beds. The sectoral distribution patterns for 1970 were different from those of 1960 primarily in the increased Standard Distance of each sector from the Loop with one important exception (See Table 3-8 and Figure 3-6). That exception was in the pattern of socioeconomic status; the Standard Distance of each sector of this pattern was closer to the Loop in 1970 than it was in 1960. These patterns indicated a relative rise in the SES of the City. In summary, suburbanization characterizes the changing distribution of these phenomena during the study period, with the minor exception of SES between 1960 and 1970. Shifts into the Northwestern Suburbs were greatest in terms of dispersal while the dispersal into the Southern Sector was more limited. SES had the most uniform pat- tern of dispersal and hospital beds the most irregular. A word of caution may be needed here lest the reader confuses the Standard Distance of the dispersal of a distribution with the relative density of a distribution found in a sector. The Standard Distance of a dispersal merely indicates how widely a phenomenon is spread over an area relative to a designated center point, but it in no way indicates what proportion of the phenomenon is located in a sector. A sector with a small Standard Distance may have a large portion of the total number of cases of the phenomenon under study, just as a sector with a few cases may have a large Standard Distance -- if they are widely scattered from the center paint. Therefore, in order to obtain a more complete understanding of the changing distribution of these locative factors, it becomes necessary to determine what proportion of the total population, retail sales volume, and hospital beds are found in each sector. Socioeconomic status cannot be shown as a specific quantity, as it is a rank- ing based on a composite score of several socioeconomic indicators. In 1950 the North- eastern fllinois Planning Ccsmmission (NIPC) published A Social Geography of Metro po1~,~~go which contains a report "of the growth and structure of all municipalities and subregions making up the six-county `Chicago Metropolitan Area. " One of the important contributions of this stody was a table which gave a compo site socioeconomic ranking of the Suburban Municipalities of 2,500 or more population. The composite ranking was based upon six socioeconomic indicators reported in the 1950 Census of Population: median school years comuleted: percent white-collar workers; median family income; median value of housing: average value of new home perniita: and per capita val- uations. ________________________ ____________ ________ 7Northeastern Illinois Planning Commission, A Social Geogr~p~y~of Metro politan Chicago (Chicago: 1960). (Cited on the "A Note to the Reader" page.) 38-693 0 - 74 - 32 (Pt. 1) PAGENO="0484" 474 43 A table ranking the 76 chicago CA's was developed based on socioeconomic indicators similar to those used in the NIPC study. Data from these two tables were merged to obtain the comparative ranking of all CA's and municipalities of the SMSA with a population of 2500 or more in 1950. The CA or municipality with the highest composite socioeconomic rank was assigned the socioeconomic status rank of one, the second high- est two. etc. The CA's with the lowest socioeconomic status rank, therefore, were the ones with the highest socioeconomic status. Similar tables have been developed for 1960 and 1970 from other studies which dealt prima rilv with the social structure of the Chicago SMSA. In 1960 Phill'p Flees conducted one of the most thorough studies of the social structure of Chicago in his dissertation. A Factorial Ecology of Metropolitan Chicago. ~ Rees selected 57 van- ables from the tnited States Census of Population. 1960. which were generally accepted as reflecting the socioeconomic character of an area. A 57 by 57 matrix of the correla- tion oetween the variables was reduced through principal components factor analysis into ten significant factors. The variables which scored highly on the first factor were those "traditionally regarded in sociology as indicators of class position or social status . . . ". i.e.." . , . people with many ~`ears of schooling, much of it at college, who are employed in white-collar occupations who earn as a result high incomes and are able to live in high-rent, sound housing. " Thus, communities scoring highly on factor I of bees' study represent the affluent areas of the SMSA; those with low scores would he the poverty areas of the region. In 1972 de Vise issued several studies which include tables of the socio- economic status of the CA's and municipalities with a population of 2,500 or more based on similar data to that used in the NIPC study in 1950. The socioeconomic status scores shown in Table 3-9 are the average rank fo all CA's and municipalities in each sector for 1950, 1960 and 1970. The sector with the lowest average rank represents the sector with the highest SES. The Northern Sector had the highest average SES throughout the study period and, with one exception, the average SES of each sector declined in a counter-clockwise order from north to south. The exception to this was in 1950 when the Southern Sector had a slightly better average SES than the Southwestern Sector. The relative rank of the sectors in socioeconomic status. therefore. did not change appreciably during the study period. There were, however, significant changes in the proportion of population, retail sales, and hospital facilities by sector in the SMSA between 1950 and 1970. There were two significant changes in the sectoral distribution of population. First, the proportion of the population in the Northwestern Sector increased significantly, and second, the proportion of the population of the Southern Sector decreased notably. 8Philip A. Rees, A Factorial Ecology of Metropolitan Chicago, 1960 (Master's Dissertation. Department of Geography, University of Chicago, 1968). Rees' study has been incorporated into the "Chicago Regional Hospital Study," Working Paper 111.9, and appears in part in Brian J. L. Berry and F. E. Horton (eds.) Geographical Perspec tives on Urban ~yst~s (Prentice Hall, N. J. , 1970) Chapter IX. PAGENO="0485" 475 The Average Socioeconomic Rankin of the Population, Retail Sales gs and Percenta~es Volume and Hospital Beds by Sectoral Divisions of the Chicago SMSA, 1950 North 16.57, 26.77~ 2l.77~ 55 Northwest 22.57~ 17.47, 8.l7~ 69 West 22.67~ 23.87~ 44.77, 74 Southwest 13.47, l0.97~ 6.27~ 105 South 25.37~ 2l.27~ 19.27, 102 1960 North l6.27~ 20.17, 25.67~ 76 Northwest 24.07, 24.l7~ 9.57~ 107 West 22.67~ 23.77~ 39.67, 120 Southwest 15.57~ 12.87~ 8.97, 149 South 22.l7~ 19.3'/~ 16.47~ 157 1970 North 15.87~ ND 26.47~ 80 Northwest 26.17, ND 12.67, 106 West 21.67, ND 34.17. 120 Southwest 15.97. ND 11.17, 155 South 20.57~~ ND 15.97, 146 Sources: U.S. Department of Commerce, Bureau of the Census, Census of Population (Washington: U.S. Government Printing Office, 1950, 1960 and 1970); U. S. Department of Commerce, Bureau of the Census, Census of Business (Washington: U.S. Government Printing Office, 1948, 1954, 1958 and 1963); Hosoitals:Journal of the American Hosmita~ ~Association (Chicago: 1951, 1961 and 1971) Guide Issue, Part II. 9The population statistics used in this table are based onl'~ on the total population of the 76 CA's and 147 municipaLties which have a population of 2,500 or more. There is, therefore, slight discrepancies between the percentages reported on this table and those on Table 3-3. The overa~l pattern, however, is the same. 44 TABLE 3-9 (1950, ]960 and ]91u) SES Average Population Retail Sales Hospital Beds Rank PAGENO="0486" 476 45 There was another, less extreme change -- a slight increase in the Southwestern Sec- tor and a slight decrease in the Northern Sector. The Northern and Southwestern Sec- tors changed in their relative ranking as a result of this shift. The Southwestern Sec- tor had the smallest proportion of the population in 1950. In 1970 the Northern Sector became the lowest with a shade less population than the Southwestern Sector. The heavy concentration of hospital beds in the Western Sector of the City is also clearly shown in Table 3-9. Nearly half (45T) of all hospital beds were located in that sector in 1950. .An additional two-fifths (40~) of the hospital beds were split evenly between the Northern and Southern Sectors in that year. There were relatively few beds in the Northwestern or Southwestern Sectors and they were widely dispersed (shown by the extrenielv high Standard Distances of those sectors). The relative rank of the sectors did not change in the twenty-year period. The Northern Sector, however, did gain relatively while the Western and Southern Sectors declined in the relative pro- portion of hospital beds located in them. The sectoral distribution of retail sales volume was also altered in the 50's. Retail sales were heavily concentrated in three sectors in 1950. Over 70~ of the retail sales volume was concentrated in the Northern. Western and Southern Sectors in that year. The proportion of retail sales in the Northern Sector dropped 6.6~ between 1950 and 1960 while the Northwestern Sector gained 6.7. The Southern Sector lost .9 between 1950 and 1960 while the Southwestern Sector increased by that exact amount during the same peciod See Table 3-9. The relative shift of retail sales from the Northern to Northwestern and Southern to Southwestern Sectors resulted in a more even sectoral distribution of these sales in the SMSA. The Southwestern Sector, however, still had a relatively small share of the total retail sales volume of the SMSA. It should lv pointed out, however, that there is a major inconsistency in the sectoral distribution of these locative factors. Hospital facilities had an increasingly higher prooortiun if its total in the Northern Sector. The relative proportions of the pop- ulation and retail sales in that sector, however, were declining due to the establishment of several retail shopping centers and great growth of population in the Western Suburbs. Affluence hih SESI was disproportionately more concentrated in the Northern Sector throughout the study period. The Standard Distance of the distribution of SES indicated that the major share of the disparity is in the Suburbs. The shift of hospitals is, there- fore. toward the area ol higher SES. Sunimarizing the general distribution of these locative factors, as determined from the measures of ceiitralitv and dispersal employed, the following can be stated: The distribution of retail sales was closely associated with the general distribution of the pop- ulation. Retail sales follows the general shifts of the population hut with a lag of about five years. On the other hand, the distribution of hospital beds was much less dispersed. The shifts in the distribution of hospital facilities was toward the areas of high SES. Socioeconomic status was concentrated in the Northern Sector of the SMSA and was the most dispersed of all the distributions: i.e. . it is the most suburbanized. PAGENO="0487" 477 46 This description of the general distributional pattern of these locative factors is useful in determining their influence on the distribution of physician offices at this broad general level. However, in order to fully understand the changing pattern of doctors offices it will be necessary to describe the changing distribution of the locative factors at more detailed geographic levels. Detailed Distributional Patterns of Selected Socioeconomic and Demographic Characteristics of the Chicago SMSA (1950-197k Population. The distribution of population in the Central City and Suburbs during the study period was not vastly different from that of preceding periods. However, certain spatial developments characterized this period and are of considerable importance since they were prime factors in the development of the present internal structure of the Metropolitan Area. The two most relevant distributional processes characterizing this period are: (1) suburbanization, particularly the flight of middle-income white families from the City, and (2) the continued influx of rural dwellers, primarily black southerners, to the inner portions of the Central City and the block-by-block expansion of the ghettos. The increased use of automobiles was of primary importance to the former, and the con- tinued growth of industry and mechanization of agricultural production was significant to the latter. The net effect of these processes has been increasing racial segregation of the population of Metropolitan Chicago. Over 95~ of the suburban population growth, dis- cussed earlier, was white. The white population of the Central City decreased, while the black population increased over a half million. Today. therefore, 90 of the black population of the Chicago SMSA dwells in the Central City area. This disproportionate distribution is more remarkable when one is cognizant of the fact that more than 66~ of the blacks who d live outside the Central City reside in older industrial satellites or in segregated suburban ghettos. 10 Some of the remain- ing suburban-dwelling blacks are domestics who reside with wealthy families of the North Shore area. In reality then, the majority of Chicago suburbs have very little Negro population. Figures 3-7. 3-8 and 3-9 clearly depict the degree of concentration and segregation of blacks within the City of Chicago. In 1950 blacks were concentrated in a narrow north-south band in the Inner City just south of the Loop. Over 60~ of the Metropolitan Area's Negroes were concentrated in six Chicago Community Areas located in this "Black Belt" (See Figure 3-7). Three of every four blacks in the Metropolitan Area lived in areas with at least 35~ Negro population. The expansion of the ghetto in the 1950's was in two directions: (1) a south- 10de Vise, Op. cit. . p. 23. PAGENO="0488" 478 47 Figure 3-7 CONCENTRATION OF NEGRO POPULATION IN THE CHICAGO OMOA. 950 PAGENO="0489" 479 48 Figure 3-8 CONCENTRATION OF NEGRO POPULATION IN THE CHICAGO SMSA 1960 PAGENO="0490" 480 49 Figure 3-9 CONCENTRAT'ON OF NEGRO POPGLATON IN T~-~E CONGO SMSA .973 -G~ L ~ ~ ~c -~ ~ .~- . ~ ~- _____________i-_____:_~ ---~ - PAGENO="0491" 481 em sector developed southward out of the former Black Belt. " arid (2) a new dovelop- merit spread westward from the Loop (See Figure 3-8). The westward expansion, as well as the southern movement, was closely associated with public transportation routes -- the Congress. Douglas and Lake Street "El's" to the west and the Illinois Central commuter line and Jackson Park and Englewood El's' to the south. Dv 1960 the total irea of black ghettos had expanded considerably but the concentration of Metropolitan Chicago's Negroes was even more acute than it had been a decade earlier. Eighty-three percent (93) of Metropolitan Chicago's Negroes lived Community Areas of 507 or more black. and 95 lived in Community Areas with 35 or more black. Many of the CA's that were 35 7 to 50~1 black were in transition and soon became over 507 black. Few areas of the City maintained a racial mixture. It has often been said that "integration was the period between the time when the first black family moved into a neighborhood and the last white family moved out." The distribution of blacks in 1970 was basically the same as in the prior period, with the Western and Southern Sectors of the City being the principal recipients of the expanding black population (See Figure 3-9). The proportion of the Metropolitan Area's blacks residing in these two areas decreased only slightlv~ 75 lived in areas of 50 or more black, and 81 lived in areas with 30 or more. There is little to indicate that any drastic changes in this pattern are in the offing. in spite of federal programs specifically aimed toward accomplishing that end, If by 1985 the City's population is 50 or more black, it can he expected, therefore. that that half of the population will dwell in the southern and western parts of the City. Retail Sales. Total sales volume for both the City and Suburbs of the Chicago SMSA increased absolutely throughout the study period (See Table 3-10). The rate of increase in the Suborhs, however, is far greater than in the City. Between 1950 and 1960 the sales volume of the Suburbs more than doubled, rising from 1.5 million dollars to 3.2 million dollars. During the entire seventeen-year period, how- ever. the City had a mere 391 increase in retail sales. In 1950 nearly three-fourths of the retail dollars were spent in the City. Dv 1970 suburban retail sales accounted for one-half of the Metropolitan Area's sales volume (See Table 3-11). These data confirm thc conclusions of other studies which describe in detail the shift of retail shooping from the Loop and major business thoroughfares of the City to Suborban regional shopping centers. Table 3-12 clearly depicts this phenomenon in Chicago. Between 1963 and 1968 twenty-three major retail shopping centers were built ``John Corham, "The State Street Story." (Chicago Sun-'I'iincs, Chicago Daily News Marketing Services Department, August. 1970), The figures used in Table 3-10 do not take account of inflated dollar values. However, according to John Gorham. a market researcher for the Chicago Sun-Times Chicago Daily News. "Wheri sales fig- ures are adjusted to constant dollars (to allow for inflation. the Central Business District is losing not only its share of total sales. but in real dollars as well. PAGENO="0492" 482 TABLE 3-10 The Distribution of Retail Sals in the Chica~goSMSA by City and Suburbs L1950, 196~~andj~,7~ 1950 1960 1967 Total Percent Total Percent Total Sales Increase Sales Increase Sales Volume 1950-1960 Volume 1960-1967 Volume City 4.093. 718 lG~ 4.738.771 23~ 5,829,871 Suburbs 1.510.714 113~ 3.210,645 81~ 5.804.850 SMSA 5.604.432 42~ 7.949,416 46c 11.634,721 Source: Chicago Association of Commerce and Industry, Chicagoland's Retail Market (Chicago 1950. 1960). U.S. Department of Commerce, Bureau of the Census. 1967 Census of Business. TABLE 3-11 Percent of Metr2p~an Retail Sales in City and Suburbs (1950. 1960 and 1967) 1950 1960 1967 City 73: 60~ 50~ Suburbs 27 40~ 50 Source: Chicago Association of Commerce and Industry. C~~g~land's Retail Market (Chicago 1950, 1960). U.S. Department of Commerce, Bureau of Census. 1967 Census of Business in Chicago's suburbs1" (See Table 3-12). During the five-year period between 1963 and 1968 the percentage of the Chicago SMSA's sales of general merchandise, apparel, and furniture in these centers rose from nearl~' 16~ to over 20 . while the Central Business District's percentage of the SMSA's sales of these goods dropped from 19 to 16. A further indication of the changing retail shopping patterns of the Chicago SMSA is shown in a series of maps. (Figures 3-10. 3-11, and 3-12). The distribution of the top twenty-five Chicago community areas and suburban municipalities in total retail sales are represented on these maps. In 1950 eighteen of the top twenty-five were in the City. Four of the highest ranking suburban municipalities were older 12Since 1968 several other major regional shopping centers have been built or are being built. PAGENO="0493" 483 52 TABLE 3-12 C-A-F RETAIL SALES (In current dollars, as reported each year) YEARS 1963 AND 1967 COMPARED Major Shopping Centers*, Chicago CBD, and Total SMSA Shopping Centers C-A-F Sales (Sl,000) Opened Name 1963 1967 Gai n/Loss 1949 Park Forest Plaza $ 22,809 $ 39,333 $ 16,524 1951 Lincoln Village 9,441 9,595 154 1952 Evergreen Plaza 44,196 81,720 37,524 1954 Lake Meadows N/A 7,832 N/A 1955 Scottsdale 9,669 11,791 2,122 1956 Edens Plaza N/A N/A N/A 1956 Old Orchard 64,546 97,178 32,632 1956 Harlem-Irving 18,491 21,262 2,771 1956 Hillside 19,982 19,372 (-610) 1956 Cerniak Plaza 14,633 19,684 5,051 1957 Meadowdale 8,275 11,475 3,200 1958 Green Meadows 1,806 3,199 1,393 1959 Golf-Mill 35,247 67,369 32,122 196O(Mar.) Winston Plaza 8,963 14,366 5,403 196O(Sept.) Canterbury 9,088 10,978 1,890 196O(Oct.) Mt. Prospect Plaza 4,257 7,155 2,898 1962(Mar.) Oakbrook Center 60,511 107,343 46,832 1962(Aug.) Lawrencewood 2,814 4,749 1,935 1962(Aug.) Randhurst 33,343 60,607 27,264 1965(Aug.) Ford City - 32,370 32,370 1966(Aug.) Dixie Square - 21,758 21,758 1966(Oct.) River Oaks - 55,107 55,107 1968(Oct.) Yorktown - - - Total (Excl. Lake Meadows, Eden~$ 368,071 $ 696,411 $ 328,340 7. of SMSA Total 15.67. 20.47. 31.37. CBD $ 446,388 $ 542,468 $ 96,080 7, of SMSA Total 18.97. 15.97. 9.27. TOTAL SMSA $`~,360,7l0 $3,410,533 $1,049,823 ~The Census of Business area is not in every case limited to the shopping plaza. Source: U. S. Bureau of the Census, Censuses of Business as reported in: Chicago Sun-Times/Chicago Daily News, The State Street Story: Outlook for Tomorrow (M~ r- keting Service Departm:nt, Chicago: 1970) PAGENO="0494" 484 33 HIGHEST 25 CA 5 AND MIJNICIPALJGS IN AETAIL SALES ASLUME IN THE CHICDGO SMSA 1955 PAGENO="0495" 485 54 HIGHEST 25 CHS AND MIJNICIPHLITIES IN RETAIL SALES VOLUME IN THE LHICVOU OMOD 960 ~~r' S-li PAGENO="0496" 486 55 HIGHEST 25 LAS AND MUNICIPALITIES `N RETAIL SALES VS,SME IN THE CHICAGS SMSA 967 S PAGENO="0497" 487 56 industrial satellites and the other three were residential suburbs located adjacent to the City. There was only a slight change by 1960 (as shown on the 1960 map) since this was the period of initial growth of the suburban centers. Between 1960 and 1967, how- ever, a dramatic change took place. In 1967 only four of the top twenty-five were in the City; one of those was the Loop and another the North Michigan Avenue extension of the CBD. The five satellite towns still ranked in the top twenty-five, hut their importance had decreased considerably. Over half of the sixteen top-ranking suburban communities were located in the middle suburban ring of recent rapid growth. Maps showing the changes in rank within the top twenty-five were also con- structed. These maps further illustrate the great decrease in importance of the City and the imniense increase in importance of the Suburbs for retail shopping (See Figures 3-13 and 3-14). From these maps it can be seen that, although most Suburbs experienced growth in retail sales in the last two decades, growth was not evenly distributed through- out the region. The growth in sales in the North, Northwest, and Western Sectors was considerably higher thar, in the South or Southwestern Sectors of the City (See Figures 3-10 through 3-14). Retail growth continues unabated in the North, Northwestern and Western Sectors of the Suburbs. Hospital Beds. The distribution of hospital beds in the Chicago SMSA in 1950 was similar in one way to the distribution of population and retail sales -- a large major- ity of the distribution was in the City (See Table 3-13). However, the similarity between these distributions ends there. TABLE 3-13 The Distribution of Hospital Beds in the_Chicag~ SMSA by C~fl~and Suburbs ,j1950. 1960 and `970L Central SMSA _c~y~ Suburbs Total Number 1950 15,000 7,701 22,701 1960 17,918 8,959 26,420 1970 20,600 12,008 32,608 1 SMSA Total 1950 707 307 100,7 1960 681 32~7 1007 1970 63~ 377 1007 The rapid decentralization, which characterized the distribution of retail sales and population was not characteristic of the distribution of hospital beds. In 1970, two out of three hospital beds were still located in the City. Actually, the gap between the number of beds in the City and ~ilxirbs had increased since 1950. This phenomenon occurred in spite of the fact that the growth rate of hospital beds in the Sutairbs was more than twice the rate in the Central City in the last ten years. Not only were hospital beds concentrated in the City but they were located in PAGENO="0498" 488 57 Figure 3-L3 HANLLET N PANE LA RETAIL SALES AJLLME SF THE HIGHEST 25 CAS AND MUNICIPALITIES IN THE CHICAGO SMSH. 1950 1960 *L9PC~~LA~R II L IT I9TL L~ ~p LII~Au:uT:~I~~L LASC PAGENO="0499" 489 58 Figure 3-14 CHANGED IN RANK IN RETAIL SALES VOLUME Of THE CAT AND MUNICIPALITIES IN THE CHICAGO TUSH 7960 967 i;~.sio~.~ s6~ 1960 ~fl 25 1961 [J 1961 ~1k lH...196~ 1960 1.60 Ill II lIp 21 1961 II lIp 05 1960 30-698 0 - 74 - 33 (PT. 1) PAGENO="0500" 490 59 a very limited area of the City. For the past two decades over half of the hospitals beds of the Metropolitan Area have been concentrated in eight communities and one out of four hospital beds in the Chicago SMSA were located in one of two CA's -- the Near North Side or Near West Side (See Figures 3-15, 3-16 and 3-17). The twenty-five community areas and municipalities with the highest numoer of hospital beds are shown in F'igures 3-18, 3-19 and 3-20. The same communities, almost without exception. have been the leaders throughout the study period. Only four Suburban municipalities -- Evanston, Oak Park, Berwyn and Evergreen Park -- rank in the top twenty-five. The stability of the distributional patterns of hospital beds is explained by the immobile nature of these institutions. Hospitals are capital intensive units and not easily moved about. It is much less expensive to remodel and expand established facilities than to build new ones. Socioeconomic Status. Figure 3-21 shows the twenty-five highest and lowest community areas and municipalities of tha SMSA by socioeconomic ranking in 1950 based on the data from the NIPC study. The most affluent areas of the City are concentrated in the inner and middle northern suburbs and in the inner northwestern and western suburbs. Poverty is conspicuously concentrated in the Inner City South and West of the Loop. However, there are several isolated concentrations of poverty in the Suburbs as well as concentrations of wealth in the Central City. Highwood, Bobbins, Phoenix, Steger. Summit, and North Chicago are suburban islands of indigence; Rogers Park, Forest C-len, Beverly. and the lake shore edges of both Hyde Park and the Near North Side are isolated areas of wealth in Chicago. The close association of poverty areas and areas of high concentrations of Negro population is obvious (Compare Figures 3-21 and 3-7). Figure 3-22 depicts the community areas and municipalities which had the 25 highest and 25 lowest scores on Bees' factor I (Socioeconomic Status) for 1960. The areas of wealth and poverty depicted on the 1960 map were similar to the 1950 map based on the NIPC study. In other words, affluence remained in about the same general area between 1950 and 1960, although there was a slightly greater concentration 3f wealth in the Northern Suburbs. Poverty continued to be concentrated in the Southern and Western Sectors of the City with a noticeable westward expansion. The detailed statistics for 1970 are depicted in Figure 3-23. There has been little change in the relative affluence of communities in the Chicago SMSA. The wealthiest areas are still in the Northern and Western Suburbs, though the Northern concentration has expanded significantly into the middle Suburbs. There has been little change in the location of the poor in the Metropolitan Area. The Western and Southern Sectors of the Inner City remain the most impoverished, with several islands of poverty still existing in the Suburbs. These are also the Suburbs with high propor- tions of Negro population. The number of studies relating other socioeconomic characteristics, such PAGENO="0501" 491 60 Pi~~-~ 3-iT OHS IN WHICH THE TOP 50% OF THE HOSPITHI REST OF ~HE CHICHOO SMSH WERE LOCHTEO IN 950 PAGENO="0502" 492 61 Pig~~ 3-16 OHS IN WHICH THE TOP 50% OP THE HOSPITAL REDS OP THE CHICAGO SMSH WERE LOCATES IN lAHO PAGENO="0503" 493 62 Figure 3-17 CAT IN WHICH THE TOP 50S OF THE HOSP TAL HEDS O~ THE Cl-I CAGO SASH WEEl- j~A'E ~ cz~~ PAGENO="0504" 494 63 Figure 3-18 HIGHEST 25 CAT AND MUNICIPALITIES IN HOSPITAL BEDS IN THE CHICAGO SMSA 1950 PAGENO="0505" 495 64 Figure 3-19 HIGHEST 25 CAS AND MUNICIPALITIES IN HOSPITAL AEDS IN THE CHICAGO OMSA 1960 PAGENO="0506" 496 65 Figure 3-20 HIGHEST 25 GAS AUG MUNICIPALITIES IN HOSPITAL BEDS IN THE CHICAGO SMSA. 1925 PAGENO="0507" 497 66 Figure 3-21 HIGHEST 25 AND LOWEST 25 CAS At~D MUNICIPALITIES RANK IN THE CHICAGO SMSA, 1950 IN SOCIOECONOMIC PAGENO="0508" 498 Figure 3-22 HIGHEST 25 and LOWEST 25 CA'S ANO MUNICIPALITIES IN SOCIOECONOMIC RANK IN THE CHICAGO SMSA, 1960 L~~_l % I Jr PAGENO="0509" 499 68 Figure 3-23 HIGHEST 25 AND LOWEST 25 CA'S AND MUNICIPALITIES IN SOCIOECONOMIC RANK IN THE CHICAGO SMSA, 1970 PAGENO="0510" 500 69 as high rates of crime, disease, infant mortality, illegitimate births, venereal disease, etc. , to poverty areas are legion, and they have been substantial enough to enable general acceptance of the interrelationships. One study of this nature has particular significance to this study. In 1969 (erald Pyle and Joyce lashof published `The Geography of Disease and Death in the Two Chicagos. 13 The City of Chicago was divided into poverty and non-poverty areas based on a statistical analysis made by the Chicago Committee on t r~n Opportunity. Pyle found that a very high correlation exists between the location of poverty and the location of high incidence of various diseases and other health care problems. Specifically. the study showed that gonorrhea, illegitimate births, diarrhea, premature births. syphilis, measles. poisonings. tuberculosis and infant mortality have their highest incidence in (and in fact, are virtually limited to) poverty areas of Chicago. Hence. Pyle grouped them into what he called a "Poverty Syndrome.' Other communicable diseases such as mumps, whooping cough, chicken pox, rheumatic fever, scarlet fever, pneumonia, rubella, and hepatitis also have high incidence in many noverty communities, but are not limited to those areas and may be more closely related to some characteristics other than poverty. The inadequate medi- cal care associated with the poor is, however, a contributing factor, especially as concerns the severity and duration of these illnesses. In summary, there are two major concentrations of wealth, the Northern and Western Suburbs. which are slowly shifting outward away from the Loop. There are also two major concentrations of poverty, the Inner and Outer City zones of both the Southern and Western Sectors, which have remained relatively stable with some encroachment upon the areas peripheral to them -- especially to the south. In addition, there are isolated areas of poverty in the Suborbs and of wealth in the City. The latter are mostly remnants of a former era when the area was generally more posh. Kenil- worth. \Vinnetka. (`lencoe, and Wilmette have been among the wealthiest suburbs during the entire period. Robbins. parts of the Near North Side, North Lawndale, the Near South Side. Kenwood. Oakland. and Woodlawn have been perennial poverty areas in Chicago since 1950. Also, there is a strong relationship between poverty areas and high rates of crime, poor health, substandard living conditions, and black residence. 13Gerald Pyle and Joyce Lastiof, `The Geography of Disease arid Death in the Two Chicagos."in Pierre de Vise, Slum Medicine: Chicago's Apartheid Health System, Report No.6 (Chicago: Community and Family Study Center, University of Chicago, 1969). PAGENO="0511" 501 CHAPTER IV A DESCRIPTION OF THE CHANGING DISTRIBUTION OF ALL PRIVATE PRACTICE PHYSICIANS' AND SPECIALISTS' OFFICES IN METROPOLITAN C HICAGO (1950-1970) Many students of health care delivery systems in the United States are begin- fling to cite maldistribution, rather than actual shortages of physicians, as the major problem of the present system. The understanding of distributions and areal relation- ships is the heart of geographic study. What is needed, therefore, is a geographic in- vestigation and analysis as it relates to health care delivery. One of the objectives of this chapter is to describe the changing distribution of private practice physicians' and specialists' offices in the Chicago SMSA and various subdivisions of that region. The patterns identified in this chante' will later be com- pared with the distribution of the locative factors described earlier, in an attempt to indicate the significance of each factor's influence on the location of physicians' and specialists' offices in the Metropolitan Area. This chapter, therefore, is not an examination of the quality, or for that matter merely the quantity. of the available health services per se, but is a geographi- cal analysis of this spatial phenomenon. The question being asked is not `Are the existing services adequate?' but rather, "How are they distributed?" More explicitly, the question iS: "Are doctors' and specialists' offices -- and hence the services provided in them -- uniformly available to all who seek medical care?" This in torn raises the question, "If not, where and why are they not available?" This chapter is divided into three sections: (1) comparison of the Chicago Metropolitan Area and national growth patterns of all physicians', private practice physicians', and specialists' offices between 1950 and 1970; (2) Description of cha~g~~in the general distributional patterns of all private practice physicians' and specialists' offices in the Chicago SMSA between 1950 and 1970: (3) Description of changes in the detailed distributional patterns of all private practice physicians' and specialists' offices in the Chicago SMSA between 1950 and 1970. It is necessary to describe the patterns of all private practitioners' offices and then private practice specialists' offices separately because private practitioners are more representative of the distributional pattern of the past while the present and expected future patterns are more like that of specialists' offices due to the recent 70 PAGENO="0512" 502 dramatic rise in specialization. ConparisonofCh~~Metropolitan Area and National Growth Patterns of All Private Practice Physicians and Specialists' Office s±~0:±97W All Private Practice Physicians Offices The total number of physicians in the United States increased nearly 115 between 1950 and 1970. an increase of over 50~. This represented a growth rate con- side rablv higher than that of the population. Thus, the physician/population ratio rose fron 1. 4~ to 1 . 64 doctors per thousand population during a period of rapid population growth (See Table 4-li. TABLE 4-1 PhvsicianandPhysiciap±~pu1atioflRa4)Os in the United States and Chicago Metroj~itan Area (1950, 1960 & 1970) United States Total Physicians 219.997 260,484 334,028 Total Ph~sicians Per Thousand Population 1.45 1.48 1.64 Private Practitioners 155.189 168,142 198.219 Private Practitioners I'er Thousand Population 1.05 .94 .97 of Total Physicians in Private Practice 72 65 59, Ch~~ Metropolitan Area Total Physicians 8,788* 9,437 11,840 Total Physicians Per Th3usand Population 1.70 1.52 1.72 Private Practitioners 7.214 6.887 7.067 Private Practitioners Per Thousand Population 1.39 1.11 1.03 of Total Physicians in Private Practice 60 Estimated Source: U.S. Public Health Departmen~. American Medical Directors'. 1950. 1960 and 1970. However, it must be pointed out that not all doctors are directly involved with patient care. In fact. further examination of Table 4-1 revealed that less than six of every ten medical doctors in the United States in 1970 were in private practice. Hence, the ratio of physicians in private practice (or direct patient care) to population actually declined, even though there was a large increase in the total number of doctors PAGENO="0513" 503 72 in the United States. In other words, the actual number of doctors available to care for the sick decreased during the period of phenomenal growth in the number of physicians. This disparity is accounted for by the fact that in recent years a far higher proportion of doctors are going into research, teaching, and administration than did twenty years ago. The increase in total number of physicians in Chicago, on the other hand, was considerably slower than the national rate. with an increase of only 35/ between 1950- 1h70 (See Table 4-1) as compared to over SOT for the United States. As a matter of fact, the growth rate of physicians in Chicago was about equal to the population growth rate. Therefore, the physician/population ratio in the SMSA in 1970 was about the same as it was in 1950. In spite of the differential growth rate, Chicago had a slightly higher ratio of doctors to population than the United States. The growth rate of private practitioners in Chicago also differed from the national pattern. The absolute number of doctors in this category in Chicago declined notably between 1950 and 1960, and then reversed and began to increase through the next decade. The recent increases, however, were slower than the earlier declines; therefore, the number of private practitioners in 1970 was still below that of 1950. Another significant fact is that the number of private practitioners in Chicago did not grow as rapidly as the population; hence, the physician/population ratio fell much more dramatically than the national rate (See Table 4-1). In 1950 the private practice physician/population ratio of the Chicago SMSA was nearly 35 doctors per 100,000 above that ratio for the United States. By 1970 the ratio dropped to only six more doctors per 100,000 than in the United States. To put it in other words, the proportion of doctors in private practice had fallen from S2~T (ten percent above the national level) to 60~i (nearly the same as the national level). Thus, while Chicago still fared better than the nation in its physician/population ratio, it had a significant relative decline. ~pecialists' Offices The importance of the change in the physician/population ratios, both in Chicago and the United States, takes on a greater meaning when considered in the light of the fact that the proportion of private practitioners who were board-certified special- ists rose from 10~ in 1950 to over 45~ in i970. When the number of doctors who limited their practice to some type of specialized medicine but who were not board certified were included, the percentage of specialists rose to over 75~. . This means that only one out of four doctors did not limit his practice to some special area of medicine. To fully comprehend the importance of this fact it must be remembered that 20 to 30 years ago one general practitioner cared for the entire range of a family's medical care. In other words, a one-doctor-per-family relationship was the usual pattern, and the number of doctors per population had a particular meaning. Today, the complete medical care of one family may include four or five doctors, each concerned with only one special part of the overall medical needs of the family. For example, one family may well utilize the services of a pediatrician, obstetrician-gynecologist, internist, PAGENO="0514" 504 73 opthalmologist, and perhaps an orthopedic specialist. Thus, one physician per family is no longer typical, and the slight decrease in the ratio of doctors to population really does not reflect the internal changes of the system. Furthermore, the 1970 ratio included a larger proportion of radiologists, anesthesiologists. and pathologists than in 1950. Although these doctors were considered as private practice, direct patient-care physicians, they really performed ancillary services for another doctor. A further discrepancy exists in that a number of specialists restrict their prac- tice to certain critical types of medical practice which involve either a limited number of cases or care of a very restricted area of the body. This group includes such specialists as cardiologists, neurosurgeons, opthalmologists, otolaryngologists, etc., who, neces- sary as they may be, only see a small portion of all patients. The net result of this is an even fewer number of physicians available for primary or preventive medicine. Description of Changes in the General Distributional Patterns of All Private Physicians' and Specialists' Offices in the 0SMSA (1950-1970) Mean Center of_Distribution (Centrographic Technique) AlL~ysicians__Offices. The mean center of all physicians' offices in 1950 was only 4.3 miles from the Loop and its bearing was slightly south of west of that center (See Table 4-2 and Figure 4-1). This proximity of the mean center to the Loop suggests a strong concentration of physicians' offices in that area. In 1960 the mean center was nearly six miles straight west of the Loop ~ the center had shifted outward TABLE 4-2 Location of the Mean Centers of All Physicians' and ~peciaiists' Offices Relative to the Chicago Loop 1960 and 1970) All Physicians' Offices Specialists' Offices 1950 1960 1970 1950 1960 1970 Distance from the Loop in miles 4.3 5.8 7.3 2.1 4.8 7.3 Azimuthal bearing from the Loop 261.0° 269.5° 276. 0° 265.0° 290.0° 288. 0° and to the north. The azimuthal bearing of the center in 1960, in other words, was nearly nine degrees north of the 1950 center, and was a mile and a half farther from the Loop. Bs' 1970 the mean center of physicians' offices had ~Mfted another mile and a half outward and 6.5 degrees northward from the Loop. In all, the mean center of all physicians' offices had shifted approximately three miles northwestward in the twenty- year period. Specialists'_Offices. The mean center of specialists' offices was only a little PAGENO="0515" Figure 4-1 MEAN CENTERS OF ALL PHYSICIANS AND SPECIALISTS OFFICES. 1950. 1960, AND 1970 -~I 4- © C)' PAGENO="0516" 506 over two miles west of the Loop in 1950, indicating that they were far more concentrated in the Loop at that time than were total physicians' offices. Between 1950 and 1970 this center shifted northwestward dramatically, until by 1970 the mean center was over five miles farther from the Loop than it was in 1950, which placed it the same distance from the Loop as physicians' offices in general (See Table 4-2 and Figure 4-1). It was, however, significantly farther north than the mean center of all physicians' offices. The northwestward shift of the mean centers of both physicians' and specialists' offices indicates that there was a relative increase in specialists on the north side of the SMSA with a corresponding relative decline in the importance of the Loo1. Disj~rsalJ~tandardDistanc~j Phvsicians'~ ealists' Offices. Standard Distances of dispersal from the Locp were generated for all physicians and specialists' offices for 1930. 1960 and 1970 (See Table 4-3. The Standard Distances of all physicians' and specialists' offices were nearly the same in 195e. and they have remained at approximately the same distance apart throughout the study period. The Standard Distances of both of these distributions increased rapidly between 1950 and 1970, with the rate of increase for physicians' offices being slightly greater than that of specialists' offices. TABLE 4-3 Standard Distance of All P~y~ans' and Sj~alists' Offices Frwu the Lo~p, J~50, 1960 and 19~ 1950 1960 1970 All physicians' Offices 14.3 16.0 17.2 Specialists' Offices 14.6 15.2 17.0 The movements of the mean centers of these distributions plus the increased Stanuard Distances indicated that these phenomena decentralized between 1930 and 1970, and that the rate of decentralization was relatively rapid. S~p~j of Distritxition(Sectorgram The general trend of decentralization was not equal in all directions from the l1)up. Sectorgrams were constructed to clarify the changes in the shape of the distri- butions which resulted from the uneven dispersal from the Loop (See Table 4-4 and Figures 4-2. 4-3 and 4-4). All Private_Practice Physicians' Offices. In 1930 expansion of physicians' offices to the northwest. southwest, and west of the Loop was far greater than to the north and south. In fact, the Standard Distance of doctors' offices to the northwest was nearly twice the distance to the south, and about one and one-half times farther than to the north. A similar pattern exists in 1460 and 1970. In 1970 the Northern and Southern Sectors had nearly equal Standard Distances (both just over 14 miles), but the PAGENO="0517" 507 Fiure 4-2 Fi~ure 4-3 SECTORGRAMS OF ALL PHYSICIANS AND SECTORGRAMS OF ALL PHYSICIANS AND SPECIALISTS OFFICES IN 1950 SPECIALISTS OFFICES IN 1960 k ~i~rivate Practice ~riv~tr Practice Physiciars 1962 / ~ N S .c1~ `ractic~ Specialists, 190 p.~ ~:~icc Thei~1ists, 1962 ~ Ficure 4-4 ~-~---~ SECTORGRAMS OF ALL PHYSICIANS AND - -~c2icr Phvsici~"~s~ 1970 SPECIALISTS OFFICES IN 1970 N rac:~Oe S~eneiists ~?72 PAGENO="0518" 508 77 TABLE 4-4 Standard Distances of All Physicians' and Specialists' Offices From the Loop ~ by Sector (1950, 1960 & 1970~ - All Physicians'_Offices - Specialists' Offices Sector 1950 1960 1970 1950 1960 1970 North 11.5 13.2 14.2 14.6 13.1 14.1 Northwest 19.1 19.7 21.0 17.8 20.9 21.8 West 14.8 16.4 17.6 12.2 15.4 17.1 Southwest 18.7 19.2 19.7 23.2 19.7 22.1 South 9.9 12.4 14.1 9.1 12.8 13.7 Standard Distance of the Northwest Sector was still one and one-half times greater, at 21 miles. The Standard Distance of the Western Sector in all three periods was greater than the Northern and Southern Sectors, and less than the Northwestern and Southwestern Sectors. In the twenty-year period the relative shape of the distribution of doctors' offices changed very little. The Northern and Southern Sectors were the most com- pacted, the Northwestern and Southwestern Sectors were the most dispersed, and the Western Sector was at a point between. Specialists' Offices . The sectoral dispersal of specialists' offices in 1950 was more uneven than total physicians' offices. The Southwestern Sector had an ex- ceptionally high Standard Distance compared to the rest of the sectors of the specialists' office sectorgrams. The Standard Distance of the Southern Sector was extremely short, as was the Western Sector. The expansion of specialists' offices was relatively moder- ate in the Northern Sector while the Standard Distance of the Northwestern Sector was comparatively large. The 1960 sectorgram of specialists' offices was less irregularly shaped; the Southwestern Sector contracted, while the Western and Southern Sectors expanded notably. The smoothing of the pattern to the south and west was slightly offset in the north: the Northern Sector contracted slightly while the Northwestern Sector expanded, resulting in a more irregular shape in that direction. The shape of the 1960 sectorgram of specialists' offices was very similar to the sectorgram of total physicians in that year, although this was not the case a decade earlier. By 1970 the sectorgram of specialists' offices was almost a replica of the 1970 sectorgram of total physicians' offices. The only difference was in the greater southwesterly expanse of the specialists' offices sectorgram. Proportional_Distribetionof Private Practice Physicians' and Specialists' Offices by Sector In order to further describe the changing distribution of doctors' offices, it is necessary to determine what proportion of the total physicians' and specialists' offices were located in each sector. The sectors in Table 4-6 and 4-7 were centered on the Loop, with the Loop practitioners being excluded from these tables for reasons PAGENO="0519" 509 79 TABLE 4-6 Number and Percent of Total Specialists' Offices in the Chicago SMSA ~1Xttside the Loopby Sectors (~~50, 1960 and 1970) 1950 1960 1970 ~ North 124 38.5 568 44.9 1,033 39.5 Northwest 31 9.6 182 14.7 449 17.2 West 56 17.4 227 17.9 621 23.7 Southwest 32 9.9 61 4.8 199 7.6 South 79 24.5 228 18.0 313 12.0 offices in the Southwestern Sector decreased to under 5%, in spite of the fact that the number of specialists' offices located there doubled. In 1970 two-thirds of the special- ists' offices were located in the Northern and Western Sectors and the Northwestern Sector had almost one-fifth more. The Southern Sector loss was 6%, while the South- western Sector rose to nearly 8%. The number of specialists' offices in the Northern Sector increased 8.5 times -- from 124 to 1,033 offices -- between 1950 and 1970. *The Southern and South- western Sectors together increased only five times, from approximately 100 to 500 offices in the same period. The relative disparity between the northern and southern parts of the SMSA will probably increase as the proportion of specialists increases. Description of the Changing Detailed Distribution of All Private Practice Physicians' and Specialists' Offices in the Chicago SMSA (1950-1970) City vs. Suburbs All Physicians' Offices. The City of Chicago lost over 2 ,000 private prac- titioners' offices between 1950 and 1970 -- a 35% decrease in twenty years. The Suburban Region, at the same time, was adding nearly 1,900 doctors -- an increase of over 130% (See Tabie 4-7). The decentralization of doctors' offices, which had begun several decades earlier, was therefore continuing. LXiring the recent period, however, the shift was from City to Suburbs rather than from the Loop to the outlying business centers of the City. The result of this shift was a substantial decline in the proportion of doctors' offices located in the City of Chicago. In 1950 four out of five doctors' offices in the Chicago SMSA were located in the City; by 1970, that ratio had fallen to one out of two. Specialists' Offices. In 1950 an overwhelming proportion (84%) of all special- ists' offices in the Chicago SMSA were located in the City; two out of three were located in the Loop (See Table 4-8). The City's proportion of specialists' offices dropped 19% in the 50's as a large number of specialists shifted their offices to the Suburbs. By 1960 PAGENO="0520" 510 (1950, 1960 and 1970) ________ __________ 1970 if City (including Loop) Loop Suburbs SMSA Totals Source: American Medical Directory The Loop's proportion of specialists' offices in the SMSA declined steadily during the twenty-year period, falling from 62/ in 1950 to 39% in 1960, and to 25% in 1970. The absolute number of specialists' offices in the Loop, however, increased throughout the twenty years, but at a much slower rate than the other parts of the City. Concentric Zones and Sectors All Physicians' Offices. The distribution of physicians by concentric zone and radial sector is shown in Table 4-9. The percent of the total physicians of the Chicago SMSA located in each sector changed significantly between 1950 and 1970. The percent of the SMSA's physicians' offices rose significantly in two sectors (Northern and Western), and decreased substantially in another sector (Southern). The increase so TABLE 4-7 Number and Percent Increase of Private Practice Physicians in the~ç çao ISA b-Chicago and Suburbs J1930, 1960 and 19701 No. of Doctors, 1950 No. of Doctors, 1960 No. of Doctors, 1970 Increase/Decrease 1950-1960 Increase/Decrease 1960-19 70 Increase/Decrease 1950-1970 of Chicago Total j~Loo Offices 5,796 80 4,592 66, 3,762 53 -20 -26 -35 of Total Offices 20/ 34% 47/ Suburbs 1,418 2,295 3,305 -133/ (7~ of Total ~22 Offices 1,490 21% 1,027 14% 739 10% -317 ~50 (/ there were more specialists' offices in the Suburbs than there were in the City outside the Loop, and by 1971) fully SI) of the specialists' offices were located in the Suburbs. TABLE 4-8 Number and Percent of Diplomate ~p~alists'_Offices in the Chicago SMSA by City, Loop and Suburbs 1950 1960 639 54~ 1,175 466 62/ 708 112 16, 628 751 100 1,803 65/ 39 35/ 100/( 1,568 787 1,569 3,137 501/ 25/, 50/ 100/, PAGENO="0521" TABLE 4-9 Percent of All Physicians Offices in the Chicayo SMSA by Concentric Zones and Sectors (1950, 1960 and 1970) Sector North Northwest West Southwest South Total 1950 1960 1970 1950 1960 1970 1950 1960 1970 1950 1960 1970 1950 1960 1970 1950 1960 1970 Central 25% 20% 16% Inner City 5% 4% 4% 6% 5% 3% 4% 2% 2% 4% 4% 2% 11% 6% 5% 30 20 16 Outer City 9 8 9 5 7 5 5 3 1 3 4 4 5 5 3 26 27 22 Inner Suburb 4 6 8 - 1 2 5 9 10 - 1 2 1 2 2 10 19 26 Middle Suburb .5 1 2 - 1 2 2 3 6 1 - - - 1 1 4 7 12 SatelliteRing .5 1 1 - - - 2 2 3 1 2 2 - 1 1 4 6 6 OuterSuburb - - - 1 1 1 1 1 1 3 2 3 TOTAL 18 20 25 12 15 13 18 20 22 9 11 10 17 14 12 PAGENO="0522" 512 82 in the Northern Sector (7~~) was the greatest change recorded for any of the sectors. The changes in the concentric zonal distribution of physicians' offices are as significant as those by sectors. There was a decrease in three of the concentric zones (Loop, Inner City and Outer City, an increase in three others (Inner Suburbs, Middle Suburbs and Satellite Ring), while one zone (Outer Suburbs) remained unchanged between 1930 and 1970. The three City Zones lost a combined total of 26 of their physicians to the Suburban zones. The Inner City zone was the largest loser (-14), and the Inner Suburbs the largest gainer (~-16 during the twenty years. The largest absolute gains in physicians' offices were in the Inner Suburbs \\est and Inner Suburbs North. The former had an increase of 404 offices and the latter 331, The largest absolute losses were in the Inner Cit~ South (ICS) and Outer City West (OCW) portions of the SMSA. The ICS lost 454 physicians' offices and the OCW lost 331, Between 1950 and 1970, therefore, there was a spectacular shift of doctors' offices from the Loop, Inner City and Outer City (especially from the Western and Southern Sectors) to the Inner and Middle Suburbs -- particularly to the Northern and Western Sectors of those zones. Specialists' Offices The distribution of specialists' offices by concentric zone in 1950 had an inverse relationship with distance from the Loop, i.e. , the tion of specialists located in each zone decreased with increased distance from the Loop (See Table 4-10~. The pattern altered slightly in 1960 as the percentage of specialists TABLL 4-10 Percent of Specialists' Office~jy Concentric Zone (1950, l960~j27~ Zone 1950 1960 1970 Loop 62 33~ 25 Inner City 14 9 lOT Outer City 9 17 15 Inner Suburbs 8 22 29, Middle Suburbs 3 8 13L Satellite Ring 4~ 6 Outer Suburbs .1 . 8~ 1 in the Loop and Inner City declined while the Inner Suburbs increased significantly~ The Loop was able to maintain its dominance over the other zones of the SMSA in spite of this shift. The Inner City and Outer City, however, fell below the Inner Suburbs in their relativejroportion of specialists' offices. This produced an irregular profile with a high in the Loop, decreasing sharply into a valley in the Inner City, rising through the Outer City to a second peak in the Inner Suburbs, and then decreasing from that point to the periphery (See Table 4-10). The pattern in 1970 reflects a continuation and accentuation of the shifts ol the earlier decade. The proportion of specialists in the Loop continued to decline while the Inner and Middle Suburban Zones increased significantly~ As a result of this, the PAGENO="0523" 513 83 Inner Suburbs rose above the Loop in its proportion of specialists. The Loop fell to second place in the SMSA while the Outer City maintained third place, even though its proportion had declined slightly. The Inner City continued to decline relatively and fell below the Middle Suburbs, which rose to within two percentage points of the Outer City. The Satellite Ring and Outer Suburbs were still relatively void of specialists, although they did increase in their relative proportion of the SMSA's specialists. It is noteworthy that all Suburban zones increased in their proportion of specialists while all City zones decreased during this twenty-year period. Hence, it can be expected that the Suburban zones will all soon rise in rank while the City zones (Loop excepted) will continue to decline in rank. Thus, the profile of the distribution of specialists' offices by Concentric Zone in the future will probably show two peaks or concentrations (the Loop and Inner and Middle Suburbs) separated by a relatively barren valley (the City outside the Loop). The portion of specialists' offices located outward from the Middle Suburbs will probably continue to have only a minor share of the SMSA's specialists' offices. The distributional data on specialists by ring and sector are combined and broken down into cells in Table 4-11. Concentrations and voids of specialists are easily identified from this table. Four cells -- Outer City North, Inner Suburbs North, Inner Suburbs West, and Middle Suburbs West -- had significant increases in their share of the specialists in the SMSA. These four cells had only 9~57 of all specialists in 1950, but by 1970 their combined total was 3517, that is, one out of every three specialists were located in one of these four cells. These particular cells also accounted for three- fourths of the growth in their respective sectors -- which when combined had nearly one-half (4917) of the specialists in the SMSA. There were also four cells -- Inner City Northwest, Outer City West, Middle Suburbs Southwest, and Inner City South -- which had significant decreases in their proportion of the SMSA's specialists. In 1950 these four cells had a total of 1317 of all of the specialists (a higher percentage than the four above-named cells) but by 1970 their combined total w~ below 517. Nearly two-fifths of this relative decrease was in the Inner City South -- which had the largest decrease in percentage in the twenty-year period. Summarizing the changing distributional patterns of physicians' and special- ists' offices between 1950 and 1970 it can be stated that: (1) the mean centers of phy- sicians' offices shifted three miles to the northwest of the Loop; (2) the Standard Distances increased significantly, i.e. , there was a decentralization of physicians' offices; (3) dispersal from the Loop, as measured by Standard Distances, was least in the Northern and Southern Sectors of the SMSA and greatest in the Northwestern and Southwestern Sectors; dispersal to the west was not as great as to the northwest and southwest, but considerably farther than to the Northern or Southern Sectors; (4) there was a spectacular shift of physicians' offices out of the City into the Inner and Middle Suburbs -- particularly from the Southern Sector to the Northern Sector of the SMSA, and (5) the changing pattern of specialists' offices reflects the shifts of all PAGENO="0524" Central Inner City Outer City Inner Suburb Middle Suburb Satellite Ring Outer Suburb TOTAL TABLE 4-11 Percent of Specialists Offices in the Chicago S~1SA by Concentric Zones arid Sectors (1950, 1960 and 1970) Sector North Northwest West Northwest South Total 1950 1960 1970 ~ 19501960 1970 I9~P 19601970 1950 1960 1970 ~f~1970 62~, 39~ 25;~ 2d 2% 3% 2% 1% .5~ 2% .5~ 3 .9 1~ .67 77 4~ 4~' 14 9 10 3 6 7 1 3 3 2 .7 .3 .8 3 3 2 4 2 9 17 15 4 12 13 .5 2 3 2 7 9 - .5 2 .5 .7 1 8 22 29 1 3 4 - .7 3 .5 3 6 2 - - .2 1 .9 5 8 13 1 1 1 - - - .8 2 3 .9 .7 2 - .3 .3 3 4 6 - - .3 - .3 .6 .1 .8 12% 24% 28% 4% 7% 9% 7% 14~ 21% 5% 6~ 8% 10% 10% 9% PAGENO="0525" 515 85 physicians' offices, with the exception that the Northern Suburbs are even more singu- larly attractive to specialists than to physicians as a whole. PAGENO="0526" 516 CHAPTER V ANALYSIS OF RELATIONSHIP BETWEEN CHANGING DISTRIBUTION OF PHYSICIANS' AND SPECIALISTS' OFFICES IN THE CHICAGO SMS~ AND LOCATIVE FACTORS (1950-1970) In this chapter an attempt is made to explain the dramatic changes in physician office distribution in the Chicago SMSA described in Chapter IV. It focuses mainly on the relationship between the changing distribution of all private practice physicians' offices and the locative factors discussed earlier, in Chanter III, The chapter is divided into the following sections: 1, Explanation of the general distribution of private pract)cgJ~~5ysicians' ~ This objective is accomplished by comparing the mean centers, shapes. and dispersal of all distributions by use of Standard Distance and Sectorgrams. 2. Explanation of detailed distribution of private practice physicians' ~ locative factors, This objective is accom- plishecl by comparing the changing distribution of physicians' offices with each locative factor at various levels of geographic detail. ~ of detailed distribution of diplomate ~jalists~ offices only as compared to locative factors, This objective also, is accomplished by comparing the changing distribution of specialists' offices with each locative factor at various levels of geographic detail. The analysis seeks to identify the most significant forces, both attractive and repel lent influencing the location of doctors in the Metropolitan Area, Attention is directed towar:l ye rifving the hvpotOeses made at the outset of this study, but other iv it in cflt Ia cOo rn are not ifi s rega rdecl Fxoianation of General Distribution of Private Practice Phvs icians'andDij~~peciatists' Off ~sas ComCa red to Locative Facto rs Cot: pa ri son of SPan Cente is In It tO the mean centers of all private practice physicians' offices, popula- torn retail salts. and hospital beds were clustered in a triangular-shaped node within one and a half cities of each other at the western edge of the City (See Figure 5-1). The population center was at the weste in cornet of the triangle, the center of physicians' oft ices was at the eastern co roe r and retail sales was at the apex of the triangle to the north. The center of hosoital tacit itit s was west of the Center of the triangle between tottation and `eta it sales. The mean center of specialists' offices itas approximately two and a half miles cfirectlv east of the cluste ted cente rs, while the center of high PAGENO="0527" ~igure ~-1 MEAN CENTERS OF POPULATION, RETAIL SALES, HOSPITAL BEDS, SOCIOECONOMIC STATUS, ALL PHYSICIANS AND SPECIALISTS OFFICES IN THE CHICAGO SMSA, 1950 PAGENO="0528" 515 88 socioeconomic status was over four miles northwest of the triangular cluster. Thus, in the early part of the study period the mean centers of doctors' offices and hospital facilities were in proximity to the mean centers of the population and retail sales. In 1960. the four clustered centers split into two separate nodes. The centers of population and retail sales shifted almost directly westward and rematned about a mile apart. The center of all private practice physicians' offices shifted northwestward away from the centers of population and retail sales and toward the center of high socio- economic status (See Figure 5-2). The center of hospital facilities shifted almost straight northward to a point close to the center of all physicians' offices. The center of specialists' offices also shifted northwestward away from the centers of population and retail sales. The latter move resulted in specialists' offices being situated signifi- cantly northeast of the center of all doctors' offices. Meanwhile the center of socio- economic status shifted farther into the Suburbs. Between 1960 and 1970 the centers for population and retail sales continued their westward migrations while centers of hosnital facilities, all private practice physi- cians' and specialists' offices shifted farther to the northwest. The center of socio - economic status, on the other hand, moved back toward the northeast. The distance be- tween the centers of doctors' offices (both total physicians and specialists) and socio- economic status, therefore, decreased considerably between 1960 and 1970 while the distance between those offices and the population center increased (See Figure 5-3). The shift toward affluence of the mean center of hospital facilities, however, was slower than that of doctors' offices because there were fewer considerations to be taken into account when a doctor moved his office than when a hospital relocated their facilities. Ilence. in the past twenty years, affluence, rather than population, seemingly had the greater effect upon the movement of the mean centers of hospital facilities and both all physicians' and specialists' offices. Comp~ison of Dispg~ats A comparison of the general dispersal of all doctors' offices with the locative factors revealed that the dispersal of doclors' offices lagged behind the dispersal of socioeconomic status. popuiatioa, and retail sales, but decentralized faster than hospital facilities (Compare Tables 3-7 and 4-4). This was also true (and to be ex- pected) of specialists' offices, since the Standard Distance of their dispersal was prac- ticallv the same as for all physicians' offices. Retail centers usually preceded the arrival of doctors' offices into an ai'ea into which population had expanded. The greater suburbanizatiori of high socioeconomic status reflected the shift of the wealthy and mid- die-income families into the Suburbs, while the Inner City became the major residential area ol the City's poor Physicians' and specialists' offices therefore, were decen- ti'alizing ~shifting to thi burbs.Lpi'eceded b~j~tail shopping and affluent population, indicating py~~ps that these two factors were attractive forces on the changing loca- tion of doctors' offices PAGENO="0529" 319 Fizura MEAN CENTERS r P0~JLATION, RETAIL SZES, U0S~ITAL SITS, sCc1TE:TNC~:: STATUS, ALL PLIV5ICIANS A';: SDECIAL:STS ::c::ES IN ThE CHICAST STMSA, 1960 MEAN CENTERS OF POPULATION, RETAIL SALES, HOSPITAL BEDS, SOCIOECONOMIC STATUS, ALL PHYSICIANS' AND SPECIALISTS' OFFICES IN THE CHICAGO SMSA, 1970 Figure 5-3 PAGENO="0530" 520 90 Comparison oL~~~s of Distribution A comparison of the shapes of all distributions, as depicted by their sector- grams, revealed a similarity in the shapes of the distributions of all private practice physicians' offices and of population, with one major exception -- the Northern Sector (Compare Table 3-8 with Table 4-5, and Figures 3-4, 3-5 and 3-6 with Figures 4-2, 4-3 and 4-4). Population was shown to be much more dispersed to the north than physi- cians' offices, probably reflecting the greater concentration of doctors' offices in the Inner Suburbs. The shape of specialists' offices distribution, with the exception of the Western Sector, compared favorably with the distribution of hospital facilities. The difference between the dispersals of these two distributions to the west is due to the high concentra- tion of hospital beds in the Inner City portion of that sector. Over one-fourth of the SMSA's hospital beds are in the Western portion of the Inner City. This unusually high concentration results in the low Standard Distance of hospital beds to the West. The relationship between the sectoral distribution of these various phenomena is clarified b~ comparing the tables which array each sector's portions of the SMSA's total of each phenomenon (Compare Tables 3-7 and 4-5). The portion of doctors' offices located in the Northern Sector in 1950 was 8~ higher than that sector's portion of the population. The Western Sector had a slightly higher share of doctorsT offices than population. The Southern, Southwestern and North- western Sectors all had lower percentages of the SMSA's doctors' offices than population. The imbalance of physicians' offices distribution became even more glaring in 1960 and 1970. By 1970 the Northern Sector had nearly 30~ of the doctors' offices but only 15~ of the population. The Southern Sector had 15~ of the SMSA's doctors' offices and 20 T of the population. The Southwestern Sector had only 11~~ of the physi- cians' offices and l6~ of the population. The Western Sector's portion of doctors' offices continued to grow faster than its share of the population. The proportion of specialists' offices in each sector is given in Table 4-6. A comparison of this table with Table 3-9 shows that specialists' offices were even more disproportionately distributed than total physicians' offices. The Northern Sector again was the chief recipient of this unequal distribution. In 1970 nearly 40~ of the SMSA's specialists' offices were located in the Northern Sector. Two-thirds of all specialists' offices were found in either the Northern or Western Sectors of the SMSA. In summary, then, the disparity between the sectoral distribution of all private practice physicians' and specialists' offices and that of population grew throu~out the two-decade study period. Analysis of Detailed Distribution of Private Practice Physicians' Offices as Compared to Locative Factors The examination of changes in the distributional pattern of doctors' offices on the broad general level indicated that recent shifts widened an already uneven appor- PAGENO="0531" 521 91 tionment of private practitioners' offices in the Chicago Metropolitan Area, Eximination at this level, however, did not single out the problem areas with enough precision to determine the significance of each locational factor. The following section, `therefore, subdivides the Metropolitan Area into succeedinglv smaller geographic units and examines and compares the patterns at various geographic levels in an attempt to more accurately pinpoint the problem areas and identify the factors which combine to produce the present distributional patte rn. Ci,~yvs. Suburbs. The physicians' offices population ratio was used to measure the relationship between the changing distribution of physicians' offices and population. An increase or decrease in this ratio meant that an area was either gaining or losing doctor~' offices at a faster rate than it was gaining or losing population. In 1950, ~0, of the doctors' offices in the six-county area of the Chicago SMSA were located in the Cite; by 1970, only 50 were located in the City, This com- pared reasonably well with the shift of population from Cit', to Suburbs, In 1950 seven out of ten People (70 1 lived in the Cite; by 1970 only one out of two (50 resided there, These figures, however, might be erroneously interpreted to indicate that the shift of doctors to the Suburbs was merely a result of the shift of population; i.e. , as the pop- ulation expanded into the Suburbs, the doctors followed. However, closer inspection of these patterns revealed that it ~s not that simple, and that several other factors had to he taken into account in order to understand the more complex relationships of these data. First, it must be remembered that the total number of private practitioners in the SMSA declined while the population was growing rapidly. This resulted in a dramatic decrease in the physician/population ratio of the Metropolitan Area, Next, the Cite was 1osingj~~h doctors and population, while the Suburbs were gamin both, The ratio of doctors to population of the City, however, ed substantially (at a rate above the Metropolitan Area as a whole, while the Suburban ratio actually rose. This indicates that doctors were abandoning the City for the Suburbs at a faster rate than the population. The Central City's historically higher ratio of doctors to popula- tion, therefore, rapidly disappeared. In fact, when the doctors located in the Loop in 1970 were subtracted from the City's total, the physician/population ratio of the City fell noticeably below that of the Suburbs (See Table 5-1). In 1950 Chicago had 70 more doctors per 100,000 population than the Suburbs, while in 1970 the difference was only 19 per 100,000, Furthermore, the ratio of the City fell from 1,60 doctors per 1,000 population to 1,13 per 1,000 while the Suburban Ilegion rose from .91 to .94 per 1,000 in this period. When the Loop is excluded from these comparisons, the City's ratio falls to . 81 1,000 in 1970 or 13 doctors per 100, 000 below the Suburban ratio. If these trends continue at their present rates both the City (Loop included) and Suburbs will have approximately the same ratio by the end of the l)resent decade 38-638 0 - 74 - 35 (Pt. 1) PAGENO="0532" 522 92 TABLE 5-1 ~~sicians Per Thousand Population in the Chicago SMSA by City and Suburbs, with the Loop Included and Excluded (1950, 1960 and 1970) 1950 1960 1970 SMSA (Loop Included) 1.39 1.11 1.03 (Loop Excluded) 1.06 .91 .88 City (Loop Included) 1.60 1.29 1.13 (Loo~ Excluded) 1.14 .93 .81 Suburban Area .91 .87 .94 (1980). The Suburbs will then take over the lead and will have a higher ratio than the City (Loop included), but they will probably have a slight absolute decrease in doctors per population. The significance of the foregoing lies in the fact that if doctors had been shifting outward at a rate comparable to the population, the ratio within these two subdivisions of the Metropolitan Area would have remained stable and both would have declined approximately the same amount in their ratios as the SMSA. The fact that the physician/population ratio of the Suburbs increased means that doctors were leaving the City for the Suburbs faster than the population. The conclusion, therefore, must still be that the shift in doctors was not simply the result of a changing population dis- tribution. Furthermore, the flight of doctors from the City and the decided absolute, as well as relative, decline in the availability of doctors in that area makes it a poten- tially greater problem area than the Suburbs, where conditions are improving. Concentric Zones. Data depicting the pattern of physicians in ratio to popula- tion relative to the ring and sector geographic subdivisions clearly illustrate the dis - persal of physicians away from the Loop in the Chicago SMSA (See Table 5-2). In 1950 the highest physician/population ratios of the SMSA were concentrated in the three urban concentric zones: the Loop, Outer City and Inner City. The Satellite Ring had the highest ratio in the Suburbs and was the only zone outside the City to have a ratio above one doctor per thousand population. The ratios of the three other Suburban zones de- creased with increasing distance from the Loop and represented the lowest ratios in the SMSA. The Suburban shift of physicians in the fifties is clearly evident in a compari- son of the distributional patterns of 1950 and 1960 (See Figures 5-4 and 5-5). The phy- sician/population ratio of the Inner City declined sharply during this period, causing that zone to drop in rank below both the Satellite Towns and Inner Suburbs. The decline of the Outer City was not as great as that of the Inner City, but it did drop sub8tantially both in ratio and rank. The ratio of the Inner Suburbs increased significantly during the decade, rising in rank above the Inner City and becoming almost even with the ratio of the Outer City by 1960. The Middle and Outer Suburbs both declined in their ratios, PAGENO="0533" TABLE 5-2 Physicians' Offices/I,000 By Rings and Sectors 1950, 1960 and 1970 Inner Outer Inner Middle Satellite Outer Total Sector Year ~ ~ Suburbs Suburbs Ring Suburbs Sector Central 1950 18.47 18.47 1960 17.35 17.35 1970 15.36 15.36 North 1950 1.27 1.38 1.63 .68 .90 .26 1.29 1960 1.09 1.29 1.56 .87 .80 .46 1.20 1970 1.24 1.40 1.95 1.28 .70 .57 1.38 Northwest 1950 .97 1.01 .82 .63 None .81 .95 1960 .86 1.17 1.09 .53 .56 .90 1970 .55 .88 1.34 .58 .45 .72 ~ West 1950 1.35 1.34 .88 .76 1.33 .90 1.10 1960 .74 .62 1.17 .69 1.22 .54 .88 1970 1.20 .17 1.35 .71 1.19. .46 .94 Southwest 1950 .96 1.06 .27 .66 1.04 .73 .91 1960 .84 1.14 .45 .34 1.17 .37 .85 1970 .37 .95 .86 .28 1.41 .24 .77 South 1950 1.14 .98 .62 .46 .57 .93 1.01 1960 .63 .97 .52 .61 1.39 .07 .72 1970 .66 .66 .45 .75 1.23 .06 .44 Total 1950 18.47 1.11 1.17 .94 .91 1.08 .73 1.39 Ring 1960 17.35 .80 1.06 1.05 .66 1.18 .48 1.11 1970 15.36 .75 .87 1.23 .71 1.10 .42 1.03 PAGENO="0534" 524 94 Figure 5-4 01 A PH~ S~3~A~3 00 ICES I CISC ACPULATICN CI CCCNCENTE CONE C 17.35 1.18 1.06 1.05 .80 .66 .48 PAGENO="0535" 525 95 Figure 5-5 DTPIkLTI~NO1~LLPH!HCIANS(J~ES 18.47 1.17 1.11 1.08 .94 .91 73 PAGENO="0536" 326 96 but their rank did not change as they were already the two lowest zones. It should be noted, however, that the declining ratio of these two zones was of a different nature than that of the City. The decrease in the Suburban zones was due to the influx of population which preceded the arrival of doctors, as brought out in the section on Standard Distances. The decline in the City, on the other hand, was the exact opposite; this decline was a result of losses of physicians at a faster rate than the loss of population in that area. Therefore, even though the Suburban zones had very low ratios, it can be expected that the outward shift of doctors will bring a change for the better. Conditions in the City, on the other hand, can be expected to get worse as doctors shift outward into the Suburbs. The pattern in 1970 verified this prediction (See Figure 5-6). The outward migration continued as the ratio in the Inner Suburbs rose while thos~ in the Inner and Outer Cits' declined. The older Satellite Towns also declined in their ratio, enabling the Inner Suburbs to rise to the highest ranking zone outside the Loop. The trend in the ratio of physicians to population in the Middle Suburbs reversed during the sixties with the influx of doctors into that zone and, although its ratio did not rise sufficiently to enable it to rise in rank above the two City zones, it can only be a matter of time until that happens. The Outer Suburbs still had the lowest ratio, and it dropped to its lowest during this period. The rate of decline decreased sharply, however, and in the next decade (1970-19~0( a reversal of that trend can be expected. Although both population and physicians dispersed outward concentrically, the character of the two movements was very different. The dispersal of the population can he described as an cxpansior. oulward from a core area while for doctors it was more a shift from one area to another. Thus, the oattern of doctors' offices can be described as having a `hollow frontier,' i.e. , one in which the core is vacated as the distribution expands as opposed to one in which the core concentration is maintained while the dis- tribution expands. Sectors. Two aspects of the changing pattern of the physician/population ratio in the SMSA by sectors were also significant to a further understanding of the locabonal factors of doctors' offices in Chicago. The first was that the highest ratio has been, and continues to be. concentrated in the Northern Sector (See Table 5-2). Furthermore, it was the only sector which had a higher ratio in 1970 than in 1950. It is also the only sector with a ratio above one doctor per thousand population. Second, the Southern Sector experienced a dramatic decrease in its ratio -- dropping from 1.01/1,000 to .441 .000 in the twenty-year period. It was also the only sector to lose ground relatively -- falling from third highest rank (only .3 doctors per thousand from the top), to the lowest-ranking sector (nearly one docto~ per thousand below the leading Northern sector). A more detailed breakdown of these data showed that disparity existed within sectors and zones as well as between them. The data in Table 5-2 and Figure 5-7 makes it relatively simple to single out those parts of the Metropolitan Area with a wealth or a dearth of doctors' offices. Examination of zones within sectors revealed that the Northern Sector gained in every concentric zone except its Satellite Towns (Waukegan-North Chicago). The PAGENO="0537" LI LI ~ * ~ U cr~ - ~`j c~~) - ~ cD c~J a~ -* I, I PAGENO="0538" 328 :~ :H~Ch I ~ iI~I ght~ Figure 5-7 DISTRIBUTION OF ALL PHYSICIANS OFFICES 1 000 POPULATION BY QUINTILE RANK BY CONCENTRIC ZONES AND SECTORS 1950 1960 AND 1970 Thi.~d ~I~tI 11 U U LI LI S~b~b~ 1950 19o0 I 1970 PAGENO="0539" 529 99 Northwestern Sector lost in every zone except the Inner Suburbs, The \\estern Sector was mixed: tremendous declines were recorded for the Outer City and Outer Suburbs, moderate declines in the Inner City, Midile Suburbs, and Satellite To~~i~s (Elgrn and Aurora), and substantial gains in the Inner Suburbs. Each cell of the Southern and South- western Sectors declined except in the Inner Suburbs and Satellite Towns (Chicago heights and Joliet, respectively). Looking at the data from the viewpoint of the concentric zones we see that all cells of the Inner City, Outer City and Outer Suburbs recorded significant decreases in their ratios, except in the Northern Sector. The Inner Suburbs gained in all cells except the Southern Sector. The cells in the Middle Suburbs were mixed with substantial losses in the Southwestern Sector, significant gains in the Northern and Southern Sectors, and moderate losses in the Northwestern and Western Sectors. The Satellite Towns to the north and west dropped in their ratios while those to the south and southwest had impor- tant gains. The Northern Inner Suburbs had the most significant gain of all the cells in the ratio of doctors to population. This happened in spite of the fact that it already had the most favorable ratio in 1950. In 1970 this cell had 54 more physicians ~100,000 pop- ulation than the second highest cell. That was double the gap which separated the first and second cell in 1950. The Western Outer City had a huge decline in ratio, dropping from the third highest cell in 1950 (1.34 physicians/1,000) to the second lowest in 1970 (.17 physicians/1,000). The Western Inner Suburbs rose from a slightly less-than- average ratio (.?~8/l 000) to fourth highest in the Metropolitan Area (1. 351, 0001. The only other large gain was the Southern Satellite Town (Chicago heights) which increased its ratio from . 57/1 000 to 1. 23/1,000. The Southern Outer Suburbs now had the lowest ratio, with only 6 doctors/100,000. This is not significantly worse off than the Western Outer City with 17/100,000. There was, needless to say, a vast disparity between those figures and the nearly 200 doctors/100,000 of the Northern Inner Suburbs, In summary, the zones of the Chicago SMSA which can be classified as having a wealth of physicians' offices are limited to the Northern Sector, from the Loop to the Middle Suburbs, the Northwestern and Western Inner Suburbs and the Western, South- western, and Southern Satellite Towns. Actually, the doctors of the Satellite Towns serve a larger population than that of the town itself, and therefore the ratios of those areas may be misleading. In reality, therefore, onl~' seven areas really had good ratios, while another seven had less than 50 doctors/100,000 and were veritable medical-care deserts. The remaining 16 areas were marginal areas, with a relative lack of physicians. The Loop. The Loop is a special and unique case; therefore, it has not been included in the discussion of concentric zones and sectors to this point, This area had the highest ratio of doctors to population in the City, and probably will ha~e for a long time, because of its accessibility, large number of offices, and low population. The fact that the Loop lost over three doctors per thousand population is of little importance, for the Loop is in a class by itself. The physician/population ratio of this area is, therefore, rather meaningless. The absolute number of doctors has more meaning than PAGENO="0540" 530 100 the physician/population ratio, since the Loop has so low a population base. Thus, com- parison of the Loop will be made through time itself, the City as a whole and the entire S MSA. In 1950 there were 1,770 doctors' offices in the Loop, representing 33/ of the City's and 257 of the Metropolitan Area's private practitioners. In 1960 there were only 1,385 doctors' offices in the Loop, and the Loop's share of the City's and SMSA's physi- cians' offices fell to 30/ and 20/, respectively. By 1970 the number of doctors in the Loop dropped to 1, 109 -- a drop of nearly 40 in the twenty-year period. In spite of this massive exodus, the Loop still had about 30 of the City's private practitioners, but the ratio for the SMSA dropped to 15 7. The Loop's loss of over 650 doctors represents one-third of the total number lost by the Cit~, yet the Loop remains the single highest concentration of doctors in the SMSA, with more than twice the number located there than in any other area (with the exception of the Northern Inner Suburbs, which had just slightly more than 50 as man~ doctors). The decline in the physician/population ratio indicated that the Loop's impor- tance as a center for the disbursement of primary medical care declined significantly between 1950 and 1970. Its importance as a center of specialized medical care was reflected by the changes in the ratio of specialists' offices to all private practice offices in the Lo~p in the twenty-year study period. The proportion of specialists' offices rose from one out of every four offices to three out of ever~' four offices. (The patterns of specialists' offices are dealt with in more detail in the next section of this chapter as well as in the next chapter). The point of emphasis is that the rise in specialization also contributed to the decline of primary medical care in the Loop. Community and Health Care Areas. Community Areas (CA) and Health Care Areas (HCA) are the most detailed geographic subdivisions used in this study. Table 5-3 and Figures 5-~. 5-9 and 5-10 depict CA's and HCA's with the 25 highest physician/ population ratios in the SMSA in 1950, 1960 and 1970. Overall the physician/population ratio of the 25 highest CA's and HCA's rose substantially in each decade between 1950 and 1970. In 1950 only the top ten had a ratio above 1.83 doctors/1,000; in 1960 the top fifteen were at that level, and by 1970 all twenty-five had a ratio at or above 1.83/1,000 (and the top ten were all at or above 3.00/1,000). The physician/population ratio of the entire Metropolitan Area, however, dropped. The extreme rise in the ratios of the top 25 indicates that doctors were be- coming increasingly concentrated in certain areas. The corollary of this is that other areas were experiencing large losses. In 1950, seven out of the top ten and sixteen of the top twenty-five CA's were located in the City. In 1960 six of the top ten and fourteen of the top twenty-five were City Community Areas. By 1970 only four of the top ten and nine of the top twenty-five were in the City. Furthermore, Figure 5-10 shows that five of those nine CA's were adjacent to Suburbs (four at the northern periphery). The Loop (CA 32) and the North Michigan Avenue extensions of the Loop (CA 8) were two more. The remaining two were in the southern part of the City; one is Hyde Park (CA 41), the community containing the University of Chica~o campus, and the other one is Avalon PAGENO="0541" TABLE 5-3 Top Twenty-Five health Care Areas in M.D. `s/l,OOO Population 1951, 1961, 1970 ___________ _______ M.D. `s/l~000 155.94 5.48 4.53 4.14 3.24 3.16 3.13 3.02 2.98 2.98 2.96 2.76 2.70 2.51 2.45 2.17 2.10 2.08 2.01 2.00 1 .98 1.97 1.92 1.89 1.83 1951 1961 1970 l'C5~ "°i~. Name M.D. `s/l.OOO FICA# HCA Nsme M.D. `sf1,000 IICA# HCA Name 32 Loop 212.31 32 Loop 236.90 32 Loop North Side 446 Orland Park 34.81 8 Near North Side 4.74 8 Near North Side 9.83 346 OaL Park 4.13 593 hhinsdale 26 West Garfield Park 3.32 593 hlinsdal.e 2.88 346 Oak Park 41 Hyde Park 3.10 45 Avalon Park 2.75 281 Glencoe 33 Near South Side 2.92 292 Evanston 2.59 377 La Grange 292 Evanston 2.28 72 Beverly 2.50 345 River 71 Auburn Gresham 2.00 377 La Grange 2.19 13 North Park 3 Uytoun 1.93 71 Auburn Greshain 2.19 41 Hyde Park 282 Winnetka et. al. 183 18 Nontclare 2.12 429 Evergreen Park and 43 South Share 1.63 13 North park 2.07 698 highland 563 EltThurst 1.60 563 Elmhiurst 1.87 Townships 42 WoodLawn 1.51 43 South Shore 1.83 292 Evanston i-'a F1y~n 1.47 698 Highland Park and 72 Beverly Glen 28 Near West Side 1.45 Deerfield Townships 1.83 Lincoln 903 Richmond and 12 Forest Glen 1.82 Square Burton Townships 1.44 26 West Garfield Park 1.82 293 291 Skokte 904 Wooostock and 355 Berwyn 1.77 Door Towuships 1.42 4 Lincoln Square 1.73 563 Elmhiurst Avalon Park 593 Hinsdale 1.38 66 Chicago Lawn 1.73 Winnetka al. 46 South Chicago 1.36 352 Maywood 1.65 282 4 Lincoln Square 1.35 281 Glencoe 1.62 262 Berwyn Glenview 7 Lincoln Park 1.34 272 Park Ridge 1.59 25 Austin 1.32 41 hyde park 1.58 2 Ridge Field and 49 Roseland 1.30 2 West Ridge 1.57 Olympia Rich 1 Roger Park 1.27 282 Wirtnetka et. al. 1.47 Broadview 283 Wilviette 1.27 PAGENO="0542" 532 102 Figure 5-8 HIGHEST 25 HCAS IN AEL PHYSICIANS OFFiCES 1.000 IN THE CHICAGO SMSA 1950 PAGENO="0543" 533 103 Figure 5-9 HIGHEST 25 HCA S IN ALL PHYSICIANS OFFICES THE IN THE CHICAGO SASH 1960 U 1-AT LI a PAGENO="0544" 534 104 Figure 5-10 HIGHEST 25 HCAS P4 ALL PHYSICIANS OFFICES/1,000 IN THE CHICAGO SMSA. 1970 PAGENO="0545" 535 105 Park (CA 45), which has a small population. In 1950 Avalon 1~rk had the fifth highest ratio in the Metropolitan Area (2.75/1,000), but by 1970 it had dropped to nineteenth with 2.00/1,000. Avalon Park is continuing to lose physicians' offices; and by 1980 will probably no longer rank in the top twenty-five. Thus, we see a decided City-to-Suburban -- more precisely Northern and Western Inner Suburban -- shift of the twenty-five CA's and HCA's with the highest physician/population ratios. The principal losses in physician/population ratio have been in the City and Outer Suburban areas, especially the Western and Southern Sectors of the City (See Table 5-4 and Figures 5-11, 5-12 and 5-13), East and West Garfield Park, North and South Lawndale, and more recently, Austin have been the big losers in the western part o~ Chicago. To the south, Englewood, West Englewood, Woodlawn, Kenwood and Grand Crossing, and more recently, Auburn-Gresham and Roseland have had big losses in phy- sician/population ratios. Gains in physician/population ratios have occurred in the following cases: Oak Park, Hinsdale, Berwyn, and River Forest', and, more recently, Oak Brook, to the west; Glencoa, Skokie. Highland Park, and Lincolnwood to the north; and Evergreen Park and rc~ent1v, Olympia Fields. to the south. These changes In physician/population ratio show that the shift of doctors' offices wa~ no'. merely a response to population. The shift of offices from the Loos and Inner and Outer City was faster than the population growth as reflected in the de- creasing physician/population ratios of those areas. The movement to the Northern and Western Suburbs resulted in great increases in the physician/population ratios of those areas, indicating that physicians were moving to those areas much faster than population. The suburban shift of population did have some effect on the movement of doctors' offices, but its importance was not great. It is conc1ude~Iherefore, that the general decentralization of population was not a significant locative factor for chan~~ in physician office location in the Chicago SMSA. Racial Structure The expansion of Negro population in the City of Chicago by census tract is shown in Figure 5-14. The changing distribution of physicians' offices, as measured by physician/population ratio, was compared with the changing distribution of the black population of the Chicago SMSA. It was found that the areas of the City in which the physician/population ratio was declining corresponded in general to location of the black population of the City or to those areas into which blacks were expanding. Figure 5-15 depicts the CA's and HCA's which changed in their racial structure between 1950 and 1970. When these are compared with Figures 5-10, 5-11 and 5-12 the relationship of influx of blacks and the exodus of doctors' offices was obvious. Fourteen of the 25 com- munities with the highest decrease in physician/population ratio between 1950 and 1960 were in the City. All but two of them -- Rogers Park and Uptown (CA's 1 and 3) -- were communities which underwent racial change (or were adjacent to such communities) and/or which were in the expected path of Negro expansion. Uptown, one of tho two non- PAGENO="0546" tABLE 5-4 Top 25 health C-ore .Srtas It ltr.t'teo ,,d Setteases , 55.5/1,000 Ptit~ Iotiott, 105t5'hIS, 19b0-'O 4 1955-25 7955-9(0 _____________ I O60~ 1970 f4/~4- o~rs~---55-F~7rn HCOO Matte 7t,S,/l~000 32 Loop 24.59 346 Oak Park 2.98 45 Aoalo,s Pat'k 2.66 13 North Park .61 593 tIle dale 1.50 12 Heoerly 1.36 18 Moettiare 1.31 70 Ashbot-,, 1 .09 291 Skokie 1.02 497 Chltago Hgts. .87 281 CI etteoe .16 429 Eoergreeo Park .74 273 MIles .69 345 hoer H orest hO 12 Forest GIrt, .61 19 Beie'tot Cragoo ui 499 Park Forest .60 698 Highlattd Park Deerhirid i5osp. .59 352 S.ayoood .59 371 La Grargr Fork .58 376 4 tttrto 077 iO~N .58 561 Loobard .58 355 Hereys .52 66 Chioago Laueo .50 272 Park Ridge .45 1955- 19'S 8F.d~ Sa,te 5.S,/i,iIIith 32 Loop 80.96 26 Wrst (207 hl#ld P07k 1.56 71 Sohoto Gt,',hoo 7.47 352 Styo.',t.i 1,15 18 lloettI,,rr .97 43 Sooth, 040!-,' .83 45 Aooloo Pack .14 40 Wati,logtoo Patk .60 25 Oostio .56 23 Hot,boldt F',,tk .54 903 Riohooo'i aol Hortoo Totp. .31 14 Albaoo P07k .52 35 Graod 8200. .57 30 Sooth Laiotdaie .49 46 Sooth Oh itago .48 73 Washitgit'o Brights .38 61 Nrc city .37 49 Rosolaod .35 22 Logat, Sqoatr .30 34 Ac000r qoarr . 55 67 West hegleoood .10 06 Chitago Lauto .28 225 Palatitto aod Toststohip .28 459 Matkhao .28 ((120 Saor 0.2/1,000 HCS" Natte 07.5/1,500 446 Stiood P.,ek 34.66 293 Llotolocood 2.00 H Nrar North 429 Foergreett Park 1.86 Side 5.09 345 Hiorr F,tcrul 1.71 13 Neor Sooth 593 Hiesdale 1.65 Side 1.95 281 Ole,,,,,' 1.62 41 Hyde Pork 1.52 41 Hod,' Fork 1.40 36 West Gartleld 556 Oak Brook sod Park 1.50 York Tocothir 1.33 073 hoothrast kill 488 Olyttpia l-i,'Ids hoooty .94 aod Blob 761 Oorthhrook .93 To'.oositips 7.29 42 Woodlaott .05 498 IhigItlood Fork 211 ((tooter l'csp. .85 attd OeerhIeid 28 -ar SeNt Sidr .72 Toottsltip 1.16 262 Ar(itgtoe 347 Hroadoieo 1.13 (coghts .69 242 otliogtoo 562 Stila Pork 02 Heights 1.06 68 h3ogiecood .64 427 Palos (heights, 29 Nocth Lao'odale .55 HIlls aed 39 ?S'ooood .52 Yoceship .99 I 0tt~rtt Pork .90 13 North Pork .99 3 ilpiooto .50 262 cleooiro .95 455 tiidlothiao .48 376 Westero Opriogs .91 itS St. charles aod 28 Near 6'cst Sidr .83 Tootoships .40 H Sear North 44 Chathao .45 side .74 67 West tegleeoed .45 291 Skokie .74 576 baperoille aod 4 Liecolo Sqoare .72 Toetoship .45 12 Forest GIrt .69 69 (eaod 2 rosttttg .42 142 hiocood Patk 697 seerhieid aod aed Hioer West Seertheld Crooe .66 Yoettship .41 283 Whlttette .69 64 Cleat' io .59 33 Sear Sooth Sidt .61 441 L,oottt astd 323 Riocr ode, 5. Toottship .39 gioers ide aod 652 Hooed Lake Graet, Yototosltip .61 aodoooelooet- 371 LaGraooe Pack .57 ships .39 ((4,S't 10 Sate Y.Il./1,O'iS HGA0 Droreaseio Nose 0,5/1,005 34u Oak Patk 7,77 52 LOOp 96.37 595 Hiosdalr 1.15 646 Oelasd Park 74,01 429 Forcgrrco Patk 2.60 0 Sear North IS North P,,ck `.56 SIde 4.25 745 Oloet borcot `.59 26 West Garlield 281 Olrotor 2. 10 Park 3.09 45 doaloo P.,rk 1.92 33 Near Sooth 293 Littoolooood 1.04 Side 1.34 297 Skokie (.76 71 Aobtir,t creshat 1.28 690 Hlghiaod P.,ck 873 Sooth Will attd trs,rhicld Coottto 1.00 Touotoklp .75 27 East Garlield 75 Ashbortt (.63 Park .90 408 Olyttpla bit Id 904 Woodsioth aod .ood Rio6 Soi'e- Door Tootoship .05 thip 1,99 15 Portage Park .01 72 teortly .55 55 Sooth Laoodale .85 376 Scetere Syrlogs. .69 68 tsglrt.ood .23 347 Broadoleto I .44 7,7 Heat tttglesood .75 12 Forest Girt, .36 455 HidI othtao .74 556 Oak Brook atd hO Washiogtot Pack .73 Sock Too'tsltip .13 211 Haoooer loortsiiip.23 377 La Gtattgc itt 61 Nec Cito .21 321 La Gtattge Park - .15 42 Hoodlat.te .70 4 Liotolt Sqoat-r .15 1 Rogers Park .62 427 Paloo Heighot, 46 So. Chioago .66 Hills aod 23 Hootboldt Park .60 Toootshkp .10 79 North Lo,.o,dale .63 497 Chioago Heights~ .05 43 Sooth Shore .63 273 ShIes .89 652 Roottd Lake, 691 Lakt Fortot ,od ci, al, .53 Lake Hloil .79 25 Aostie .99 355 Oerooe .73 73 Washiogtoe Heights .99 C;' 4- Ct PAGENO="0547" 537 107 Figure 5-11 HIGHEST 25 HCAS IN INCREASE AND DECREASE OF ALL PHYSICIANS OFFICES 1 000 POPULATION IN THE CHICAGO SMSA 19501960 0 5 0 5 MILES 3A-69A 0 - T4 - 36 (Pt. 1) PAGENO="0548" 538 108 Figure 5-12 HIGHEST 75 HCA S IN INCPEASE AND DECREASE OF ALL PHYSICIANS OFFICES 1 000 POPULATION IN THE CHICAGO SMSA lARD 1A70 N ~t 10 IS MILES PAGENO="0549" 539 109 Figure 5-13 HIGHEST 25 HCAS IN INCREASE AND DECREASE OF ALL PHYSICIANS OFFICES 000 POPULATION IN THE CHICAGO SMSA, 1950 1970 0 5 I~ ~5 ~~LE5 PAGENO="0550" 540 110 lo.6y 1700 Dno~ 6400 By' 6li~ 0600 4400 25 PCR CENT OR MflPE NEGRO ,~g P.,6 4000 8,lmon 0200 N,II,,7o, 2400 N,!lh 7600 Chcz~o 400 1950 $960 $965 $970 200 0900 COMMUNITY AREAS Peuh!~g 479 0579 62 ~d 77,7 Figure 5-14 0 2979 4714 9574 700'd 00774 71974 127,6 10574 7474 EXPANSION OF POPULATION, 1950-1970, BY CENSUS TRACT PAGENO="0551" 541 111 Figure 5-15 HCAS IN THE CHICAGO SMSA WHICH UNDERWENT A CHANGE IN THEIR RACIAL STRUCTURE 1950-1970 I PAGENO="0552" 542 112 Negro communities with a high decrease in physician/population ratio, was the area of the principal concentration of poor white immigrants from Appalachia and other depressed areas. Again, between 1960 and 1970 there were only two communities in the City having a large exodus of d)ctors which were not undergoing racial change or adjacent to such communities. One of the two, Logan Square (CA 22), had a large influx of poor Spanish-speaking peoples, principally Puerto Rican immigrants, during this period. It is also noteworthy that the two non-rural suburban municipalities (Maywool and Markham) experiencing large losses of doctors were also areas into which large numbers of Negroes were moving. It is evident from the foregoing that a large influx of blacks into an area usually results in an exodus of physicians offices from that area, even though it is these areas which have not only high.~rates of infant mortality, high-risk pregnancies, disease, etc., but also have the greatest medical need. Ohvio~~~changing racial structure (from white to black) must be listed as a repelling force in the location of doctors in the Chicago SMSA. Socioeconomic Status A visual comparison of the maps of the 25 CA's and HCA's with the highest physician/population ratios and those showing the greatest gains and losses in that ratio (Figures 5-8, 5-9, 5-10, 5-11, 5-12 and 5-13) with the maps of 25 CA's and municipal- ities with the highest and lowest rank in socioeconomic status (Figures 3-15, 3-16 and 3-17) reveals a close alignment between areas with high socioeconomic status and those with the highest physician/population ratios. There was also a tremendous disparity between the absolute number of physicians available for care of the sick in poverty areas as compared to the number available in affluent areas of the City. This disparity is clearly illustrated in Table 5-5, which compares the physician/population ratio of the ten most affluent and ten poorest CA's and municipalities with a population of 2,500 or more in the Chicago SMSA. As can be seen the ratios in the affluent areas fluctuated but always were above 1.00/1,000. In 1970 the ratio was above 2.00/1,000. Yet, the ratio of the ten poorest areas was never as high as 1.00/1,000 and has deteriorated sub- stantially since 1950 to .26/1,000 in 1970. The gap between the two ratios more than doubled in the last twenty years rising from .79/1,000 in 1950 to 1.84/1,000 in 1970. What this means can be best illustrated by restating these ratios in the following manner: the affluent communities had 2.10 doctors per thousand, or one doctor for every 475 persons, while the poor communities had .26 doctors per thousand, or one physician for every 3,850 persons. In other words, there are about eight times the number of doctors per person in the ten wealthiest municipalities as there are in the ten poorest. The study by Pyle and Lashof referred to earlier in Chapter Iii indicated that there was a strong relationship between the location of poverty and the location of high incidence of various diseases. This also indicates that the areas with the greatest medical need have the least medical care in the form of available doctors -- just the PAGENO="0553" 543 113 TABLE 5-5 Physician/Population Ratios in the Ten Highest and Ten Lowest Communities in Socioeconomic Status in the Chicago SMSA~195O, 1960 and 1970 1950 1960 1970 Ten Most Affluent 1.78/1,000 1.36/1,000 2.10/1,000 Communities Ten Poorest .99/1,000 .46/1,000 .26/1,000 Communities Difference Between Most Affluent and Poorest Communities .79/1,000 .90/1,000 1.84/1,000 reverse of what could be said to be desirable. Thus, affluence, rather than demand for medical care, appears to be a very attractive locative force for doctors' offices. "Demand for medical care" has different meaning to different people and a word of clarification is needed at this point, Fein, in his book, The Doctor Shortage: An Economic Diagnosis ,~ defined medical demand in the economic sense, i.e., market demand as measured by consump- tion. He used the marketing of Cadillac automobiles to illustrate what he meant. The market demand of Cadillacs is determined by how many people buy Cadillacs, not by how many would buy them if they had enough money to buy one. The real demand for medical services, he went on, is therefore measured by the number of visits people make to physicians, not by how many they would make if they could afford doing so. If, for example, the annual average visits per person to a doctor is 7.5 then that is the present real demand for medical services and projections of future physician need should be based on these real demand figures. Fein acknowledged that demand might have other meanings, such as the number of people who are sick and need medical care. However, he dismissed this definition of demand as being unrealistic on the grounds that measure- ments of morbidity for small areas of cities are unreliable. "Demand for medical care," as used in the context of this study is construed to mean the distribution of illness, or a need for medical care, regardless of whether the afflicted can afford the cost of the care or not. There is no precise measure of how much medical need exists in poverty areas nor, as Fein indicated, can such estimates be made at the present time. It stands to reason, however, that if there is more illness in poverty areas, then more medical need also exists there. Hence, more physicians would be expected to be found in those areas. In Chicago, however, the highest concentrations of doctors are in healthier, more affluent, areas while the less salubrious and economi- `Rashi Fete, The Doctor Shortage: An Economic Diagnosis, (Washington, D.C., Brookings Institute, 1967). PAGENO="0554" 544 114 callv impoverished areas have the lowest physician/population ratios. Therefore,_it can be concluded that the socioeconomic status of an area was a very significant factor in the location of doctorsT offices in the Chicago SMSA. Uospital Beds The sectoral distribution of hospital beds/1,000 and doctors' offices/1,000 between 1950 and 1970 are displayed in Table 5-6. A close examination of this table reveals that the distribution of hospital beds per thousand population had changed in the past twenty years to more closely resemble the distribution of doctors' offices. The \Veslern Sector, which had by far the largest bed/population ratic in 1950, experienced a (lecided decrease while the Northern Sector rose substantially and passed the formerly leading Western Sector, If hospitals attract doctors then the physician/population ratio of the Western Sector should have had a large increase (in physician/population ratio), hut it did not. Conversely, the Northern Sector had fewer hospital bede per population than the Western Sector. According to the above hypothesis it should not have attracted TABLE 5-6 Phvsi c ian s' Of~P~pu1ationllatiosand ~ BvSectors ~1~Qan~j970 SI. D. Office/ Hospital Beds/ ~~oulation 1,000 Population Sector 1950 1960 1970 1950 1960 1970 North 1.68 1,13 1.74 6.27 7,43 8,07 Northwest .87 .75 .74 1.69 1,86 2,33 West 1.15 .98 1.00 9,30 8,37 7,61 Southwest .59 .63 .67 2,19 2,69 3,38 South 1,06 .52 .69 3.56 3,49 3,75 more doctors than the Western Sector, but it did, In fact, it was the only sector that had a higher physician/population ratio in 1970 than 1950. The data in Tabie 5-6, therefore, strongly supports the hypothesis that hospital growth tends to follow doctors, and not vice versa. The distribution of hospital beds was not a great influence in the location of doctors' offices in general. There were, however, specific areas where large concen- trations of offices were associated with areas which had large concentrations of hospital facilities. For example, the Western Inner City with the highest number of hospital beds in the entire SMSA had an unusually high physician/population ratio compared to other areas of the Inner City. It was also the only area of the Central City with significant increases in physician/population ratio between 1960 and 1970. Two other Chicago com- munity areas which ranked high in both physician/population ratio and hospital facilities were the Near North Side (CA 8) and Hyde Park (CA 41), In the Suburbs, Evanston, Oak Park, Berwvn, and Evergreer~ Park all ranked in the top 25 HCA's in both physician/ population ratio and hospital beds/population ratios, Other communities ranking high PAGENO="0555" 545 115 in hospital facilities did not rank high in rhysician/population ratio, arid vice versa. `thus, although there was apparently some relationship between the distribution of hospital facilities an(l physician office distribution it did not have the (lii'ect influence upon the location of docto rs' offices that racial structure and socioeconomic status hail. The close association of high physician/population ratio and hospital beds/pop- ulation r~tio of only a few areas in(ticate that a conht)inatron of factors were operative in this r'clationship~ For example, the association between specialists' offices and hospital facilities noted earl icr in the general analysis indicate that special iiation is an additional factor in the relationship of the distribution of doctors' otfices and ho spital tacil ities, I lence , the location )f hospital facilities is only a in inc r lactor influencing the location of doctor's' offices ri the Chicago SMSA , i.e. , the concentration ot hospitals in the Inner City ope rate saga inst tIre general outward dispersal ot rhysie ions but it (toes not as directly dictate tIre I ocatiori of itrysie ian s offices as the above-cited lacto is Iletail Sales and Services The i-c was so ire relationship between the list riliut ions of retail sales and (loch) rs ` offices in tIre (h icago Mel rope Ii Ian A rca but they were riot is closely associated is those factors discussed previously (Compare Figures 1-1), 3-1 1 , 1-12 and 5-16 with Figures 5-s, 5-9 and 5--Id). 1-or exarirple , in 195)) only ten ot the top twenty-live I ICA `s in retail sales also ranked in the lop twenty-five in rtrysiciiris' ollices I ,0011 population; in 196)) nine and 1971) c ight of ito- to)) twe nity- five It CA's in retail sales at so ranked in ttre top twenty-five iii iI do rs ` offices, I 001), In 1950, there tore, nearly half ri I Ire 25 Ii rgtrest ranking IICA's in retail sales did not rank high in doctor's' oltices/ 1 001). In 1961) arid 1970 nearly two third sot the 25 highest ranking I ICA `s in retail sates did not rank high in doctors' offices/I ,000, When this is eorrilrar'aI with the tact thrat alt of tIre IICA's in which the population cira rrgcd from white to black were a rnori4 tire highest 25 in Icc rca se in doeto i-si office s/ 1 000, arid rica n-tv at I of the II CA's with a tr iglr S I/S go iricd srgrr it iea cr1 lv in (tocto is o fficcs/ t , 00)) , it heeorn e sr divious that the ic is a closer relation sir np between the (list ri - tart ion of blacks or S t-:S am! the ihrsenrcc or o i-c since 01 lilly sic ia irs' oil ices than bi_-tween i-eta it shopping centers md physic iaris' iii iiees (list rntut norr. A ~055i ide explanation br this cray be tina t ri-ta it slrop(i irig eeritc r's ire muu-hn rrro cc evenly iii s~- rsed at,out the S MSA a hil e ph siciaris' offices ar-c rrrueti u rore eonreerit ia ted - Arc tar I shopping eerite r' located in an a i-ca wIre n-c I Ire ptrv sic ian s ` offices I 000 is tow cray, therefore , he expected to have a low ratio of offices to population - Corrvc i'sel~' , a shoppinge enter located in an a n-ca wtie re tIre pirvsieiaris ` offices 1 ,00)) is high nrav bee xpeeted to have a nigh ratio, t'hi s led to tire conclusion that a rio re ire per taunt relationship ray exist between ire tist rihut ion ot rI)icto rs' office s are I !~~ii sholipinig u-cuter's than shopping center's in gene n-al - lAn rttre n-nro n-c, tie rue ic LX1 steni eeof a newly-planned i'cgion:i I shopping center wit hi all of its aft i-active a rnenit ics does riot insure I he alt rail ron oi doeto rs' otfices. 1-or exarriple , sonic centers, o~ rticula clv those in the No r'ttie rn arid Weste in PAGENO="0556" 546 116 Figure 5-16 CAS AND MUNICIPALITIES IN THE CHICAGO SMSA WITH A MAJOR RETAIL SHOPPING CENTER OR CBS 19AT PAGENO="0557" 547 117 Suburbs of Chicago, have been very successful in attracting physicians' offices, while other areas of the SMSA have not been so successful. The Old Orchard Shopping Center in Skokie and the Golf Mill Shopping Center in Niles in the Northern Suburbs have been very successful in attracting physicians' offices, as has the Oakbrook Shopping Center in Oakbrook in Western Suburbs. The Old Orchard Center in Skokie was constructed in 1956. In 1950 there were only five physicians' offices in the entire municipality of Skokie; in 1960 this area had 82 physicians' offices, most of which were located in the new shopping center; in 1970 there were 101 physicians' offices in Skokie. The nearby Golf Mill Shopping Center opened in Niles in 1960 and the number of doctors' offices in the village of Niles doubled from 14 to 28 between 1960 and 1970, with most of the offices locating in the new shopping center. The Oak brook Center was opened in 1962. In 1960 there were no physicians' offices In the village of Oakbrook, but by 1970 there were 26 -- all located in the new shopping center. On the other hand, regional centers in the Southern Suburbs, with the exception of Evergreen Park, have not had as much success in attracting doctors. River Oaks Shopping Center in Calumet City added only eight doctors' offices since opening, while in the twenty years since the opening of Park Forest Plaza the entire Village of Park Forest has attracted only nineteen physicians while the Plaza itself has attracted only less than a half dozen. It appears, then, that retail centers were a secondary attractive force; that is, doctors concentrated first in highly affluent suburban areas and then within those areas they chose office locations in large regional service centers. Other Pertinent Locative Factors There were several other secondary factors in the location of doctors' offices, expecially in suburban areas. One of these factois is the rise of group practices by physicians. In an increasing number of cases , doctors joined together and established medical office buildings or clinics. A number of benefits were achieved through this pooling of resources. First, they obtained the amenities a new office building offered but avoided, to some extent, the high rents they would be charged for comparable space in a commercial office building. Second, they could build the office specifically to their needs. Third, they gained the tax benefits of the depreciation of the building. Fourth, the appreciation of the real property accrued to them. Fifth, they could often locate in or adjacent to residential areas nearer to their homes and to those of their clients. Sixth, expansion was usually not as difficult if forethought was used in the original land purchase. Seventh, they could locate near a hospital or work to establish a hospital near their clinic. In short. medical office buildings or clinics could act as secondary attractive forces in the location of physicians' offices in an area. Another factor which played a role in the location of doctors' offices was the location of physicians' residences. Doctars, like everyone else, desire to minimize the journey to work, and thus would be expected to locate their offices as close to their homes as possible. It is common knowledge that the majority of doctors' residences are PAGENO="0558" 548 11 in more affluent communities. The establishment of a practice near to their places of residence, therefore, resulted in the concentration of doctors' offices in those areas. Briefiv,this meant that the location of doctors' residences could be a secondary attrac tive factor influencing the location of physicians' offices in an area. ~iana~p of Detailed Distribution of Diplomate Specialists' Offices Only As Comj 0th Locative Factors P9p4lation and Specialists' Offices Location Citvvs,_Suburbs. The ratio of specialists' offices to population is different from that ratio for all physicians' offices, The specialists/population ratio increased throughout the Metropolitan Area and in nearly every subdivision of that region between 1950 and 1960 (See Table 5-7~. The specialists/population ratio in the Central City was more than twico that of the Suburbs in 1950. By 1970 these two ratios had both increased substantially hut were nearly equal. Specialists' offices, therefore, were increasing at a faster rate than the population, and the rate of increase in the Suburbs was greater than that in the City. TABLE 5-7 ~p~alists Per Thousand Population in th~çj~cao SMSAbvcitvand Suburb ç~jp60an4i9j9J ~p~ç~ist~/1, 000 1950 1960 1970 Chicago .l~ .33 .47 Suburbs .07 .24 .44 Total SSISA .16 .32 .45 Source: American Medical Dire~p~y~ 1950, 1960 and 1970. This trend is likely to continue throughout the 1970's. The specialists/population ratio, therefore, wilt rise to a level closer to the ratio of all physicians' offices and the Sub- urban ratio will be slightly higher than the City's. Concentric Zones. The concentric zonal and sectoral patterns of specialists' offices/i ,000 population are shown in Table 5-s, Looking first at the totals br the concentric zones and sectors we see that the specialists/population ratio increased in every zone and sector of the SMSA. In general, the increase in the ratio of the Inner Suburbs was twice that of most of the other zones. The Outer City and Satellite Towns also had relatively high rates of increase. The rates of increase in the Northern, Northwestern and Western Sectors of the SMSA between 1950 and 1970 were double the rate of the Southern Sector, and almost twice that of the Southwestern Sector. A comparison of specialists population ratios at a more detailed level, i.e. PAGENO="0559" TABLE 5-8 Specialiits Per Thousand Population in the Chicago SMSA by Concentric Zones and Sectors, 1950, 1960 and 1970 Inner Outer Inner Middle Satellite Outer Total Sector Year ~ ~_ ~ Suburbs Suburbs Ring Suburbs Sector Central 1950 4.84 1960 8.87 1970 10.90 North 1950 .05 .06 .21 .18 .13 0 .09 1960 .14 .30 .85 .52 .17 .06 .37 1970 .36 .50 1.37 .88 .30 .14 .68 Northwest 1950 .04 .02 .11 0 .01 .03 1960 .06 .12 .34 .10 .04 .10 1970 .05 .20 .73 .28 .11 .22 West 1950 .07 .05 .04 .03 .06 0 .05 1960 .05 .05 .25 .17 .28 .07 .16 1970 .64 .03 .53 .34 .57 .12 .38 Southwest 1950 .02 .03 0 .42 .09 0 .05 1960 .07 .23 .05 0 .16 0 .12 19/0 .07 .28 .32 .01 .68 0 .23 South 1950 .07 .05 .04 .05 0 0 .06 1960 .11 .22 .08 .20 .18 0 .14 1970 .26 .17 .14 .23 .39 0 .20 Total 1950 4.84 .05 .04 .07 .10 .08 .005 Ring 1960 8.87 .09 .18 .33 .19 .21 .04 1970 10.90 .22 .26 .61 .34 .49 .10 PAGENO="0560" 550 120 the cells formed by the Intersection of concentric zones and sectors, makes the dis- parity in the distribution of specialists in Chicago more distinct. Only one cell in the Inner City West had a significantly high specialists/population ratio in 1970. In the Outer City only the Northern Sector was high. All of the Inner Suburban cells had high ratios with the exception of the Inner Suburbs South. It is interesting that the Outer City West, which had one of the lowest specialists/population ratios in the SMSA, was sandwiched between two zones which had high ratios. The Middle Suburbs North and West were the only cells in that zone with high ratios. Each of the cells of the Satellite Ring had above-average ratios, while all of the Outer Suburban cells had low ones. There was also disparity within the sectors. The cells of the Northern Sector all had high ratios with the exception of the Outer Suburban cell. The Inner City and Outer Suburban cells were both low in the otherwise high Northwestern Sector. In the Western Sector the Outer City and Outer Suburbs were low and the rest of the sector was relatively high. All of the cells in the Southwestern and Southern Sectors were low with the exception of the Satellite Towns (Joliet and Chicago Heights) and the Inner City South. The Outer Suburban zones were virtually void of specialists. Six cells (Inner Suburbs North, Middle Suburbs North, Inner Suburbs North- west, Inner City West, Inner Suburbs West, and the Satellite Ring West) had ratios above 50 specialists per thousand population in 1970. All of them were located in the Northern, Northwestern, and Western Sectors. One was in the City (Inner City West), three were in the Inner Suburbs, one was in the Middle Suburbs, and one was a Satellite Town. There were also six cells (Inner City Northwest, Outer City West, Inner City Southwest, Middle Suburbs Southwest, Outer Suburbs Southwest and Outer Suburbs South) with less than .10 specialists per thousand population in 1970. As can be seen, three of them were in the City while the other three were in sparsely-populated Outer and Middle Suburbs. The lowest cell in the City was the Outer City West, which was also one of the four cells with the greatest relative decline in specialists. The Outer Suburban cells always had few specialists due to their sparse population and lack of centrality. The Inner Suburbs North is the only area in the entire SMSA with a ratio above one specialist per thousand population (1.37). This ratio is more than double the ratio of all except two cells in the SMSA (the Middle Suburbs North and Inner Suburbs North- west), both of which are adjacent to the Inner Suburbs North. It more than triples the ratio of all except six of the thirty cells in the Metropolitan Area (the two named above plus the Outer City North, Inner City West, Inner Suburbs West, and Satellite Ring West) most of which form a contiguous area of concentration with the Inner Suburbs North. Actually, there was a remarkable concentration of specialists in a contiguous block which extended from the Northern periphery of the City to the Middle Suburban North Shore around to the Middle Suburbs West, including the Satellite Towns, back into the western edge of the City, and then back to the Outer City North. The eight cells in this block contained nearly two-thirds (60%) of the specialists outside of the PAGENO="0561" 551 121 Loop and almost one-half (45) of the total specialists in the SMSA, It is noteworthy that the Outer City West which is adjacent to this block had the lowest specialists/ population ratio in the City and had the third lowest ratio in the SMSA. Furthermore, this cell was the sixth highest cell outside of the Loop in 1950, It was also the only cell in the entire City which had an absolute loss in specialists. Commu~t and Health Care Areas. The twenty-five leading Community and llealth Care Areas of the SMSA in specialists/population ratio during the study period are shown in Figures 5-17, 5-18, and 3-19. Figures 5-20, 5-21, and 5-22 depict the leading areas of growth and decline in specialists per thousand population between 1950 and 1960 and 1970, and for the twenty-year period 1950-1970. Decline was minimal, but there were some IICA's which did decline in their specialists' office/opulation ratio. The concentration of sl)eclalists' offices in the IICA's of the Northern and Western Suburbs and the shifts into those areas were obvious. It is interesting to note that in 1930 eleven of the top twenty-five CA's cr IICA's in specialists per thousand were located south of the Loop and four of these were in the top ten, by 1970 only four of the top twenty-five were south of the Loop, and none of them were in the top ten. The four southern communities remaining in the top ten in 1970 were Hyde Park, Bev- erly, Evergreen Park, and Olympia Fields. The great and increasing disparity in the specia1~4~Zp~pWation ratio in dif ferent parts of the SMSA meant that the~~ging distrihutio~fpo)u1ation was not an !pii~oltan~j~cative factor in the distribution of specialists' offices. Racial Structure The great declines in the physician/population ratios in the Southern and Western Sectors of the City which aligned so obviously with the changes in the racial structure of those areas, were not so evident in the changing distribution of specialists' offices. The relationship between the influx of Negroes and specialists' offices distri- bution b~' concentric zone and sector relies instead on the more subtle fact that the growth rate of specialists' offices in those areas which underwent racial change was far below the rate of growth in all other parts of the City. The only exception was in the Outer City West which was the only cell of the SMSA to have a decrease in specialists/ population ratio. The association of this decline with the influx of blacks is obvious. The distribution of the twenty-five leading CA's and RCA's in increase or decrease of specialists' offices per thousand are shown in Figures 5-20, 5-21 and 5-22, A comparison of these maps with those of increase in blacks (Figures 3-14 and 3-15) reveals the close relationship between the decrease in specialists' offices/1,000 and the influx of blacks. The racial structure of an area, therefore, was as important in affecting the distribution of specialists' offices as it was for all physicians' offices. Conse~uent1y those areas which change in racial structure from white to black also experience a simultaneous exodus of specialists' offices. PAGENO="0562" 552 122 Figure 5-U H~A IN OP~ AL TC (0 1:1 S 055 POPuLATION N CHICAGO OMSA N PAGENO="0563" 553 123 Figure 5-18 HIGHEST 25 HCAS IN SPECIALISTS SPlICES I CISC POPSIATISN IN CHILE ISM~AH~~ 1 * 1-10 LI 11-TO C a 38-698 0 - 74 - 37 (Pt. 8) PAGENO="0564" 554 1~4 Figure 5-19 HIGHEST 25 HCA IN SPECIAlISTS CFFICES~ I 000 POPUlATION IN CHICAGO SMSA 970 U ~T L I ~ PAGENO="0565" 12~ Lt Figure 5-20 HLIFI~ A A N(FuAS~ AND )F (A DI ((F DPI ((DI (1 ((((((ID DA) POPI(IA((ON IN I ((11(11 All) DMDA ND)) DII) [1 PAGENO="0566" 556 126 Figure 5-21 HrSHEST 25 HCA S IN INCREASE AND DECREASE OE SPECIACISTD DEEICES I Xe POPUCATION IN THE CHICAGD SMSA I9C IS/C u~T, J - I ~LH c~ ~ PAGENO="0567" 127 Figure 5-22 HIGHEST 5 HAS IN INIATASE ANIT IIIIREASI SF SPIIIA II II I H ri PAGENO="0568" 558 125 Socioeconomic Status The extreme concentration of specialists' offices in eight areas of the SMSA noted above (the Northern, Northwestern, and Western Inner and Middle Suburbs, the Western Satellite Towns, and the 1~iter City North), exemplifies the great influence of socioeconomic status on the location of specialists' offices. No two distributions of the Metropolitan Area are so closely associated. A cemparison of the distribution of specialists' offices with socioeconomic data recorded in preceding chapters indicated that the leading CA's and HCA's in specialists/population ratio and those with the most significant increases in this ratio are closely associated with areas which have high socioeconomic status. In 1950 eleven of the top twenty-five IICA's in socioeconomic rank were also in the top twenty- five in specialists per thousand population, and fifteen were either in the top twenty- five in specialists per thousand or increase in specialists per thousand. By 1960 eigh- teen of the highest twenty-five socioeconomic areas were either in one or the other of these categories of specialists. All of the communities which ranked in the top twenty- five in socioeconomic status in 1971) ranked in the top twenty-five in specialists per thousand or increase in specialists per thousand. This clearly illustrates the close relationship between the location of affluence and specialists and the increasing ten- dency for these two to concentrate in the same area. Conversely, the places with the greatest decreases in the specialists/popu- lation ratio were those areas which had declining socioeconomic status. This became clear when comparisons of Figures 5-17, 5-18 and 5-19 were made with Figures 3-15, 3-16 and 3-17. The comparison of these maps revealed the very definite association of the location of high socioeconomic status and high ratio of specialists' offices to popu- lation. The socioeconomic status of a community, therefore, was found to be the most significant locative factor in the distribution of special ists' offices, Hospital_Facilities Some relationship between the distribution of hospital facilities and special- ists' offices distribution was indicated earlier. Certain areas of the City have both a high concentration of soecialists' offices and hospital beds, the most significant being the Near \Vest Side (CA 8~. Nearly one-fourth of the Metropolitan Area's hospital beds were concentrated in this Community Area. It was also the only Community Area in the City to experience a significant increase in specialists' offices/population ratio. This took place in spite of the fact that this Community Area's percentage of Negroes rose from 50 to 75 between 1960 and 1970. Several other HCAs (Evanston, Oak Park, Berwyn, Hyde Park, and Ever- green Park) had high concentrations of both hospital beds and specialists' offices, The direct effect of the hospital facilities as a locative factor in these HCA's is not clear since these same HCA's ranked high as retail shopping centers and also had relatively high socioeconomic status. PAGENO="0569" 559 129 Hospital facilities surely had some influence, but due to the complications just cited it was difficult to unequivocably designate how important they were. Hospital facilities, therefore, were a very important influence on the distribution of specialists' offices in some areas (the Near West Side, for example) and of undetermined importance in others. Retail Sales The relationship between the distribution of retail shopping centers and specialists' office distribution is difficult to assess. This is clue to the widespread distri- bution of retail shopping areas. There are usually offices in or near a major retail shopping center and they are located at points of great accessibility. Retail shopping centers, therefore, were undoubtedly of some significance as locative factors. How significant they were was another question. No strong relationship was observed in a comparison of the maps displaying the distributions of these two phenomena. Several HCA's also ranked high in other locative factors, as indicated above. Retail sales asa locational factor of specialists' offices was, therefore, a secondaryjnfluence rather th~~~J~gime locational factor of these offices. PAGENO="0570" 560 CHAPTER VI DESCRIPTION AND ANALYSIS OF THE GROWTH AND CHANGING DISTRIBUTIONAL PATTERNS OF DIPLOMATE SPECIALIS~ BY SPECIALTY (1950-1970) While the discussion in preceding chapters depicted the distributional pattern of all private practice diplomate specialists as a group, it is essential to further sub- divide these diplomate specialists ~y peci~jfl, because some of the individual special- ties do not reflect the distributional patterns of the group as a whole, Furthermore, the fourth hypothesis of the study states that the type of specialized medicine practiced injluences office location. Thus, this chapter will examine the growth and distributional patterns of each specialty separately and will be divided into the following sections: 1. ~pjtion of the chanting growth and distribution of privatefiractice diplomate specialists' offices by specialty in the Chicago SMSA from 1950 to 1970. This section will (a) describe the absolute and relative growth patterns of each specialty, (b) classify each specialty by geographic location and (c) describe the distribution of each specialty by the various geographic levels used throughout the study. 2. Analysis of the changii~ distribution of private practice diplomate sj~2~l- ists' offices in the Chicago SMSA by specialty (1950-1970) as compared tolocationalfactors. This goal is accomplished by comparing the changing distributional patterns of each specialty with the locative factors des- cribed in Chapter III at various geographic levels. Description of the Charging Growth and Distribution of Private Practice Diplomate Specialists' Offices B~y~Specialty in the Chicago SMSA (1950-1970) GroWt~firn~j95o~7o Those specialties which had the longest histories also had the greatest num- ber of practitioners in 1950. Sixty-six percent (66~) of all diplomato specialists in that year were either Surgeons, Ophthalmologists, Otolaryngologists, or Internists; one out of four (25~) were Surgeons. Psychiatry and Pediatrics were the only other specialties with as much as five percent of the total diplomate specialists. Since 1950, however, widespread public acceptance and perceived need led to the rapid growth of certain specialties. Obstetricians-Gynecologists led the way with over 1,000~ increase in the twenty years (Table 6-1). Whereas in 1950 Obstetri- cian-Gynecologists ranked eighth out of sixteen specialties, by 1970 they had risen to third out of nineteen specialties, Internists and Surgeons, two of the oldest specialist groups, still outranked them. Internists and Surgeons maintained their high ranks; they had the greatest absolute increases in numbers during the twenty-year study period. There v'ere more 130 PAGENO="0571" 561 131 TABLE 6-1 ~jp]pmate Specialists Ranked by Number of Specialists 1950, 1960 & 1970 Surgery 181 Surgery 319 Internal Medicine Ophthalmology 126 Internal Medicine 279 Surgery Oto1aryngolog~ 113 Obstetrics- Gynecology 179 Obstetrics- Gynecology Internal Medicine 91 Psychiatry- Neurology 163 Pediatrics Pediatrics 44 Pediatrics 161 Psychiatry- Neurol ogy Psychiatry- Neurology 42 Ophthalmology 153 Ophthalmology Radiology 32 Otolaryngology 121 Radiology Obstetrics- Gynecology 30 Radiology 82 Orthopedic Surgery Dermatology 26 Orthopedic Surgery 76 Otolaryngology Orthopedic Surgery 22 Urology 49 Anesthesiology Pathology 15 Dermatology 40 Urology Anesthesiology 14 Anesthesiology 34 Pathology Urology 14 Pathology 27 Dermatology Neurosurgery 11 Neurosurgery 17 Thoracic Surgery Plastic Surgery 8 Thoracic Surgery 17 Neurosurgery Physical Medicine and Rehabilitation 5 Plastic Surgery 14 Preventive Medicine Preventive Medicine 7 Plastic Surgery Colon and Rectal Surgery 5 Physical Medicine and Rehabilitation Physical Medicine and Rehabilitation 502 467 378 316 289 184 180 154 123 114 106 83 66 48 34 21 20 5 Colon and Rectal Surgery Total Total Specialists Total 774 Specialists 1,747 Specialists 3,094 PAGENO="0572" 562 132 Internists and Surgeons in private practice in 1970 than there were total diplomate specialists in 1950 (Table 6-1). The number of Pediatricians and Psychiatrists-Neurol- ogists also rose spectacularly in the two decades. The five specialists just discussed -- Internists, Surgeons, Obstetrician- Gynecologists, Pediatricians, and Psychiatrist-Neurologists -- accounted for the major- ity of diplomate specialists (63R) in 1970 (See Table 6-2). The significant increases in those five specialties resulted in a decided decrease in the relative numerical importance of Ophthalmology and Otolaryngology, both of which had long been among the leading specialties numerically. During the study period, the former dropped from second to sixth place, and the latter from third to ninth place, Surgeons also declined in rank, in spite of their significant numerical increase, yielding first place to Internal Medicine. Dermatology, Pathology, Neurosurgery and Plastic Surgery also declined in rank, although each experienced large absolute gains in the last two decades. Distributional Patterns of Specialists, by Specialty (1950-1970) Distributional Classification of Specialties. The specialties in the Chicago SMSA were classified into five categories based on their distributional patterns. This classification system was developed after extensive examination and tabulation of specialists office location in the Chicago SMSA. The classes used in this system in- clude the major patterns that distributions can form; that is, a distribution is either concentrated, dispersed, or grouped in dispersed clusters about an area. The dis- tinction between Loop concentration and non-Loop concentration is obviously also an imporant consideration in the Chicago SMSA. The final category used, Numerically Insignificant Specialties, was necessary to distinguish those specialties which might fit into one of the above categories but were too few in number for proper classification. Ten was chosen as the minimum number of specialists for which classification can be made. The following are, therefore, the classification types and their definition: Type A~ Loop-Concentrated: 60~ or more of the physicians of a specialty were located in the Loop. There were, however, a total of at least ten specialists in the specialty. Type B, Nucleated: 50Y~ or more of the physicians of a specialty were located in one contiguous area outside of the Loop. If the Loop was included as a part of the nucleation it had to have less than 50% of the total SMSA's specialists. There were two or more specialists in the majority of the Community or Health Care Areas of the concentra- tion, and a total of at least ten specialists in the specialty. Type C, Dispersed: 40~ or more of the physicians of a specialty were located in Community or Health Care Areas with 1% or less (or two of fewer) specialists of that specialty. There were two or fewer concentrations outside of the Loop with 3% or more of the members of that specialty. There was, however, a total of at least ten special- ists in the specialty. PAGENO="0573" 563 133 TABLE 6-2 Percent of Total Soeci~1ists in Each Specialty (1950, 1960 and 1970) 1950 1960 1970 47, 10~ 127, 117, l67~ 177~ 67, 97~ 107, 57, 107, 97, 27~ 27, 47, 37, 47,, 57, 47, 57, 67, - 17~ 27, 27, 37~ 37, 27, 27, 37, - .47, .77, 17, 17, 17, - .37, .17 17 .7% .67, 17, .27~ .2% 37, 2% 27~ 237~ 187, 157~ 177, 97, 6% 157, 77, 47, Obstetrics - Gynecology Internal Medicine Pediatrics Psychiatry and Neurology Anesthesiology Orthopedic Surgery Radiology Thoracic Surgery Urology Pathology Preventative Medicine Neurosurgery Colon and Rectal Surgery Plastic Surgery Physical Medicine & Rehabilitation Dermatology Surgery Ophthalmology Otolaryngology PAGENO="0574" 564 134 Type D~ Nucleated-Dispersed: Generally dispersed, as in Type C, but more than two concentrations interrupted the dispersed pattern. Within each concentration the majority of Community and Health Care Areas had more than two specialists and accounted for 3~ or more of the physicians of the specialty. The Loop had less than 65~ of the special- ists of the specialty, and there was a total of at least ten specialists. Type~Nurnerically Insignificant Specialties: Any specialty with a total of less than ten specialists in the Chicago SMSA. Specialty Types 1950. In 1950 there were ten Type A (Loop Concentrated), one Type B (Nucleated), two Type C (Dispersed), one Type D (Nucleated-Dispersed), and two Type E (Numerically Insignificant) specialties (See Table 6-3). The over- whelming majority of specialists were located in or near the Loop. Over 609L of the specialists of eleven of the sixteen boards certifying competency in a medical specialty had offices in the Loop (one, Plastic Surgery, was numerically insignificant) (See Table 6-4). The specialists of only four of the numerically significant specialties -- Anesthesiology, Pathology, Pediatrics and Radiology -- had a majority of their offices outside of the Loop. In each case the majority of the specialistst offices were located in the City. Only Pediatricians had more than 20~ of their offices in the Suburbs. Neurosurgery was the most highly Loop-oriented specialty, with nine out of ten such specialists having Loop offices. Dermatologists were nearly as cort entrated in the Loop with 88T of the SMSA Dermatologists located in that area. Pediatricians were the most decentralized with less than one out of ten offices located in the Loop. Over three-fourths of the Anesthesiologists and seven out of ten Radiologists had offices in Community or Health Care Areas with 1~ or less, or two or fewer, specialists (See Table 6-5). Pediatricians were also widely dispersed, but there were five distinct nodes or concentrations of Pediatricians' offices outside the Loop (Uptown, Hyde Park, South Shore, Winnetka, and Orland Park). Each concentration had 5,~ or more of the total offices, and within each node the majority of Community or Health Care Areas had more than two specialists. Thus, Pediatricians were classified as Type D (Nucleated-Dispersed). Specialty Types, 1960. In 1960 the Loop no longer had the dominant share of the SMSA's specialists, even though there were several specialties which were still Loop-oriented (See Table 6-3). The Suburban areas rose in importance and vied with City-outside-of-the-Loop for the non-Loop specialists. In most cases the Suburbs equaled or bettered the proportion of specialists located in the City outside of the Loop (See Table 6-4), Three specialties (Neurosurgery, Plastic Surgery and Psychiatry-Neurology) continued to be definitely Loop'concentrated (Type A), There were four Type B (Nu- cleated) specialties: Orthopedic Surgery, Urology, Internal Medicine, and Thoracic Surgery. Four other specialties (Dermatology, Pathology, Radiology, and Surgery) were Dispersed (Type C), and five (Anesthesiology, Obstetrics-Gynecology, Opthal- PAGENO="0575" 565 135 TABLE 6-3 Distributional Classification of Specialists (1950. 1960 and 1970) Specialty 1950 1960 1970 Specialty 1950 1960 1970 Anesthesiology C D D Pediatrics D D D Colon & Rectal Surgery - E E Physical Medicine- Rehabilitation E E E Dermatology A C D Plastic Surgery E A B Internal Medicine A B C Preventative - E C Medicine Neurosurgery A A C Psychiatry- A A A Neurology Obstetrics- A D C Radiology C C D Gynecology Ophthalmology A D D Surgery A C C Orthopedic A B D Thoracic Surgery - B D Surgery Otolaryngology A D C Urology A B B Pathology B C C 1950 1960 1970 Loop-Concentrated (Type A) Total 10 3 1 Nucleated (Type B) Total 1 4 2 Dispersed (Type C) Total 2 4 7 Nucleated-Dispersed (Type D) Total 1 5 Numerically Insignificant (Type E Total 2 3 2 PAGENO="0576" 566 136 TABLE 6-4 Percent of Specialists in Loop, City Outside of Loop and Suburbs (1950, 1960 and 1970) City Outside Loop of Loop Suburbs 1950 1960 1970 1950 1960 1970 1950 1960 1970 Anesthesiology 237, 37~ 77, 697, 247, 24'h 87~ 737, 697, Colon and Rectal Surgery - 40'!, 507, - 2O7~ 0 - 407, 5O7~ Dermatology 887~ 417, 267, 87, 327, 327, 47, 277, 417, Internal Medicine 747, 467, 327~ 127, 237~ 257, 147, 307, 437, Neurosurgery 907, 657, 427~, 107,, 107, 117, 0 257, 477, Obstetrics- Gynecology 697, 377, 207, 137, 287, 287~ 187, 347, 527, Ophthalmology 647, 417, 277, 227, 267, 247, 147, 337, 497, Orthopedic Surgery 767, 477, 257, 147, 227, 17'!, 107, 317, 587, Otolaryngology 627~ 457, 377, 227, 237, 207, 16'!, 337, 427~ Pathology 437, 217, 77, 437, 367, 307, 147, 437, 637, Pediatrics 97, 67, 47, 557, 507, 377~ 367, 447, 597, Physical Medicine & Rehabilitation 207, 257, 0 807, 257~ 607, 0 507, 407,, Plastic Surgery 757, 797, 507, 257~ 0 107, 0 21~ 407, Preventative Medicine - 147, 107, - 437, 247, - 43'!, 667, Psychiatry_Neurology7s7, 757, 607, 127, 87, 77, 107, 177, 337, Radiology 35'!, 257~ 167, 487, 417, 297, 167, 347, 557, Surgery 667, 367, 207, 207, 267, 287, 147, 387, 527~ Thoracic Surgery - 507~ 257~, - 67, 297~ - 447, 467, Urology 667, 417, 327~ 177, 257~ 217~ 177, 337, 477, All Specialists 627, 397, 257~ 237, 267, 257~ 157, 357, 507, (Average 7, for the SMSA) PAGENO="0577" 567 137 TABLE 6-5 Percent of Specialists of a Specialty in CA's or HCA's With iT, or Less (or Two or Fewer) Specialists Specialty 1950 1960 1970 Anesthesiology 77~~ 697, 427~ Colon & Rectal - lOO7~ lO07~ Surgery Dermatology l27~ 517, 567~ Internal Medicine l97~ 247, 377~ Neurosurgery 2O7~ 357, 507~ Obstetrics-Gynecology 257~ 217~ 387~ Ophthalmology 277, 347~ 357~ Orthopedic Surgery 247~ 387, 227, Otolaryngology 297~ 377~ 48~ Pathology 507~ 71~ 547, Pediatrics 507~ 7l~ 547, Pediatrics 507~ 287~ 487~ Physical Medicine 1007, 1007, 1007, and Rehabilitation Plastic Surgery 177, 35Z 5l7~ Preventative Medicine - 10O7~ 867, Psychiatry-Neurology l57~ 157, 227, Radiology 717, 607, 337~ Surgery l77~ 357, 5l7~ Thoracic Surgery 257~ 2l7~ 507, ~.irology 357~ 4l7~ 387~ PAGENO="0578" 568 138 mology, Otolaryngology, and Pediatrics) were Nucleated-Dispersed (Type D). There were also three Type E (or Numerically Insignificant) specialties (See Table 6-3). Most specialists (75~) became more dispersed between 1950 and 1960. Dermatologists and Pathologists were the most noticeable. The concentration of Derma- tologists in the Loop declined dramatically (over 50%) to about the Loop average (See Table 6-4). There was, however, an absolute growth in the number of Dermatologists in the Loop. The proportion of Pathologists located in the Loop also decreased 50cc to the fourth lowest proportion (of Loop specialists) of all specialties in the Loop. The low pro- portion of Pediatricians in the Loop fell even farther from 9~ to 6~, but Anesthesiologists almost completely abandoned the Loop and their 3~ became the lowest proportion of specialists located there in 1960, The majority of the specialties also had two or less significant nucleations. The principal exceptions to this were Pediatrics, Anesthesiology, Obstetrics-Gynecol- ogy, Opthalmology, and Otolarvngology, Pediatrics had seven distinct concentrations: West Ridge, Uptown , South Shore and the Loop; Evanston, Highland Park, and Skokie in the Suburbs. There were three important clusters of Anesthesiologists: Evanston, Glencoe, and Oak Park. Evanston, Skokie, Oak Park, Berwyn, and Joliet had slight concentrations of the other specialties as well. Specialty Types, 1970. In 1970 the proportion of specialists' offices located in the Suburbs was greater and the Loop's portion of specialists was much less than in 1960. There were considerable changes in the number of certain specialty types. There was one Type A (Loop-Concentrated), two Type B (Nucleated~, seven Type C (Dispersed), seven Type D (Nucleated-Dispersed), and two Type E (Numerically Insignificant) specialties in 1970 (See Table 6-3). Fifteen of the nineteen specialties had a majority or plurality of their special- ists in the Suburbs in 1970. Only Plastic Surgeons, Urologists, and Psychiatrist- Neurologists still had a majority of their offices in and around the Loop. Nine special- ties had 5O~T or more of their doctors' offices in the Suburbs and two of these had over 65~ (See Table 6-4). Anesthesiology had the highest Suburban proportion (69~T) and Psychiatry-Neurology the lowest (33~). Evanston and Oak Park were, again, the most important nodal centers, although the Near West Side in the City and Skokie and Hinsdale in the Suburbs also became significant points of concentration in the second decade of the study period. Dermatology, which was highly Loop-oriented in 1950, became one of the most dispersed in 1970, while Psychiatry-Neurology, which also had a high Loop concentration in 1950, was still mainly Loop-concentrated in 1970. It must be noted that the decrease in the Loop's proportion of specialists is relative; all but four specialists had substantial absolute increases in Loop offices. Only Dermatology, Ophthalmology, Otolaryngology, and Surgery actually decreased in number of Loop offices, whereas the number of total specialists' offices in the Loop increased almost 60% between 1950 and 1970. The overall tendency between 1960 and 1970, however, was decentraliza~p, PAGENO="0579" 569 139 or more specifically recentralization, as specialists decentralized out of the Loop and City into the Suburban clusters of lesser individual significance. Concentric Zonal and Sectoral Distribution of specialists by SpecialtyL 1950-1970 Table 6-6 depicts the concentric decentralization of each specialty. From this table two things are obvious. First, the concentric distribution of the individual specialties generally reflect the concentric distribution of the combined specialties dis- cussed in Chapter V. Second, the range between the percentages of the majority of specialties in each zone was small with one or two exceptions. For example, in the Inner City in 1950 the proportion of the majority of specialties in that zone ranged between 8~ and 20~. There were only four numerically significant specialties which were not within that range: Anesthesiology - 69', Dermatology - 0 , Pathology - 43, and Radiology - 29'~. In this chapter the exceptions to the general pattern are of greater significance because the general pattern was analyzed in Chapter V. The following sections will, therefore, identify the exceptions from the general pattern in each zone (except the Loop which was discussed earlier) for numerically significant soecialties in 1950, and the succeeding section will identify the exceptions for 1970. Concentric Zones, 1950. Deviations from the general pattern are of two types: (A) The first type results from the almost exclusive concentration of the soe- cialists of a specialty in one or two zones with their subsequent absence from the other zones -- hence the specialty's usually lower than the general range of percentages in all hut one or two zones and much higher than the general range of percentages in those zones. For example, in 1950 Anesthesiologists were concentrated in the Inner City to the extent that they were virtually absent from the other zones. Dermatologists were extremely Loo7-concentrated and therefore were hardly found in any other zones, The vast majority of Pathologists and Urologists we're located in the Loop and Inner City leaving the other zones nearly void of these specialists. (B) The second pattern is one in which there is an exceptionally high concentration of specialists in a zone relative to the general range of percentages in that zone but the proportion of that specialty's specialists may be higher in other zones or evenly distributed throughout all of the zones. Examples of this pattern were mostly in the Suburbs in 1950, Tbe percentage of Pediatricians in the Inner Suburbs was higher than the general range of percentages in that zone but only 18~ of all Pediatricians were in the Inner Suburbs. Internists, Obstetrician-Gynecologists, and Pediatricians all had higher-than-usual concentrations in the Middle Suburbs, although there were greater concentrations of each of these specialties in other zones, There was a notably higher percentage of Pediatricians in the Outer City while Radiologists were above the general range of percentages in the Inner City. Concentric Zones, 1970. In 1970 there were few numerically significant specialties with an overwhelming high proportion of their specialties in only one zone. Plastic Surgery and Psychiatry-Neurology were the exceptions -- both had a majority 38-698 0 - 74 - 38 (Pt. 1) PAGENO="0580" `CABLE 6-6 rc `)t.rc cf ~` ~r~' Ccr71ii~. ~peciaiists ~v 7T~~6o and 19707" tnLQ i2~Q ~a ~!` In»=Q !naQ I 4,,~ ~ 7.07. - 7071 0 - 0 0 401 53)7/ - `3 0 - 0 0 - 0 0 0~~1~lo4y 887. 217. 267/ (1 17. 117. 8.2 247. 277. 73 11". 237/ 6)2 307,1)2 3 33 b7, 0 0 9.21 1~~. 747. 467. 127, 85 37/ II?, 47. 17, 47. `7 207. 237. 0') 77.1 127. 27, 3') 37, 0 0 171 907. 6)7. 427, 197. 57. 117. 0 57. 0 207/ 2)7. 0 0 67. 3) "7. 177. 0 0 0 0b.t.t~ 1~.-Cy,.o~logy 697. 377. 207. 672 67. 107. 67. 237. 187. 3' 257. 307. 21,7. 87. 337. 3) 27. 77. 0 0 17. 0ph8h~I.,,l,gy 647. 427. 277/ 97. 3071 47 337. I)', 97/ 1(1 0371 00'. 3.7. 1,71 337,1711,7. 77. 71 "2 0 08 13~ 3 27. 8 A, P.thoto8y 437. 217. 37, 4371 187. 167. 0 187. 145 0 427 147. 77/ 77 77. 37. 0 971 0 6"/ 277/ F.dt.6,1,. 97/ 67. 47. 187. 1271 1471 367. 36". 221/ 33' 2,7. 357, 117. 1571 257, 37. 27. 37. 071 17. 37. Thy.t,.0 N.dl,1,,. .97 6.6.61016.81,,, 205 257. 0 607/ 0 2071 2071 257. 407. (3 257. 427/ 0 2571 3 0 0 0 0 0 P1.971, S971.,,7 88% 3971 507. 0 0 55 127 0 5% (3 147. 007. 0 77. 57/ 0 0 0 0 0 0 PN.N.8t.t 1,. 8.dI,1,,. . 14% 1071 - 0 147. . 437. 07. - 297 297-0397. .34", 347, - 0 57. 976y,h 1.283-8.78.171, 1~gy 787. 317. 607. 107. 577/ 35 37. 37. 47. 05 1171 197/ 02 57/ 97, 5)1 5'3 37. 0 0 0 R.dlol,1y 3571 257. 167. 2971 147. 157. 197. 257. 145 100 2071 117/ "'2 1(37. 367. 37. 5') 87. 0 17. 17. ~ 667. 367. 207. 137. 97. 1371 77. 177. 157. 92 217. 2971 32 97. 4", 0' 67. 07, 0 21. 2" Th.,t, S~g.~" . 5072 257. . 0 197. . 67/ 107. - 227. 217-67. 157.177. 87. - 0 27. U8,1~IY 677. 41'. 3271 137. 107. 87. 0 167. 137. 87 267. 2)2 0 27. 217/ 8.. 6'. 117. 0 0 0 PAGENO="0581" 571 141 of their specialists in the Loop. There were a few specialties of the second type dis- cussed in the last section. The percentage of Thoracic Surgeons in the Inner City zone was slightly higher than the general range of percentages in that zone, while there was an exceptionally low proportion of Dermatologists and Opthalmologists there. Neuro- surgeons are notably absent from the Outer City. Anesthesiologists were higher than the overall general high percentage of specialists located in the Inner Suburbs. Neuro- surgeons were significantly lower than the general range of percentages in the Middle Suburbs, while they were unexpectedly high in the Outer Suburbs. Sectors. The following discussion on the sectoral distribution includes only those private-practice diplomate specialists' offices outside the Loop. The pattern by sectors is shown in Table 6-7. In 1950 the offices of two specialties (Pediatrics; Physical Medicine and Rehab- ilitation) were concentrated in the Northern Sector and Anesthesiology was strongly con- centrated in the Southern Sector. Most of the other specialties had an even dispersal throughout the five sectors. The Southwestern Sector generally had the smallest pro- portion of specialists of each type. By 1960 there was a definite shift into the Northern Sector with a secondary movement into the Western Sector. The proportion of specialistst offices in the South- ern Sector declined in importance in all numerically significant specialties with the exception of Pathology, which increased significantly. By 1970 the dominance of the Northern Sector was obvious, since one to two fifths of the offices of most specialties were located in that sector. The Western Sector still had a significant and increasing proportion of most specialties, while the relative importance of the Southern Sector declined in almost every case. The distributional pat- tern of each specialty in 1970, therefore, was also similar to the overall pattern de- scribed earlier, i.e., high increases in the Northern Sector and major decreases in the Southern Sector. Tj~jype of specialty, therefore, had little bearing on the distribution of specialists by rings and sectors. Community and Health Care Areas A cartographic display of the distribution of each specialty by CA's and HCA's was impractical because of the small number of specialists in each specialty. Several Community Areas and municipalities were cited earlier as having significantly high con- centrations of certain specialties. The communities noted for having high concentra- tions of certain specialties shared many common characteristics. Most of them were older residential suburbs with relatively large hospital facilities and retail shopping centers -- usually a Central Business District. They also usually had high socioeco- nomic status and a low proportion of blacks. Influence of Locative Factors on the Distribution of Specialists' Offices by Specialty In 1950 the offices of only three specialties had distributions substantially PAGENO="0582" TABLE 6-7 Percent of Board-Certified Specialists by Sector, 1950, 1960 and 1970 North Northwest West Southwest South 1950 19(0 1970 1950 1960 1970 1950 1960 1970 1950 1960 1970 1950 1960 1970 Anesthesiology 15 3 42 0 0 9 15 29 24 0 18 12 46 15 6 Colon & Rectal Surgery - 2() 25 - 0 0 - 20 25 - 20 0 - 0 0 Dermatology 8 2') 31 0 7 10 4 12 15 0 2 6 0 7 13 Internal Medicine ii 3~ 32 4 4 8 4 7 17 6 4 6 2 8 6 Neurosurgery 0 10 17 0 10 3 10 5 28 0 10 6 0 0 6 Obstetrics- Gynecology 17 25 24 0 6 12 0 14 22 9 8 12 6 10 10 Ophtleilmology 6 16 25 4 7 8 9 18 24 7 8 9 10 10 6 Orthu.Siirgery 10 2? 27 0 8 10 5 12 24 5 4 8 5 8 6 Otolarviigology 13 17 25 4 8 7 9 18 21 4 5 5 8 7 5 Pathology 7 21 32 7 7 8 29 25 28 0 4 13 14 21 13 Pediatrics 43 45 42 9 10 9 7 13 20 9 9 7 23 17 18 Physical Medicine, Rehabilitation 40 0 40 0 25 0 20 25 20 0 20 40 20 0 0 Plastic Surgery 0 7 15 0 0 10 12 14 25 0 0 0 0 0 0 Pro v en tat i ye M~dJ clue 0 14 24 - 0 5 - 29 38 - 43 24 - 0 0 Psychiatry- Neurology 5 14 20 5 1 4 3 10 14 3 1 2 8 2 3 Radiology 10 25 32 10 8 10 10 18 23 10 8 11 25 17 9 Surgery 12 21 25 5 9 11 6 17 25 4 8 10 7 9 9 Thoracic Surgery - 33 27 - 0 4 - 6 35 - 0 4 - 6 4 Urology 8 24 22 - 8 10 8 16 23 0 4 7 17 6 8 0i PAGENO="0583" 573 143 different from the common pattern, i.e., Loop concentration. Two of them (Anesthe- siologists and Radiologists) were dispersed and the other (Pediatricians) was nucleated- dispersed. The principal locative factor in the distribution of Anesthesiologists' and Radiologists' offices was hospital facilities. All Anesthesiologists' offices and 63~ of the Radiologists' offices were located in communities which had important concentra- tions of hospital facilities. A large share (35'7r) of the remaining Radiologists' offices were located in the Loop. Pediatricians' offices were widely dispersed, similar to the population in general. There were, however, important nodes of concentration in the more affluent areas of the SMSA. By 1960, the increased mobility of the population stemming from the wide- spread use of the automobile made accessibility a much less important locational factor. Specialists, therefore, began to shift their offices out of the Loop and relocate them in the Suburbs. A major portion of the offices of seven specialties, however, were still concentrated in the Loop (See Table 6-3). Accessibility to patients from all parts of the SMSA, therefore, appears to be the prime locational factor of the offices of those specialties. Four of the seven Loop-oriented offices were surgical specialties -- Neurosurgery, Orthopedic surgery, Thoracic surgery, and Plastic surgery, Internal medicine, Urology, and Psychiatry were the other three, In 1960 offices of four specialties were widely dispersed -- Dermatology, Pathology, Radiology, and Surgery. The distribution of Pathologists' offices was closely associated with hospital facilities -- 75% of their offices outside of the Loop were in communities with large hospital facilities. The offices of two of the other three specialties, Dermatologists and Radiologists, were more scattered, and reflected the distribution of municipalities which had a combination of high socioeconomic status, large hospitals, and major retail shopping centers. There was seldom more than one or two of these specialists' offices at any one location, however, so they should not be con- sidered concentrated in these centers. The dispersal of Surgeons was even more wide- spread than Dermatologists or Radiologists. Their distribution resembled the general distribution of population. In 1960 the offices of the nucleated-dispersed specialties varied in location, The offices of three of these -- Opthalmology, Otolaryngology, and Obstetric s-Gynecol- ogy -- were widely dispersed in the City and scattered in the Suburbs with minor con- centrations in municipalities which had a combination of high socioeconomic status, large hospital facilities, and major retail shopping areas. The fourth nucleated-dis- persed specialty, Pediatrics, was dispersed in the Suburbs with minor concentrations in the Northern Suburbs. The distribution of Anesthesiologists, the fifth of the five nucleated-dispersed specialists, still strongly resembled the dispersal of hospital facilities. Three out of four were located in communities which had large hospital facilities. Four locative factors were attractive forces affecting the distribution of the 19 specialties of the American Board of Medical Specialties in 1960. The accessibility afforded by the Loop was important for seven of the nineteen. On the other hand, PAGENO="0584" 574 144 hospital facilities were significant in the location of Pathologists and Anesthesiologists. A combination of factors -- socioeconomics, hospital facilities, and retail shopping centers -- in one area attracted Dermatologists, Radiologists, Opthalmologists, Oto- Ia ryngologists, and Obstetrician-Gyriecologi sts. Pediatricians, however, were affected mainly by socioeconomic status and attracted to the affluent areas of the City. Finally, Surgeons were widely dispersed, like the population, with a slight emphasis toward con- centration in the afluent areas of the Northern and Western Suburbs. By 1970, the importance of the Loop as a locational factor practically dis- appeared, remaining important to only three specialties -- Urology, Plastic Surgery, and Psychiatry-Neurology. The overwhelming majority of the specialists (14 of 19) were decentralizing out of the Loop. Half of them recentralized in nodes outside the Loop and the rest became widely scattered. Two of the seven nucleated-dispersed specialties (Anesthesiology and Thoracic Surgery) were hospital-oriented by 1970 and four others (Opthal mology, Orthopedic Surgery, Radiology, and Dermatology) had concentrations in areas where retail shopping centers, hospital facilities, and high socioeconomic status were all located. The distribution of the other specialty (Pediatrics) was closely associated with the distribution of high socioeconomic status, A large portion of the Pediatricians' offices were located in the Northern and Western Suburbs. The factors in the dispersed location of specialties in 1970 varied consider- ably. The distribution of one of the seven dispersed specialties -- Preventive Medicine -- was more closely aligned with the distribution of affluence than any other factor. The locational pattern of two others, Neurosurgery and Otolaryngology, reflected the dis- tribution of centers which had a combination of high socioeconomic status, large hospital facilities, and major retail shopping centers. Pathology was dispersed in centers which had large hospital facilities. The remaining three dispersed specialties were distributed like, the population in general, although these also tended to be slightly more concen- trated in the affluent areas of the SMSA. In summary, specialties exhibited a trend of increasir~ decentralization with associated factors. In 19~30 the distribution of only one specialty (Pediatrics) was closely associated with the distribution of high socioeconomic status. Two others (Anesthesiology and Pathology) were aligned with the distribution of hospital facilities, and the others were Loop-oriented. By 1960 only seven specialties were Loop-oriented, two were still hospital-oriented, and the distribution of four others was closely associ- ated with areas which had a combination of high socioeconomic status, large hospital facilities, and major retail shopping centers. By 1970 socioeconomic status was the most important factor in the location of two specialties, and it played a lesser role in the the distribution of three others. The Loop's influence was dominant in only three specialties. Hospital facilities were also of major significance in the location of three specialties. The distribution of six soecialties were influenced by a combination of the three factors noted above -- the Loop, socioeconomic status, and hospital facilities. High socioeconomic status was significant as a general locational factor, but hospital PAGENO="0585" 145 facilities and retail centers were of greater importance in choosing a specific site after the choice of general area had been made. PAGENO="0586" 576 CHAPTER VII SUMMARY AND CONCLUSIONS Trends in the Redistribution of Physicians in Metrop~~n Chicago Ten trends emerged from this study of the changing distribution of physicians' offices in Metropolitan Chicago during the twenty years since 1950. First, there has been a decrease in the total number of private practitioners in the Chicago Metropolitan Area between 1950 and 1970 as well as a significant decline in the ratio of private practitioners to population. This decline has taken place despite vast increases in the number of new entrants into the medical profession and increased need for primary medical care. Furthermore, Chicago's share of the nation's private practitioners has decreased and there has been a decline in the ratio of physicians to population relative to the national physician-population ratio, Secç~4~ there has been a decided decentralization of physicians' offices; that is, doctors are moving to the Suburbs. ~ the mean center of the distribution of both physicians' and specialists' offices have shifted northwestward away from the mean centers of populat on and retail shopping and toward the mean center of high socioeconomic status. Fourth, the Loop had the largest absolute loss of physicians' offices, but continues to have the largest single concentration of doctors' offices in the Sr'~lSA. Fifth, the suburban shift of doctors has left some areas of the City, which formerly had high concentrations of doctors, as veritable medical care `wastelands." Sixth, many parts of the Suburbs still have physician/population ratios far below the Metropolitan average, in spite of the large suburban influx of physicians. Seventh, the most significant shifts of physicians' offices in the Chicago SMSA have been from the Inner City to the Inner Suburbs and from the Southern Sector to the Northern Sector. ~ the trend in physician office relocation has been toward a greater inal- distribution of doctors' offices -- towards increased concentration of doctors in a few areas and increased scarcity of them in the others. The North Inner Suburban area of the SMSA had a disproportionately high share of the SMSA's doetors' offices in 1950, and its proportion increased throughout the study period; this trend is found even though the Northern Sector's share of the population was the lowest in the SMSA and declined throughout the study period. By contrast, the Southern and Southwestern Sectors of the Central City had disproportionately low shares of the SMSA's physicians' offices in both decades. The Southwestern Sector's proportion of doctors' offices, however, has Increased. ~h there is a high association between the shifts in physicians' offices and the socioeconomic status and racial structure of an area. 146 PAGENO="0587" 577 147 Tenth, there is an inverse relationship between the rise in specialization and the availability of physicians for primary medical care. Examination of the Trends in the Redistribution of Physicians' Offices in Metropolitan Chica,go There were as many doctors in the City of Chicago in 1907 as there are today. The City, once a world medical center, lost 2,000 private physicians in the twenty years between 1950 and 1970. Chicago had almost two doctors for every 1,000 people between 1840 and 1930. This ratio gradually slipped to 1~7/1,000 in 1940, and to 1.6/1,000 in 1950, then precipitously dropped to 1.3/1,000 in 1960 and to 1.1/1,000 in 1970. Chicago today has half as many doctors per capita as it had in the nineteenth and early twentieth century. In terms of population served, Chicago's current physi- cian/population ratio is the lowest in the City's history, and is expected to establish new record lows every year for the next twenty years. The City of Chicago continues to have a slight edge in physicians per 1,000 people over the Suburbs (1.13 versus .94) in spite of the suburban shift of physicians' offices. The ratio of physicians per 1,000 for the entire Metropolitan Area, therefore, is even lower than that of the City (1.03 versus ~ Chicago, which was once the nation's medical mecca, and which is still na- tional headquarters of the American Medical Association, the American Hospital Association, the Blue Cross Association, and the American Dental Association, is the only large American metropolitan area to have fewer private physicians today than twenty years ago. Incredibly, Metropolitan Chicago's physician/population ratio in 1970 was one-fifth below that of the average for the nation's large metropolitan areas ft.03 versus 1. 27/1, 000). The total physician population in Metropolitan Chicago, however, actually increased between 1950 and 1970 (from 9,270 to 11,840) although the population ratio went down slightly (from 1.79 to 1.70/1,000). This gain was accounted for by non- practicing salaried physicians working for hospital, schools, and government. The percent of all physicians engaged in private practice slipped fmm eighty percent in 1950 to sixty percent in 1970. Greater physician mobility has hurt Metropolitan Chicago not only by short- changing it in its share of physicians, but also by greatly aggravating the maldistribution of physicians. Doctors have traditionally favored office locations in affluent and densely populated communities not only for accessibility to patients able to pay for their services but also because of hospitals where they see their patients. They also desire to locate in proximity to the fashionable neighborhoods where they reside. Downtown Chicago remains far and away the single location that best meets all these criteria. The number of physicians with Loop offices has dropped from 1,770 to 1,100 since 1950. Although the Loop's share of Chicago physicians stayed at thirty per- cent, its share of Metropolitan physicians dropped from 25 to 15 per cent during this PAGENO="0588" 578 148 period. - Among the major concentric divisions of the Metropolitan Area, the greatest losses in physicians per population since 1950 occurred in Chicago outside the Loop (from 1.14 to .81/1,000) and in the exurban rural ring of Lake, Kane, and Will counties (from .73 to .42/1,000). All seven major ring divisions suffered losses in physicians per population with the exceptions of the Inner Suburbs, whose physician/population ratio increased by almost a third (.94 to 1.23), and two of the satellites (Chicago Heights and Joliet), whose ratios rose from .57 to 1.23 and 1.04 to 1.41, respectively. Dividing the Metropolitan Area into five directional sectors, all sectors show moderate losses in physician/population ratios except for the North Sector, whose ratio went up slightly (from 1.29 to 1.38/1,000) and the South Sector, where the ratio skidded down from 1.01 to ~ to the twenty-year period. The ratios for the 31 zones which result when the six concentric rings and the Loop are combined with the five directional sectors, `show that all Inner Suburban zones gained except for South Cook County. South Cook County had one of the highest ratios in 1950 and has registered the greatest loss (from 1.34 to .17), closely followed by the south exurban zone of Eastern Will County (from .93 to .06). One third of the physi- cians' offices in the SMSA were located in the following four cells of these 31 zones: Outer City North, Inner Suburbs North, Inner Suburbs West and Middle Suburbs West. One may conclude from the physician movements described so far that two vectors have emerged: physicians tend to favor northw~.rd and Inner Suburban destinations much more than the general population. North Cook County, therefore, appears to be the major magnet for physicians. When the distribution of physicians' offices/population ratios are examined by selected Health Care Areas, other pertinent aspects of the changing pattern of phy- sicians' offices become evident. In 1950, five of the twenty-five Health Care Areas (HCA's) with the highest physicians' office/population ratios were in the northern or western Inner Suburbs and only nine of the top twenty-five HCA's were lo~ted outside the City. By 1970, eighteen of the top twenty-five HCA's were in the ISN or ISW and only nine of the top twenty-five HCA's were still in the City. Hinsthle (4.50 physi- cians/1,000), Oak Park (4.14 physicians/1,000) and Glencoe (3.27 physicians/1,000) were the HCA's with the highest physicians' office/population ratios in 1970. Oak Park (-P3.27 physicians/1,000), Hinsdale (-~3.15 physicians/1,000) and Evergreen Park (~-2.60 physicians/1,000) were the HCA's with the greatest increases in physicians' office/population ratios between 1950 and 1970. West Garfield Park (-3.05 physicians/ 1,000), the Near South Side (-1.34 physicians/1,000) and Auburn-Gresham (-1.28 phy- sicians/1,000) were the HCA's with the greatest declines in physicians' offices/pop- ulation ratios between 1950 and 1970. The reasons for this disproportionate thstril~ition and its increasing trend was examined by comparing the shifts of physicians' offices relative to shifts in popu- lation/hospital beds, high socioeconomic status, and retail shopping centers. First, PAGENO="0589" 579 149 comparisons of the mean geographic centers of these phenomena in 1950, 1960 and 1970 were made. In 1950, the mean centers of population, retail sales, hospital facilities, and physicians' offices were concentrated in a cluster nearly directly west of the Loop. The mean center of socioeconomic status was significantly more suburbanized and more northwest of the Loop than these other centers. By 1970 the mean center of doctors' offices had shifted three miles west and two miles north. The center of hospital facil- ities moved only one mile west and one mile north in the twenty-year period, reflecting the inertia of established hospital locations in the Inner City. The centers of population and retail sales both shifted about three miles west, but only 0,5 miles north. The centers of socioeconomic status shifted 2.5 miles almost directly westward between 1950 and 1960, and then shifted back one mile north and one mile east between 1960 and 1970. In 1950, then, the center of physicians' offices was within two miles of the center of population, and the center of hospital beds was less than one mile from the center of population. The mean centers of both doctors' offices and hospital facilities were over five miles from the center of socioeconomic status. By 1970, the mean centers of hos- pital facilities and doctors' offices were equidistant (or about 3 miles) from the centers of population and socioeconomic status. Thus, socioeconomic status has apparently had a stronger influence on the location of doctors' offices and hospital facilities than the distribution of the population in general. All the communities in Chicago and the Suburbs which experienced rapid racial change and decreased socioeconomic status since 1950 lost physicians. When maps showing the areas with the greatest gains and losses of doctors are compared with maps depicting those areas with the highest socioeconomic status and those whose population changed from white to black two things become obvious. First, an influx of blacks re- sulted in an exodus of doctors. Second, the shift in the distribution of doctors was into the areas of highest socioeconomic status. West Garfield Park and Oak Park illustrate the extreme effect this can have on a community undergoing social and economic change. West Garfield Park is a com- munity on Chicago's westside and Oak Park is a suburban community of similar popula- tion located two miles west of West Garfield Park. Garfield Park's racial structure changed from no Negro population in 1950 to 96.8( Negro in 1970. The racial structure of Oak Park (less than 1~ Negro) hardly changed in this same period. West Garfield Park declined in its socioeconomic rank between 1950 and 1970. In 1950 it ranked 126th out of 164, but today it has fallen to 200th out of 235 communities and municipalities with over 2,500 population. In 1950 there were 161 physicians in West Garfield Park, but in 1970 only 13 remained. Oak Park, on the other hand, had only 73 doctors in 1950, but that number rose to 276 by 1970. The physician/population ratio of West Garfield Park fell from 3.32/1,000 to .27/1,000 between 1950 and 1970; that is, from one doctor for every 300 people to one doctor for every 3,700 people. Meanwhile, Oak Park's ratio rose from 1.15 physicians/1,000 to 4,42 physicians/1,000, or from one d3ctor for every 870 people to one doctor for every 225 people. PAGENO="0590" 580 150 The Chicago zone of communities that are presently black lost 66~ of its phy- sicians -- down to a present ratio of .51/1,000. The ten most impoverished of the 222 communities in 1970 saw their physician/population ratio plummet from .99/1,000 to .26/1,000, while the ten presently most affluent communities saw their already inflated ratio of 1.78/1,000 go even higher to 2. 10/1,000 in the twenty-year period. The final trend that must be considered is that virtually one out of two private practitioners in the Metropolitan Region today is a diplomate specialist; that is, one who has a diploma from one of the boards of the American Board of Medical Specialists. These specialists limit their practice to certain areas of medicine which may not be involved with the delivery of primary medical care. Those specialists who do deliver primary health care usually only deal with a certain type of affliction or limited part of the body. Thus, seldom does one specialist provide complete medical care for a family. One family may require the services of four to five doctors. Therefore, the physician/ population ratio today does not mean the same thing it did twenty years ago when less than ten percent of the doctors were diplomate specialists. For example, the Near West Side (CA 28) has had a resurgence of doctors. The number of doctors rose from 92 to 121 between 1960 and 1970 after having dropped from 232 to 92 between 1950 and 1960. The physician/population ratio rose from .73/1,000 in 1960 to 1.56/1,000 in 1970 -- slightly higher than the 1950 ratio. However, two-thirds of the doctors in this area (CA 28) in 1970 were specialists, as compared to less than six percent in 1950. Nearly one-half of the 1970 specialists were in Anesthesiology, Radiology, Pathology, and Plastic Surgery, and were not really available for primary medical care. When these doctors are deleted from the total number of doctors, the physician/population ratio drops to just over one doctor per thousand -- far below the 1950 ratio. So the rise in speciali- zation has had a definite effect on the availability of general medical care in Chicago. Factors and Forces Behind the Trends The socioeconomic status of communities appears to be the single most im- portant determinant of physician location. Moreover, this factor is becoming increas- ingly important. Changing racial structure may also be cited as a negative locative factor of physicians' offices. The location of hospital facilities exerts an influence on certain physicians' offices, particularly certain specialists' offices, e.g., Anesthe- siologists, Pathologists, and Radiologists. The distribution of retail centers also exerts an influence on the location of physicians, although much less so than socioeconomic status. It is especially the larger new regional shopping centers, with their professional and office buildings, that are the most attractive to physicians, particularly if they are in the Northern and Western Suburbs. In the other sectors, only Evergreen Plaza has proved to be a magnet for physicians' offices. Another factor which plays a role in physician office location is the location of physicians' residences. Because of the pull of downtown and the Inner City hospitals, PAGENO="0591" 581 151 about two-thirds of the Metropolitan Area physicians lived in Chicago twenty years ago. Today, this proportion is down to one-third, as many of the former fashionable neigh- borhoods on the south and west sides of Chicago have become absorbed by the expanding black ghetto. Coupled with this trend is the increasing concentration of expensive homes in a score of suburbs, mostly north and west of Chicago. Chicago lost over half of its houses valued over $50,000 in the last ten years, while most suburban developments are in price ranges below $50,000. With an average annual income of about $50,000 a year, few seif-resDecting physicians would purchase homes below $59,000, Most of the homes in this high price range are confined to high income areas in the North Shore and Skokie Valley. Therefore, one finds a situation where more physicians live in Evanston than in all of South Cook County, more live in Wilmette than in all of South- west Coo¼ County, more live in Winnetka than in all of Will County, more live in Skokie than in all of Kane County, and more live in Lincoinwood than in all of McHenry County. Because of the high value of his time, the physician has traditionally kept his office close to his home, often as close as the front parlor. Proximity between home and office today is even more valued because of the high cost of commuting, the physician's time being worth about $25 an hour. The increasing concentration of physician residences in a score of high-income suburbs in the north, northwest, and west is another reason for northward and close-in suburban concentration of physicians' offices. Co'iclusions There has been a relative decline in Chicago's proportion of the nation's doc- tors as well as an absolute decrease in the number of private practitioners, while the population was growing rapidly. This has resulted in a severe decline in the ratio of private practice physicians to population in the Chicago area. Physicians are decentralizing out of the City and into the Suburbs. More specifically, they are leaving those areas which are changing from high to low socio- economic status and those whose racial structure are changing from white to black, and they are going to the more affluent areas of the Northern and Western Suburbs. The disparity in the distribution of physicians' offices is the antithesis of the appropriate distribution based on need as indicated by morbidity. Specialists' offices display an even greater concentration in affluent areas than all physicians' offices. Hence, the distribution of specialists' offices is even more irregular and these doctors are less available to the poor of the Metropolitan Area. The trend toward increased specialization in the medical profession will result in a more inequitable distribution of physicians' offices in the future. Finally, the so-called doctor shortage in the central cities of large metro- politan areas, with high concentrations of poverty, could be partially alleviated by the redistribution of the available doctors. Recommendations No one can really tell how many physicians per capita we need, anymore than PAGENO="0592" 582 152 one can tell how many hospital beds per population we need. Actually, utilization of physician and hospital services, regardless of real need, generally determines norms such as physician and hospital bed/population ratios. Yet, when we witness huge dispar- ities in physician/population ratios of communities -- of the order of 10 to 1 among Chicago-area communities, for example -- it is hard not to conclude that some commun- ities enjoy large surpluses of physicians while other communities suffer from dangerously low numbers of physicians. Pierre de Vise suggests that: The projection of 1980 physician needs for metropolitan Chicago is complex indeed when we examine the consequences of the area's gain of 2,700 physicians in the 1960's. More physicians have meant fewer private practitioners and fewer physicians of any kind for all but a handful of the area's communities. One might be tempted to urge fewer physicians for 1980 if indeed the trends of suburban gravitation and shift away from primary care practice might thereby be reversed. Even if we were to agree on the national norm of 1.27 phy- sicians per 1,000 as the metropolitan area goal, we would have to find a way to implement this goal. The increased importation of foreign gradu- ates was the main source of physician growth in Chicago in the 1960's. The number of graduates of Chicago Medical School, which has increased but slightly in the 1960's -- from 516 in 1960 to 550 in 1970 -- is expected to go up to 800 by 1975. On the other hand, the retention rate of Chicago graduates is going down. Unless the trend of retention losses can be reversed, and some way found for Chicago to successfully compete against superior climate amenities, gains in local medical school pro- duction will benefit California more than the Chicago Metropolitan Area. If we should be successful in raising the number of physicians to match the national norms, there would then remain the goals of redressing the geographic maldistribution of physicians and of making better use of hospital-based practitioners for delivering primary care services. There are, unlortunately, few good models to guide us in these tasks. The OEO Neighborhood Health Center model of the 1960's has given way to Health Maintenance Organization model of the 19 70's as the panacea for improving health delivery services. &it HMO will do no better than OEO unless this health delivery model can keep Chicago graduates in fllinois, and unless it can attract these graduates to practice in communities with the greatest need, rather than in communities with the greatest wealth. 1 1Pierre de Vise, "Physician Need for fllinois in the 1970's," Health Plann4~g in illinois , Fall 1971, (Chicago: illinois Regional Medical Program) Vol. II, No. 3, pp. 8-9. PAGENO="0593" 583 153 In the meantime, we should realize that incentives alone are not sufficient to induce doctors to practice where they are needed.2 Hill-Burton Hospital and Clinic construction funds as well as many other federal programs have helped subsidize the suburbanization of physicians and hospitals. We should seriously consider a moratorium on these kinds of public subsidies when they facilitate the flight of hospitals and doctors out of inner city and rural areas. Instead, these federal funds should be diverted to Inner City hospitals to be used to equip and operate outpatient departments that would provide primary ambulatory care in communities lacking private physicians. The physician/population rati.o of com- munities should become a criterion of need in the determination of hospital and clinic construction priorities under Hill-Burton. A diversion of federal funds from communities with a surplus of physicians to commuities with a deficit of physicians is the least that our government should do in slowinl dnwn the flight of hospitals and doctors to affluent suburban communities. ~ Medical Association, March 20, 1972, Vol. 219, p. 1621. Pierre de "ise, "The Effect of Federal Spending on the Distribution of Phy- sicians in the United States," (Text of paper presented to the Congressional Black Caucus Forum on Health Care at Harvard University, Boston, Massachusetts, April 8, 1972.) PAGENO="0594" LA*5 *1 C~..,ts, 61.5..,, d 86*~1,1~.I680.~ MAS 2-2 ~3. SOAS~SO,OI. 66 062o.g.. o.o. 89 . 1.1'. !t. !s !o.. 2. *..s 5041. 22. L*11s 599..-. 45. Ao.loo P.,k 68. F.l.g2.9.....1 91 1. 4. L0.so*I.. Sq..8. 2 44..s~,, 47. lo.-~s0d~ 00. Oohbo!0 60 II.-.... 5. I*85hC**t~1 25. 99.50, 48. 0*010115 0815658 720obo,., 4,o11... 946051 4. L.A. Vi.. 26. 01.0 G.,62,Id P.,k 49. 8o..0.Vd 02 8..o.slo ~`0 ` I. 5*1W 8,.-sh 504. 28. 8.., 5..osjo. 50 SooSh 0~s~'g 14 so~oo .o.,~ 91 `6. 8. 146*5.. P*1A 29. 818860.184.2. 52. E..0 004. 0 0M..~59o 7014 08 .0 .1 10. 5*15.884 8*16 30. 0o,~o6 L..~d.2. 53 A,.o P,~0I-oo 06. Eo*s1sOol 9~ `~` 02. 818..s GO... 02. Tb. L*op 55 H,g,ol..o6 78 115029(111' I~1 Ro....1 1.-. 03. 8*,568.,k 33. 8*8 50986 00.0. 06. G.,00,ld ROIg, 0 990,o,ok 0 100 `-. S 04. Alb...y P.,6 04. AIOIOI Sqo.,. 50. 9106.8 Hsgho~ 80. G0~V001 0 05. P..-s.g. P.,6 35. 0005191 58. B~0gP0... PITA 80. 60g60.od Po,4 `04 Po,4 8,.. 16. 01*0~g P.,k 36. 0.41.,4 09. VoKOsI.o P.14 82 6186*104 leo. 10'. 62 08. 09*1*0#~ 30. 6,0',, 8,-k 60 l~ldg~pos8 8 0I..k.Pos-oso 08 8o,0,0.,, 38. Cs.,d ~ 61 9~A Toso 84. 0968 81.00 00' ". o( 09. 1*1.185 C,..g0~ 09. K.soood 60 9.106 bOo,. 85. 0o,shCh,....' 106 .0,2.. 026. 605061102,' 023 PAGENO="0595" C j35 S~!hFlgt HI 100. 313 ~ IH~ H.~I ~ (I~~o 145 B. I!~~.3 SB lot .~o0olt 4.11 PAGENO="0596" C;' 25 2EIkG!'~? 5~.7 ~ 5 5 St.5,' 262 N~!(hb!k 348 6..6~I*~ 4~3 233. #11.. 355. F@,.ss P~sk 451. Bl~s 1~l~sd 552 2~13~ Is, 281. CI,ss~, 355 6.,s,,,, 457 5,,,,2sIs 573 C.,p~,, Is 5~ 4 28 3W33~5Is 372 8,7,, 1.7 155 5,75 .~ 1~ ``~~."`` , 2 ,, 191 54s33. 373. Rlssss 3, 455 Hss.s 33 .,,, 57, 292. Es&,,lss 314. Lysss PAGENO="0597" 587 157 SELECTED BIBLIOGRAPHY Books BERRY, BRIAN J. L. and MARKLE, DUANE (eds) Spatial Analysis: A Statistical Reader, Englewood Cliffs, N. J.: Prentiss-HaIl 1968. BONNER, THOMAS NEVILLE, Medicine inç a.o1850-l95~, Wisconsin American History Research Center 1957. CHICAGO MEDICAL SOCIETY, History of Medicine and Surgery and Physicians and ~~geons of Chicago, Chicago: Biographical Publishing Corporation 1922. DUNCAN, OTIS B. and DUNCAN, BEV., ThQ~g~o Population of Chicago~ University of Chicago Press 1957. ______________ Et.al, Statistical Geography, Glencoe, illinois: Glencoe Press 1961. HAUSER, PHILIP and SCHNORE, LEO (eds), The Study of Urbaniza~p, New York: John Wiley 1965. HOYT, HOMER, One Hundred Years of Land Values in Chicago, University of Chicago Press 1933. MARTIN, FRANKLIN, Joy of Life, Vol. II, New York: Doubleday 1933. NEW YORK ACADEMY OF MEDICINE, Medicine in the Changing Order, New York: Commonwealth Fund 1947. STERN, BERNHARD J., American Medical Practice in the Perspective of a Century, New York: Commonwealth Fund 1945. VERNON, RAYMOND, The Changing Economic Function of the Central ç~y, Committee for Economic Development, January 1959. ___________ Metropolis, 1985. An Interpretation of the Findings of the New York Metropolitan Region Study, Cambridge: Harvard University Press 1960. WEAVER, ROBERT C., "Emerging Patterns," in Our Changir~g Cities by J. B. Tucker, Washington D.C.: Public Affairs Press. Periodicals "Offices Debate, City vs. Suburbs, "ASPO Newslette~, p. 98, December 1955. BACHI, ROBERT, "Standard Measures and Related Methods of Spatial Analysis," ~(2~al Science Association: Papers and Proceed)~g~, Zurich: 1962. CLARK, FREDERICK P., "Office Building in the Suburbs, "Urban Land~ Vol. XIII, pp. 3-10, July 1954. CONVERSE, P. D., "New Laws of Retail Gravitation," Journal of Marketing, Vol. 14, pp. 329-385, 1949. DE VISE, PIERRE, "Physician Need For illinois in the 1970's," Health Planning in illino~, illinois Regional Medical Program, Vol. II, No. 3, pp. 8-9, Fall 1971. DICKINSON, F. G., "A Medical Service Area in the U.S.," JAMA Vol. 133, pp. 1014- 15, April 5, 1947. PAGENO="0598" 588 158 _______________ "A Medical Service Area Map of the U.S., "JAMA, Vol. 133, pp. 1014-15, April 5, 1947. ____________ "Medical Service Areas: Population, Square Miles and Primary Centers, Including a Medical Service Area Map Supplement," JAMA, Vol. 145, p. 162, January20, 1951. DICKINSON, Et al, "Comparison of State Physicians Population Ratios, 1938 and 1949," JAMA, p. 244, September 16, 1950. FEIN, RASHI, "Studies of Physician Supply and Distribution, "American Journal of Public Health, Vol. 44, pp. 611-624, 1954. HART. JOHN FRASER, "Control Tendency in Area Distribution, "Economic Geography, Vol. 30, 1954. HOYT, H., "Recent Changes in the Classical Models of Urban Structure, "Land Economics, Vol. 40, 1964. KERSTEN. E. and ROSS. D. R., "Clayton: A New Metropolitan Focus in the St. Louis Area," Annals of the A.A.G., December, 1968. LOWENSTEIN, L. K., "The Location of Urban Land Uses," Land Economica, Vol. 39, pp. 407-20, November, 1963. MASON, HENRY R., "Manpower Need by Specialty," Journal of the American Medical Association~ Vol. 219, p. 1621, March 20, 1972. MOUNTIN, JOSEPH W., "Location and Movement of Physicians, 1923-1938," Public Health Reports in 4 parts; Vol. 57, pp. 1363-75 (1942); Vol. 57, pp. 1752- 61 (1942); Vol. 57, pp. 1945-53 (1942); Vol. 60, pp. 173-85 (1945). ODOROFF, MAURICE E. and ABBE, L. M., "Use of General Hospitals' Factors in Outpatient Visits, ` Public Health Reports, Vol. 72, pp. 478-83, 1957. "Office Decentralization: A Challenge the Central City Must Meet," Urban_Lan4~ Vol. IX, pp. 1 and 3, October 1950. PROUDFOOT, MALCOLM J., "City Retail Structure," Economic Geography, Vol. 13, pp. 425-428, 1937. SWIATLAVSKI, E. E. and WELLS, W. C., "The Centrographic Method and Regional Analysis," Geographical Review, Vol. 27, pp. 250-254, 1937. TERRIS, MILTON "Recent Trends in the Distribution of Physicians in Upstate New York, "American Journal of Health, Vol. 46, pp. 585-91, 1956. VANCE, JAMES E. "Emerging Patterns of Commercial Structure in American Cities," Lund Studies in Geography, Proceedings of the IGU Symposium, pp. 485- 518, Lund, Sweden: 1960. WEISKOTTEN, H. G. and ALTENDERFER, M. L., "Trends in Medical Practice -- Analysis of the Distribution and Characteristics of Medical College Grad - uates," Journal of Medical Education, Vols. 15 and 27, 1940 and 1952. Research Papers and Reports American Medical Directory, American Medical Association, Chicago. BELCHER, JOHN C., The Changing Distribution of Medical Doctors in Oklahoma, Oklahoma A & M College, Agricultural Experimeni Station Bulletin, 1955. PAGENO="0599" 589 159 BERRY, BRIAN, The Changing Retail Structure of Northeastern lll)~~, Chicago: Northeastern Illinois Planning Commission, 1965. _____________ Etal, The Impact of Urban Renewal on Small lInsiness: The Hyde Park-Kenwood Case, Chicago: Center of Urban Studies, The University of Chicago, in cooperation with the Chicago Department of Housing and Urban Development, 1968. BOGUE, DONALD, Population Trends and Prospects for the Chicago-N.W. Indiana Consolidated Metropolitan Areas, 1960-1990, Population Research and Training Center, University of Chicago, 1962. Chicago Area Transport Study, Chicago Area Transportation Study, Vol. 1, 1964. CHICAGO ASSOCIATION OF COMMERCE AND INDUSTRY, Chicagoland's Retail Mark~~, Chicago: 1950. Community Area Factbook, Chicago Inventory, University of Chicago, 1950 and 1960. CUZZORT, RAYMOND, Suburbanization of Service Industries Within S1'~IA's, (Studies in population distribution No. 10) Oxford, Ohio. Scripps Foundation of Research in Population Problems. University of Miami and The Population Research and Training Center of the University of Chicago, 1955. DE VISE, PIERRE, The Effect of Federal Spending on the Distribution of Physicians in the United States, text of a report presented to the Congressional Black Caucus Forum on Health Care at Harvard University, Boston: April 18, 1972. -, Basic Planning Studies on Metropolitan Chicago: An Inventory of Local Research, Technical Bolletin No. 1, Hospital Planning Council for Metropolitan Chicago, 1965. ________________ Hoseital Study Districts for Metrop~~n Chicago: A Geographic Analysis and Methodology, Technical Report No. 2, Hosoital Planning Council for Metropolitan Chicago, 1966. _______________ Slum Medicine: Chicago's Apartheid Health Systep~, a research report sponsored by the Interuniversity Social Research Committee, Chicago Metropolitan Area, Report No. 6, Community and Family Study Center, University of Chicago, 1969. _______________ Chicago's Widening Color Gap, Interuniversity Social Research Committee, 1967. DICKINSON, FRANK G., Supply of Physicians' Serviçç~, American Medical Associa- tion, Chicago: 1951. - , Distribution of Medical School Alumni in the U.S. as of April, 1950, a report of the Bureau of Medical Economic Research, American Medical Association, Chicago: 1956. A Comparison of State Physician-Population Ratios for 1938 and 1949, American Medical Association, Chicago: 1950. Directory of Medical Specialists, American Medical Association, Chicago. Distribution of Physicians by Medical Service Areas, a report of the Bureau of Medical Economics, American Medical Association, Chicago: 1954. FOLEY, D. L.. The Suburbanization of Administrative Offices in the San Francisco Bay Area, Research Report No. 10, Real Estate Research Program, Bureau of Business and Economic Research, University of California, Berkley: 1957. PAGENO="0600" 590 160 GORHAM, JOHN, The State Street Sto~, Chicago Sun Times/Chicago Daily News Marketing Services Department, August 1970. HAUG, J. N., Distribution of Physicians, Hospitals, and Hospital Beds in the U.S., 1967, a report of the Department of Survey Research, American Medical Association, Chicago: 1968. JONASSEN, C. T., The Shopping Center Versus Downtown, a report of the Dereau of Business Research, Ohio State University, Columbus: 1955. KITAGAWA, EVELYN, Population Projections for City of Chicago and Chicag~o Metro politan Area 1970-198k, Chicago: 1964. MAYO, SELZ and HORACE C., Distribution and Characteristics of Physician and Other Health Personnel inNorth Carolina, Agricultural Experiment Station Progress Report, R.S. 38, North Carolina State College, Raleigh, N.C., November 1960. MITCHELL, THOMAS, A Survey of Health Facilities and Needs in South Cook County. illinois, Developmental Program for Comprehensive Health Planning, Chicago: April, 1969. MORRILL, RICHARD, Hierarchy of Hospital Services: Classification of Hospita1~ Working Paper 1.8, Chicago Regional Hospital Study, December, 1966. __________ Relationship Between Transportation and Hospital Location and Utilization, Working Paper 1.14, Chicago Regional Hospital Study, July 1967. _______________ et al, Hospital Service Areas: Distance of Hospital from Patient Home, Working Paper 1.5, Chicago Regional Hospital Study, December 1966. ____________ et al, Hospital Variation and Patient Travel Distance, Chicago Regional Hosoital Study, 1967. __________ eta!, Influence of the Physician on Patient To Hospital Distance, Working Paper 1.16, Chicago Regional Hospital Study, October 1968. Movement of Doctors' Places of Practice, Greater Cincinnati Hospital Council, 1965. NELSON, L., Rural-Urban Distribution of Hospital Facilities and Physicians, Agricul- tural Experiment Station, Bulletin 432, University of Minnesota, 1956. NORTHEASTERN ILLINOIS PLANNING COMMISSION, Suburban Fact Book, 1950, A Socio-Economic Data Inventory for 100 Municjpalities in Northeastern flhiq~~ Chicago: June 1950. NORTHEASTERN ILLINOIS PLANNING COMMISSION, Suburban Fact Book, 1960, A Socio-Economic Data Inventory for 100 Municipalities in Northeastern illinois, Chicago: June 1960. REES, PHILIP H., Movement and Distribution of Pj~ysicians in Metropolitan Chicago, Working Paper 1.12, Chicago Regional Hospital Study, 1967. --_______ , Numbers and Movements of Physicians in Southeast Chicago: 1953- 1965, Working Paper 1.13, Chicago Regional Hospital Study, 1967. SCHNEiDER, JERRY B., The Spatial Structure of the Medical Care Proces~, Dis- cussion Paper Series No. 14, Regional Science Research Institute, Seattle, Washington, July 1967. U.S. DEPARTMENT OF COMMERCE, &ireau of the Census, Census Population, 1950, 1960, 1970. PAGENO="0601" 591 161 U.S. DEPARTMENT OF COMMERCE, &ireau of the Census, Census of Dosiness, 1948, 1955, 1958, 1965, 1967. Theses and Dissertations BROWN, LOUIS, Doctors' Offices in Hospitals: A New Trend, unpublished Master's Dissertation, Department of Hosoital Administration, Washington University, St. Louis, Mo., June 1950. JOHNSON, EARL SHEPPARD, ASti.idy of the Ecology of the Physician, unpublished Master's Dissertation, Department of Sociology, University of Chicago, 1932. LIBERSON. STANLEY, Ethnic Groups and Medicine, unpublished Master's Disserta- tion, Department of Sociology, University of Chicago. 1958. PYLE. GERALD F., Some Examples of Urban Medical Geography, unpublished Master's Dissertation, Department of Geography, University of Chicago, 1968. REES, PHILIP H., The Factorial Ecology of Met~~itan Chicago, ~ unpublished Master's Dissertation, Department of Geography, University of Chicago, 1968. WELCH, CHARLES, The Trend Toward Physicians' Offices in Hospital-Owned Buildings, unpublished Master's Thesis, Department of Hospital Administration, State University of Iowa, June 1959. PAGENO="0602" 592 163 illinois Regional Medical Program Chicago Regional Hosoital Study STAFF PUBLICATIONS Hospital StudLpistricts for Metropolitan Ch~~g~: A Geographic Analysis and Meth- odology, by Pierre de Vise, Chicago: Hosoital Planning Cou~ci1 for Metropolitan Chicago (April 1966), 75 pp. $1.25 ~Vidcning Color Gap, by Pierre de Vise, Report No. 2, Interuriiversity Social Research Committee (December 1967), 158 pp., 41 tables, 22 figures. $2.50 Slum Medicine: Chicago's Apartheid H~tlth Syg~~y~ by Pierre de Vise et al., Report No. 6, Interuniversity Social Research Committee (January 1969), 91 pp., 2 tables, 18 figures. $1.00 The Sj~atial Behavior of Hospital Patients: A Behavioral Approach to Spatial Inter- action in Metropolitan Chicago, by Robert A. Earickson, Chicago: University of Chicago, Geography Research Paper ~124 (March 1970), 138 pp. $4.00 Heart Disease, Cancer and Stroke i~ç~cao: A Geographical Analysis with Facil- ities Plans for 1980, by Gerald F. Pyle, Chicago: University of Chicago, Geography Research Paper ~134 (1971), 312 pp. $4.00 1970 Hosoital Discharge Survey of Metropolitan Chicago: An Analysis of Demographic, Hospital and Medical Data, by John D. Denne, Chicago: illinois Regional Medical Program (1972), 61 pp., 21 tables, 26 maps. $1.00 Where the Doctors Have Gone: The Changing Distribution of Private Practice Phy- sicians in the Chicago Metropolitan Area, 1950-1970, by Donald Dewey, Chicago: illinois Regional Medical Program (1973), 164 pp. ~ REPRINT SERIES 25~ each I. THE HEALTH CARE SYSTEM 1. "Variation in the Character and Use of Chicago Hospitals," by Richard L. Morrill and Robert Earickson (Fall 1968). 2. "Hospital Variation and Patient Travel Distances," by Richard L. Morrill and Robert Earickson (December 1968). 3. "Location Efficiency of Chicago Hospitals: An Experimental Model," by Richard L. Morrill and Robert Earickson (Summer 1969). 4. "Optimum Allocation of Services," by Richard Morrill and Philip Kelley (July 1969). 5. "Emergency Medical Services in Cook County," by Geoffrey Gibson (March 1972). I. THE URBAN SYSTEM 1. "Changing City," by Van Gordon Sauter (May 1967). 2. `How Chicago is Changing," by Pierre de Vise (Fall 1968). 3. "Characteristics of Chicago Area Communities, " by Pierre de Vise (July 1969). PAGENO="0603" 593 164 4. "The Future of Chicago," by Gregg Ramshaw (February 1970). 5. "Chicago, A Victim of Its Own Success," by Pierre de Vise (May 1970). 6. "A Shrinking Chicago Buta Better One?" by Lois Wile (May 1970). 7. "Chicago, First in Residential Segregation in 1970, " by Pierre de Vise (November-December 1971). 8. "Future Shock in Hyde Park and the Southeastside," by Pierre de Vise (December 1971). III. METHODS AND CONCEPTS 1. "Methods and Concepts of an Interdisciplinary Regional Hospital Study," by Pierre de Vise (Fall 1968). 2. "A Diffusion Model of the Spread of Cholera in the U.S. ," by Gerald Pyle (January 1969). 3. "A Factorial Ecology of Rockford, flhinois," by Gerald Pyle (February 1970). IV. THE PLANNING COMPONENT 1. "Medicaid in Cook County," by Lawrence S. Bloom, Peter R. Bonavich, and Daniel Sudran (June 1969). 2. "Med~cal Care for City's Poor," by Harlan Draeger and Michael Smith (March- June 1968). 3. "Putting a Lid on Rising Hospital Costs - Diagnosis: Monopolistic Control by Private Medicine," by Pierre de Vise and "Prescription: A Federal-State System of Controls and Incentives, "by Anne Somers (September 1969). 4. "We Spend Enough Mooey on Care for the Poor, But We Spend It Badly," by Pierre de Vise (May 1970). 5. "Health Care Crisis in Chicago," by Linth Rockey (May 1970). 6. "Chicago Hospitals -- A Disaster," by Pierre de Vise (Fall 1970). 7. "Cook County Hosoital -- Revolt Within the Establishment," by Harold Levine (Fall 1970). 8. "Consumers Revolt Against Medical Dictatorship, "by Pierre de Vise (February 1971). 9. "Cook County's Medical Wastelands, "by Jack Star (May-June 1971). 10. "Cook County Hospital: Bulwark of Chicago's Apartheid Health System," by Pierre de Vise (June 1971). 11. "Chicago Northside: Feast and Famine in the Medical Mecca," by Roger Flaherty (September 1971). PAGENO="0604" 1594 MORE MONEY, MORE DOCTORS, LESS CARE: METROPOLITAN CHICAGO'S CHANGING DISTRIBUTION OF PHYSICIANS, HOSPITALS, AND POPULATION: 1950 TO 1970* (By Pierre de Vise and Donald Dewey) (This paper integrates and summarizes the findings of two reports by Pierre de Vise on the physician distribution in the States of Illinois and Ohio, and the doctoral dissertation in process by Donald Dewey on the physician distribution in metropolitan Chicago. Mr. Dewey's dissertation will be presented in a forthcoming series of working papers. These reports were prepared with the support of Illinois Regional Medical Program and the Department of Geography of DePaul University.) SEVEN TRENDS IN THE RLDISTRIBUT1ON OF PHYSICIANS IN METROPOLITAN CHICAGO Seven trends-one exogenous and six endogenous-.-emerge from a study of the changing distribution of physician offices in metropolitan Chicago during the 20 years since 1950. The examination of geographic shifts of physicians in other parts of the nation suggests that the six endogenous trends are manifest in all large urban areas. The increasing maldistributjon and segregation of physicians' offices Is the vector of the seven converging trends. The seven trends are first enumerated, and then exemplified in greater detail. First, there has been a decrease in the total number of private practitloner~ In the Chicago Metropolitan Area, as well as a significant decline In the ratio of private practitioners to population. This decline has taken place despite vast increases in the number of new entrants into the medical pro- fession and increased need for primary medical care. Furthermore, Chicago's share of the nation's private practitioners has declined and there has been a decline in the ratio of physicians to population relative to the national physician-population ratio. Secondly, there has been a decided decentralization of physicians offices; that is, doctors are moving to the suburbs. Third, many parts of the suburbs still have physician-population ratios far below the metropolitan average, in spite of the large suburban influx of physicians. Fourth, the suburban shift of doctors has left some areas of the city, which formerly had important concentrations of doctors, as veritable medical care "wastelands." Fifth, there is a high association between the shifts in physicians' offices and the socio-economic status and racial structure of an area. Sixth, the trend in physician office relocation is toward a greater maldis- tribution of doctors' offices. i.e.. towards increased concentration of doctors in a few areas and increased scarcity of them in the others. Seventh, there is an inverse relationship between the rise in specialization and the availability of physicians for primary medical care. There were as many doctors in 1907 as there are today In Chicago. The city, once a world medical center, lost 2.000 private physicians in the last 20 years, from 5.800 in 1950 to 3.760 in 1970. In terms of population served, Chicago's current physician-population ratio is the lowest in the city's history, and is expected to establish new record lows every year for the next 20 years. Chicago had almost two doctors for every 1.000 people between 1840 and 1930. This ratio gradually slipped to 1.7/1.000 in 1940. and to 1.6/1.000 in 1950, then precipitously dropped to 1.3/1,000 in 1960 and to 1.1/1.000 in 1970. Chicago today has half as many doctors per capita as it had in the nineteenth and early twentieth century. Alt~hoiigh many doctors mov~'d from Chicago to the suburbs in the last 20 years. Chicago continues to have a slighf edge in4physieians per 1,000 people over the suburbs (1.13 versus .94~,. Thus, the ratio of physicians per 1.000 for * The data sources for this study are punch-card decks and tapes of characteristics of Illinois physicians In the years 1950. 190(1 and 1970 supplied by the American Medical Association. Private practice physicians with addrosses in the 0-county Standard Metro- politan Statistical Area of Chicaro were culled out and coded to the 222 health care areas of the SMSA. The AMA's series of the Distribution of Physicians were the source for national and regional data. This study was supported by the Illinois Regional Medi- cal Program, and the Department of Geography of DePaul University. PAGENO="0605" 595 the entire metropolitan area is even lower than that of the city (1.03 versus 1.13). (See Table 1) TABLE 1.-PRIVATE PHYSICIANS IN THE CHICAGO SMSA Numbers Per 1,000 population 1950 1970 1950 1970 Chicago Suburbs SMSA 5,796 1,418 7,214 3,762 3,305 7,067 1.60 .91 1.39 1.13 .94 1.03 Chicago, which was once the nation's medical mecca and which is still national headquarters of the American Medical Association, the American Hospital Asso- ciation, the Blue Cross Association and the American Dental Association, is the only large metropolitan area to have fewer Private physicians today than 20 years ago. Incredibly, metropolitan Chicago's physician population ratio is today one- fifth below that of the average for the nation's large metropolitan areas (1.03 versus 1.27/1,000). The six-fold increase in federal health care spending since 1950, and the related expansion of medical jobs in medical schools and hospitals are major reasons for Chicago's dwindling supply of private practitioners. Vastly increased federal spending has no doubt contributed greatly to the 50 l)ercent increase in the nation's physician population since 1950-directly through sul)sidies to medical education and indirectly by adding to demand for medical services, with consequent inflationary effects on physician income. However, this greatly increased economic demand for the services of physicians has further reinforced their freedom of choice of where to locate. They have exercised this greater freedom by further concentrating in urban centers that are most desirable in terms of the three attractions of affluence, density and amenities. Thus, the centers of the East and West Coast, that were already endowed with two to three times the physician population ratios of less attractive centers, simply increased their advantage. In the 1900 decade, for example, the physician-population ratio grew by .34 for the five states with the highest ratios, compared to a .09 gain for the five states with the lowest ratios in 1960, as shown in Table 2. TABLE 2.-NON-FEDERAL PHYSICIAN-POPULATION RATIOS: 1970 AND 1960 1970 1960 5 highest State ratios: New York Massachusetts Connecticut California Colorado 5-State total 5 lowest State ratios: Alaska South Dakota Alabama South Carolina Mississippi 5-State total 2.33 2.12 1.91 1.90 1.84 1.87 1.71 1.57 1.47 1.44 2.00 1.66 .71 .78 .85 .87 .79 .56 .71 .74 .75 .76 .83 .74 Even though Chicago already ranks high in urban population and affluence and contributes its share to the production of new physicians, it cannot compete with tile superior reputed amenities of East and West Coast centers. In fact, California and New York have become the main beneficiaries of the increased production of physicians by Chicago medical schools. As ninny Chicago medical school gradu- ates gravitate to California as to metropolitan Chicago. As many gravitate to PAGENO="0606" 596 New York as to downstate Illinois. Many more Chicago graduates are practicing in the states of California, New York, Florida, Arizona, Colorado and Washington than are practicing in Illinois. Location of practice of Illinois graduates Percent California 22 Metropolitan Chicago 21 I)ownstate Illinois 7 New York 0 Florida 2 Arizona 2 Colorado 2 Washington 2 Total physician population in metropolitan Chicago actually increased since 1950 (from 9.270 to 11.840) although the population ratio went down slightly (from 1.79 to 1.70/1,000). But the entire gain was accounted for by non-practicing salaried physicians working for hospitals, schools, and government. As a conse- quence, the percent of all physicians engaged in private practice slipped from 80 per cent in 1950 to 60 per cent in 1970. Greater physician mobility has hurt metropolitan Chicago not only by short- changing it in its share of the nation's physicians, but also by greatly aggravating the maldistribution of physicians within its region. 1)octors have traditionally favored office locations in affluent and densely populated communities both for accessibility to patients able to pay for their services and to hospitals where they see their patients, and for proximity to the fashionable neighborhoods where they reside. Downtown Chicago remains far and away the single location that best meets all these criteria. The number of physicians with Loop offices has dropped from 1.770 to 1.100 since 1950. but the Loop's share of Chicago physicians stayed at 30 per cent, while its share of metropolitan physicians dropped from 25 to 15 per cent during this period. Among the major concentric divisions of the metro- politan area, the greatest losses in physicians per 1,000 population since 1950 occurred in Chicago outside the Loop (from 1.14 to .81/1,000) and in the exurban rural ring of Lake, Kane and Will counties (from .73 to .42/1,000). All seven major ring divisions suffered losses in physicians per population with the excep- tion of the inner suburbs of north, west and south Cook county, whose M.D./1,000 ratio increased by almost a third (.94 to 1.23) and the river satellites (Elgin, Aurora, Joliet), whose ratio inched up from 1.08 to 1.10. When we divide the metropolitan area into five directional sectors, all sectors show moderate losses in physician-population ratios except for the north sector, whose ratio went up slightly (from 1.29 to 1.38/1.000) and the south sector, where the ratio skidded down from 1.01 to .44 in the 20-year period. Thus, the two major patterns of physician office relocation appear to be: (1) A build-up of the close-in suburban ring at the expense of the inner city and the exurban rural ring. (2) A gravitational pull from south to north. When we examine the ratios for the 35 zones which result when we combine the 7 concentric rings with the 5 directional sectors, we find that all inner suburban zones gained except for south Cook County. (See Table 3) North Cook County had the highest ratio in 1950 and has registered the largest gain since (from 1.63 to 1.95). The Lawndale zone on Chicago's west side registered the greatest loss (from 1.34 to .17) closely followed by the south exurban zone of eastern Will County (from .93 to .06). The physician-population ratio is useful not only as a measure of a com- munity's supply of physicians but also as a measure of the differences between physician office movement and movements of residential population. An increas- ing ratio means that doctors are moving into a community faster than population and a decreasing ratio, the reverse. PAGENO="0607" 597 TABLE 3.-PRIVATE PHYSICIAN/1,000 POPULATION RATIOS BY RINGS AND SECTORS, CHICAGO SMSA: 1950 AND 1970 (LOOP EXCLUDED) Sector No Ring 1950 rth 1970 North 1950 west 1970 We 1950 st 1970 South 1950 west 1970 Sou 1950 th 1970 All se 1950 ctors 1970 Innercity 1.27 Outercity 1.38 Innersuburbs 1.63 1.24 1.40 1.95 0.97 1.0 .82 0.55 .88 1.34 1.35 1.34 .88 1.20 .17 1.35 0.96 1.06 .27 0.57 .95 .86 1.14 .98 .62 0.66 .66 .45 1.11 1.17 .94 0.75 .87 1.23 Middlesuburbs 68 1.28 .63 .58 .76 .71 .66 .28 .46 .75 .91 .71 Satellites 90 .70 None None 1.33 1.19 1.04 1.41 .57 1.23 1.08 1.10 Exurban-rural 26 .57 .81 .45 .90 .46 .73 .24 .93 .06 .73 .42 All rings 1.29 1.38 .95 .72 1.10 .94 .91 .77 1.01 .44 1.39 1.03 One is tempted to conclude from the physician movements described so far that two vectors seem to emerge: Physicians tend to favor northward and inner suburban destinations much more than the general population. Thus, north Cook County appears to be the major magnet for physicians, whereas the northwest sector from O'Hare Field to Schaumburg and Palatine was the major magnet for residential population in the last 20 years. Evanston added many doctors hut little new population, while Schaumburg Township gained 40,000 people but not a single physician in the last 20 years. In fact, this middle class white subur- ban community of 50,000 people is the only community of its size in the nation to be without the services of a doctor. Physicians are much more sensitive than the general population to racial and economic changes of communities. But they also need to he close to downtown and the large research hospitals near downtown that are surrounded, for the most part, by impoverished black ghettos. Downtown, the North Side and the contigu- ous suburbs of Evanston, Park Ridge and Oak Park are reasonable compromises to the push-and-pull e~ect of the ghettos and research hospitals of the inner city. The shifts of physicians' offices relative to shifts in hospital beds and popula- tion may be compared by plotting their respective mean geographic centers in 1950, 1960 and 1970. (See Figure 1 and Table 4.) PAGENO="0608" 1950 1960 1970 ~9 ~i9 ~ C;' FIGURE 1: Mean Centers of Population, Physicians, and Hospital Beds In Metropolitan Chicago Population M.D.' s Hospital Beds PAGENO="0609" 599 TABLE 4.-LOCATION OF MEAN CENTERS RELATIVE TO CHICAGO'S LOOP Mean centers Miles from Loop Miles from Madison St. Physicians' office: 1950 1960 1970 Hospital beds: 1950 1960 1970 Population: 1950 1960 1970 4.4 5.8 7.4 5.6 5.6 6.3 6.4 7.9 9.3 10.7 2.1 `1.5 17 `.3 2~3 `1. 0 `.8 1~5 1 South. 2 North. In 1950, all three mean centers were located near Roosevelt Road, separated by one-mile intervals from the Loop. Physician offices were most centralized (4.4 mIles), followed by hospital beds (5.6 miles) and po~pulation (6.4 miles). All centers moved west and north of these locations In the 1950's and 1960's. By 1970, the center of physician offices had shifted 3 miles west and 2 miles north. Reflecting the Inertia of established hospital locations In the inner city, hospital beds moved only one mile west and one mile north In the 20- year period. From the highly abstract geographic mean centers we move to the highly detailed ratios for the 222 Chicago community areas and suburban health care areas. FIgure 2 Illustrates the geographic concentration of doctors In the northern and western suburbs In 1970. Seven of the top 25 communIties and munici- palities are located in the more affluent areas of the close-in northern suburbs and six more are In similarly affluent western suburbs. That is, nearly thr~e- fifths of the leading communities are In one of these two areas. Only nine of the top 25 are Chicago communities and five of those are at the periphery of the city; the Loop and North Michigan Avenue extension account for two more and Hyde Park-the location of the University of Chicago-Is the eighth of the nine. In 1950, In contrast, 15 of the top 25 were In the city and only three northern and western suburban municipalities were In the top ten category. (See Figure 3). PAGENO="0610" 600 H m~22~ K -~~2 LN I -< T ~: n~r-~-n, Figure 2 HIGHEST 25 cO~:52;ITIES IN pHysTcIA;-P0EULAIICN RATIOS: 1970 HEALTH CARE AREAS FOR METRIRILITAS c:c 0 5 IS IS MILES Top 10 N'~N NexI 15 PAGENO="0611" 601 Figure 3 I., I." IIIGIIOST 25 Cc:2~J~1TIES IN r~I5sIcI2A-IoUIATI2N RATIOS: 1950 HEALON CORO COCCI FOR TR0OOL:TA~ Ceic 0 5 I? 5 MittS Top 10 Next 15 38-699 0 - 74 - 40 (Pt. 1) PAGENO="0612" 602 Figure 4 plots the 25 communities which registered the most increase in physician-population ratios since 1950. Most of these are located in the North Shore and Skokie Valley suburbs. The 25 communities experiencing the largest losses in physician-population ratios are depicted in Figure 5. Here, the inner city and ex~urban rural communities predominate, with the biggest losers to the south. All the communities in Chicago and suburbs that experienced rapid racial and economic change since 1950 lost physicians. When maps showing the areas with the greatest gains and losses of doctors are compared with maps depicting those areas with the highest socio-economic status (Figure 6) and those which underwent changes from white to black (Figue 7), two things became obvious. First, an influx of blacks results in an exodus of doctors. Second, the ~eeing doctors move into the areas of highest socioeconomic status. Figure 4 HIGHEST 25 C0~2IJ1ITIES IN GAINS IN PHYSICIAN- POPULATION RATIOS: 1950-1970 ALTH CARE ~REOS FOR METROPILITA~ CUCO 9 `9 ~9 MILES - ~ I Top 10 L~J 15 _____________ L ~.. ~ ~ ~ i~ ~ -14- PAGENO="0613" 603 Figure 5 25 CSTTTJTTTIES TIER cARATEST LOSSES IT PRYSICIRA- POPULATIOT RATIOS: 1950-1970 cueg AREAS EQS ME~RCPOLiT~~ CACAS Btt~10 0D. t 15 I~~II~ L -15- PAGENO="0614" Figure 6 25 HICIEST ~ 25 LO~TET CO7IOJCITICS i:~ scCIotCo:;o~ic RANK: 1970 604 E**~~1~Th.,1 ~ __ ROOLTO toRt OREOS FOR MET0000LITON CR10000 ( 0 5 10 IS MILtS fl 25 H gh 25 Lowest ~ L L -16- PAGENO="0615" 605 CO~rU~ITIES UHICH C~L\.~CED FRO~ PRLDO::I~\NTLy U~I1TE TO OL.\CK: 19 50-19 70 HEALTI-{ CARE AR!LS FOR METROPOLIT4N C~IC~G0 0 I 2 3 4 5 MILES PAGENO="0616" 606 West Garfield Park and Oak Park illustrates the extreme effect this can have on a Community undergoing social and economic change. West Garfield Park is a community on Chicago's westside and Oak Park is a suburban community of similar population size located two miles west of West Gar- field Park. Garfield Park's racial structur'e changed from no Negro population in 1950 to 96.8% Negro in 1970. The racial structure of Oak Park hardly changed In this same period. In 1954) Oak Park had less than 1% Negro, just as it does today. West Garfield Park also declined in its socio-economic rank between 1950 and 1970. In 1950 it ranked 126th out of 164. Today It has fallen to 200th out of 235 communities and municipalities with over 2500 population. In 1950 ther~ were 161 M.D.'s in West Garfield Park; in 1970 only 13 remained. Oak Park, on the other hand, had only 73 doctors in 1950, but that number rose to 276. While West Garfield Park fell from 3.32 M.D.'s/l,OOO, that Is, from one doctor for every 300 people to one doctor for every 3,700 people, Oak Park's ratio rose from 1.15 M.D.'s/l,OOO to 4.42 M.D.'s/l,OOO or from one doctor for ever 870 people to one doctor for every 225 people. The Chicago zone of communities that are presently black lost 66 per cent of Its physicians, down to a present ratio of .51/1,000. The ten most im- poverished of the 222 communities In 1970 saw their physician-population ratio plummet from .99 to .26, while the ten presently most affluent communities saw their already inflated ratio of 1.78 go even higher to 2.10, in the 20-year period. The final trend that must be considered Is that virtually one out of very two private practitioners in the Metropolitan Region today is a diplomatic spe- cialist, that is one who has a diploma from one of the Boards of the American Board of Medical Specialists. These specialists limit their' practice to certain areas of medicine which may not be involved with the delivery of primary medical care. Those specialists who do deliver primary health care usually only deal with a limited type of affliction or part of the body. Thus, seldom does one specialist provide the complete medical care for a family. One family may require the services of four to five doctor~. Therefore, the physician-population ratio today does not mean the same thing it did 20 years ago when less than ten per cent of the doctors were diplomate specialists. For example, the Near West Side Medical Center has had a resurgence of doctors. The number of doctors rose from 92 to 121 between 1960 and 1970 after' having dropped from 232 to 92 between 1954) and 1960. The M.D./populatlon ratio rose from .73/1,000 in 1960 to 1.56/1,000 in 1970-slightly higher than the 1954) ratio. However, two-thirds of the M.D.'s in 1970 were specialists compared to less than six percent in 1950. Nearly one-half of the 1970 specialists were in anesthesiology, radiology, pathology, and plastic surgery, and were not really available for primary medical care. When these doctors are deleted from the total number of doctors, the physician-pop~ulation ratio drops to just over one doctor per thousand-far below the 1950 ratio. So the rise in specialization has had a definite effect on the availability of medical care in Chicago. Having examined each of the seven trends cited at the outset of the paper in greater detail, the following generalizations can he made. First, there has been a relative decline in Chicago's portion of the nation's doctors, as well as an obsolete decrease in the number of private practitioner's, while the population was growing rapidly. This has resulted in a severe decline in the ratio of private practice physicians to population. Second, physicians are decentralizing out of the city and into the suburbs. More specifically, they are leaving those areas which are changing fr'om high to low socioeconomic status and those whose racial structure are changing from white to black, and they are going to the more affluent areas of the northern and western suburbs. Third, the rise in specialization has had a negative effect on the availability of physicians, especially for primary medical service in the southern and western portions of the city. FACTORS AND FORCES BEHIND THE TRENDS The socioeconomic status of communities appears to be the single most im- portant determinant of physician location. Moreover, this factor is becoming increasingly important. The coefficient of rank correlation between socloeco- PAGENO="0617" 607 nonilc status and the physician-population ratio climbed from .64 in 1950 to .81 in 1970. The distribution of retail centers also exerts an influence on the location of physicians, although much less so than socioeconomic status. The coefficients of rank correlation between retail sales of communities and their physician ratio were .62 in 1950 and .60 in 1970. It is especially the larger new regional shop- ping centers, with their professional and office buildings, that are the most attractive to physicians, especially if they are in the northern and western suburbs. In the other sectors, only Evergreen Plaza has proved to be a magnet for physicians' offices. Another factor which plays a role in physician office location Is the location of physicians' residences. Because of the pull of downtown and the inner hos- pitals, about two-thirds of metropolitan area physicians lived in Chicago 20 years ago. Today, this proportion is down to one-third as many of the former fashionable neighborhoods on the south and west sides of Chicago became ab- sorbed by the expanding black ghetto. Another factor is the increasing concentration of expensive homes in a score of suburbs, mostly north and west of Chicago. Chicago lost over half of Its houses valued over $50,000 in the last ten years, while most suburban de- velopments are in price ranges below $50,000. With an average annual income of about $50,000 a year, few self-respecting physicians would purchase homes below $50,000. Because most of the homes in this price range are confined to high income areas in the North Shore and Skokie Valley, more physicians live in Evanston than in all of south Cook County, more live in Wilmette than In all of southwest Cook County, more live in Winnetka than in all of Will County, more live in Skokie than in all of Kane County, more live in Lincoln- wood than in all of McHenry County. Because of the high value of his time, the physician has traditionally kept his office close to his home, often as close as the front parlor. Proximity be- tween home and office today is even more valued because of the high cost of commuting, the physician's time being worth about $40 an hour. The increasing concentration of physician residences in a score of high-income north, north- west and west suburbs is another reason for northward and close-in suburban concentration of physician offices. INCREASIN(~ SEGREGATION OF PHYSICIANS' OFFICES IN THE REST OF THE STATE AND THE NATION When we look at these explanations for the massive shifts in physician office location and widening community physician-population ratios, two vari- ables stand out-average personal income and population density-both corre- lating positively with physician-population ratios, and both increasing in im- portance since 1950 and 1960. Hospital beds, on the other hand, have been much less sensitive to racial and economic change and thus exert a decreasing in- fluence on physician location. In fact. Chicago's poorest communities have a somewhat higher hospital bed-population ratio than the richest communities In 1970. The same relationships prevail when we expand the total study area to the entire nation, the sub-units to the nation's counties, and the physician popula- tion to all (Non-Federal) physicians in and out of private practice. Tbo tenth of Americans living in the 1.805 counties of lowest population density-per capita income have nine percent of the nation's hospital beds hut less than four per cent of the doctors. On the other hand, the 20 million Americans living in the 12 counties of highest population density-per capita income have nine per- cent of the hospital beds and 16 percent of the nation's doctors. Thus these two extreme deciles of counties have identical hospital bed-population ratios but a disparity of 4 to 1 in physician-population ratios. The nation's 300 metropolitan areas encompass the most densely populated and affluent counties, and their physician-population ratio is more than twice that of non-metropolitan areas. r1~he5e metropolitan areas contain 73 percent of PAGENO="0618" 608 the hospital beds, 56 percent of all physicians, and 93 percent of all hospital- based physicians. Hospital bed and physician-population ratios for metropolitan and non-metropolitan areas are given below: * Hospital beds per 1,000 population M.D's per 1,000 population Metropolitan areas 4.2 1.73 Nonmetropolitan areas 4.0 .80 United States 4.1 1.48 Note-The source of hospital bed and physician data in this and the following tables is the American Medical Associa- tion's "Distribution of Physicians in the U.S., 1970." The hospitals are defined as "non-Federal short-term hospitals," and the physicians as "non-Federal physicians." We saw earlier that New York City. New England and the West Coast have physician-population ratios two to three times higher than those of less well endowed regions. Again, it is physician-population ratios rather than bed- popnlation ratios that are affected by regional nonenities. A breakdown of the two ratios by each of the four major regions of the nation in 1970 make this abnndantly clear: Census region Per cent of nation Beds per 1,000 population M.D's per 1,000 population Population Hospital beds M.D's Northeast 24.1 24.6 31.2 4.2 1.88 North Central 27.7 30.0 23.8 4.5 1.29 South 31.2 29.2 24,9 3.9 1.21 West United States 17.0 15,4 19.2 3.8 1.66 100.0 100.0 100,0 4.1 1.48 For counties in Illinois. as in Chicago metropolitan area, population density and iaucome are major explanations of variations in physician-population ratios and in changes in these ratios since 1960. Ia Table 5, physician-population ratios and hospital-bed-population ratios are sloown for counties in the United States, Illinois and 01mb, classified in nine groups of popnlatioa density and income. Ohio is ioucluded to provide a state comparable to Illiooois in regional location, climate, incooae and url~n population. TABLE 5.-NON-FEDERAL PHYSICIAN AND HOSPITAL BED-POPULATION RATIOS, BY DEMOGRAPHIC COUNTY GROUP UNITED STATES, ILLINOIS, AND OHIO: 1970 Physicians per 1,000 population Hospital beds per 1,000 population United United County group by population size States Illinois Ohio States Illinois Ohio Metropolitan counties: Over 5,000,000 2.26 1.70 4,25 4.37 1,000,000 to 5,000,000 1.90 1.92 4.11 3.96 500,000 to 1,000,000 1.58 1.35 3.87 3.72 100,000 to 500,000 L31 1,11 .90 444 5.61 4.21 50,000 to 100,000 1.23 1,02 ,76 440 5,43 5.13 Nonmetropolitan counties: OverSO,000 25,000 to 50,000 1.04 .74 .81 .67 .76 .63 4.14 4.60 4.11 5.24 3.25 3.20 10,000to25,000 Underl0,000 .56 .47 .58 43 .44 0 3,58 3.99 3.47 1.09 2.15 0 All counties 1.48 1.37 1.32 4.15 4.55 3.86 PAGENO="0619" 609 After allowing for differences in population density, Illinois and Ohio show physician-population ratios generally 20 percent below national norms. Phy- sician-population ratios in both Ohio and Illinois also exhibit greater sensi- tivity to population density than the nation~s counties. Ohio counties have lower hospital-population ratios than the nation, but among Ohio county groups there is no clear relationship between physician and bed-population ratios. Moreover, Illinois counties have much higher bed-population ratios than the nation in contrast to their lower physician-population ratios. PROBLEMS RESULTING FROM THE WORSENING DISTRIBUTION OF PHYSICIANS No one can really tell how many physicians per capita we need, anymore than one can tell how many hospital beds per population we need. Actual utili- zation of physician and hospital services, regardless of real need, generally determines norms such as physician and hospital bed-population ratios. Yet, when we witness huge disparities in physician-population ratios of communi- ties, of the order of 10 to 1 among Chicago area communities, for example, it is hard not to conclude that some communities enjoy large surpluses of physi- cians while other communities suffer from dangerously low numbers of physicians. The present disparities in physician-population ratios between black and w-hite communities-half a physician per 1.000 blacks versus one-and-a-half physicians per 1,000 whites-produce corresponding l)lack-white differentials in per cent of families without a family doctor (64% versus 21%), and without health insurance or medicaid (28% versus 11%). The use of emergency depart- ments in lieu of doctors' offices is also much more prevalent for blacks than for whites-423 versus 172 emergency room visits per 1.000 persons per year for all hospitals and 184 versus 31 for such visits at Cook County Hospital. Although most of the teaching hospitals are remaining, a number of smaller community hospitals in the inner city ha'c~e closed their doors and followed physicians to the suburbs. The relocation of St. George Hospital from Engle- wood to Palos Heights, the sale of Evangelical Hospital to a black church, and the merger of South Shore with St. George Hospital involve bui. three of a dozen hospitals in the inner city that are presently considering closing or moving to the suburbs in large part because of the wholesale exodus of physi- cians' offices to the suburbs. POLICY IMPLICATIONS OF THE WORSENING DISTRIBUTION OF PHYSICIANS Perhaps the most tragic aspect of the flight of physicians from inner city and rural communities is the failure of dozens of public and private programs, most outstandingly Medicaid~ the OEO Neighborhood Health Centers, and Model Cities, involving billions of dollars of funds, to make any dent in re- versing the apparently irreversible flight of physicians from areas of greatest need to areas of greatest wealth. We in Chicago cannot even manage to keep the bulk of our medical school graduates from gravitating to more glamorous medical meccas on the west and east coasts. Even incomes of $50.000 to $100,000 a year-which is the going rate-were not sufficient lures to attract more than a dozen new physicians a year to start a practice in Chicago's inner city ghettos. far short of the replacement rate. After 5 years of Medicaid. about 130 physicians (out of 6.000 in the county) care for 240,000 welfare and medicaid patients in Cook County. This compares with 75 physicians caring for 130.000 welfare patients in 1966. the year before Medicaid began. Although 55 more physicians joined the program, the case load by physician actually increased from 1.700 patients to 1.S~50 patients, and average physician earnings climbed from $34,000 to $72000. The projection of 1980 J)hysician needs for metropolitan Chicago is complex indeed when we examine the consequences of the area's gain of 2.700 physicians in the 1960's. More physicians have meant fewer private practitioners and fewer physicians of any kind for all but a handful of the area's communities. One might be tempted to urge fewer physicians for 1980 if indeed the trends of suburban gravitation and shift away from primary care practice might thereby be reversed. Even if we were to agree on the national norm of 1.27 physicians per 1,000 as the metroplitan area goal. we would lave to find a way to implement this goal. PAGENO="0620" 610 The increased Importation of foreign graduates was the main source of phy- sician growth in Chicago in the 1960's. The number of graduates of Chicago medical schools, which has Increased but slightly in the 1960's-from 516 in 1960 to 550 in 1970-is expected to go up to 800 by 1975. On the other hand, the retention rate of Chicago graduates is going down. Unless the trend of retention losses can be reversed, and some way found for Chicago to successfully compete against superior climate amenities, gains in local medical school production will benefit California more than the Chicago metropolitan area. If we should be successful In raising the number of physicians to match the national norms, there would then remain the goals of redressing the geographic maldistribution of physicians and of making better use of hospital-based prac- titioners for delivering primary care services. There are, unfortunately, few good models to guide us in these tasks. The OEO Neighborhood Health Center model of the 1960's has given way to Health Maintenance Organization model of the 1970's as the panacea for improving health delivery services. But HMO will do no better than OEO unless this health delivery model can keep Chicago graduates in Illinois, and unless it can attract these graduates to practice in communities with the greatest need, rather than in communities with the greatest wealth. In the meantime, we should realize that incentives alone are not sufficient to Induce doctors to practice where they are needed. Hill-Burton hospital and clinic construction funds and many other federal programs have helped sub- sidize the suburbanizatlon of physicians and hospitals. We should seriously consider a moratorium on these kinds of public subsidies when they facilitate the flight of hospitals and doctors out of Inner city and rural areas. These federal funds could be diverted to inner city hospitals prepared to equip and operate outpatient departments that would provide primary ambula- tory care In communities lacking private physicians. The physician-population ratio of communities should become a criterion of need in the determination of hospital and clinic construction priorities under Hill-Burton. A diversion of federal funds from communities with a surplus of physicians to communities with a deficit of physicians is the least that our government could do in slowing down the flight of hospitals and doctors to affluent suburban communities. A SURVEY AND ANALYSIS OF THE CHANGING AGE DisTRiffirrioN OF PRIVATE PRACTICE PrrYsIcL&Ns IN METROPOLITAN CHICAGO BY OEYICE LOCATION, 1950, 1960 AND 1970 (By Donald F. Dewey, Dc Paul University) ABSTRACT A popular belief suggests that younger physicians of the late 1960's were more "socially" oriented and thus are providing better medical care for the city's poor than their predecessors of the 40's and 50's. This study probes the veracity of this concept, by examining the age distribution of private practi- tioners by office location between 1950 and 1970 to see if younger doctors are returning to Chicago's "medical waste lands." The investigation compares and analyzes: Metropolitan Chicago and the United States, the central city and its suburbs, concentric zones and radial sectors of the Metropolitan Area, and selected "community areas" of Metropolitan Chicago during the study years. Six conclusions emerged from the study. 1) The average age of private practice physicians In metropolitan Chicago is three years higher than the national average. 2) Chicago's proportion of physicians under 45 years is dwindling more rapidly than the national average, while the region's proportion of doctors 65 and older is growing as the national proportion is declinIng. 3) These characteristics are more descriptive of the central city than the suburbs. 4) The southern inner city zone has had the greatest increase in average age of physicians. 5) The northern and western middle suburban zones have had the largest decreases In average age of physicians. 6) The average age of doctors in poor, predominantly Black community areas, those changing in racial struc- ture, or with a high average age in 1950, rose significantly above affluent white suburban communities. PAGENO="0621" 611 This study of changing age distribution of physicians in Metropolitan Chicago by place of practice reveals several interesting facts about health care delivery In this region. (1) The average age of physicians practicing in Chicago is three years higher than the national average. (2) Chicago's proportion of phy- sicians under 45 years has declined faster than the national average. (3) The region's proportion of doctors 65 years and older has grown while the national proportion dwindled. (4) These characteristics describe the central city more than the suburbs. (5) Between 1950 and 1970, the southern sector of the city zone-part of Chicago's Black "ghetto"-had the greatest increases in average age of physicians, while the northern and western sectors of the middle suburbs -the affluent parts of the metropolitan area-had the largest decreases. (6) The average age of doctors in poor communities, those changing in racial struc- ture, or with an high average age In 1950, rose significantly above affluent white suburban communities. Each of these points is now considered In greater detail. Table One compares the average age and age structure of physicians in Metropolitan Chicago and the U.S. The average age of physicians In the Chicago Area was three years above the national average in 1950. In 1970, Chicago's average age was still three years above the national average In spite of the fact that the national average rose nearly three years during that twenty year period. The increase is probably due to the rise in specialization and the Increased years of schooling required to specialize. TABLE 1.-AVERAGE AGE AND PERCENT OF PRIVATE PRACTICE PHYSICIANS UNDER 45 YEARS AND OVER 65 YEARS IN THE UNITED STATES AND CHICAGO METROPOLITAN AREA, 1950, 1960, AND 1970 1950 United States Chicago 1960 United States Chicago 1970 United States Chicago Average age Percent under 45 47.0 43.0 50.0 39.0 48.8 44.0 50.4 37.0 1 49.7 39.0 52.7 29.0 Percent 65 and over 17.0 15.0 14.0 16.0 13.0 19.0 11967. Changes in the age structure of these two regions is more significant. In 1950, 39% of Chicago's doctors were under 45 years, compared to 43% in the United States. By 1970, Chicago's percentage of these physicians had fallen to 29% while the same percentage in the United States fell to only 39%. (See Table 1) 15% of Chicago's physicians were 65 or older in 1950, compared to 17% in the United States. Between 1950 and 1970, Chicago's percentage of older doctors rose to 19% while this percentage fell to 13% in the United States. (See Table 1) Chi- cago's proportion of young doctors declined while its share of older doctors in- creased relative to the United States. This means that young doctors are aban- doning the Chicago area. TABLE 2.-AVERAGE AGE OF PHYSICIANS IN THE CITY OF CHICAGO AND ITS SUBURBS BY PHYSICIAN OFFICE LOCATION, 1950,1960, AND 1970 1950 1960 1970 City Suburbs 50.4 46.6 51.7 47.8 54.4 48.8 The average age of M.D's in the City of Chicago in 1950 was 3.S years older than the average age of physicians in the suburbs. By 1970, this difference in- creased to 5.6 years. In other words, the average age of doctors in the city was increasing faster than in the suburbs. Over half of the suburban physicians were under 45 in 1950 while only 38% of the urban doctors were that young. In 1970, more than one-third of the subur- ban doctors were younger than 45 while less than one-fourth of the city's physi- cians were under 45. PAGENO="0622" 612 Between 1950 and 1970, the proportion of older doctors in the city rose from 15% to 25%, while the proportion of physicians of the mme age in the suburbs dropped from 13% to 11%. TABLE 3.-PERCENT OF PRIVATE PRACTITIONERS UNDER 45 YEARS AND 65 YEARS AND OLDER IN THE CITY OF CHICAGO, THE SUBURBS, AND METROPOLITAN AREA, 1950, 1960, AND 1970 1950 1960 1970 Percent <45 Percent 65+ Percent <45 Percent 65+ Percent <45 Percent 65+ City Suburbs 38 51 15 13 30 50 19 10 23 36 25 11 Metropolitan area 39 15 37 16 29 19 There are presently more doctors over 65 than under 45 in the city, while young doctors outnumber old ones 2 to 1 in the suburbs. Jf the older doctors were fleeing the city for the suburbs, while younger doctors were dedicating themselves to caring for the inner city poor, then the proportion of physicians over 65 in the city should have decreased while the suburban proportion of older doctors increased. But that is not what happened. In fact, precisely the opposite took place. A comparison of the average age of physicians by concentric zones in the Metropolitan Area in 1950, 1960 and 1970, reveals that the Loop and inner city had the highest average age in 1950, while the inner suburbs had the lowest average age. By 1970, the outer city and middle suburbs had the highest and lowest average ages respectively. (See Table 4 and Map I) TABLE 4.-AVERAGE AGE AND PERCENT INCREASE OR DECREASE IN PRIVATE PRACTICE PHYSICIANS BY CON- CONCENTRIC ZONE IN METROPOLITAN CHICAGO, 1950-70 Average age Percent increase or decrease 1950 1960 1970 1950-60 1960-70 Loop 50.8 51.4 54.6 -20 -20 Innercity 50.8 54.7 54.9 -33 -20 Outer city 49.4 53.4 55.1 +4 -19 Innersuburbs 47.4 47.2 50.1 +89 +35 Middle suburbs Satellite ring 49.6 48.9 44.4 47.9 46.5 50.8 +75 +50 +71 Even Outer suburbs 49.4 47.1 47.1 -33 +50 PAGENO="0623" 613 MAP I AVERAGE AGE OF PRIVATE PRACTICE PHYSICIANS IN METROPOLITAN CHICAGO BY CONCENTRIC ZONES 1950, 1960 AND 1970 AVERAGE AGE 1950 1960 0 47.4 44.4 48.9 47.1 49.4 47.2 49.4 47.9 49.6 51.4 50.8 53.4 50.8 54.7 0 10 MILES N 6 1970 46.5 47.1 50.1 50.8 54.6 54.9 55.1 PAGENO="0624" 614 The outward shift reflected by these data coincides with the decentralization of physicians. (See Table 4) Those areas which had large decreases in physicians had higher average ages. Those which had large increases in physicians had lower average ages, indicating that the younger doctors moved to the suburbs while the older physicians remained in the city. The average age of physicians by sectors is shown in Table 5 and Map II. In 1950, the average age of physicians in all sectors except the southern sector was uniformly low. The average age of physicians rose in all sectors between 1950 and 1970. The southern sector, however, continued to have the highest average age. The northern sector had the lowest average age in 1950, while the western sector was lowest in 1910. Once again, this reflects the decentralization pattern of physi- cians. The southern sector had the least growth in physicians while the northern and western sectors had the greatest growth. (See Table 5) PAGENO="0625" 615 MAP ]I AVERAGE AGE OF PRIVATE PRACTICE PHYSICIANS IN METROPOLITAN CHICAGO BY RADIAL SECTORS 1950, 1960 AND 1970 AVERAGE AGE lifli 1950 1960 1970 49.1 49.0 50.2 49.3 49.8 51.5 49.7 50.3 52.1 49.9 52.5 53.6 51.1 54.2 53.8 o 1,0 MILES N PAGENO="0626" 616 TABLE 5.-AVERAGE AGE AND PERCENT INCREASE OR DECREASE IN PRIVATE PRACTICE PHYSICIANS BY RADIAL SECTOR IN METROPOLITAN CHICAGO, 1950, 1960, AND 1970 Northern Northwestern Western Southwestern Southern 1950 1960 1970 1950 to 1960 1960 to 1970 Average age 49.1 50.3 51.5 49.3 49.7 54.2 49.0 52.1 50.2 49.9 49.8 53.6 51. 1 52.5 53.8 Percent increase or decrease +11 +25 +25 +11 +13 +11 +22 -9 -18 -14 The cells formed by the intersection of the lines delimiting the zones and sectors yield a more detailed picture of the age distribution of private physicians in the Chicago Area. In 1950, there was little pattern in the age distribution of physicians. (See Map III) Both suburban and urban areas have high and low average aged physicians. (See Table 6) In 1960 a definite pattern emerged. All of the urban cells have high average ages and all but a few suburban cells have low average ages. PAGENO="0627" 617 NAP 111 AVERAGE AGE OF PRiVATE PRACTICE PHYSICIANS IN METROPOLITAN CHICAGO BY CONCENTRIC ZONES AND RADIAL SECTORS 1950, 1960 AND 1970 1950 1960 1970 El 43.4-45.2 40.5-44.3 44.5-46.9 47.3.48.4 44.4.47.4 47.4-49.4 48.6-49.1 47.5-50.4 50.1-52.1 11111 49.6-50.0 50.6-53.5 52.5-56.1 51.3-52.0 53.1 -59.3 56.5.592 - P ~2 _30 MILES N 3S-698-74--pt. 1-41 PAGENO="0628" 618 The pattern became more pronounced in 1970. The cells with the lowest average ages are concentrated in the northern, northwestern and western suburban sec- tors and the cells with the highest average ages are concentrated in the urban and southern, and southwestern suburban sectors. There are only four excep- tions to this pattern. TABLE 6.-AVERAGE AGE OF PRIVATE PRACTICE PHYSICIANS BY CONCENTRIC ZONES AND RADIAL SECTORS IN METROPOLITAN CHICAGO, 1950, 1960, AND 1970 North- South- Northern western Western western Southern 1950: Inner city Outer city Inner suburbs Middle suburbs Sutellite ring Outer suburbs 1960: Inner city Outer city Inner suburbs Middle suburbs Sutellite ring Outer suburbs 1970: Inner city Outercity loner suburbs Middle suburbs Sntellite ring Outer suburbs Tlue lower :1 verage age of physicians in the western intner city is probably related to the fact tluat this area is ksuown as the "medical ceuster" and a number of sna los te:schiisg hsosl)itals are located there. The relatively isigher average age of tlue western inner suburbs is related to its proximity to the westward expan- sioss of blacks. The lower average age of the southern middle suburbs reflects the fact that this cell has the highest socioeconsonsic status in the soutluern sector. The satellite towsis present a special case. They are microcosms of the central city asud, ericelit for size and conceoutration of blacks, reflect the sanne patterns of devel lnuenst as the cenutral city. The problems of aging office facilities, congestion, lack ~`f jarksuig space. coml)etition fronsu nuewer regional shopping centers, etc., as'e as couasaon to these satellites as to the central city. The satellites, however, have sue nuuothfyisug influence-their location. They are in Else suburbs and act as servicE' ceators to adjacent resideistial suburbs. Hence, they have sonic urbanu and some suburbasi clus~racteristics asud tlue average age of phuysicians located there \v:t s between city a sud ssnbnrban physicians' ages. Thus, it appears that young doctors are in thue van of tlue decentralization of dotors and are cstaldislsing their practices ins flue affluent parts of the metro- ~ dutasu area, leaving tIne city to the care of the older physicians. lletwecsu 19.jO and 1970 the average age of physicians in the 25 Cosumunity Areas I (.`X's I with the highest average age rose 7.7 years, while thue average age ~f ~luysioias1s inn the 25 CAs with the lowest average age rose only 4.5 years. (SEe Table 7 I This resulted in an increase in the gap between them from 16.3 years to sucarly 20 years. Thus, yousiger doctors were beconuiag more concesutrated. TABLE 7.-AVERAGE AGE OF 25 COMMUNITY AREAS AND MUNICIPALITIES WITH THE HIGHEST AND 25 COMMUNITY AREAS AND MUNICIPALITIES WITH THE LOWEST AVERAGE AGES IN 1950, 1960, AND 1970 1950 1960 1970 Anernie sge sf25 highest 55.0 57.9 62.7 Aoersge uge sf25 lowest 38.7 39.2 43.2 51.6 29.7 48.6 49.6 47.3 43.4 48.4 45.2 47.6 47.4 48.7 53.1 56.2 50.6 59.3 47.4 43.2 48.0 41.2 51.6 44.3 46.1 54.5 57.8 54.1 56.1 49.0 46.5 46.7 44.5 52.5 45.8 47.4 49.6 49.1 52.0 51.4 47.4 49.8 47.8 43.7 48.6 50.0 51.4 45.2 49.0 49.7 48.7 51.3 44.0 N.P. 50.0 53.0 55.4 56.2 50.6 52.4 48.4 40.5 47.5 44.4 45.3 43.4 47.4 45.7 49.6 50.4 53.5 N.P 48.0 58.4 55.0 56.5 55.0 56.7 52.1 49.4 50.1 46.9 51.9 49.0 50.2 50.4 51.2 48.8 59.2 N.P. Yeurs diflerence Lessens fishest nod lowest 16.3 18.7 19.5 PAGENO="0629" 619 TABLE 8.-AVERAGE AGE OF PRIVATE PRACTITIONERS IN 10 POOREST AND 10 MOST AFFLUENT CA'sAND MUNIC- IPALITIES IN METROPOLITAN CHICAGO, 1950, 1960, AND 1970 1950 1960 1970 10 poorest 51.8 57.6 62.4 10 most affluent 48.3 47.2 48.3 Between 1950 and 1970, the average age of physicians in the 10 poorest Ci's rose over 10 years from 51.8 to 62.4. (See Table 8) The rate of increase was divided relatively evenly between the two decades of this 20-year period. The aver- age age of the 10 most affluent CA's remained static during the same 20-year period. It must be remembered that the average age of physicians in the metro- politan area rose three years during this period. This means that affluent areas attract more than their share of young doctors, while poverty areas lose, or are shunned, by younger physicians. This is clearly evident when the age structure of physicians of these areas are compared. The percent of doctors under 45 in the 10 poorest CA's dropped over 50% from 33.6 to 16.6% while the percent 65 and over rose from 20.3 to 29.2%. (See Table 9) The percent 65 and over was nearly twice that of those under 45 in 1970. In the 10 most affluent CA's, the percent under 45 declined only slightly from 41.7 to 38.2. The proportion 65 and over declined also from 11 to 10.3%. There were nearly four times as many physicians under 45 than 65 and over in the ten most affluent CA's. TABLE 9.-PERCENT OF PRIVATE PRACTITIONERS UNDER 45 YEARS AND 65 YEARS AND OLDER IN THE 10 POOREST AND 10 MOST AFFLUENT CA's IN METROPOLITAN CHICAGO, 1950, 1960, AND 1970 tIn percentj 1950 1960 1970 <45 65+ <45 65+ <45 65+ 10 poorest 33.6 20.3 22.0 37.0 16.6 29.2 10 most affluent 41.7 11.0 46.4 7.8 38.2 10.3 The average age of physicians in Black communities has always been high. In 1950, it was 54.6: in 1970, 56.8 years. (See Table 10) This is younger than the average age of physicians in the 10 poorest CA's. This is probably due to the fact that Black doctors usually must practice in Black communities. The few young Black doctors coming out of medical school who do stay in Chicago are, there- fore, in Black communities, thus helping to lower the average age slightly. This can not be interpreted as saying that young doctors are responsibly moving Into Black communities. The average age in Black communities is still nearly five years above the metropolitan average. TABLE 10.-AVERAGE AGE OF PRIVATE PRACTICE PHYSICIANS IN CA's AND MUNICIPALITIES OF METROPOLITAN CHICAGO WITH 50 PERCENT OR MORE BLACK POPULATION IN 1950, 1960, AND 1970 Average age: 1950 54.6 1960 54.1 1970 56.8 TABLE 11.-AVERAGE AGE IN CA's AND MUNICIPALITIES WHICH UNDERWENT CHANGE IN THEIR RACIAL STRUCTURE BETWEEN 1950-60 AND 1960-70 1950 to 1960: Average age: 1950 51.5 1960 52.3 1960 to 1970: Average age: 1960 s&s 1970 587 PAGENO="0630" 620 `lie :i v''ra g~' `ge f ci mtnn ii] ties iii \vlIi('Il tine racial structure (`ha ngcd 1)et ~veen 1 Ei'i( a iid it Hit i ia'rea seil si iglitly and was oniy slightly higher thait the average age in the Metu ~ iit a n A rca. See Tat Ic 11 A change in racial strurl tire in the Ii ft les dii tint have a great iui~ a it on the age structure of tine physicians llract ic- ill there. tinin:iinit h's nn which till' racial structure cliange(l between 1960 and 1070 were lit so fortunate. The a verai.Ee age in these c~ tniiiuiiities jumped inca ny five yea i's in the de,';nde and were siX years all lye tine metropolitan average in 1970. Ta ii1~' 12 i'eveals thc' age structure of coininuiiities in which population shifted fruiti white to black. `oiiiiniinities changing between 1950-1960 had an increase ~fl till' percent of physicians uhn(Ier 45 years as well as an increase in the pro- port 1011 If dictoi's 65 a tid older. The percent under 45 in conimunities chatigug racially bet ~veen 1960 ~iii1 1970, fell dramatically while tile percent 65 and (1111cr rose just tis sinaiply. Tim' younger idmysicialis of the fifties, therefore, appear much hi'ss reluctant to move hit o racially changing neighborhoods than their counter- mat Of tile sixties. TABLE 12.-PERCENT OF PRIVATE PRACTICE PHYSICIANS UNDER 45 YEARS AND 65 YEARS AND OLDER IN CA's AND MUNICIPALITIES WHICH UNDERWENT RACIAL CHANGE, 1950, 1960, AND 1970 tin percent] <45 65+ C:ianged between 1950 and 1960: In 1950 35.6 18.7 In 1960 38.5 24.2 Changed between 1960 and 1970: in 1960 26.3 19.8 in 1970 17.8 29.1 C071.L610-NS Till' obvious conclusion that must l)e drawn is that younger doctors of the sixties did itot reverse tine trend of decentralizing away from the urban iioor and to~va i'd affluent suburbs. The (PIta refute tine popular notion that younger doctors are iinore "socially'' oriented and dedicated to caring for the sick, with little re- gard for mi onetary re\Va i'd. linstead, tine findings of this study persuade that tile v:mst iiiajonity of voinilger ImInysicinins are following the traditions of tine fifties and Iie:i(ii ig t.o tine *`lands (it pleiity'-the affluent SUl)U1'bs. Mr. Roy. Thanh von, Dr. Dewey. Mr. I)invrv. In subsequent studies, looking at the age distribution or 1)hvsicians by geographic area, we found that it was the young doctors, the recent medical graduate, who is moving into the white sulciit'baii areas. The average age of physicians is rising in the Inner City and decliiun~r in the suburbs; that is, it is the old doctor who is l'ell1aifl1n~ behind. ~\lr. Roy. Since we have put our original information in the record, it has conic to my attentton that over 30 percellt of the physiciaiis un my ~tate of Icatisas are 54 years of age or ovet'. Mr. Drwvv. Wlieti von project that ahead 10 years, noting that those 55 and 65 probably won't be practicing at that time, it begins to point, out the problem in its most critical instance. Mi'. Roy. 1)r. Madison. STATEMENT OP DONALD L. MADISON, M.D. Dr. MADIsoN. Mr. Chairman, members of the committee, it is my pleasure to respond to the committee's request to discuss the physi- cian maldistribution problem as it affects the rural regions of our PAGENO="0631" 621 Nation. During the past several years, I have come in contact with i~ iany rural communities that found themselves, sometimes quite abruptly, without local access to a source of medical care. I have also been interested in examining the various ways in which individual communities, as well as the larger institutions of society, have re- spondeci to this problem in the past. Froimi a review of the data on geograpii~c distribution of physicians ii the I ii ited States, I should I ike to (Irii\V t\V() (OilciU;~iO~iS for your consideration and then, if I might, offer an opinion. The first conclusion is that time rural deficit in physician distribu- tion has beemi a recognized fact and a focus of concern for at least live decades vet, except for certain localities, it ha.s shown no im- provenieilt at any time in the past 50 years, even in places where specific progranis have been directed toward the problem. In fact, the imrbai-rural differential has been widening. A 1925 article in the ,Journal of the American Medical Association reported the results of a question to the State medical societies: Whether the older generation of physicians in the rural districts is being sufficiently replaced to meet the future needs of these districts. Four State societies answered. ~ves" (one was ilumode lslaimd with es- seiitialiy no rural districts).' Two years before, iii 1923, a report is- sued by the Con ference of State and Provincial health Authorities of North America summarized its conclusions as follows: 1. There is a universal tendency for physicians to abandon rural districts in favor of the cities. 2. The number of those remaining belong in a very large proportion of cases to the older generation. 3. There is little or no tendency for recent graduates to seek practice out- side the large centers of population. 4. In hundreds of rural districts, medical care is most inadequate or abso- I utely lacking: That was how the situation was viewed in 1923. Those conclusions were prophetic. During the 15-year period after 1923, the net supply 0! physicIans in metropolitan (lOllhltieS had ilicleliSed by 2i) percent while the populat ion increased liv only 200 pemeemit. In semi-rural counties, those with small cities of less than 50,000, the net physician supply increased by 20 percent while the population increased by 25 pe tcent. however, in the pu rd v rural counties, while the population W;~S iiicreesIllLr liv 10 I)ercelit, tilti net supply of physicians actually (TeciIlmed i)V 19.3 l)eIcellt.3 tire that time. altliouirli time ploi)oItionote l)hlVSi('iOli Supply ~fl ru nil relatIve to urban areas has cent i imued to (le(hilme. the su~)plv of (bet ors within rural America has held relatively stable. The phvsi- (ian-population ratio for vu iral count i('S in 1963 was e~senti ally tile Sanme ~is it was in 1940. And the stability appears to have centlnue(l lip to tIle pieseilt. lint time urban-rural difference is strikini~. There are approximately 156 active physicians ~ 100,000 population in metropolitan counties. 1 vi iaiti ~\ 1-n Pn soy `Meiiioal Educatii ii a iii Me~ii(~il S,rvie& : I. Tin Si (anti in'' J.4.1T.A. 54 :2S1-~5 (January 24, 1925). Iuntod in Jill. J. `iV. 11w nri a. et ni. ``T,oca tin a nil 1.1 oviriont of Ptvstoii us. 1 9211 a ad 1 !~i~ .\ ce Distribution in Relation to County Characteristics.' Public IIaith Rcports, 5S :453-490 (Mar. 19, 1943). PAGENO="0632" 622 Non-metropolitan counties have 64 physicians for every 100,000 peo- ple.1 In certain regions of the United States the rural areas are espe- cially disadvantaged. In the South, rural counties generally have fewer doctors than they do in the North and West. In the Deep South States of South Carolina, Georgia, Alabama, and Mississippi, rural counties have only 28 doctors per 100,000 population.2 The people of these areas have been tolerant partly because the lack the financial resources to pay for medical care, accessible or not. When a program of national entitlement is enacted, the unmet demand will be enormous. The second conclusion I should like to draw is that the data con- trasting rural and urban distribution tend to hide another trend which is internal to rural America. By and large, doctors have con- tinued to settle in the larger towns and commercial centers of rural regions, the dramatic doctor loss has been in the smaller, more iso- lated towns. For example, between 1950 and 1959 isolated rural counties lost doctors six times as fast as people.3 However, this trend had started well before 1950. A study of some 187 remote, undoctored towns in Minnesota, the Dakotas, and Montana found that the peak year for physician presence was 1921. In that year, almost 90 percent of these towns had a doctor. The subsequent loss was gradual but steady up to 1965, t.he year of the study, when none of them had a doctor.~ Another study of physician distribution in a nine county region of Upper New York State showed that out of 102 rural towns that had physicians as some time between 1905 and 1960, 93 percent of the smaller towns-those between 1,000 and 7,000 population [in 1960]- had lost physicians, while of the larger towns of between 7,000 and 24~0O0 population. percent had gained physicians.~ In my experience, the critical problem areas are not the regional centers but the smaller towns, too small to support even a modest assortment of specialists but actively seeking the return of the coun- try doctors they once had. These places are not usually within the shadow of a metropolitan area or near a regional commercial cen- ter. Their immediate market areas contain fewer than 15,000 people. Typicail, such a community will have experienced a diminution of physician manpower over the years to the point that it now has no physicians. or realizes that it may soon have none. The nearest pri- mary medical practice is either overtaxed or too far away for con- venient access. These are the places where the familiar rural com- plaint of not enough doctors is heard loudest and most often. Testi- molly taken by this committee 4 years ago on a bill to establish the 1 Derived from "Distribution of Physicians, Hospitals, and Hospital Beds in the U.S., 1972" AmerIcan Medical Association, Chicago, 1973. 2 Ibid. `Rurality. Poverty, and Health-Medical Problems in Rural Areas," Agricultural Economic Report No. 172, Economic Research Service, U.S. Department of Agriculture, Washington, D.C., Feb. 1970. `Ivan Fahs and Osler Peterson. "Towns Without Physicians and Towns With Only One-A Study of Four States in the Upper Midwest, 1965," Am. J. of Public Health 58:200-1211, (July 1968). ~ R. C. Parker, et al.. "Social, Economic, and Demographic Factors Affecting Physician Population in Upstate New York," New York State J. Med. 59.706-712 (Mar. 1, 1969). PAGENO="0633" 623 National Health Service Corps is filled with documentation of the plight of these smaller rural conununities. Obviously, none of the several ideas that have been tried or pro- moted for correcting the problem has yet succeeded in reversing the trend. I have submitted for the record an assessment of some of these ideas. I think it unlikely that new strategies of intervention will succeed either, when they are directed only to the physician training continuum. Such indirect intervention as influencing student selec- tion for medical school, tying financial assistance during training to subsequent practice location obligation, and changing the content and location of training are important, and they can be expected ulti- mately to provide some relief for nonmetropolitan regions; the laws of supply and demand can certainly be biased more than they have been for a more equitable physician distribution. However, it is highly questionable whether the classic problem of small towns seeking doctors will be helped very much by such proposals alone. Most of the benefit from these kinds of manpower training interven- tions will likely be more concentration of physicians in the medium- sized centers. The total supply of medical manpower within a pre- dominantly rural region may improve, and the doctor distribution data at the macro level (national and statewide) should change; but local access to primary medical care for smaller, outlying com- munities will, I believe, remain a problem and the familiar com- plaint of the rural spokesmen will continue to be heard. There are two main reasons why the country doctor role which small communities find so desirable goes unfilled. The most popular reason is that many, perhaps even a substantial majority, of young physicians and their families find the idea of smalitown living un- acceptable. This is unfortunate but, to the extent that it is true, there is not much that can be done. The other, more important problem is that the medical practice norms in such communities are incon- sistent with the professional work expectations of most newly trained doctors. If the young physician does not recognize this immediately and proceeds to establish a smailtown practice, the chances are strong that delayed discovery of these "facts" of rural practice will lead within a few years of a change of location (usually from rural toward urban) or of specialty (invariably from the broad to the narrow). Whatever the inclination of the young physician and his family might be to live in such a community, his professional expectations will rarely be satisfied by the traditional form of independent solo or two-physician practice, which has been customary in small corn- munit jes. Manpower programs that are directed to the redistribution of physicians need to include a means of effecting change in the way smalitown medical practice is organized, so that it can begin to be seen as a professionally viable alternative by a much larger propor- tion of new physicians. I should like to believe that the medical schools possess an enormous capacity to assist in building quality rural medical practice. I am not referring here to providing existing rural physicians with con- tinuing education opportunities or consultative specialty back-up, al- PAGENO="0634" 624 though I readily agree on the importaiice of helping busy rural doc- tors maintain their quality. What I am suggesting is that the major medical training centers, having recently extended their obligated training responsibility from medical school graduation to comple- tion of the postgraduate residency period, might now extend this responsibility still further. What beneficial results for rural areas might. follow if a medical school were to consider its responsibility incomplete, until its students are well situated in practice settings that fulfill not only their own professional expectations but also the needs of society in regard to geographic distribution and program quahit~? rUle problem is one of attitude. Very few medical schools and post- grailuate training programs have, as vet, begun to look beyond their tIa(titional single goal of assuring the technical competence of the students they produce, toward the equally important question of whether their products, technically competent or not, will occupy professional roles that will have maximuni value in society. It should be 1)osslbhe for government to assist the medical schools in adopting this new attitude. [The article attached to Dr. Madison's statement follows:] [From Health Services Reports, October 1973] RECRUITING PhYSICIANS FOR RURAL PRACTICE (Dv Donald L. Madison, M.D.) A number of excellent studies have correlated the choice of a rural location for medical practice with certain characteristics of physicians (1-4). Re- searchers have shown that smalitown physicians are more likely to be the sons of farmers and to have grown up in a rural environment. But they are known also to be a group of older physicians, most of whom made their decision to locate some years ago. Therefore. the findings of Bible, Champion, Hassinger, and others on the reasons why l)hySicianS decide on a rural practice have to he considered as descriptions of the situation at a point in the recent past and not necessarily as the definitive answers to the question of what physicians might be looking for in a rural practice today. If ideas regarding recruitment of more physicians to rural areas are limited to what is suggested by the findings of this body of research, the prospects are anything but bright. For example. Parker and Tuxill in their study of metro- politan and smalltown physicians in an area of upstate New York found that the most important factors influencing those physicians who had gone into practice in a small community were the idea of living in a small community, the likelihood of developing a busy practice earlier, and their perception of the need of a small community for another physician (5). These researchers con- eluded that "the 1)001 of new physicians then possibly interested in small- community practice seems largely restricted to physicians coming from small communities who like small-coniinunity living, feel the need for physicians in those communities, and wish to establish a busy practice early. With our present educational and population trends, this will be a small pool" (6). The question of what physicians may be looking for in a rural practice is interesting, hut it is an important question only if the answers can he related in some way to an effective intervention strategy. If it were found that most health professionals (or their families) are looking for opera, professional football, or a local branch of Neiman Marcus. that w-ould be interesting (and discouraging for rural areas) but not terribly important. It is not possible to change the geography of the country, nor can we influence the marriages of physicians whose spouses may disagree with them over the importance of some of these factors. There are, however, some actions that may be taken in order to capitalize on PAGENO="0635" 625 the findings of research and maximize the pool of potential health professional recruits for rural areas. I shall review briefly a few strategies that have been tried in the past. Most of them assume an answer to some variation on the question of what physicians look for in a rural practice. TIlE RURAL BACKGROUND FACTOR The first such variations on this question are, Why aren't more physicians looking for anything in the way of a rural practice? how can the 1)001 of potential recruits be made larger than it is? Certainly the evidence is strong that a rural background will correspond to the selection of a rural location for practice, and there is a way to intervene based on this evidence. Medical schools could preferentially select a larger proportiomi ~f students whose back- grounds would appear to maximize the likelihood of their returning to rural areas. However, the prospect of this happening soon is not good. Few medical schools and postgraduate training programs have, as yet, begun to look beyond their traditional single goal of assuring the technical competence of the students they produce toward the equally important question of whether their products -technically competent or not-will occupy professional roles that will have maximum social value to society. Of course, the prospect of funds specifically earmarked for the support of students selected by these nonacademic criteria might quicky change this outlook. TIlE EXPOSURE FACTOR Another possible way of enlarging the pool of potential rural practitioners is by scheduled exposure to rural practice and lifestyles during the medical education continuum. Students have received this exposure in two ways: (a) through precej)torships under rural practitioners. sometimes as a part of the formal curriculum, particularly in State-supported medical schools, and (h) in "community medicine" projects, in which a large group of medical and other health science students spend their summers in rural communities under the auspices of a regional project sponsored either by a medical school or a student organization. Considerable anecdotal evidence is beginning to accumulate which suggests that both tactics yield some return in physicians who decide to locate in rural areas because of this exposure while they were medical students. However. the best evidence that the rural preceptorship and student health project are an effective intervention strategy will probably always remain anecdotal, be- cause these projects do not lend themselves to an experimental evaluation design, and most of the students that participate tend to be self-selected. FINANCIAL AID DURING MEDICAl. SCHOOL Another type of attempt to increase the number of rural practitioners is by tempting students when they are most vulnerable. Medical education is expen- ~ive to society and to the students. Many of them need financial help during medical school, and the offer of a loan, to be forgiven upon fulfillment of a service commitment in a rural area, can be tempting and a possible inducement. Such loan programs tied to a service commitment have been operated by several States, particularly in the South, since the end of World War II. In a recent study of these programs, Mason reported that nearly half of the students receiving loans chose to repay the loan in cash rather than through service, although the success varied greatly from State to State (7). In a study of the total experience of the second oldest of these programs, it was found that 74 percent did some service as payback. although some physi- cians paid partly by cash to reduce their obligated time. The study group included only physicians who were beyond residency training an(I military service and therefore were in a position to have begun fulfilling their service commitment. Forty-one percent of those doing service stayed in the community for some period beyond the terms of their service commitment, but less than 18 percent are in the same communities at present (unpublished data from a study of the North Carolina Medical Care Commission's student loan program by the Rural Services Research Unit, Health Services Research Center, Uni- versity of North Carolina, 1972). PAGENO="0636" 626 Again, there is anecdotal evidence that this strategy is partially effective, but whether it is sufficiently so to justify the cost of such incentives can be questioned. The Issue of self-selection applies in these programs too. It Is Impossible to know how many physicians who receive loans would have gone to rural locations anyway compared with how many were induced to locate in a rural area, at least temporarily, because of this assistance. In at least one State, North Carolina, this program may also have contributed rather heavily to high physician turnover in small communities. OTHER MATERIAL INCENTIVES A tactic frequently used by small towns to recruit physicians suggests a further variation on the question of what the physicians want-can they be recruited to a rural practice with a material incentive? Under the assumption that a significant number can be, many communities have offered some form of guarantee or financial bonus to physicians who will set up practice. The Province of Ontario recently instituted a program of this type to recruit physi- cians to its isolated regions (8). In earlier times, as recorded by Roemer, com- munities sometimes offered free housing or an automobile as inducements (9). More recently, the initial gift or subsidy has been a building or equipment. Perhaps the best known example of this recruitment tactic is the now defunct program carried on for many years by the Sears Roebuck Foundation and the American Medical Association. Undoubtedly some physicians are looking to be recruited and can be recruited with these sorts of incentives. Each tactic has its individual success stories. But the Sears-AMA program, the Vermont Regional Medical Care Project, and other similar programs based on a building and a subsidy are usually considered now as having been failures (10, 11). METHODS OF COERCION Another possible answer to the question of what might attract some physi- cians to a rural practice is that they look for the best among a set of sharply limited alternatives. With few exceptions, coercion has not been attempted In the United States as a tactic to improve medical manpower distribution, but at least three partly coercive methods have been successful in other countries as well as in the United States. All of them require Government authority. First, is the negative incentive of designating closed areas. The experience In the United Kingdom is the best known example of this tactic, which is only possible within the framework of a national health service. The Government closes geographic areas having favorable physician-population ratios to new practitioners under the British National Health Service, and this ban then has the effect of increasing the competitive recruiting advantage for the remaining areas with fewer physicians. The second method is conscription. In the United States only the armed services have used this method of recruiting physicians. However, several less economically developed countries conscript young physicians for limited terms of service in communities of need, usually rural ones, as a method of obtaining a better geographic distribution of medical manpower. Finally, there is indirect conscription; that is, offering the physician the opportunity to enter one form of Government service as an alternative to another, possibly less desirable, service to which he might otherwise be con- scripted. The Public Health Service-particularly the Indian Health Service- has relied on this method successfully for many years. This Indirect conscrip- tion for service in a Government-operated system contrasts with another more recent example, the National Health Service Corps. The Corps' physicians are in the service of Government but are assigned to practice in a locally adminis- tered system In a community having an acute need for primary medical man- power. With the end of the draft, both direct and indirect conscription in this country will, of course, no longer be possible. THE INCENTIVE OF AN ORGANIZED SYSTEM Finally, I suggest still another possible strategy to promote redistribution of medical manpower to rural areas; this strategy Implies several answers to the question of what physicians might be looking for in a rural practice. It PAGENO="0637" 627 requires a somewhat different look at the problem. If one considers physician manpower as but one necessary element of the primary health care system- the element that contains professional medical knowledge and skills, and one does not insist that the physician also possess the material means to practice- then recruitment of physicians by organized health care systems is a valid strategy for redistributing medical manpower to rural areas. The underlying assumption is that where an organized medical care system which requires medical manpower to function already exists, recruitment will occur much more readily. The physician selling only knowledge and skills Is easier to find than one who must come ready and willing to market a building, equipment, and employees in addition to professional skills and knowledge. Evidence of the correctness of this assumption is the relative ease with which physicians are recruited to small communities which are the homes of estab- lished group practice organizations, or, for that matter, of the much smaller physician staffs of rural neighborhood health centers. It is not an accident that the towns of Elkins, W. Va., Madisonville, Ky., Gallipolis, Ohio, and Marshfield, Wis., have far more favorable physician-population ratios that do the vast majority of communities of similar size and location. This redistribution strategy must start with the establishment of newly organized medical care systems. For a community, this would obviously be a much larger and more difficult initial task than is the recruitment of a physician entrepreneur, but its accomplishment could have much greater and more lasting payoff in the overall objective of redistributing physicians to areas where they are most needed. But is the organized system based on group practice a means of increasing the pool of potential recruits to rural practice, or would it merely further con- centrate those who would likely be in rural practice in any event? I think its Impact would probably be mostly on those physicians who otherwise would probably not be in a rural practice, at least not for long. Data from recent research support this view. Parker and Tuxill's study of upstate New York physicians showed that those physicians already in rural areas, who tend to be older, came because they wanted to develop a busy practice quickly in a community without sufficient numbers of physicians (5). Yet a 1971 study by Crawford and McOormack of physicians in Virginia who recently left primary practice (men and women mostly in their thirties) re- vealed that the apparent uncontrollability of the "busy practice" was the most important reason for leaving it, and 96 percent of those who left mentioned "group practice" as a likely benefit in enhancing the viability and atractive- ness of primary practice (12). Also pertinent are some preliminary findings from a current nationwide study of group practice organizations and physician staff stability (1.1). Questionnaire responses were examined from 74 primary physicians (general- sits, internists, and pediatricians) who practice in six multispecialty groups. All ~ix groups are located in towns of 12.000 or less population and distant from a metropolitan area. Most of the physicians had rural or smailtown origins. If circumstances were to force them to leave their present organiza- tions, the great majority would favor another smalitown location and disfavor a metropolitan environment. In these two respects they are not unlike all rural physicians, regardless of form of practice. However, the reasons why they decided to work in their present organiza- tions are of interest. The majority held the community and the general geo- graphic location of the group as unimportant to their decision. The most impor- tant factors were (a) freedom from the business aspects of medical practice- 91 percent considered this an important factor. (h) predictable working hours, and (c) immediate access to other physicians for consultation and referrals. These conditions of work are particularly associated with organized multiple-physician practice. Finally, in answer to the question of which form of practice they might consider if circumstances were such that they had to leave their present organization, they strongly favored multispecialty group practice and strongly disfavored solo or two-physician practice. This finding suggests that, by and large, these physicians practicing In rural areas tended to be from rural areas, and apparently like rural areas, but they were attracted not so much because of any particular characteristics of the community but because of how the practice they entered was organized. PAGENO="0638" 62S In Parker an(I Tuxill's study (.~), urban physicians were asked to rate van- oris factors which deterred them personally from locating in a small corn- mimnity. Heading the list was favoritism toward large-community living, un- related to practice consi(lerations, Nearly 70 percent mentioned this factor as important. But, of the next five factors in order of frequency of mention, none was derogatory of small-community living. Items such as lack of cultural and entertainment facilities, influence of spouse, and scarcity of nonmedical intel- lect ual companionship appeared further down the list. The next most fre- quently mentioned deterring factors were all professional considerations of practice thought by urban physicians to be associated with rural practice, but factors that need not necessarily he true of small-community locations, depend- ing ~a the \Ya~ practice is organized. The principal findings suggested by all of the research I have cited can be sumimiarized as follows: (a) the number of physicians not adverse to rural areas as practice locations is limited : but (b) the number who can be attracted to 11 h siiiall-coiiimuiiity living and to the solo or two-man entrepreneural jmracf ice style, w-hich has been customary in small communities, is sul)stantmally sniahler. The miio~t effective redistribution stratocy wnul(1 seem to he one directed to- ward maximizing the return on the numbers of physicians who rnight~ be will- ing to locate in small communities, given certain conditions. I suggest that most of these conditions can be summarized as those professional benefits Corning from association with an organized system of medical care. If this assumption is true, then what is needed is develol)ment of niore organized systems in rural areas. Most medical doctors are not trained nor particualnly well suited for this difficult task. Developing organized systems can be made even more (liffidult by the opposition of physicians alrea(ly practicing in the area. Rural physicians, in particular. have not been reluctant to oppose new programs that appear to he unconventional in their sponsorship or financing. Yet consumer sponsorship and adoption of the prepayment prindil)le have been associated for many years w-ith the successful provision of medical care to geographically dispersed populations throughout the world. Unconventional administrative models for the delivery of medical care to rural areas have been developed and operated in this country under a variety of auspices including companies, unions, govern- ment. consumer cooperatives, medical care funds, hospitals, and, of course, J)I'i\-ate physicians. In a study of a sample of rural group practice organizations in which admin- istrative control is shared to some degree with a consumer group, five out of six experienced during their development open hostility from the local medical community (unpublished data from a comparative study of medical practice organizations and stability of physician staff. Health Services Research Center, University of North Carolina. March 197~). This was true even though the establishment of these new groups had the effeet, on the average, of at least doubling the numbers of physicians serving the medical care needs of these undeserved rural areas. My point is that many health professionals may be far more willing to work in rural areas under unconventional practice condi- tions. and that the medical community can be an important force against bet- tering the situation, as well as for improving it. CONCLUSIONS Research has made a modest contribution to the question of how more physicians mirht be recruited to rural practice. This contribution consists mostly of pointing out that there may he certain predispositions on the part of physicians toward certain lifestyles, locales, and practice patterns. They have these predispositions for a variety of reasons, many of them closely related to time experience of the individual person. Time major contributions toward answeninr the question will not be made by researchers. The recruitment of more physicians to rural practice is a means toward a broader socIal goal. The answers will come from the work of those who can apply the finclinrs of research. together with the lessons of the past. to promotin~ the most equitable distribution of health services among all of time peaple. PAGENO="0639" 629 REFERENCES (1) Bible, B. L.: Physicians' views of medical practice in nonmetropolitan communities. Professional and social aspects. Public Health Rep 85: 11-17, January 1970. (2) Champion, D. J., and Olsen, D. B.: Physician behavior in southern Appalachia; some recruitment factors. J. Health Soc Behav 12 :245-252, Sep- tember 19~1. (3) Hassinger, E. W.: Background and community orientation of rural physicians compared with metropolitan physicians in Missouri. University of Missouri Research Bull 822, Columbia, Mo., 1963. (4) Peterson, G.: A comparison of selected i~rofessional and social charac- teristics of urban and rural physicians in Iowa. Health Care Research Series No. 8, Graduate Program in Hospital and Health Administration, University of Iowa, Iowa City, 1968. (5) Parker, R. C., Jr., and Tuxill, T. G.: The attitudes of physicians toward small-community practice. J Med Educ 42: 327-344, April 1967. (6) Parker, R. C., Jr., Rix, R. A., and Tuxill, T. G.: Social, economic, and demographic factors aff~ting physician population in upstate New York. NY State J Med 59: 706-712, Mar. 1, 1969. (7) Mason, H. R.: Effectiveness of student aid programs tied to a service commitment. J Med Educ 46: 575-583, July 1971. (8) Guaranteed annual net professional income and establishment of practice grants for physicians in private practice. Public Health Division, Ontario De- partment of Health, Toronto, August 1970. (9) Roemer, M. I.: Approaches to the rural doctor-shortage (with special reference to the South). Rural Sociol 16: 137-147, June 1951. (10) Can doctors be kept down on the farm? Med World News 12:15, 16, Dec. 24, 1971. (11) Phillips, M. L., Mabry, J. H.. and Houston, C. S.: Eager communities and reluctant doctors, N Engi J Med 278: 1263-1268, June 6, 1968. (12) Crawford, R. L., and MeCormack. R. C.: Reasons physicians leave primary practice. J Med Educ 46: 263-268, April 1971. 13) Madison. D. L. : Recruitment of physicians into target practice organiza- tions. Paper presented at the Invitational Conference of Health Services Re- search Centers, Bethesda, Md., Oct. 12, 1971. Mr. Roy. Thank you very much, Dr. Madison. The committee, because there is a vote on the floor, will recess for 5 ni ii iutes. [Brief recess.] Mr. Roy. Dr. Cooper. STATEMENT OP E. LEON COOPER, M.D. Di'. COOPER. Mr. Chairman, I am Dr. E. Leon Cooper, acting execu- tive director of the National Medical Association, an oi~tanization predominantly representative of minority physicians of this country and of their interests. We are located in Washington. l).C.. and have existed as an organization for a'most 80 years. The primary goals and objectives of the organization relate to the provision of adequate health care to minority populations and serve the interests of the minority physicians serving these popula- tion groups. We appreciate the invitation to appear before you and your com- mittee members today and will endeavor to contribute positively to your deliberations as best we can. Recently we have had the opportunity to testify before Chairman Mills of the Ways and Meaiis Committee ni regaid to the issue of PAGENO="0640" 630 national health insurance. Much of what we will say today has been previously submitted in the testimony before the Ways and Means Committee; however, we will attempt to supply more details to the specific issue of health manpower and the distribution of physicians, particularly in the central and inner city areas. We recognize that the current health manpower authorizations expire on June 3, 1974, except for certain residual provisions in the student financial aid sections (authorizing appropriations to continue for students to whom commitments have been made). It is our understanding that until yesterday the administration, according to Dr. Henry Simmons, Deputy Assistant Secretary for Health, was still drafting replacement legislation which would re- quire medical students to pay a greater share of the costs of medical education on the grounds that: Large public subsidies to highly paid professions are inequitable and un- necessary, especially where demand for admission to school far outstrips the supply of available places. [Remarks of Dr. Henry E. Simmons at the Annual Spring Meeting of National Academy of Sciences Institute of Medicine, May 9, 1974.] HEW, we understand, contends that continuation of current Fed- eral policies will eventually lead to an oversupply of health profes- sionals, particularly physicians. Dr. Simmons' May 9, 1974, remarks at the Annual Spring Meeting of the National Academy of Sciences Institute of Medicine are com- pletely compatible with the November 5, 1973, remarks of Dr. Charles Edwards, Assistant Secretary of Health, before the Association of American Medical Colleges in its Annual Convenlion in Washing- ton, D. C. Dr. Edwards questioned whether it is appropriate for the Fed- eral Government to bear so substantial a share of the cost of prepar- ing individuals for careers which offer about the highest earning power in our society. The Federal Government had, Dr. Edwards emphasized, between 1963 and 1973 spent $3.5 million for health professions education. To his credit, Dr. Edwards has recognized that the problem of minority and female underrepresentation in the health professions would have to be addressed. So far as blacks are concerned, there is no surplus of physicians nor is there any prospect that there will be a surplus of physicians in the black medical community. While there is increasing evidence that physicians-to-be of what- ever race are attending the majority of medical schools, and we are truly hopeful that such openness will continue, we are forced to note that presently there is but one black M.D. per 2,800 blacks. By con- trast, there are five white M.D.'s for a comparable number of whites. Figures published by Congressman William Roy in connection with the introduction of his health manpower bifi, H.R. 14357, on April 25, 1974, confirm what we all know to be fact. Dr. Roy states that, generally, inner cities have fewer physicians on a per capita basis than do suburban areas. For example, New York City poverty areas have a 0.65 to 1,000 ratio, while affluent areas of New York have a 2.50 to 1,000 ratio. This is a variation of 400 percent. In Chicago, the variation is from a PAGENO="0641" 631 0.26 to 1,000 ratio to 2.10 to 1,000 ratio-a variation of more than 800 percent. The number of physicians in inner cities has actually decreased over the past. two decades. In Chicago, for example, the private office- based physician/population ratio decreased from 1.11 to 1,000 ratio in 1950 to 0.75 to 1,000 rato in 1970. But, on the ot.her hand, the pri- vate office-based physician/population ratio in the suburbs simultane- ously increased from 0.95 to 1,000 in 1950 to 1.23 to 1,000 in 1970. There are clear inequities in the supply of physicians to popula- tion groups on a geographic basis. In one 1959 survey, the physician! population ration in New York was 1.87 to 1,000 while in Mississippi it was 0.72 to 1,000. In 1969, the physician/population ratio in New York was 2.21 to 1.000 while in Mississippi it was 0.77 to 1,000. This indicates that New York's physician/population ratio had improved considerably between 1959 and 1969 and had remained essentially un- changed in Mississippi. Blacks had become so underrepresented in the medical profession that by 1970 (in school year 1969-70, when total medical school en- rollment was 37,690, of which the black component was 1,042 and most of whom were concentrated in the Howard and Meharry Medi- cal Schools-only 2.8 percent of total medical school enrollment) an Inter-Association Committee composed of the National Medical As- sociation, the American Medical Association, the Association of American Medical Colleges, and the American Hospital Association established a long-term goal of achieving a minority physician popu- lation at least proportional with minority population. Since little was known about other minorities, the blacks were proxy for all minorities. It was determined that we should strive to attain 12 I)eIce11t black representation in the medical profession with the interim goal of 12 percent black medical school enrollment by school year 1975-76. Stated more simply, there should have been 24.000 black M.D.'s, whereas, in fact, there are only 6,000 black M.D.'s. While there have been significant increases in black enrollment, with blacks now enrolled in significant numbers in all medical schools, we were far short as of school year 1972-73 (the last period for which we have available and accurate figures 011 medical school enroll- ments) of meeting this goal. It is clear that there is a lag between projected rates of black en- rollments per school year and actual rates of black enrollment per school year. For example, it was predicted that by school year 1972- 73 that there would be a total black enrollment of 2,979 out of a pro- jected total medical school enrollment of 41,888; where as there were only 2,582 blacks out of a total of 47,234 medical students in school year 1972-73. In the recently completed school year 1972-73, black enrollments rose onl to 5.4 percent of total medical school enroll- ments rather than the 7.2 predicted. We should emphasize that total medical school enrollments ex- ceeded all predictions; so that, while medical school enrollments are increasing, the black component thereof, even though showing a dra- matic improvement over the school year 1969-70 base year of 2.8 percent, is in absolute terms flattening out. Put another way, we hoped to realize 7.2 percent by school year PAGENO="0642" 632 1972-73. but in fact realized only 5.4 percent of total medical school enrollment. \Vhile we a ic gratified that total medical school enroll- men t s exceeded predict ions, we are disturbed that black enrollments have not kept pace. \Viii le there are ~averal ivason~ for the failure to nieet 1)rolected ievel~ of bl~uk health lnanp(nver. there is one basic prol)Iern.' It simply (o~tH a. lot to go to medical ~ehoo1. Many persons ot all races, even if ~ lower (`(010)01 i( strata. lit)) WI) oh eateuoiv fl1~llV blacks amid otloi' 1111 norities are caSt, (.0111(1 (1ll~i1ifV for medical school if they i~i'e pa ie I in a Eva n e. Too often, however, high school counselors discourage many who would otherwise aspire. by a foreknowledge that medicine is an "impossible dream." Gaged against, such background facts, it is possible to grasp why we believe that it. is vital, as a bare minimum, to continue the author- it.v for certain vital features of the expiring Comprehensive Health Manpower Training Ac.t of 1971 (P.L. 92-157), legislation which ceases to be effective after this June 30th in many particulars. rfhe most vital program of those which are set to expire is the low income background health professions scholarship program, section 780 of the Public Health Service Act, authorizing scholarships for all categories of iow income background health professions students -students of optometry, podiatry, pharmacy, and veterinary medi- cine. as well as to students of medicine, osteopathy, and dentistry. Under the low inCome background health professions scholarship program aid was restricted to low income background students of "exceptional financial need." Since "low income background" was administratively defined to be from families with an income range of from $3,700 to $9,000 per year, the scholarship aid was restricted to students from families with incomes under $9J)'UO per year who were in exceptional financial need. Obviously, such grouping describes that reservoir of black people from whom NM's effort to increase black health manpower must be drawn. Budget restraints have never allowed the low income background scholarship program to reach its potential. WThile we do not know what the administration intends to do with respect to financial sup- port for the low-income student, scholarships distributed to the sev- eral health professions schools have never totaled more than $7.9 million for low-income background health professions student scholarship aid available to students of medicine in school years 1970-71, 1971-72, 1972-73 and 1973-74. In order to maintain NMA's talent recruitment effort, which has as its purpose to increase the pooi of black students who can be 1 It has been noted by Dr. Edmund C. Casey, immediate past president of NMA, in New York City at the Annual NMA Convention, that many medical school deans lack a commitment to admit blacks, but also lack a commitment to present programs to retain blacks. Dr. Casey also cited the failure to meet the 1972-73 goal of 7.Z percent in terms of a lack of preentrance counseling, a lack of tutorial programs, lack of advisers, plus a lack of consideration of the financial problems black students face. Nevertheless, Dr. Casey indicated that NMA had identified at least 5,500 students not only in colleges but down through the secondary school levels who could pursue scientific careers. PAGENO="0643" 633 matriculated into medical school, there must be au ample Sll1)ply of ow-income scholarship money available. We believe that low income background scholarship program should be targeted to first-year students, and provide enough for the first year's tuitioii and a living stipend. Support in the first year should be "no strings attached" so that the student could look to the type of program most suited to his needs, be it NHCS, physician shortage area program, or guaranteed loan program. Each such program has its pros and cons. In our view, the first-year student should have 1 year without having to make his choices to funding programs. As we understand the Roy bill,' it is a complete replacement of titles VII and VIII of the Public Health Service Act, which includes: (1) grants and loan guarantees for construction of teaching facil- ities for medical, dental, and other health professionals; (2) capita- tion grants to improve the quality of schools of medicine and other health professions schools; (3) start-up assistance; (4) special pro- ject grants; (5) grants to assist health professions schools in financial distress; (6) health manpower education initiative awards; (7) stu- dent loans; (8) low-income background scholarships; (9) physician shortage area scholarship program ; and (10) training in family medicine. `We have emphasized the scholarship portion of the Comprehen- sive Health Manpower Act of 1971. However, that legislation added authority to the Public Health Service Act to assist through grants amid loan guarantee.s the construction of new teaching facilities. If this legislation is not continued, and liberalized so as to provide greater than 90 percent construction assistance, institutions such as More- house College in Atlanta-which has under study plans for the es- tablishment of a medical school-w'ill most likely be frustrated in their efforts in this regard. Morehouse could, if properly funded, add substantially to the capability of our health professions schools to make significant and timely increases in the number of black physicians and other black health professionals. We offer our comments of other aspects of student financial aid: NATIONAL HEALTH SERvICE CORPS The National Health Service Corps, a program authorized by the Emergency Health Manpower Act-I'ublic Law 92-585-w-hile available as a matter of law to any physician shortage area, urban as well as rural, has been targeted toward primarily rural areas. About 85 percent of the area served by NHSC projects are rural areas. Dr. Roy's figures printed in the April 25, 1974. Congressional record show that it had been estimated that a primary physician-population ratio of 1.33/1,000 is necessary to provide adequate primary care to the people, but in the United States today the primary physician-population ratio is but 0,60/1,000. It is a fact that approximately 47 percent of the physicians are in primary care specialties of general or family medicine, laternal medicine, pediatrics, or obstetrics and gynecology. In the United States the number of primary physicians In prepaid group practices Is 69 percent. whereas the number of physicians practicing surgery is 20 percent. The U.S. population which are not members of prepaid groups undergo twice as much surgery as subscribers of prepaid groups. 38-698-74-pt. 1-42 PAGENO="0644" 634 Students who are supported under this program are given a stipend equal to a second lieutenant's pay and the G-overiirnent pays tuition costs. Students who join the Corps agree to serve one year in a shortage area as a member of the corps for each year of subsidized schooling. Congressman Roy's bill would amend the requirement of service so that the period of mandatory service would be 6 month's service in a shortaue area as a member of the NHSC for each year, and allow an allowance of $5,000 per year for members of the NHSC while in school. If, as expected. such a program as the NHSC would prove most attractive to black students, given the present rural orientation of the XI-ISC. it is probable that minority students recruited into the NHSC would not return to the inner city. While dispersal of blac~ in a position of authority and responsibility throughout the Nation at large has doubtlessly beneficial secondary societal benefits, incen- tives 1110SF be plovi(led so as to allow those who are inner city resi- dents to return to inner cities if they so desire. We believe that the physician shortage area scholarship program, section 784 of the Public Health Service Act, should be retained and expanded to provide just such an incentive. While we favor NHSC, we do not believe that it should be the only scholarship pro- gram available. *We believe, for reasons advanced, that the low income background health profess ions schol a rslii ~S and tIme physicians shortage area scholarships proginins should be continued and funded. PHYSICIAN SHORTAGE AREA SCHOLAIISIIIP PROGRAM The physician shortage area program legislation sponsored by Senator Beall was incorporated into section 784 of the Public Health Service Act. by the Comprehensive Health Manpower Training Act of 1971-Public Law 92-157. Under this program, which the Nixon administration has declined to fund, but with respect to which Congress did appropriate $2 mil- lion in 1974, authority existed to grant $5,000 a year in scholarships to medical students who agree in advance, while in school, to prac- tice 1 year of prinifiry care in a physician shortage area for each year of schooling. Under the expiring legislation, first priority in the award of Scholarsllil)s was accorded applicants from low income background who are residents of a physician shortage area. This program has a unique feature in that applicants for scholar- ships could, if from a physician shortage `area-which would clearly encompass many of our larger cities and many rural areas-and from low income background and willing to return to their home area to practice primary care, have received $5,000 per year in medical school. We urge that physician shortage scholarship legislation should be extended. We believe that students should be given an option to practice medicine in their home communities, as distinct from the power that the XHSC would have to require service at any boa- PAGENO="0645" 635 tion within the United States in the case of a student assisted under the NHSC. Any such extension of the physician shortage area program should make the terms comparable to the terms of participation in NHSC. That is, if the Government were to pick up total tuition costs of a NHSC student and to allow a cash stipend of $5,000 per year for living expenses for a NHSC student and only require 6 months ser- vice in a shortage area for each year of schooling under the NHSC program. the same conditions-tuition allowance, stipend, and obliga- tory service period-should be made applicable to any extension of the physician shortage area program. GUARANTEED STUDENT LOAN PROGRAM NMA has since 1970 been involved in the guaranteed student loan program, acting as a go-between between banks making the loans and the Federal Government that guarantees the loans. Such was as a result of an agreement reached at a White House meeting with President Nixon. The Nixon administration in 1971, as part of its proposals for the Comprehensive Health Manpower Act of 1971-section 10 of S. 1183-proposed to eliminate direct health professions loans, and to amend title IV of the Higher Education Act to give special considera- tion to health professions students so as to be able to borrow on a federally guaranteed basis "p to $5,000 per year. Provision was made for forgiveness of the amount of the loan in the case of persons who later practiced in a shortage area. The Sen- ate adopted the guaranteed loan program-S. 934, 92d Congress, July 14, 1971. The House, however, upon representations from medical schools that the guaranteed loan program would "remove from the educa- tional institutions all judgment concerning the individuals to whom loans are made," successfully urged the House to delete the guar- anteed loan program. The conference committee struck the guaran- teed loan feature. The legislation as enacted continued the direct medical school controlled health loan program. We would urge reconsideration of the guaranteed loan program at this time, as it has particular meaning in relation to economically disadvantaged medical students, especially the loan forgiveness for service in a shortage area. HEALTH PROFESSIONS STUDENT LOANS The currently executive health professions student loan program- section 747 of the Public Health Service Act-which is due to expire on June 30, 1974, allocates loan funds to health professions schools solely on the basis of student enrollment without regard for the fi- nancial need of students enrolled. This formula is patently incapable of applying funds on the basis of need of students for financial aid and we support its discontinu- ance. No provision is made in the formula for allocation of funds to schools to accord extra funds for schools that enroll significant num- bers of low income background economically deprived students. PAGENO="0646" 636 In our view, the piesent health Professions loan program, as entlv constituted, has the least potential of all student financial aid plans to assist the low income background persons into which category many blacks and other minority students would fall, but who must be attracted iiito health piofessioiis careers. Accordingly, the committee must make choices between continu- in~.r. say, the low income background health professions scholai~hip program and the health professions loan program. We most strenu- Ousiv support the low income background scholarship program. While we support most of the various provisions relating to funding of health professions students and medical schools, we obviously feel that the most meritorious program is the low income background health professions scholarship program. As a matter of general philosophy, seen from underrepresented blacks, we find none of the administration's general observations as to an oversupply of health manpower applicable to the needs of minorities today. While perhaps someday such generalities will be supportable, the NMA continues to urge appropriate support for the particular issue of minority health professions development. Mr. Chairman, this completes my commentary. I appreciate the opportunity to appear today in behalf of the National Medical Asso- ciation and I would be pleased to answer any questions that you and the committee members may have. Mr. Roy. Thank you for the statement. I would like comments from the members of the panel on this question: Do you find sometimes that urban areas have a greater ability to pay, therefore inducing physicians to practice in those areas? Mr. DEWEY. Ability to pay, in the past, at least in Chicago, has not altered the distribution. Financial incentives have not caused doc- tors to return to the inner city. So it seems to me, at least, providing an ability to pay does not call doctors into au area. Mr. Roy. You think national health insurance may indeed exag- gerate the situation? Mr. DEWEY. It could, but I don't know. Mr. Roy. Dr. Madison. do you have any reflections on that concept? Dr. MADIsoN. I don't know why it should exaggerate the problem. I would like to hear Dr. de Vise on that. I certainly don't think it will correct it. Experience in other countries has shown that a na- tional program of health care financing will not correct it. Mr. DE \IsE. When you look at the effect of a program specifically designed to meet the demand for medical services on the part of low- income people, like medicaid, the effect was counter-productive in terms of physician distribution. What actually happened was that the market, demand for medical services was increased by billions of Federal dollars. Physicians could tap the Federal till, with the expansion of the effective demand for their services by one-fourth to one-third. Physicians were then able to go in even larger numbers to urban areas to which they had been gravitating before. There was one hope that that market would reach its saturation point. The full saturation of the private and public market would presumably en~ the subsidy which was relocating physicians to doctor-rich areas. PAGENO="0647" 637 What will happen with national health insurance is that the middle class and the lower-middle class will now also get. some subsidies in medical services, so we don't even have a case where a program is designed to underwrite health care for poor people. This will under- write services for middle class people who are already getting more services than poor people. To the extent that national health insurance will rel)reSent a con- tributioii to physician income by the Federal Government of 50 pereelit as compared to 23 percent now, physicians will be able to go in even larger iuimbe.rs to the areas they prefer. For another 5 or 10 years we will have a continuing flight of physicians from the Middle West and other parts of the United States to the East and the West Coasts, until saturation of the expanded demand for pliysi- cian services. Dr. COOPER. I would like to comment, because I think there are two undercurrents that iinclei'lie this, particularly as to minorities and poor people. The exodus which has occurred has been chiefly in white areas. TheY black physicians are bludgeoned with the idea that their primary goal in life is to treat black patients. On the other hand, as the dollar flows, so does the flow of physi- cians. That is an economic thing, as distinguished from a medical thing. When there was that influx in terms of black physicians, it really was not a numerical influx, but what it meant was that physi- cians were suddenly being paid for 50 percent of the I)atientS they saw. So what we have to deal with is a racial thing on one had and the economic thing on the other hand. Mr. Roy. This situation is likely to come before our courts. J)m~ COOPER. W~e have been aware of that since the de Fun~s suit. We have not taken a position as to the possibility of suits that might issue based on economics more so than race. We are attempting to get. over that hurdle to the point where we can sort out the race as op- posed to economics. housing patterns, those kinds of things. The issue cont blues to be clouded as to what is race and what is ceo- liOlfl i CS. Mr. Roy. I am not disagreeing with you in that sense. But if a case such as this came before the court and they ruled that the medi- cal schools couldiit. admit students who were not fully qualified. wouldii't this decrease the number of blacks in training because of the time lag necessary to get more qualified black students at high school and college level? 1)i. COOPE1~. Let me answer that iii this manner. On the one hand. and project 1973 has already developed a list of some 5.000 minority students who (oul(l negotiate the. niedical school curriculum, it is not a matter of curricula, it is an attitude problem on the part of medical schools. I reference one program in particular, the Barnham program in ~ew York. which has no trouble coining up w-ith bright scholars every year. I donUt think that is wholly the problem. On the other hand, if we could get some relaxation and help in terms of what medical schools themselves might do. like the Morehouse School in Atlanta, we could deal with some of them. Mr. Ror. I think you gentlemen have done an excellent job of out- lining the problems facing us. Do any of you, except possibly Dr. PAGENO="0648" 638 Madison, who made the one suggestion, have one, two or three points or solutions which you think might be used to overcome what are apparently increasing problems? Mi. 1)1: ~IsE. I suggest that the. distribution problem can't be tackle.d by increasing production nationally or even production by the States which now suffer manpower shortages. Minority recruit- ment. does not work because blacks too, gravitate to both coasts; 15 percent of black physicians go to California, only 2 percent go to Illinois, even though there are more blacks in Illinois than in Califor- nia. Medical students from rural areas likewise tend to locate in urban areas. Mr. Roy. Our retention rate in Kansas is about 40 percent. So where this has to be effected is at the site of practice in the National Health Servic.e Corps. As it is now designed, it is not well enough organized to supply the areas that need to get doctors. Are you familiar with the bill I introduced ? Mr. DE VISE. Yes, I am. Mi. Roy. You think this offers a possible solution? Mr. DE `\IsE. Yes; it is an improvement in being an open-ended appropriation: you are not restricting the authorization to $38 mil- lion in fiscal 19Th as does the Rogers bill. It offers a better potential in the kind of programs which have been provide.d, and especially in the kind of programs that could be established to receive such stu- dents. Tha.t is what is lacking now, deficiency eithe.r in the criteria de- termining what is a medically underserved area or in .the mechanism to attract and retaiii medical graduates. The program needs to be beefed "p so that all eligible areas can participate. Mr. Roy. Anybody else? Dr. COOPER. We would support the National Health Service Corps pro am as one goal to be achieved. But particularly what you have to address yourself to is that you have to work on both the front and the return end to be successful. That is what we would propose, strong efforts in recruiting as well as incentives to return, if no more than a forgiveness kind of feature. Mr. DE VISE. Actually. I would look upon the components of a lmealt.li insurance bill such as the HMO as important: Making it a very major provide.r under national health insurance, then havin certain priorities where. HMO's are to be located_this, I think, woul be a more basic solution. But I appreciate this is not under considera- tion by this committee. Mr. Roy. Are you aware of any health insurance bill which insures adequate physician distribution? Dr. COOPEI~. Do you remember way back when the legislation was drafted, it said it. would be incentives for lIMO areas? Somebody politicked that away and decided it would be for lIMO's serving those communities and it took away from the hEW some 110. I know of one in t.he country located in a low-income area. There is no reason to locate an lIMO in a low-income area. Mr. Roy. The problems of unevenness can only be influenced to a very limited extent by changes in the educational programs. It is my understanding that Dr. John Cooper agreed with this. Dr. M~DIsox. I agree. I think the problems is rather one of the PAGENO="0649" 639 kinds of institution that are in rural communities. A permanent in- stitution for delivery of medical care has recruitment built in. Mr. Roy. Permanent institutions-are you speaking of permanent health care or educational institutions? Dr. MADISON. Medical care institutions, I recall talking to a public health nurse in a small North Carolina town who ticked off eight doctors who had been in that town one at a time, over the last 15 years. Whenever one left and the next one came, there was no insti- tution for him. He had to build his own, had to make new records, hire new staff, new financing, and so on. We have to think of alternative practice organization that will tend to be permanent in the community, that may be community- owned, that might be part of a larger network from a major medical care source. When a particular individual leaves, that is, a health practitioner, it shouldn't be that critical, because the void will be felt and then filled by a permanent institution which remains in the com- munity. Mr. Rot. I respectfully disagree with about 90 percent of what you say. Dr. Franklin Murphy some 30 years ago thought it proper tered throughout the State and have not had continuing institu- ions in the sense you are speaking of. And, I understand in the Scandinavian countries there has to be some kind of bonus to get physicians out in the less desirable rural areas. Do you have any response to my disagreement? Dr. MADISON. Yes, in Dr. Murphy's Kansas plan the physicians were not to be recruited by the hospitals as staff. They were recruited to be enterpreneurs who would open their own practices. The physi- cian's practice was a temporary institution. The hospital was there as an attraction, for his convenience, for him to use, and it was permanent. But it was never meant to be the definitive institution in the community for the practice of medicine. Mr. Roy. J honestly don't understand what you are talking about. Dr. MADISON. I am talking about the usual system of medical prac- tice in rural America, where every physician, when he enters practice, forms an organization, an institution, which is his own private prac- tice. When he leaves, his practice goes with him. The problem might be partially corrected if the practice organization did not go when the doctor left. For example, when there is a three-physician rural group practice and one doctor leaves, and there are two left, the re- maining two feel the void within their institution; they concentrate all of their energy on recruiting a replacement, and replacements usually come. Mr. Roy. I would say a replacement does come more often than not, but I could cite to you thousands of places in this country where there ale groups of physicians who can~s recruit additional physicians Do you disagree? Dr. M~uIsoN. I would not disagree that many groups have trouble recruiting, but it is far less likely to be a problem for them than it is for the rural community that has no existing organizational frame- work for practics. In preparation to coming here, I picked out the eight rural counties in the State of Kansas which show the most favorable physician-population ratios. Then I went to the AMA's PAGENO="0650" 640 listing of group prac~ ice in the United State, 19G~. They haven't pub- I shied a new one since then. Mr. lh~. And we are all wondering why. I )r. ~I:~aIsox. I found the thing in common that I anticipated find- ing. in all of those eight counties there was cii organized group plu(1t ice of at least eight ph sicians. Mr. R iv. Why should the medical school take the responsibility for the continuity Dr. M~DIsex. I think the medical school could follow its residents, for 1-extra year offering the same kind of supervision and help in estab] ishling practice that. the resident received in his clinical train- ing when lie was on the wards. Possibly the medical school could develop one or two demonstrations. In general, they might follow I lie example of the land grant agriculture colleges, amid become as concerned with piuctical application of the art of medicine as they have been in the further development, of the basic science and tech- liology of medicine. If the medical schools were to accept such re- spoliHbil itV. 1 be! leve ]t \volIl(l help solve the rural medical care prob- lem. But I dont. know how much they would be willing to help with- out a push. Mr. Roy. Should national health insurance pay physicians in under- served areas or undesirable Places more than they pay those in areas with adequate numbers of Physicians ? J)r. Manisox. I do not think that would be necessary, nor would it contribute particular to the solution. Mr. DE \ismi. Let me offer an answer. Medicaid does provide this incentive, and it does not. work. In the Chicago area, it is possible for a graduate to make ~00.000 a year on medicaid. There are fewer than 130 physicians who substantially participate in the program, and they collect. from the State an average of about $100,000 a year, with about 2() to ~5 l)e1~elit of them making $200.000 a year. As we look over the years, we find out they generally stay in the program until they learn English, then the ~200.000 is not enough to retain them; they will settle for $50,000 a year in the `middle income white suburbs shunned b U.S. graduates. 1)r. Coopi;jt. That is mint true of the black physician. Mr. DE \JSE. Generally the black physicians can't `make it physi- cally. They tend to be older and would have to see about 80 patients a dcv to earn this hi~ money. I)~. Coocru. The g~iv iii the suburb pays the usual and customary fee. so consequently you have to have those tradeoffs understood to lmndleistalid what goes on. Mr. Roy. 1)oes the National health Service Corps have to pay physicians more than they can earn outside the National Health Serv- ice Corps? These ame not suggestions I am offering, but I am trying to look for alternative because the alternative haven't been great in number, at least so far. Mr. I )r:wm;y. It seenis to mile that what the physicians can make in income is not the critical factor. I don't think raising his salary by a slight amount will draw a doctor to a particular location. Mr. Roy. I will ask whether the panel agrees with your statement. Is there any way to pay a ph sician enough money to overcome the drawbacks of less desirable locations? PAGENO="0651" 641 Dr. CooPER. If you put it on the front end. Mr. Roy. With service as a quid pro quo? Dr. COOPER. Right. But if you put it on the tail end of it all, they can make us much money anywhere they are going. Mr. DEWEY. That is what I was saying. The little difference they would make is not essential. Mr. Roy. Do you anticipate States `may refuse licenses to physicians to practice in already oversaturated areas? Mr. DEWEY. When you begin to talk about a 16 to 1 differential in physician/population ratios in one city, when the magnitude becomes that great, then stronger measures seem necessary. Perhaps when the disparity between ratios gets too wide, then withholding licenses is doctor-rich areas until the doctor-poor areas can catch up may be the only way to adjust such extreme situations. So I see that as per- haps an alternative. Dr. COOPER. I don't see States dealing with that, and I certainly don't know of any Federal regulation allowing this. Mr. Roy. I agree, no State is going to cut off the supply of physi- ci ans. I was very interested in Dr. Madison's statement, your first con- elusion, that the rural de~cit has been a recognized fact and a focus of concern for at least five decades. I presume there have been volun- tary approaches t.o solving this. Have any been successful? Dr. MAI)Isox. None have been sucessful in reversing the trend to the point that it would show up in the distribution data. There is some equivoeal evidence as to whether or not some of these approaches have worked, but certainly none of them have been strikingly suc- cessful. Mr. Roy. I will ask each member of the panel this: Why should we do less than we do in the bill I introduced? Mr. DE VIsE. We should do more. Dr. COOPER. Clearly. Mr. DEWEY. WThy should we do less? Mr. Roy. Yes. In other words, this committee is going to be con- sidering these bills and it appears there is a possibility we will go back to our old, tired recommendations. Our first witness made the statement, `~old, tire(l recominciudations." Mi. DE \isr. I would suggest a shift from institutional subsidjes to student subsidies. Medical schools can get all this money just for having students, regardless of where the graduates locate their prac- t.ice. But if this assistance went directly to the students as forgiveness loan in exchange for service in cloctoi-short areas, it would be much better use of public money. Dr. Coorra. You asked a question earlier as to the value of educa- tion doing this. That brings up a broader question of what the medical schools are out there to do. Medical schools have a role in providing a solution to these problems. What we have are medical schools which are responsive to `~business as usual." rather thou prescribing solu- tions to problems. To the extent that medical schools, in this instance the health schools and the universities at large, will perform the necessary train- ing. then 1 see no reasoii to continue to invest in the universit. That is where we are in a nutshell in the whole medical education ques- PAGENO="0652" 642 tion. If doctors are to diagnose and treat disease and this is all, fine, but then don't look to the medical schools to answer your prob- lems about distribution. Mr. Roy. You think the AMA ought to work on it? Dr. CooPER. I really wouldn't like to comment on that. Mr. Roy. Would anybody? Dr. MADISON. I would like to correct my answer to the last question you put. to me. There is one type of method, I think, which has been very successful in correcting the maldistribution problem. Those approaches that are based on coercion, either direct or indirect have worked rather well. The Indian Health Service has been able to place medical person- nel in its service position, most of which are located in parts of the country that are raised in the extreme. They have done this through indirect, conscription. This approach has worked for the army and the ~ationa1 Health Service Corps, and for other countries that have used it. I think that is a proven method. Mr. Roy. I have been in the habit of quoting Senator Stennis say- ing. "We will have an all-volunteer army when we draft it." I would say this is analogous to that problem. I think you outlined the prob- lem. I am impressed with the 50 years of effort to overcome the shortages and the record of that 50 years. Thank you for appearing here today. Your testimony has been most helpful. Our next witnesses are Dr. Joseph L. Dorsey, Medical Direc- tor, Harvard Community Health Plan, Dr. John P. Bunker, pro- fessor of anesthesia, Stanford Medical School, visiting professor, Department of Preventive Medicine, Harvard Medical School and Di'. Gerald Weber, acting associate professor, Childhood and Govern- rnent Project, School of Law, University of California. We thank you gentlemen for coming and for waiting. We look forw~nd to your testimony. I understand, Dr. Weber will make the initial presentation. STATEMENT OF PANEL CONSISTING OF GERALD I. WEBER, PH. D., ACTING ASSOCIATE PROFESSOR, CHILDHOOD AND GOVERNMENT PROJECT, SCHOOL OF LAW, UNIVERSITY OP CALIFORNIA, BERKELEY, CALIF.; DR. JOSEPH L. DORSEY, MEDICAL DIRECTOR, HARVARD COMMUNITY HEALTH PLAN, BOSTON, MASS.; AND DR. JOHN P. BUNKER, PROFESSOR OF ANESTHESIA, STANFORD MED- ICAL SCHOOL, VISITING PROFESSOR, DEPARTMENT OP PREVEN- TIVE MEDICINE, HARVARD MEDICAL SCHOOL, BOSTON, MASS. Mr. WEBER. I appreciate being invited to appear before the com- mittee this afternoon. I would like to present an updated summary of the study I prepared ~ years ago on .the Distribution of Physicians Amongst Specialties. A copy of that paper will be provided for the I'C(O1(i ( s~e p. G46) I have been asked to especially focus my comments on the past trends in the specialty distribution, the development of residency positions in the various specialties, and the likely status of the specialty distribution during the next decade. Upon completion of PAGENO="0653" 643 my overview, I will discuss several factors which I feel should be given serious consideration in your development of policy in this area. GENERAL TRENDS IN THE DISTRIBUTION AMONG SPECIALTIES There is little precision in the meaning of specialization either for statistical and planning purposes or for the information needs of consumers. I go into that problem in detail in my paper. The num- bers I will use are based on survey data collected by the American Medical Association and depend on the individual physician to de- note his area of specializwtion. Many physicians indicate that they provide services which can be categorized under several specialties. The published compilations refer only to the primary specialty so that the actual distribution of effort may differ considerably from that portrayed in the available data. In 1949, there were a total of 173,000 active physicians in the con- tinental United States, excluding interns and residents. Nearly 63,- 000 physicians, 36 percent, reported that they limited their practice to a specialty. Almost half of the full-time specialists concentrated in a surgical area and 31 percent were in medical specialties. An addi- tiona.l 14 percent of all physicians were part-time specialists, more than three-quarters in surgical specialties, while 50 percent of all physicians considered themselves to be general practitioners. By 1960, there were 203,000 active physicians in the 50 States, Washington, D.C., Puerto Rico, and outlying areas, excluding in- terns and residents. Almost 117,000, 58 percent, were full-time spe- cialists. Nearly 41 percent of those specialists concentrated in a sur- gical area and 33 percent were in medical specialties. The number of physicians who considered themselves to be general practitioners had declined to 36 percent. In 1970, there were almost 260,000 active physicians in the United States and possessions excluding interns and residents. Only 55,000, 21 percent, indicated that they were primarily in general practice. Almost 31 percent of the specialists were in the medical specialties while about 35 percent were in both surgical specialties and other specialties-anesthesh~logy, radiology, pathology, psychiatry, et cetera. The proportion of physicians in psychiatry and neurology had increased to 8 percent from 2.5 percent in 1949. For the reasons noted earlier, data on specialty distribution may not be very accurate. However, the broad trends since 1950 provided by the data can certainly be accepted. Provideis of plirnaly care-~en- eral practice, internal medicine, and pediatrics-increased from about 103,000 to about 104,000 during the two decades. There was an increase of only 12,200 physicians in the other medi- cal specialties as compared to increases of 41,000 in the surgical spe- cialties and of 56,000 in other specialties. The impact of this tre- mendous change in the nature of physician manpower in a mere two decades has not been evaluated and is certainly not well understood. I\Ioreover, the trend is reinforced when we. look only at physicians in office based practice. Primary care physicians in office based prac- tice actually declined from about 99~000 to around 85,000 between 1963 and 1971 according to the published data. While a considerable PAGENO="0654" 644 part~ of that decline may be due to adjustments in the AMA classi- fication procedure which took place in 1968, I am confident that the (1i1ection of movement is correct. GENERAL TREND IN RESIDENCY TRAINING Most formal preparation for specialty practice is undertaken in the residency training programs. It is true that changes are taking p}a(~e on both sides of the residency. There has been a rapid increase in the numbe.r of internships which focus on a particular specialty, with the. consequent reduction in the rotating internship. Similarly, fellowship programs which provide additional specialty training have been expanded. Nevertheless, my discussion will focus on the offering of residencies and the choice of residency with special atten- tion on the general trends of the last two decades. There were slightly more than 19,000 residencies offered in the Inited States in 11).~O. Only 75 percent of the residencies offered were filled. In fact, of the major specialties, oniy general surgery and pediatrics were able to 1111 more than 80 percent of the available posi- tions. General sur~rerv attracted ~1 ~ of all residents while in- ternal medicine had ~0 percent. Foreign medical graduates filled Sii~iltlV hss than 10 percent of all positions. Dv l9G~. tile number of residencies offered had increased 70 per- cent, almost reaching 33.000. Almost 88 percent of the residency posi- tions were filled and foreign medical graduat.es-FMG--were in more than ~S percent of the filled positions. Tile major increase in the relative. diSt.ril)ution of residents (luring the deca(lc from 1930 through l9~1) occurred in the. specialties of pathology and psychiatry. There was an additional 44 percent increase in the number of resi- dencies olleied during the decade between 1960 and 1970. Almost 17,000 first. year residencies wercav ailable in 1970, but there were only S.307 graduates of F.S. miiedic.al schools. Thus, although 85 prce~it. of the iehdencies were filled, FMG's were in 33 percent of those positions. fiie oiiiv specialty which showed a Slil)St.antial m- cicase ni tile 1)loport.ioII of a~i trainees ~t attracted WaS Ia(liologv. Sham declines in the relative proportion of residents occurred in general surgery and oh.-gvn. Important. tren(ls may halve been iiiitiat.e.d in tile first years of this decade. More than 9.501) additional hospital residency positions were available for the 11)74-75 year than for the 1970-71 year. About ~ percent. of that increase was in family practice and general prac- tice resicleiicies. however, only 60 percent of all residencies in those specialties were filled in 197~. as compared to 88 percent for all residencies. Also, about ~.) perce~it of family practice and general practice residencies ate in hospitals not afliliateci with medical schools as opposed to nine. I)eIeellt. of all resl(lencies. Slightly less than 2,000-~0 percent- of the. ~n(reaSed residencies were ill internal medicine. P1~OJECTE[) DEVELOPMENTS iN SPECIALTY DISTRIBUTION Given tile current distribution and absolute number of physicians in specialty training, a continued relative increase in the number of nonprimarv care specialists can he expected. Simply put, the primary PAGENO="0655" 645 care specialists made up 46 percent of patient care physicians ex- cluding interns and residents in 1072. but the primary care special- ties only had about 35 percent of the first-year residencies that year. rUm trends toward relatively faster ~rowt.h in residencies for the primary care specialties should help. However, the number of resi- dents in those fields would need to be more than doubled in order that the current relative ratio of primary care physicians be main- t a i iiecl. CONCLtDING T~EMARXS Public intervention to afiect the specialty distribution will require an objective.. The determination of this optimum may be the most difficult task facing the policymaker. Unfortunately, there is little hard evidence available to aid in the decisionmaking process. Two operational procedures Ii ave been suggested for planning purposes. One procedure is to use the experience of large group pi'actices which are responsible for providing care to given popula- tions. To the extent. that these groups have an incentive to provide ~rood quality care in an efficient manner, one would expect them to use an efficient distribution of specialists. However, they are faced with relative income patterns of physi- cians determined outside their system, the relative shortages of the overall system for physicians in certain specialties, and 1)hySicians trained in the general patterns of care. Moreover, the J)repa.id group practices which are usually used for comparisons have memberships which vary in demographic and socioeconomic characteristics from that of the general population and they do not have certain special- ists on their staffs but piiic.hase their services when needed. I am not satisfied with the guidelines which can he developed from the available data on staffing patteins of those organizations. A second1 procedure is to use projections of physician requirements based on epiclemiological studies of the distribution of illness. One recent application of this procedure was provided by the study of ~(honfel(l, ct al. Data on the incidence and piev~tT~ce of diseases and conditions requiring primary care were (levelOped from infonna- tion provid1ed by the National Center for Health Statistics while interviews with 1)ediatricians and mternists provided the data on the services required for each disease and the average amount of service time rec1llil'C(l per procedure. They concluded that there was a need for 133 physicians per I ( )0,00() persons for piinotIy care, as against the available supl)ly of about one-half as many. ~\ii additional factor making national policy difficult will he the variation in specialty distribution required in different geographical areas. States vary couisideiably in income levels, age distributions and their total stock of physicians. rfhie~fo~e. their requirements for dill eient sI)ecial~sts are not. similar. Current distributions show great variation. In 1970, the proportion of physicians in a State who called themselves general practitioners ranged from 14 percent in Connecticut, Maryland. and New York t.o more thaui 40 percent in Idaho, South Dakota, and Wyoming. The proportions iii psychiatry rangedi from less than 3 peice1~t in Ala- bama, Idaho, Montana, and Wyoming to more than 10 perceiit in Connecticut, Marylandl, Massachusetts. and New York. In contrast to my uncertainty with respect to the specific distri- PAGENO="0656" 646 bution which should be aimed for, I have considerable confidence in the following two statements. First, there is no doubt that there niust be a change in the direction that the natural flow is taking us. Second, the market forces, broadly considered, will not adequately ad- just the flow. Let. me briefly expand OH the latter. Residencies were developed as part of the hlosl)ital milieu while primary care should be outpatient oriel ited at id comm tin i ty based. Hospital administrators focus on the need for service iii their hospitals and the financial factor involved with residency pi'ogi~~ms. In county and mi.micipal hospitals, where interns and residents frequently piovide much of the medical care, the overriding factor is the need to provide service. Thus, subject to general financial constraints, the types of residencies offered are dic- tated by the hospital service needs. l~urtlle1Inore. chairmeii of departments at. medical schools fre- (j1l@litlv place i)1e~~~~e on the hospital administration anti deaii to untIl exi~aiisioii of their academic program. This is based on the de- site for status associated with large programs and the need to gain a.dditioiial hands to expand their service. If a department chairman is successful in attracting residents and patients, lie can place con- sideiable pressure 011 the hIosl)ital administrators to enlarge his resi- ikuit 1uota. There is 110 evidence that accrediting organizations and 1)Iotesslollai societies can or will adequately ~ian and control the gio~v iii of residencies. ill ((iflCllIsiOll. 1 suggest that this is an ideal time to introduce an eXl)IiuIded l)lIbhic role in the piocess. The substantial increase in mnedi- cal sd io1 gIa(lllates will provide a large enough pooi of physicians to aiiect tIle overall specialty distribution in a period of a few years. First \ear eiirolhi~ieiits at U.S. medical schools have already increased froni IP,-iOU in 19UP-T() to more than 14,000 in 1973-74. \ie.dicai schools and teaching hospitals are under increasing linan- cial pressure amid are, I believe, increasing their sensitivity to corn- niiuiitv an(l iiiitiomial needs. They aie very responsive to the monetary carrot anti are likely to be more accepting of reasonable and flexible controls. Finally, changes ill the delivery system are likely to im- prove the relative monetary rewards to the primary care physician. Thank you. [The study referred to follows:] Ax ESSAY ON THE DIsTnIrnjTIox OF PHY5ICIAXS AMONGST SPECIALTIES* (By Gerald I. Weber) INTRODTCTION An increased sensitivity towards the need for a public concern with the dis- triliution of physicians amongst specialties has evolved during the past year. To a great extent the large projected increase in graduates from United States medical schools by 19S0 has provided the impetus for this interest. There is an expression of fear that a simple enlargement of the number of practicing physi- cians will not overcome the alleged personnel shortages in the medical care delivery system. Instead, it is asserted that attempts must be made to direct physicians into specialties and to locations which currently have relatively little success in attracting them. The need for public intervention is suggested * The research for this paper was funded under a contract from Georgetown Univer- sity/DHEW-OS 171-71. Research assistance was provided by Robert Berry and Mahia Ong. PAGENO="0657" 647 because of the large role of the federal and state governments in financing the expansion of undergraduate medical education and the expectation that market forces will not work in a manner to alleviate the distortions which exist. Unfortunately, there has neither been adequate conceptualization of the relevant considerations to be focused on in judging the optimum amount of specialization nor the required empirical analysis. Judgments are being made on the basis of untested hypotheses, a smattering of small sample surveys with varied possible interpretations, and biased opinion. In this report I provide an introductory effort at conceptualization and empirical analysis of several issues and topics relevant to the specialization question. It is hoped that direction will be provided to the efforts which should be made to clarify this issue in the near future. THE MEANING OF SPECIALIZATION Specialization refers to the concentration of physicians practice on a par- ticular type of illness (Dermatology), a particular part of the body (Oplithal- mology), a limited age group (Pediatrics), or to a specific set of services (Anesthesiology). Today, most specialization occurs through a specified amount of training of the physician in residency programs. However, in the recent past much specialization simply evolved as the generalist physician took a limited amount of post M.D. training and then concentrated his area of services and continuing education. There is little preciseness in the meaning of speciali- zation either for statistical and planning purposes or for the information needs of consumers. Many physicians, when surveyed by the American Medical Association, indicate that they provide services which can be categorized under several specialties. The published compll~ations of the distribution of physicians amongst specialties refer only to the primary specialty so that the actual dis- tribution of effort may differ considerably from that portrayed in the available data. In addition to the self denotation of the AMA surveys, there are a number of institutional arrangements which provide information on the extent of specialization. There were 123.101 physicians certified by one or more specialty boards as of December 31, 1971. This was slightly more than one-third of all physicians. Board certification is an indication that the physician has completed a residency program of specified length, has passed the examinations required by the relevant board, and has satisfied the practice experience requirements of many boards. In recent years, the specialty boards have attempted to clarify the difference in their certification from that of licensure. Quoting from the Approved Directory of Internships and Residencies: "The boards are in no sense educational institutions, and the certificate of a board is not to be considered a degree. It does not confer on any person legal qualifications, privileges, nor a license to practice medicine or a specialty. The hoards do not in any way interfere with or limit the professional activities of a licensed physician, nor do they desire to interfere in the regular or legitimate duties of any practi- tioners of medicine." 1 This is an apparent change from the earlier approach of the boards since it has been reported that in 1940 five boards specified that 100 percent of the applicants' practice should be devoted to the specialty, as defined by the board, and three boards demanded at least 70 percent concen- tration.2 In 1971, the proportion of self defined specialists who were board certified varied from 43.1 percent in internal medicine to 90.6 percent in otolaryngology.3 Physicians who have satisfied varying requirements by the different boards to be eligible to take their examinations are specified to be "hoard eligible." However, as one board has indicated in the recent Directory of Approved In- ternships and Residences. "The Board decries the usage of the term either by th candidate or any organization in such a way as to imply that having received notification that he has been accepted for examination the candidate is now possessed of some special qualification which is more or less equivalent to certification."' American Medical Association, Directory of Approved Iuternships and Residencies, j971-7?~, p. 3~O. 2 Rosomary Stevens, American Medicine fInd the Public Interest, Yale University Press (1971). P. 24G. 8 Henry II. Mason, "Manpower Needs by Specialty," Journal of the American Medical Association (March 20, 1972), P. 1621. `Ameriean M~dieal Association, Directory of Approved Internships and Residenclea, 1971-72, p. 354. PAGENO="0658" 648 Many I)hysicians are members of national scientific societies. These organi- zations tend to concentrate on an educational role. In most cases, no proof of Competence is required to join a society. There are 300.327 members of these scientific medical societies including many multiple memberships. Over one-third of the physician membership be- longed to six organizations. They were the American Academy of Family Physicians, the American College of Surgeons, the American Psychiatric Association, the Amimerican College of Physicians, the American Society of Internal Medicine, a mid the American College of Obstetricians and Gynecologists.6 The diffusion in tile meaning of specialization might be best illustrated by a 1)artidular example. A survey of psychiatrists was carried out by the American Psychiatric Association and the National Institute of Mental Health in 1965.° The basic survey population was all physicians who had reported to the American Medical Association that their primary specialization was in psychia- try, child psychiatry, or neurology. Of the 12.153 respondents (excluding trainees) who had reported that they worked one or more hours providing direct psychiatric services, 75.1 percent reported 3 years or more of residency training, 21.0 percent rel)orted less than 3 years of residency training, and 3.4 percent failed to respond to the relevant question. Thirty nine percent of those particular respondents were Boam-d certified and 72.5 percent were members of the American Psychiatric Association. It should be noted that 8.9 percent of all respondents reported that they had no residency training in psychiatry. A final factor which might provide consumers information on the capabilities of a physician in a particular specialty is the ability of the physician to gain access to a hospital. Although open access is generally preached, many hos- pitals will restrict the use of their facilities to doctors they consider to be properly trained and who satisfy minimum levels of ability. With an increasing dependence of physicians on hospital privileges, there is increased pressure on them to attain the residency training and board certification which would guarantee their acceptance by hospitals of their choice. If the federal government is going to intervene to affect specialty choice, much better information should be collected on the types of service provided by different physicians, their areas of concentration, and their relative abilities to treat different illnesses and to provide preventive care. Additional analysis should be done on AMA data which has the hours of effort physicians allocate to their primary and secondary specialties. However, care must be given to any results from physician self designation. The area of consumer education is very sensitive. Whereas there can be little doubt that they are confused by the meaning of specialist in the current en- vironment, we do not have adequate knowledge of the relative capabilities of physicians to perform most services to greatly improve their choice patterns. Serious evaluation should be made of the impact of Mr. Dennenberg's attempts to educate the consumers of medical services in Pennsylvania in his pamphlet, "14 Rules on How to Avoid Unnecessary Surgery." GENERAL TRENI)S IN THE DISTRIBHTION AMONG SPECIALTIES In 11)49, there was a total of 173.129 active p1hysicians in the continental United States. excluding interns and residents. Nearly 63.000 physicians (38 percent reported that they limited their practice to a specialty. Almost half of the full time specialists concentrated in a surgical area and 31 percent were in medical specialties. Only 2.5 percent of physicians limited their practice to psychiatry and neurology. An additional 14 percent of all physicians were part time specialists, more than lhree-quarters in surgical specialties, whitme 50 per- cent of all physicians considered themselves to be general practitioners.7 By 1960, there were 203.307 active physicians in the 50 states. Washington, D.(~.. Puerto Rico and OutlyinE areas, excluding interns and residents. Almost 117.1)00 (58 percent) were full time specialists. Nearly 41 percent of those specialists concentrated in a surgical area and 33 percent were in medical \niericnn Medical .Assoe!atlon. The Profile of Medical Practice (1972 editIon), p. 32. National Institute of Mental Health. The Nation's Pgychiatrists, 1969. 7 Paul Q. Peterson and Maryland V. Pennell, Health Manpower Sourcebook: Section 14 (Medical Specialists) FSGPO (19621, PP. 7-10. PAGENO="0659" 649 specialties. The proportion of all physicians limiting their pra~iice to p~ychia- try and neurology had increased to 4.8 percent. The number of physicians who considered themselves to be general practitioners had declined to 3G percent.8 1ii 1970, there were 250,617 active physicians in the United States and possessions excluding interns and residents. Only 54,938 (21 percent) indicated that they were primarily in general practice. Almost 31 percent of the special- ists were in the medical specialties while about 35 percent were in both surgical specialties and other specialties (anesthesiology, radiology, pathology, psychiatry, etc.). The proportion of physicians in psychiatry and neurology had increased to 8 percent.° For the reasons noted earlier, data on specialty distribution may not be very accurate. However, the broad trends since 1950 provided by the data can cer- t;iiuly be a(('epted. Providers of I)riulaIy care (general practice, internal medi- cine, and pediatrics) increased from about 103,000 to about 104,000 during the two decades. There was an increase of only 12,200 physicians in the other medical specialties as compared to increases of 41,000 in the surgical special- ties and of 56,000 in other specialties. The impact of this tremendous change in the nature of physician manpower in a mere two decades has not been evalu- ated and is certainly not well understood. THE OPTIMUM DISTRIBUTION AMONG SPECIALTIES Public intervention to affect the specialty distribution will require an objec- tive. The determination of this optimum may be the most difficult task facing the policymaker. Unfortunately, there is little hard evidence available to aid in the decision-making process. As indicated earlier in this paper, physicians in a particular specialty have greater training and experience in providing certain services than specialists in other fields and general practitioners. They also are likely to have superior knowledge of potential treatments and their effects. The optimum distribution of physicians among specialties (including general or family practice) will depend on the mix of illness among the population, the relative success of various specialists in treatment (including preventive care) of those illnesses, the relative negative impact of the illnesses, and the costs involved in the additional training of specialists. Of course, the ability of patients to find the proper specialist for their needs under different aggregate mixes must also be taken account of. According to this framework, the frequent assertions that there is a maldistribution of physicians among specialties would imply that: (A) Services are being performed by physicians in a specialty which have a negative valuation. Excess surgery falls into this category. (B) Services are being performed in one specialty which are less valued in some sense than those produced by physicians in another specialty. The impli- cation that there should be relatively more primary care physicians is a case in point. (C) Services are being performed by physicians in one specialty which could be performed as well by a physician in another specialty which requires less training. The case of neurosurgeons performing general surgery would be absorbed here. (D) The value of the improved output produced by a specialist with addi- tional training is not equal to the costs of his training in terms of his output foregone, if any, and demands on thejime of teaching faculty. Criteria B, C. and D are difficult to make operational. There is some hard evi(lence that criterion A is true and the efforts of tissue committees and utiliza- finn review committees are attempts to alleviate the distortions which follow from it. It may be that efforts focused on improvement in the process of pro- viding medical care combined with the choice patterns of physicians will work as well as direct intervention into specialty determination. However, there are also serious defects in the market model which I will focus on later. The operational procedures available for planning purposes fall into two categories. One procedure is to use the experience of large group practices which are responsible for providing care to given populations. To the extent ~T.N. Hang. G. A. Roback. and B. C. Martin, Distribution of Physicians in the Unitcd States, American Medical Association (1971). as-09S--74-pt. 1-43 PAGENO="0660" 650 that these groups have an incentive to provide good quality care in an efficient manner, one would expect them to use an efficient distribution of specialists. However, they are faced with relative income patterns of physicians deter- mined outside their system, the relative shortages of the overall system for physicians in certain specialties, and physicians trained in the general patterns of care. Moreover, the prepaid group practices which are usually used for comparisons have memberships which vary in demographic and socioeconomic characteristics from that of the general population and they do not have certain specialists on their staffs but purchase their services when needed. Nevertheless, information from prepaid group practices do provide a baseline for comparison. A paper by Henry Mason recently compared the distribution of physicians in six major prepayment groups with analogous physician I)OPula- tion ratios for individual states.1° The prepaid groups included the relatively small Puget Sound and Group Heath Association programs, several of the Kaiser Permanente regional groups, and the HIP program of affiliated groups. Each of the sample groups had one internist or family practitioner for between each 2000 and 3000 enrollees in the prepaid practice. For the whole country there was one for each 2100 pojulation. The plans generally had greater physi- cian population ratios for dermatologists, obstetricians and gynecologists, and pediatricians than the median state ratio. They had lower ratios for general s'pery. ~ litha In 1 ay. ~yel1ia t cv. a ml ra Ii ~l gv. ~l Tuhl a r ia ti us were found for a nesthesiologists. arthopedists. and otolaryngologists. A second procedure is to use projections of physician requirements based on epideniiologicil studies of the distribution of illness. One recent application of this procedure was provided by the study of Schonfeld, et al.1' Data on the incidence and prevalence of diseases and conditions requiring primary care were ileveloped from information provided by the National Center for Health Statistics while interviews with pediatricians and internists provided the data on the services required for each disease and the average amount of service time required per procedure. They concluded that there was a need for 133 physicians per 100.000 persons for primary care, as against the available supply of about one-half as many. Tli e nuzrl:ct and speciulty di.stribation One procedure the government can follow in determining the distribution of physicians amongst specialties is to simply guarantee that all prospective practitioners are able to get training in the specialty of their preference. Taking account of the non-pecuniary aspects of each specialty, the personal attitudes of the physicians. and the variation in the length of training, they would choose according to the relative expected incomes. The question which then arises is to what extent incomes reflect the relative needs for different specialists. Data from the most recent AMA survey indicates that surgeons earned S4~.S4S in 10t~0 compared to net incomes of $34,734. $33,916. and $31,812 in general practice. psychiatry, and pediatrics, respectively.'~ Furthermore, there was a rapid rise in the net income of surgeons of 12 percent from 1968 to 19ui9. If t.he relative levels of income and changes in relative income are indica- tions of relative value of services, an increased relative expansion in the num- ber of surgeons would be optimal. However, the validity of that relationship must. he questioned. To start with, there is generally a longer period of training required of surgeons. More surgical than outpatient medical services are covered by insurance. Therefore, the connection between payee valuation and relative purchases of service may be small. Of even greater import, there is little reason to believe that consumers have an accurate perception of the value of different physician services in improving their health status. To a larre extent they must depend on the advice of physicians which provides the latter with considerable potential to control the demand for their services. It appears that skills which seem to he of considerable difficulty to acquire and which are used in situations where patients seem to be faced with considerable ~0 Henry R. Mason. `Manpower Needs by Specialty," Journal of the American Medical Ae,qoriation (March 20. 1972). pp. 1621-1626. 11 Flvrnan K. Schonfeld, Jean F. Heston. and Isidore S. Falk, "Numbers of Physicians Required for PrImary Medical Care," The New England Journal of Medicine, (March 16, 1972), pp. 571-576. 1~ American Medical Association, The Profile of Medical Practice (1972 edition), p. 66. PAGENO="0661" 651 risks, will tend to be relatively Mghly valued even though other services may have greater impact. One of the primary benefits which will accrue from an expansion in the num- ber of providers who take responsibility for providing total care to populations will be an increased capability to acquire knowledge of the combin.ation of niedical resources which are most efficient in providing such care. The federal government should encourage the introduction of the information systems and research designs which would provide useful information for general planning purposes. In the meantime, it would be useful to study the factors which lead to rela- tive income differentials among specialists. Relative value scales suggested for the use in the distribution of physician fees usually do not apply across major specialty groupings such as medicine and surgery. Furthermore, they are based on the actual charges determined by individual physicians. There is no indica- tioii that they bear any relationship to the effectiveness of services provided. Finally, I would suggest that relevant information might be derived from the experience of state medical societies' placement efforts. The California Medical Society collects no information on the characteristics of physicians who request their substantial listing of available positions. RESIDENCY TRAINING Most formal preparation for specialty practice is undertaken in the residency training programs. It is true that changes are taking place on both sides of the residence. There has been a rapid increase in the number of internships which focus on a particular specialty, with the consequent reduction in the refuting internship. Similarly, fellowship programs which provide additional specialty training have been expanded. Nevertheless, our discussion will focus ~iu the offering of residencies and the choice of residency with special attention on the general trends of the last two decades and the differences amongst states. GENERAL TRENDS IN SPECIALTY TRAINING There were 19,364 residencies offered in the Tjnited States in 1950. In that year, there were only slightly more than 77,000 physicians in private prac- tice who either limited themselves to services of a specialty or paid special attention to such services. Only 75 percent of the residencies offered were filled. In fact, of the major specialties, only general surgery and pediatrics were able to fill more than 80 percent of the available positions. General surgery attracted 21 percent of all residents while internal medicine had 20 percent. Foreign medical graduates filled slightly less than 10 percent of all positions. By 1960, the number of residencies offered had increased 70 percent to 32.786. There were now 129,000 physicians at least giving special attention to a specialty. Almost 88 percent of the residency positions were filled and For- eign Medical School Graduates (FMG) were in more than 28 percent of the filled positions. General surgery (93 percent), obstetrics and gynecology (95 erc(clt 1. ophthalmology (96 nercent ) . orthionedic surgery 1 93 i ercent ) , ot laryngology (91 percent), and pediatrics (90 percent), were all able to fill 90 percent or more of their positions. However, the major increase in the relative distribution of residents during the decade from 1950 thru 1960 occurred in pathology and psychiatry. The former increased its proportion of total residents from 4.6 percent to 7.0 percent while the latter increased its proportion from 8.2 percent to 11.0 percent. Declines in their relative attrac- tion of greater than 1 percent occurred in general surgery, internal medicine, and pediatrics. The change in the number of residents in each specialty can he distributed among Increases in the number of residencies offered and the change in the proportion filled. There was a relatively rapid growth in residencies offered in anesthesiology, pathology, and psychiatry among the larger specialty areas dnrin~z the 1950-11J60 cle'ade. Ta nipa risen. ophthu! ni logy. orthepedic surgery. and otolaryngology had relatively slow rates of growth. However, this was parti~lly offset by relatively large increases in the proportion of offered posi- tions which were filled to high levels. There was an additional 44 percent increase in the number of residencies offered during the decade between 1960 and 1970. By the latter year, there PAGENO="0662" 632 were 46.00~ residencies offered and there were now 201,000 non-federal l)hSSi- cians concentrating on a specialty. Almost 17,000 first year residencies were available, but there were only 8,367 graduates of United States medical schools. Thus, although S5 percent of the residencies were filled, FMGs were in 33 percent of those positions. The only specialty which showed a substan- tial increase in the proportion of nil trainees it attracted was radiology, which had an increase from 5 percent to 6.8 percent. This was occasioned mainly by an increase of 52 percent in the number of residencies offered which was considerably more than the increases in the other specialties. Sharp dechnes in the relative proportion of residents occurred in surgery and ob-gyn. Important trends may have been set off in the first two years of this decade. Almost 5,000 more residencies were available for the 1972-1973 year than for the 1970-71 year. About 11 percent of this increase was in family practice and general practice residencies. Somewhat more than 1000 or 20 percent of the increase was in internal medicine. All of the surgical specialties showed relatively small gains. Affiliation During the decade from 1960 to 1970 major changes were evolving in the allocation of responsibility for residency training. The medical school was becoming the primary institution of responsibility either through expansion of its own programs or through affiliation agreements with hospitals who had previously acted independently in the provision of specialty training. Although there was the substantial increase in residencies offered, the number of ap- proved programs in almost all specialities declined. In 1960, there was a total of 972 non-affiliated hospitals offering residency programs. They had 15,032 positions and 12,752 of the positions were filled. By comparison, there were 352 affiliated hospitals with 17,588 positions and 15.604 positions filled. In 1970 only 590 non-affiliated hospitaLs had residency programs. There were 7,192 positions offered in these hospitals and 5,402 positions flUed. That compared to 38,811 positions offered and 33,818 posi- tions filled in 927 affiliated hospitals. During that year a much larger proportion of the residencies filled in the non-affiliated hospitals were in general surgery and psychiatry than in the affiliated hospitals. Foreign medical school graduates As noted above, 33 percent of all residents in 1970 were graduates of For- eign Medical Schools. They were distributed among specialties in a manner considerably different from that of United States graduates. In 1970, the FMGs were preparing for anesthesiology, pediatrics, and pathology to a con- siderably greater extent than their American and Canadian counterparts. Relatively few FMGs were in ophthalmology, orthopedic surgery, otolaryngology, and radiology. Wonmcn physicians An increasing number of women are being accepted into medical school. In the entering class of 1971, they were about 1675 or 13.5 percent of all first year medical students. This compared to the total of 1,778 female graduates of U. ~. and Canadian medical schools who were in residency training in 1970 These trainees were concentrated in psychiatry (21 percent), pediatrics (21 percent). internal medicine (17 percent), pathology (8 percent), and radiology (8 percent). The 2151 women graduates of foreign medical schools who were in residency positions had a somewhat different distribution among specialties. They emphasized anesthesiology, ob.-gyn., and pathology to a much greater extent. and they had a much smaller concentration in the fields of psychiatry and radiology. Only 3 percent of all the women trainees were preparing for the specialty of general surgery. Scfreticity of schools The underlying intellectual and personality characteristics and medical students combined with the environmental of their medical school to affect the specialty choice of the young physicians. Using unpublished data we computed distrihutions among specialties of physicians graduated from United States medical schools between 1955 and 1965 who were primarily providing direct patient care in 1971. The choice of specialty was cross classified with the PAGENO="0663" 653 selectivity of the medical school. The latter index was based on the average scores of the 1965 entering class on the Science section of the Medical College Admission Test. This tends to be correlated with substantial levels of federal funding support particularly for research. In both of the sample periods we looked at, 1955-1960 and 1961-196o, there was a considerably larger proportion of graduates from the low selectivity schools who indicated that they were primarily in general practice. However, larger proportions of graduates from the more selective schools chose internal medicine and other medical specialties than did those from the less selective schools. The other major differences appeared in the relative preference of the graduates from high selectivity schools for psychiatry. Implications Given the current distribution and absolute number of physicians in spe- cialty training, a continued relative increase in the number of non primary care specialists can be expected. if physicians in each specialty were equally distributed in each age bracket and we assumed a 3() year practice life on the average, a ratio of 3.5 new trainees in the field for each 100 J)hysicians (excluding interns and residents) would provide for a static iiumber in that specialty. In 1970 general surgery had 12.2 new trainees for each 100 physi- cians in that field. That was the largest ratio for any major specialty. Most specialists would be moderate growers but ob.-gyn., ophthaiuiology, and ito- laryngology face relatively slow growth. However, although internal medicine had 10.5 new trainees per 100 physicians, the combined primary care fields of general practice, internal medicine, and pediatrics have but 4.5 new trainees per 100 physicians. The differential growth of about 9 to 1 for gen- eral surgery relative to primary care for each 100 physicians in their respective fields more than offsets the current ratio of about 4 primary care physjcmans for each general surgeon. The trends toward relatively faster growth in residencies for time primary care specialties should help. However, the number of residents in those fields would need to be almost tripled in order that the current relative ratio of pri- mary care physicians to general surgeons be contiauetl. The increasing number of women in United States medical schools should be held to fill residency slots made available in the primary care fields. There were 1,674 vacant first year residencies in affiliated hospitals during 1970. More than 10 percent of those vacancies were available in internal medicine, in pathiogy, in surgery, and in psychiatry. An additional 3,227 positions in affiliated hospitals were filled by Foreign MedicaL Graduates. While internal medicine, pathology and surgery are a large proportion of those positions, pediatrics and anesthesiology also were relatively large. Thus, with no expansion in the number of residencies, there would have been alniost 5.000 positions potentially available to new T.~. graduates. Whet her these would have been of acceptable quality in preferred locations is another question. The geographical supply and demand for residencies There is considerable variation in the number of residents training in different states relative to the population, the number of hospital beds, and the number of patient care physicians. This is a reflection o the combined effect of the number of residencies offered in each state and their ability to attract residents. The number of residencies offered depends on the availability of large hospitals and the associated population to provide an adequate quantity and mix of cases to the physician in training. The existence of medical schools and their associated faculty increases the capacity to offer residencies and to attract trainees. The three states with the greatest number of residents relative to population were New York, Maryland and Massachusetts. Of course, the numbers In Maryland are affected by the National Iii~titutes of Health In gum ins in Bethesda. That state had more than 10 residents for every 100 hospital beds while New York had 8.6 residents for every 100 hospital beds. It also had 21 residents for every 100 patient care physicians while New York had about 20 residents for each 100 patient care physicians, Ia comparison, California only had 4.2 residents per 100 hospital beds and 9.7 residents per 100 patient care physicians. PAGENO="0664" 654 Of greater relevance to policy decisions are the trends in the number of residents in each state during the past decade. When the growth in the number of residents is allocated to the individual states, four states-Massachusetts, Pennsylvania, New York, and California-accounted for 52.2 percent of the increment between 1960 and 1965. From 1965 to 1970 the four states of New York, Illinois, Texas, and California accounted for 47.6 percent of the incre- ment. Those states had relatively large numbers of residents at the start of the decade. The fastest rates of growth actually occurred in other states. Of the states with greater than 100 residents in 1970. increases of over 50 percent during the decade took place in Rhode Island, Vermont, New Jersey, Florida. South Carolina. Alabama, Arizona, and New Mexico. However, the states of Iowa and Arkansas actually had fewer residencies filled in 1970 than in 1960. When the trend in residents is separated into American and Canadian graduates, on the one hand, and Foreign Graduates, on the other, some dis- tinct changes occur. Connecticut, Indiana. and Louisiana show a net decline in the number of F.S. and Canadian residents. However, of the states with greater than 100 residents in 1970 who had graduated from foreign medical schools, Connecticut, New Jersey, New York, Illinois, Indiana, Michigan, Florida, Texas and California showed greater than a 75 percent increase in positions filled by FMGs for the decade. In 1970, the states of Rhode Island (60 percent), New Jersey (78 percent), New York (52 percent). and Delaware (66 percent) had FMGs in more than 50 percent of their filled residencies. The predominance of New York in the training of specialists is high- lighted by the fact that more than 20 percent of all residents were located there in 1970. In some specialties it had even greater impact. For instance, 25 percent of all pediatric residents were in New York. The only state to ap- proaeh it in importance was California which had 9 per cent of all residents. \. I noted earlier, the demand for residency position in the various states n Piìjortunt part in the actual geographical distribution of residents. In order to analyze the potential demand for residencies in various regions. we di ci rjlut'al the cra dna tes from medical school in each division amnng the (livOz!'i1 of their first and second graduate training as listed on the AMA rec- ords. M:inv divisions are greatly dependent on graduates from their own schools to provide residents. More than 70 percent of the trainees in the East South (`entral Divjsjcn and the West South Central Division hoc] gone to meci- ical school in those divisions. It is also interesting to note th~ differences in the nuniher of residencies filled relative to the nuniher of medical school grad- uates. Five divisions had considerably fewer residents than medical school gr;.1uato~. Only the Pacific Coast had the opposite situation. a piiev point of view, the considerable variability in the number of rE-~ie1Its arnori~ the states has a number of serious implications. To the ex- tent that quality of care and hiractice location are related to the stock of resi- dents. tli~ variation i~ a causal factor in the lower standards of care avail- 0 ~ ~ sti tes. Tlii n~ a v ic of ~onsiderahle importance to the federal gov- ernment as it begins to pay for much of the cost of graduate training through reinibnr~ements for ho~pitnl costs, stipend supports, and direct Oi(] to medical schools. It may be wise to encourage the relative growth of residencies in those areas which have relatively few- to offer at present hut do have the popula.tion Ictential. In particular, encouragement might be focused on the expansion of residencies in the primary care specialties which piredominate the physician mix in relatively poor, less metropolitan states. 5O~TE GENERAl. FACTORS AFFECTING THE SUPPLY OF RESIDENCIES In our interviews and review- of the literature, there appear to be a num- of forccs which affect the decision to offer residencies. These vary accord- ing to the type of hospital and affiliation agreement. The participants in the de'i.~in~iiaking process are the hospital administrator, the dean of the medical school, chairmen of clinical departments in the medical school, directors of services in the teaching hospital, and attending physicians. IT-iltil administrators focus on the need for service in their hospital and the financial factors involved with residency programs. In county and munici- pal hospitals, where interns and residents frequently provide much of the rare, the overriding factor is the need to provide service. Thus, subject to 10nov01 financial constraints, the types of residencies offered are dictated by the service needs. PAGENO="0665" 655 In private non-profit community hospitals, ward services are relatively small so most of the services provided by interns and residents are complementary to those of the private attending physicians. Because the attendings take pri- mary responsibility for the patients, they will be reluctant to allow trainees the experience and responsibility required. The attendings are faced with conflict between their desire for the aid of the residents in providing services and this reluctance to pass on responsibility. Data provided in the Directory of 1n~ernships and Residencies on utilization in the different services is likely to be misleading with respect to the potential for training. Any given level of utilization at a community hospital with a limited affiuliatioii implies a much sittalier potential for training than at a county or municipal hospital. rhairmen of departments at medical schools frequently place pressure on the hospital administrator and dean to gain expansion of their academic pro- grain. This is based both on the desire for status and the need to gain addi- tional hands in order to expand the service. If a department chairman is su(cessJul in attracting residents and patients, he can place considerable pres- sure on the hospital administrator to enlarge his resident quota. Financing Several of our interviews indicated that financial factors play an important role in the determination of the aggregate number of residencies offered by the hospital. The cost factor is asserted to be increasing in importance as the recent rapid rise in resident salaries continues. The annual survey by the Coun- cil of Teaching Hospitals of the Association of American Medical Colleges indicates that the salary of first year residents increased from $6800 in 1968-69 to $9.5P2 in 1971_72.13 In the latest survey, 8 percent of the 225 hospitals sur- veyed stated that they had already reduced residencies iii response to the in- creased salaries. however, it must be noted that the total number of residen- cies offered has increased by about 11 percent from 1970 to 1972 which cer- lain'y is not consistent with the survey evidence. The same AXMC survey collected information on the sources of financial support for stipends. In 155 cases patient revenues l)rOvided more than 75 ls~n'ent of the support. State and municipal appropriations provided more than T5 lereent of support for 10 hospitals. Only 27 hospitals reported the direct contribution of federal dollars to stipend support. Nine percent of the hos- pitals indicated that more than 10 percent of the hospital budget was allocated to house staff stipends and fringe benefits. Less than 6 percent of the hospital loa1get was used for that purpose in 58 percent of the hospitals.14 Iii addition to the stipend payment, there are costs associated with the pay- iiient of the attending physician. This burden is partially borne by the medical schools and partially by the teaching hospitals. In milany cases some of the salary funds are collected from patient fees. Furthermore, considerable support of full time faculty at medical schools is provided by federal research and training grants. In 1970. about 47 percent of all full time clinical faculty ro- ceived all or part of their salary from federal sources. This varied from 62 percent in neurology and ~ percent iii ophthalmology 011(1 in psychiatry to 21 rercent in anesthesiology.'1 It is likely that the distribution of this support does affect the capabilities of medical schools to expand their residencies in the various specialties. One of the most controversial issues in the interface between government arid the supply of residencies is the policy f~r reimbursement of services pro- vided by interns, residents and attending physicians under the Medicare pro- gram. The Title XVIII legislation provided that attending physicians' services rendered to beneficiaries would be covered under the supplenientary insurance prirrani and the payment for such services would he on the basis of reasonable charges. In order to be eligible for such payment the attending was required to provide personal and identifiable direction to the house staff participating in the cn~e of his patient. A definition of personal and identifiable direction was provided in the legislation. Compensation of physicians for services in approved teaching programs other than services rendered to ptmtients was reimbursable to the hospital on a cost basis. 1~ Association of American Medical Colleges, COTH ~urs'e~ of Ffou.e .~taff Policy- 19'll. Part 1, p. 1. "Op cit p 12 16 AmerIcan Medical Association, Journal of the American Medical .4ssociation (Novem- ber 22. 1971), p. 1215. PAGENO="0666" 636 IuJ)~Itjeflt services of interns and residents in approved teaching programs Were (`x('lu(Ied from the (letinition of physician services'' and were cv'rcsl as hospital services. They were simply a component of allowable costs defined by the principles of reinillursemnent for isrovider costs. Outpatient services are covered by the supplementary medical insurance program, Part B, but at SO T0-'I(l'Ii t (If Cost ra thor t liia rca sona hi e elia rges. ~ever:i I government reports have been critical of the actual operation of the iii Seas fr n'i nil iirs'mnent of 111 USe staff and teaching physicians.'~ They assert (`(I. md Irvaled evidence. that there had heeii dual payments fr the 5:7 lao s'rviee. Ta yrnelits P attending physicians for services which were not l;rovid1. and j~(vrli~~flts lv lnterina'(hiaries for services which they did not reini- Ilirse in their private Thins. I have nt been Ille tI find evidence on the impact of the Medicare rc'im- lurseinelit TIll icy n tm ther the total number of residents or their distributb ii a inciaz 5~ (`la tics. \Vlie~i Medicare a ad ~.ledicmi id were i itrouueed it was thought tlimit sim rgical nrograns would fine difficulties in finding teaching patients but tlmis (1~s hot apjc':ir 1) have evolved into a major problem. I itci' (iC I'S 1)7111 ng tb ~:ist sov(r:m 1 717 cit l:s we have interviewed a number of individuals ivilli :`7sIonsit~lity fr till' :l(lrliinisrr:itmon of residency programs in university liospmta Is. non-Trout a rnamunitv heqIltals. and county hospitals. While no use- ful generallzati as (:in lie made, some of the comments which were made dur- ing the interviews Iou mr vhh- useful insights. These will not be quotations but. r:ither, paralllrasinirs of Their comments. At i riistrat r (f ii tin I versO y hios~ ital : There are real costs involved with tr:iii~im.~ irog~aiits. For examole. sargeons are slow when they first start. This roil ::"es extra nursing time and capital costs. C'l:iefs of serv:ce have had ilmajar say in the decisions to expand residencies. n sum has I cart rota. ted to lilt number of patients in a service, its quality, te:isli:ng strengths. iinI public needs. There are large variations in admissions ~er Ii' use stuff in different Jrgranis because of differences in the ratio of pri- vato tatierits to s4rv-Ic' to tieni* The strong tend to get stronger. Good quality loads ti mncrca.ed patient Pa Il-i which require additional house staff. U' ~dmysicians were forced to pay part of residents salaries in community h:snmt als, they would stay away from the teaching hospitals. SPecIalty boards huvo some influence through their ability to set require- 11101115 for resider~av I a gr:i Ins. Many boards are closely intertwined with aca- (1(111 ` modici flt---flili I1V lo~i rd members are chairmen of departments. Puulic poll('v would ho most effective if it focused on institutional programs ratlor than (hero rtnletmts. Medical schools should provide a particular distri- but~ ii of residencies in order to receive ca.pitation support for Jx)st M.D. edu- cation. Almmiinistrator of a county hospital : The hospital has a general practice residency which began about 20 years ago. Recently, when the County Board of Supervisors was considerinr a reduction in funding for the hospital, the hospital found it needed to justify the residency program in terms of local lieneflt'z A survey f general practitioners in the county revealed that a great m:irity had been trained at the hospital. The hospital d~reetors believe that the residents pay for their training with servmaes they render. hut they can't prove this to the Supervisors and that lea vs the program in jeopardy. Director of iimedieal education at community hospital When supervisory physicians charge the third party. they include charges for their residents ser- via's as well as their own. A variable proportion is returned to the clinic as a donation. Psychiatry residencies have increased since 190~ due to the hospital partici- pation in a community mental health elmie an(I to increased NIH funding. The hospital has not had many unfilled vacancies bitt if it did, it would interpret that as a sirn of declining demand for flint residency. This year there were two unfilled slots in pediatrics because "our choices went elsewhere.'~ Comptroller General of the United States, Problemt in Paying for Services of Super- visory and Teaching Ph~isicians in. Hospitals Under Medicare, (November 17, 1971) Committee on Finance, United States Senate, Medicare and Medicaid Problems, Issues and Alternatires (February 9, 1970). PAGENO="0667" 637 In so far as the hospital plans the number of residencies, it responds to community iieeds, especially through its clinics. A family practice residency is being idanned mainly because potential residents seem to want such a program. The anesthesiology staff rejected the proposal for a residency because of in- huuse reasons. 1)ireetor of resident services at university hospital: In 1971-1972 academic year. about 38 percent of residents at the hospital were on grants. The re- niaiiider of the resident financing comes from per diem fees in the hospital and from charges of the faculty in the clinics. Twenty of 58 psychiatry resi- dents were on grants and 20 of 41 radiology residents were on grants in all the affiliated hospital~. Tue university was not resplonsible for payment of any iieurnlogy resi(ients since 50 percent were on grants and 50 percept were at the ailbiated V.A. hospital. To the present, financing by third party carriers has not affected the number of residents. The increase in residents salaries has been financed by increases in isr (lien! charges. The liniit to the number of resi(Ieflts is the size of the lI( spital." 1lead of physical medicine in university hospital: Physical medicine is frowned upon by other physicians because it is not connected to acute illiiess and the (lia~nostic and primary therapy phase of treatment. There was a successful residency program under the general auspices of the Orthopedic Surgery department. The Board of Physical Medicine requested that the program become an independent entity. When this was made impossible by medical school politics, the training program was 110 longer accredited. There is substantial demand for the services of physiatrists and they do well financially. head of neurosurgery in university hospital: Many neurosurgeons are locating where there is inadequate practice for them to retain their skills. lie has stopped the growth in the number of trainees and is substituting paramedics to provide the required services usually provided by residents. The national board has not taken a stand on the issue. STATE VARIABILITY OF SPECIALISTS RELATIVE TO POPI2TATION I have used a measure of variability to compare the relative availability of different specialists services to populations which has comaionly been used to measure inequality in the distribution of income. It is called the Gini co- efficient. This index measures the aeea between a line which would indicate perfect equality between tile proportion of the populatin in each state and the proportion of physicians in a given specialty practicing in the state and the curve of actual distribution. The closer the Giid coefficient is to zero, the more equal the distribution of physicians. The least variability amongst all patient care physicians in 1970 was corn- pute(I for general practice. Next was radinlogy, followed by the surgical specialties. Following these were the medical specialties and all other spe- cialties. The greatest variability amnng the individual specialties I analyzed was in psychiatry which had a Gini coefficient for patient care physicians of .315 compared to a coefficient of .1-19 for all patient care physicians. It is instructive to study the raw (1ata which was used for these compu- tations. For all patient care physicians, the ratio of i state's share to its total population varied from .562 for Mississippi to 1.SS for New York. Twelve states had a ratio greater than one. A total of 26 states hlad a ratio greater than one for general practice with many states having much higher mtios than for total physicians. For the specialty of psychiatry the ratio ranged from .233 for Alabama to 2.467 for New York. Many of the individual states showed substantial variation in their relative ability to attract different specialists. This is reflected in the different mixes of physicians providing patient care. The proportion of physicians in a state who called themselves general practitioners ranged from 14 percent in Con- necticut, Maryland and New York to more than 40 percent in Idaho, South Dakota and Wyoming. The proportions in psychiatry ranged from less than 3 percent in Alabama, Idaho. Montana and Wyoming to more than 10 percent in Connecticut, Mary- land, Massachusetts, and New York. PAGENO="0668" 658 Recent location patterns of specialists In order to better understand the locational patterns of physicians In different specialties, I made some tabulations on the behavior of the graduates of United States medical schools during the years from 1955 through 1965. The sample was limited to those physicians who, in the 1971 American Medical Association survey, indicated that they were providing patient care services In private practice or as a salaried physician in a non-federal hospital. How- ever. interns and residents were excluded from the analysis. Separate tabula- tions were prepared for those physicians whom I estimated had completed their training in the years 1960-1962, 1963-1964, 1965-1966, 1967-1968, and 1969-1970. Tabulations were further subdivided into nine specialty groupings. The distribution of the overall attraction of physicians by the various states was relatively consistent in each of the chronological groupings, California increased its proportion from 15 percent in 1961-1962 to about 16 percent in 1969-1970. Several of the midwestern states-Iowa. Tndiana, Michigan, and Ohio-had relatively large percentage declines in their share of physicians. Massachusetts was able to increase its share by almost 80 percent during the decade under consideration. There was considerable variance in the shares of different specialists at- tracted by the states. In 1969-1970, California attracted 10.5 percent of the general surgeons and 21.6 percent of psychiatrists; Alabama attracted 1.75 percent of general surgeons but only .76 percent of psychiatrists: New Jersey attracted 3.1 percent of all physicians but 5.5 percent of pediatricians; New York attracted 7.8 percent of all physicians but 5.2 percent of anesthesiologists, pathologists and radiologists. These proportions varied in a non-linear fashion among the different time periods so it is difficult to generalize in terms of trends. In addition to the relationships discussed In the preceding paragraph, I looked at the prior contact physicians had with their state of practice in 1971 according to the typology developed by Phil Held. Five groups were used: (al medical school and some graduate (internship or residency) training In the state of practice: (h) medical school only in state of practice; (c) graduate training only in state of practice; (d) no contact with state of practice: (e) birthplace was state of practice but no other contact. Groups (a). (c), and (d) accounted for more than 85 percent of the physicians in each of the time periods under consideration. There was a general trend for group (a) to decline in importance and an increasing percentage of physicians to fall into groups (c) and (dl. Some variance was noted in the distribution of different specialists within the typology. In all time periods, psychiatry had the smallest proportions In group (d) and a relatively large percentage In group (a). General practice started with a large percentage in group (a) for the 1960-1962 period hut had a rapid decline in that group by the 1969-1970 period. Anesthesiology, radiology, and pathology generally had large percentages in group (d). SOME LESSONS FROM EXPER~ENCFJ The greatest effort of the federal government to affect specialty choice has been focused on the support of psychiatric training. According to data pro- vided by NIMH the number of grants they awarded in support of trainees increased from 124 In 1952 to 718 In 1968 and then declined to 600 in 1971. The funds provided by these grants Increased from $483,000 in 1948 to 842.311,850 in 1971. It is impossible to evaluate the specific impact of these funds on the numbers of physicians who have gone Into psychiatry. The rapid expansion of residency training In psychiatry during the past two decades coincided with a similar expansion in all specialties. However, while psychiatry was able to increase Its share of trainees during the decade from 1950 to 1960. there has been a decline in its relative share from 1960-1970. From our interviews. it would seem that psychiatry would he less likely to gain the support of the usual sources of funds (hospital per diem charges) for regi- ~lency programs than services which pros-ide acute medical care. However, the broad range of Institutions-state mental hospitals, community hospitals. npuro-psychintric institutes, community mental health centers-which are the locus of training may have been successful in finding support from sources other than the federal government. Certainly, the majority of trainees are supported by funds from other sources. PAGENO="0669" 65~J Whatever the impact of federal intervention on the number of psychiatrists trained; and the potential impact of the reductions In trainee support pro- posed by the Office of Management and Budget, some general problems which would be faced by any government attempt to affect specialty choice have been brought out by the program. The first problem deals with geographical loca- tion. According to a 1965 survey of NIMH trainees, 41 percent of former trainees in psychiatry were located in the four states of New York, California, Massachusetts and Pennsylvania.'7 Our date indicate that the first three states were among the five states with the largest number of patient care psychia- trists relative to populations. Together, the four states had about 40 percent of all patient care psychiatrists. In comparison the states of Alabama, Arkansas, Georgia, Indiana, Iowa, Mississippi, and Tennessee, who had relatively few patient care psychiatrists relative to population, attracted 5 percent of the former NIMH trainees but had 31.3 percent of all patient care psychiatrists. Thus, to a great extent, physicians trained with federal funds located in states relatively rich in psychiatric manpower an(l reinforced existing in- equalities. This is not surprising since 45 percent of the former trainees had their last NIMH training in the four relatively successful states mentioned above while only 4 percent had received their training in 7 relatively unsuc- cessful states. Earlier analysis has shown that psychiatrists are more likely to locate where they have had previous training than other specialists. A second problem area is that of the work setting of supported practitioners. A perusal of the literature Indicates that the apparent shortage in manpower at mental health hospitals was the primary basis of the early support of psy- chiatric training. The latest report on the allocation of psychiatrists' time among work settings indicates that 18.1 percent spend 35 or more hours in the that they worked 35 hours or more in private practice, only 39.6 percent spent no time in private practice. Exactly comparable data are not available for inpatient department of a mental health hospital.18 Fifty-six percent indicated former trainees supported by NIMH. Fiowever, a survey conducted in 1965 did show that 48 percent of former trainees spent most of their time in private practice with 35 percent spending most of their time in all hospitals and clinics.'9 Certainly the characteristics of the general NIMH training program would not seem to be conducive to the attraction of physicians to practice in public hospitals. To start with, the income in state hospitals tends to be lower than competitive opportunities. Training under an NTM1I grant would likely improve the ability of psychiatrist.s to take advantage of those other oppor- tunities. In fact, data indicate that psychiatrists who work full time at mental hospitals have less residency training than those in private practice and are not as likely to be board certified. A third problem relates to the opportunity costs involved in training a physi- cian in a particular specialty. Among the real opportunity costs are the services which could have been provided by the physician as a different type of specialist. The response of public support cannot he made to absolute shortages, in some sense. but must be made to relative shortages. In the particular case under discussion it is not obvious what specialties physicians were attracted from, if any. Another specialty which the federal government has attempted to encourage through stipend and training support has been pliysiatry (physical medicine and rehabilitation). In Fiscal Year 1971. the Social and Rehabilitative Service helped to support 234 residents and advanced trainees in physiatry. An ad- ditional 397 undergi'ailuate medical st iidemits iee~ved sti ~end~'. T~ tol ft mling for stipends came to $2.24 million while an additional $2.03 million was pro- vided for teaching grants and administrative allowances. In Fiscal Year 1956 there had teen a total of 62 trainees who had received S2~7.150 in grants. Even with federal support, this specialty field has had a difficult time in increasing the number of residents wi (hose to he trained for it~ ra et ici~. In 1970 there were only 165 first year residencies offered in physical medi- cine with but 101 filled postions. Part of the difficulty lies with the peculiar nathre of the specialty relative to the general focus of the academic medical center. The physical medicine specialist takes responsibility after diagnosis and therapy for acute illness has been provided. He must coordinate the `7Franklyn N. Arnoff and l3eatrlae M. Shriver, Mental Health Personnel ~upporte! rJnler National fn~titute of Mental Health Traininq Grants, TTSDHEW (1966). p. 26. ~` National Institute of Mental Health. The Nation's Psychiatrists, 1969, p. 64. ~ Arnoff, op. cit., p. 22. PAGENO="0670" 660 activities of physical therapists, social workers, and other aides. These ac- tivities. dealing with chronic rehabilitative requirements, have never been at the forefront of interest for academic medicine. Furthermore, the need for ihysical medicine specialists has never been fully accepted by other specialists such as orthopedic surgeons and internists who would be the logical physicians to seek their consultation and assistance. In fact, the physical medicine pro- gram is frequently limited to a sub-unit of one of the other specialty depart- meat-s The fact that rehabilitative medicine receives little emphasis in most medical schools and is not even introduced in many schools certainly affects the interest of those J)hysicians entering residency training. However, there aCe certainly other factors involved. One-fourth of the physiatrists who indi- cated that their major professional activity was provi(ling patient care (ex- cluding interns and residents) were in the service of the federal government, the majority with the Veterans Administration. Less than 10 percent of all patient care physicians (excluding interns and residents) were in the service of the federal government. Furthermore, about 40 percent of the non-federal patient care physiatrists (excluding interns and residents) were on full time hospital staffs as compared to about 14 percent of all patient care physicians (excluding inteCns and residents). A survey in 1966 indicated that only 9 percent of physiatrists allocated 75 percent or more of their working time to the provision of patient care activities for fees.2° Once again we are not able to estimate the incremental impact of the general program of federal support on the number of physicians choosing to specialize in physiatry. Since a considerable effort has been made to increase undergraduate medical students contact with the specialty, it may he of interest to note that, ns of 1967, there is rio evidence that the subgtantial sup1~ort for undergraduate training provided to New York University Medical Center has had much impact on their graduates. Only two graduates from that medical school during the years 1955-1967 listed physiatry as their major area if specialty in 1967.~ The real opportunity costs are also of importance in evaluating the success of programs to attract physicians into physiatry. The 1966 survey of physia- trists showed that 77 percent of the respondents had practiced in another area of medicine before specializing in physical medicine. Another 53 percent had been in the primary care fields of general practice, internal medicine, and pediatrics. The third specialty which the federal government is currently trying to encourage is that of family medicine. During the past two years there has been a doubling of residencies offered in this specialty. Almost 86 percent of fanmily medicine residencies for 1972-1973 were in hospitals affiliated with medical schools. This compared to 45 percent of general practice residencies in hospitals affiliated with medical schools. In 1970, only 48 percent of all family practice residencies had been filled but 61 percent of first year resi- dencies in the field were filled. We used data provided by the National Intern and Matching Program to see which United States medical schools had pro- vided time most first year residents in family practice for the 1972-1973 year. They were Minnesota (IS). Virginia Medical College (16), Illinois (11), South Carolina (10), and North Carolina (9~. It is interesting that neither the Uni- versity of Illinois or the University of North Carolina had family practice programs under their jurisdiction. Sum mary All three specialties discussed above have a common characteristic that the services they J)rovide do not coincide with the major emphasis of the teaching hbspitals. Thus, special incentives may be required to induce the offering of training programs in their fields. In addition, special monetary incentives may he needed to induce physicians into physiatry and family medicine since they (10 not seem to easily fit into the current system of providing cam. Furthermore, there seems to be a tendency for physiatrists to enter into Commission on Elurntlon In Physical Medicine and Rehabilitation, The Vocationat IfltCilSt,9, Valucs an'l Career flerelopment of Specialist3 in Physical Medicine and Reha~flitation, locs. ~. 2.0. I'. M. Theodore, G. E. Sutter and J. M. IPiug, Medical School Alumni, 1967, AMA PAGENO="0671" 661 specialty training later in their careers which might call for extra support. however, it would seem to be a difficult question to separate the impact of federal funding on the growth of these specialties from the environment of changing medical interests and physician organization. Whether the benefits are great enough, and satisfactorily distributed, to be worth the cost is im- possible to answer. TABLE 1.-DISTRIBUTION OF PHYSICIANS 1 AMONG SPECIALTIES, BY YEAR 1949 1960 1970 ToIaI physicians 173,129 203,367 259, 717 General practice 86, 745 73, 751 56,712 Medical specialties 19,467 38, 892 63,075 Internal medicine Dermstnlsgy Pediatrics Other Surgical specialties 29, 653 48, 307 General sergery 9,931 17,027 22, 619 Ob-Gyn 5,074 10,257 16,357 Optithalmnlsgy 2,756 4638 8,639 Otolaryngolegy 6,468 5,720 4,595 Urslsgy 2,193 3,387 4,963 Other 3,231 7.278 13, 397 Other specialties 13, 568 29, 379 69, 360 Anesthesiology 1,231 4,449 9,452 Pathology 1,730 3,804 8,015 Psychiatry 2,210 8,152 17,868 Radisisgy 2,866 5.659 8,467 Other 5,5117,315 25, 558 Part-time specialists 23, 696 14, 038 Medicsl 3,940 2,383 Surgical 16, 537 8,849 Other 3,219 2,806 I Encludes isterss, residents, and retired physicians. Source: P. Q. Peterson and M. Y. Pensell, "Health Manpower Sourcebsnk No. 14", U.S.C.P.O. (1962) pp. 9 and 10. J. N. Hasg, G. A. Rohack, and B. C. Martin, "Distribstiss at Phyviciass in the United States," American Medical Association (1971) p.25. TABLE 2.-TRENDS IN RESIDENCIES OFFERED AND FILLED Growth in percent 1950 1960 1970 1950-70 1960-10 Anesthesiology: Number at approved programs 204 Total offered 725 Total tilled 524 Percentage tilled 72 Child psychiatry: Number at approved programs Total offered Total fdled Percentage tilled Dermatology: Number at approved programs 85 Total offered 221 Total tilted 170 Percentage tilled 77 General practicefamily practice: Number of approved prngramn 66 Total offered 224 Total tilled 97 Percentage tilted 43 Surgery: N umber at approved programs 474 Total offered 3,698 Total tilled 3,056 Percentage tilted 83 -10 -24 182 14 221 35 13 -1 113 480 437 -13 85 86 1 1 315 619 182 96 298 599 252 101 95 97 26 2 728 536 6,052 7,221 5, 640 6, 539 93 91 13 -26 95 19 113 16 10 -2 11,588 22,459 32,807 1,609 2,429 3,447 4,315 9,157 14,485 1,955 4,~47 ~?_~~! 70, 510 241 184 1.794 2,046 1,244 1,681 83 82 58 124 107 621 79 425 78 68 184 183 790 1,210 549 532 69 43 177 -1 440 53 448 -3 0 -38 PAGENO="0672" 662 TABLE 2.-TRENDS IN RESIDENCIES OFFERED AND FILLED-Continued Growth in percent 1950 1960 1970 1950-70 1960-70 internal medicine: Numbe of approved programs 559 622 Total stteced 3,873 5,814 Total filled 2,949 5,197 Percentage tilled 76 89 Neurolcgica! surgery: Number of approved programs 92 131 Total offered 206 418 Total fdled 158 369 Percentage filled 77 88 Neurology: Number of approved programs 80 136 Total offered 216 448 Total filled 131 342 Percentage filled 61 76 Obstetrics and gynecology: Number of approved programs 381 495 Total affered 1.599 2,650 Total tilled 1.266 2,517 Percentage tdled 79 95 Ophthalninlogy: Number at approved programs 172 179 Tctul offered 551 837 Total fdled 437 8t7 P' Percentage tilled 79 96 Orthopedic surgery: Number of approved programs 260 311 Total offered 901 1,354 Tnfal tilled 715 1,262 Percentage filled 79 93 Otnlaryngalngy: Number of approved programs 152 133 Total cffered 408 553 Total tilled 273 504 Percentage tdled 66 91 Furennic pathnlngypathulsgy: Number of apprueed programs 438 741 Tatal effered 1,108 2,794 Total fdled 678 1,985 Percentage Idled 61 71 Pediatrics: Namberoeapprnved prsgramn 242 309 lutal offered 1,258 1,922 Total hlled 1,073 1,740 Perceutuge fdled 85 90 Pediatric allergy: Nrimberot approved programs 25 Total offered 14 Tcial f~led 10 Percentage tdled 71 I ediatric cordialegy: Number of approved prcgrams Tctal efferec Tctsl tilled Percentage hiled Physical medicine: Number of approved prngramn 43 80 Tatal offered 79 263 Tutal Idled 33 153 Percentage tilled 42 58 Pediatric cardiology: Number at appraved programs Tatal affered Total tilled Percentage tilled Physical irsedicine: Number at approeed programs 41 80 Total offered 38 103 Tntal filled 21 55 Percentage filled 55 53 Plastic o.~ rgery: Ncmber at approved prugramu 27 78 Tutal offerud 24 52 Total filed 14 47 Percentage filled 58 90 Psychiatry: Number at approvud programs 246 308 Total offered 801 1,383 Total filled 1, oyo Percentage filled 62 79 93 1 -29 621 200 48 578 165 56 93 21 6 107 34 -21 945 337 111 781 496 128 83 36 10 -9 -29 92 16 110 5 9 10 -7 -11 151 65 211 69 24 2 107 -30 -20 978 139 77 910 233 80 93 41 2 44 -15 228 30 247 19 5 -15 45 105 95 90 54 159 119 75 70 63 12 484 512 84 308 833 101 64 52 10 54 76 56 74 70 71 -13 165 334 60 101 381 84 61 94 248 30 133 454 156 120 745 155 90 262 7 -15 1,732 116 25 1,388 180 28 80 421 7, 920 7, 194 91 -25 -32 104 36 142 37 20 2 350 3,081 2,655 86 160 1, 385 1, 360 98 192 2. 117 2,015 95 -27 -43 134 56 182 60 20 2 633 3, 644 2, 355 64 258 2,830 2, 592 92 7 -17 124 47 141 49 8 2 80 650 850 27 PAGENO="0673" 663 TABLE 2.-TRENDS IN RESIDENCIES OFFERED AND FILLED-Continued Anesthesiology: Number of approved programs 199 Total offered 408 Total filled 284 Percentage filled 70 Child pnychiatry: Number of approved programs Total offered Total filled Percentage filled Dermatology: Number of approved programs 82 Total offered 112 Total filled 90 Percentage filled 80 General/family practice: Number of approved programs 93 Total offered 266 Total filled 119 Percentage filled 45 Sargvry: Number of appronvd programo 503 Total offered 1,576 Total filled 1,202 Percentage filled 76 Internal medicine: Number of approved prvgramn 579 Tota offered 1,875 Total filled 1,256 Percentage filled 67 Neurosurgery: Number of approved prugramn 89 Total offered 98 Total filled 61 Percentage filled 62 Neurology: Numberaf approved programa 78 Total offered 118 Total filled 69 Percentage tilled 58 Obstetrics and gynecology: Number of approved programs 406 Total offered 754 Total filled 564 Percentage tilled 75 Ophthalmology: Number of approved pragrama 164 Total offered 213 Total filled 188 Percentage tillvd 69 Orthapvdic nurgery (all typen of pro- gramn): Namber of approved programs 256 Total offered 316 Total filled 219 Percentage filled 79 184 -8 -24 827 102 18 688 142 25 83 124 114 254 535 178 535 70 86 5 1 209 84 84 205 128 100 98 183 97 0 213 -20 -57 131 10 -64 62 536 7 -26 2, 883 83 23 2, 514 109 18 87 -28 -31 80 36 142 39 b3 4 -29 148 50 33 141 130 40 95 107 37 -21 155 31 -17 146 112 -2 94 350 -14 -24 989 30 6 857 52 -3 87 160 -2 -11 464 118 54 460 145 60 99 311 192 -25 -47 385 560 77 53 353 528 141 08 92 94 Growth in percent 1950 1960 1970 1950-70 1960-70 Colon and rectal sargery: Number of approved prngramn 15 Total offered 14 Fatal filled 11 Percentage filled 93 Radinlogy: Number of approved prngramn 377 376 272 -28 -28 Total offered 493 674 972 97 45 Total filled 318 544 906 185 67 Percentage filled 65 81 93 Thoracic nurgery: Number of approved prngrams 56 114 80 43 -30 Total offered 72 100 141 96 41 Total filled 57 89 125 119 41 Percentage filled 79 89 89 Iirclngy: Namber of approved prngramn 220 241 178 -19 -26 Total offered 214 255 321 50 26 Total filled 129 204 311 141 52 Percentage filled 60 80 97 Sources: 1951-J.A.M.A., Sept. 27, 1952; 1960-Directnry of Approved Internnhips and Renidencien, 1961 ed.; 1970- Directory ot Approved Internshipn and Residencies, 1971-72 ed. TABLE 3.-TRENDS IN 1-YEAR RESIDENCIES OFFERED AND FILLED Growth in percent 1950 1960 1970 1950-70 1960-70 241 699 550 79 58 40 28 70 85 113 102 90 184 498 364 73 728 2, 342 2, 122 91 622 2, 481 2, 193 88 131 111 101 91 136 187 149 76 462 942 880 93 179 302 288 95 421 3, 364 3, 044 91 PAGENO="0674" 107 -4 -20 257 100 48 234 200 53 99 633 45 -15 1,120 91 4 758 129 0 68 258 9 -17 1,278 91 31 1, 175 121 33 91 45 80 6° 690 53 760 85 94 276 280 483 256 700 91 38 262 13 -15 5.024 184 34 3. 870 213 24 77 10 -7 15 25 20 80 Pa cli ol spy: Narniber of approved programs 345 375 272 -26 ToLd offered 1673 1.883 2,859 165 T~fal filled 777 1,537 2.604 235 Parceosoge l:ilod 72 82 91 26 Thorocic sorgory: Nersibor of ooorooed programs 45 114 80 78 Total offered 110 211 262 165 Tofol filled 84 179 271 223 Percenfage filled 76 85 93 22 Urology: Nomberofooproved programs Tofal offered Tofal filled. - Perceotage filled TABLE 4.-DISTRIBUTION OF ALL RESIDENTS AMONG SPECIALTIES - 1950 1955 1960 1965 1970 Aoeofhesiology 3.5 4.2 4.2 3.7 4.23 Child poychiafry .3 .5 1.1 Diagnoofic radiology -- .7 Dermatology 1.1 1.1 1.1 1.3 1.5 Family practice .7 General pracfice .7 2.1 1.9 1.6 .7 Surgery 21.0 21.0 19.8 18.9 16.6 Infernal medicine 20.5 18.6 18.4 17.7 18.3 Naurologicai surgery 1.1 1.2 1.3 1.5 1.45 Nvurolagy .9 1.0 1.06 1.8 1.98 Obsfefrico and gynecology 8.9 9.8 9.2 7.9 6.76 Dphfhafmologp 3.0 2.4 2.8 3.2 3.4 Orfhopedic surgery 4.8 3.7 4.2 4.7 5.0 Ofolaryngology 1.9 1.5 1.8 2.2 2.3 Pafhology 4.6 5.9 7.0 6.56 5.0 Forensic pafhology .04 .05 Pediafrics 7.3 6.0 6.0 6.3 6.5 Pediafric allergy .06 .2 Pediafric cardiology ..-.. .2 .3 Physical medicine .2 .3 53 .63 .78 Plasfic surgery .2 .35 .45 .57 .6 Colon and rectal surgery .07 .04 .05 Psychiatry 8.2 8.9 11.0 11.0 9.9 Radiology 5.4 5.6 5.3 5.0 6.6 Therapeufic radiology .2 Thoracic surgery .6 .6 .6 .6 .5 Urology 2.8 2.3 2.5 2.5 2.6 Sources: Various issues of Direcfory of Approved Infernships and Residencies. 664 TABLE 3.-TRENDS IN 1-YEAR RESIDENCIES OFFERED AND FILLED-Confinued Growfb in percect 1950 1960 1970 1950-70 1960-70 Dlolarysgology: Number of approoed programs 112 133 Tofal offered 129 174 Tofal Elled 78 153 Perreslage filled 60 88 Foresoic pathology Pothology: Nomber of approved programs 437 741 Total offered 585 1,079 Tofal filled 530 757 Percentage filled 56 70 Pediafrirs: Norsrber of approved programs 237 3P9 Tolal offered 673 981 Tsfol idled 533 886 Percentage frIled 50 90 Pediofric ollerpy: Number of ayprooed prooroms 25 Tolol offered 9 Told Idled 7 Peresfoge Ellod 74 Plastic rurgery: Number of osproved prograors 25 78 Total offered 48 148 Total fdled 32 135 Perceotoge Shod 66 91 Psych iviry: Nocrber of approved orogramr - 232 308 Tolal offered 1,768 3.736 Tolol idled 1,234 3.107 Prieofoge Idled 70 83 Ccloo arch recfal su:gery: Nvorbsr of aoproved prograo TrIal offered Tofal ShIed - Porceofage filled 20 90 90 -28 52 70 11 -30 38 51 213 241 178 536 795 1,060 418 681 1,011 78 86 95 Sources: 1951-J.A.M.A.. Sepf. 27. 1952: 1960-Directory of Approsed Direclcrp of Approved Isleroohipo and Residencies, 1971-72 ed. -17 -17 98 33 149 48 22 10 loferoships and Residencies, 1961 ed.; 1920- PAGENO="0675" 663 TABLE 5.-DISTRIBUTION OF RESIDENTS AMONG SPECIALTIES: GROUPEO BY UNITED STATES-CANADIAN OR FOREIGN MEDICAL SCHOOL TRAINING AND AFFILIATED-NONAFFILIATED HOSPITALS Percent distributicn amnng specialities- Unites Staten- United Staten Canadian Canadian Affiliated, Nnnatttliatnd, graduates, graduates 1970 1970 total, 1970 attiliated, 1970 Anesthesiology 4.7 2.2 3.0 3.2 Child psychiatry .0 t.6 1.2 1.1 Diagnustic radialagy 1.0 t. 2 1.3 Dermatalagy 1.7 .2 2.0 2.1 Family practice .6 .9 .9 .8 General practice .2 3.3 .3 .02 Surgery 15.3 24.0 13.2 14.9 Internal medicine 18.9 15.4 17.6 17.8 Neurological surgery 1.6 .2 1.7 1.7 Neurology 2.2 .4 2.1 2.2 Otostetrico and gyneonlogy 6.5 7.5 6.1 5.8 Ophthalmolugy 3.6 2.4 4.6 t5 Orthopedic uargery 5.1 3.7 6.8 6.6 Otolaryngalagy 2.5 .7 3.0 3.1 Pathnlagy 5.6 7.2 4.2 4.0 Forensic patholagy Pediatrics 6.7 4.4 5.7 5.8 Pediatric allergy .2 .2 .2 Pediatriccardinlngy .3 .2 .2 Physical medicine .9 .4 .5 Plastic surgery 7 .4 .9 .8 Colon and rectal surgery .03 Psychiatry 8.7 17.4 10.6 9.5 Radiology 7.1 3.8 3.0 8.1 Therapeutic radiolugy .2 .4 .3 Tharacic surgery .8 .2 1.0 .7 Urulugy 3.0 1.5 4.2 2.9 United States- Canadian Fsreign Fareiga Foreign giaduatea graduates graduates graduates nonafflhiated tntal, affiliated nanattilisted 1970 1970 1970 1970 Anesthesiology 0.9 6.7 3.0 3.1 Child psychiatry 2.7 .7 .7 1.2 Diagnostic radiology .3 .3 Dermatology .5 .6 .7 Family practice 1.5 .2 .2 .4 General practice 1.5 1.3 .5 4.4 Surgery 16.9 10.2 16.1 29.6 Internal medicine 13.5 19.3 21.0 16.6 Neurological surgery .2 1.0 1.3 .1 Nearology .3 1.8 2.3 .3 Obstetrico and gynecology 6.8 8.1 8.3 8.1 Ophthalmology 5.0 .8 .9 .5 Orthopedic surgery 8.2 1.5 1.7 1.2 Otolaryngology 1.5 1.0 1.2 .3 Pathology 5.0 9.6 10.1 8.4 Forensic pathology .2 .2 Pediatrics 3.6 8.3 9.7 5.0 Pediatricallergy .2 .3 .3 Pediatric cardiology .4 .6 - Physical medicine 1.5 1.9 Plastic surgery .8 .4 .5 .2 Colon and rectal surgery . 1 .1 Psychiatry 20.4 8.1 6.0 15.0 Radiology 6.3 4.0 4.4 2.2 Therapeutic radiology .2 .2 Tharacic surgery .8 1.0 .3 Urology 2.0 2.1 2.7 1.0 3S-698---74--pt. 1-44 PAGENO="0676" 666 TABLE GA-SPECIALTIES CHOSEN BY SELECTIVITY OF SCHOOL, 1955-60 GRADUATES Specialty General practice laterral medicine Pediatrics Other medical General surgery Obntetrics and gyaecstagy Othersurgical Psychiatry Aaenthesivlngy, radialagy, aart pathatagy Tntat Quartile of nelecti vity index 1 High 2 3 Low 10.18 16.43 6.8 8.3 8.0 7.6 18.7 10.2 10.8 17.7 11.3 7.1 6.6 8.2 8.4 19.1 6.8 12.3 26.4 10.2 5.7 5.4 7.4 8.1 15.2 6.3 12.6 27.2 9.1 5.7 4.7 7.9 8.9 16.0 6.0 12.3 7,798.0 8,384.0 6,796.0 7,926.0 I Selectivity indea wan the average acare of entering freshmen in 1965 an Science MCAT. TABLE GB-PROPORTION OF SPECIALISTS GRADUATED FROM SCHOOLS OF DIFFERENT SELECTIVITY, 1955-60 GRADUATES Specialty High 2 3 Low Tat al number General practice 12.7 23.8 28.8 34.6 Internal medicine 35.1 26.0 19.0 19.8 Pediatrics 26.9 30.3 19.7 23.1 Other mecrical 33.1 28.5 19.0 19.3 General surgery 25.6 28.2 20.6 25.6 Obstetrics and gynecnlagy 23. 1 27.7 21.6 27.7 Dther surgical 27.2 29.8 19.3 23.7 Psychiatry 35.2 25.1 18.8 20.9 Anesthesralagy, radislagy, ar patheingy. - 22. 8 27.7 23.2 26.3 6,231 3,649 1,962 1,944 2,438 2,556 5,365 2,269 3,705 Talat I 25.2 27.1 22.0 25.6 30.904 I Tstat includes a few physicians in specialties nat listed individually. TABLE 7A.-SPECIALTIES CHOSEN BY SELECTIVITY OF SCHOOL, 1961-65 GRADUATES Quartile of ne~ectieity index I Specialty High 2 3 Low General practice 9.3 18.2 25.1 Internal medicine 16.1 12.0 11.1 Pediatrics 8.9 7.7 7.9 Other medical 10.2 7.1 6.4 General surgery 5.2 6.1 4.8 Obstetrics and gynecelsgy 6.2 8.5 7.5 Othersargery 18.3 18.4 15.2 Psychiatry 11.1 7.9 6.8 Anesthesislngy, radinlagy, and pathstngy 10.7 10.4 11.8 29.6 10.1 6.9 5.1 6.3 9.2 15.2 5.4 9.6 Tutal number 4,201.0 4,888.0 4,331.0 5,163.0 `Selectivity indes was the average scare of entering frenhmen in 1965 on Science MCAT. TABLE 7B.-PROPORTIDN OF SPECIALISTS GRADUATED FROM SCHOOLS OF DIFFERENT SELECTIVITY, 1951-66 GRADUATES Total Specialty High 2 3 Law number General practice Internal medicine Pediatricn Other medical General surgery Obstetrics and gysecslngy Othersurgical Psychiatry Anesthesiclagy, radislsgy, ur pathnlagy Tstal 1 10.0 29.8 25.9 32.5 20.9 17.6 24.7 32.7 22.8 22.8 25.9 26.0 26.5 28.4 28.0 28.9 27.0 25.9 28.0 21.2 23.4 21.1 19.8 22.1 21.1 20.8 26.0 39.2 23.1 24.7 19.9 31.0 32.2 25.2 19.6 25.3 3,894 2,266 1,450 1,318 1,053 1,473 3,109 1,426 1,963 22.6 26.3 23.3 27.8 18,583 I Total incladen a few physicians in npecilaties not lint ed indieiduatly. PAGENO="0677" 667 TABLE 8.-RATIO OF OFFERED AND FILLED RESIDENCIES TO PHYSICIANS, EXCLUDING HOUSE STAFF, IN FIELD Offered Filled 22.89 18.80 36.29 24.83 28.04 27.26 19.34 18.72 2.24 .989 35.00 31.7 27.18 24.69 32. 75 30. 48 47.61 39.34 19.93 17.18 16.96 16.66 29. 90 28. 47 23. 16 21.55 51.08 33.11 23.03 11.24 21.32 19.52 30.97 28.02 39.65 29.67 47.73 30.37 22.04 20.16 31.42 24.20 3.94 3.15 36.87 35.58 19.12 16.01 19.92 18.49 22.87 21.82 Anesthesiology Child psychiatry Diagnostic radiology Dermatology General practice General surgery Internal medicine Neurological surgery Neurology Obstetrics and gynecology Ophthalmology Orthopedic surgery Otolaryngology Pathology Forensic pathology Pediatrics Pediatric allergy Pediatric cardiology Physical medicine Plastic surgery Psychiatry Colon and rectal surgery Radiology Therapeutic radiology Thoracic surgery Urology Sources: AMA, `Directory ot Approved lnternships and Renidencien, 1971-72" J. N. Haug, G. A. Roback, B. C. Martin," "Distribution of Physicians in the United States, 1970," AMA. TABLE 9.-RATIO OF OFFERED AND FILLED 1ST-YEAR RESIDENCiES TO PHYSICIANS, EXCLUDING HOUSE STAFF IN FIELD Offered Filled Aneutheuiology 9.25 7.69 Child psychiatry 14.84 10.40 Dermatology 6.53 6.41 General practice .40 .24 General uurgery 13.98 12.19 Internal medicine 11,55 10.45 Neurological surgery 7.81 7.44 Neurology 7.81 7.36 Obstetrics and gynecology 6.4 5.54 Ophthalmology 5.68 5.63 Orthopedic uurgery 7.91 7.46 Otolaryngology 6.09 5.54 Pathology 15.88 10.75 Pediatrics 9.63 8.85 Pediatric allergy 18.29 15.63 Pediatriccardiology 18.95 13.97 Physical medicine 16.27 9.96 Plastic surgery 10.47 9.45 Psychiatry 10.83 8.68 Colon and rectal surgery 2.20 1.73 Radiology and therapeutic radiology 11.62 10.83 Thoracic surgery 9.62 8.53 Urology 6.93 6.71 G. A. Roback, B. C. Martin, Sourceo: AMA, "Directory of Approved Isternships and Residencies, 1971-72" J. N. Huug, "Dintribution of Physiciann in the United States," AMA. PAGENO="0678" 66S TABLE 10.-RATIO OF ALL RESIDENTS IN A GIVEN STATE TO ITS TOTAL POPULATION, HOSPITAL BEOS AND PATIENT CARE PHYSICIANS, 1970 Alabama 0.0713 0.0184 0.0967 Alaska .0085 .0218 .0062 Arizona .0335 .0253 .0630 Arkansu .0613 .0159 .0802 Califorma .1554 .0419 .0972 Colorado. - .2247 .0491 .1462 Connecticut .2353 .0704 .1488 Delaware .1332 .0397 .1155 Oistr:ct of Columbia .6117 .0080 .2103 Florida .1281 .0305 .1058 Georgia .1043 .0310 .1139 Hawaii .0875 .0308 .0722 Idaho .0050 .0014 .0067 lilinnio .1729 .0379 .1453 lndiana~ .0666 .0169 .0737 Iowa .1089 .0200 .1203 Kansas .1221 .0245 .1276 Kenticlay .0918 .0241 .1033 Louisiana - .1451 .0363 .1442 Maine .0275 .0064 .0300 Maroiarrd .3143 .1027 .2093 Massarhasett~ .3161 .0691 .1865 Michigan... .1905 .0531 .1836 Minnesota .2600 .0452 .1940 Mianrsoippi .0439 .0136 .0703 Missouri .1997 .0431 .1829 Montana .0042 .0008 .0046 Nebrasea .0906 .0149 .0931 Ne:oio .0941 .0010 .0042 New l-tom~s5ire .0669 .0159 .0560 Newie-ons .1222 .0356 .0989 New Monica .0915 .0276 .1007 No.0 York .3793 .0860 .1945 NorTh Co:oiina .1263 .0337 .1341 North Dakota .0141 .0023 .0176 USia .1864 .0498 .1653 Oklahoma .0703 .0192 .0895 Oregon .1240 .0302 .0989 Peorrooloania .2053 .0456 .1602 Rtaoae :land .1617 .0134 .1180 South Carolina .0729 .0208 .0951 Sauth Lrokata .0117 .0022 .0165 Tennessee .1433 .0330 .1424 Teaan .1096 .0266 .1074 Utah .1487 .0420 .1255 Vernanrrt .0773 .0584 .1773 Virginia .1443 .0403 .1316 Washington .1224 .0381 .1015 West Virginra .0335 .0165 .0934 Wiacnnnia .1125 .0216 .1037 Wyoming .0931 .0905 .0034 Sources: AMA. "Di rectnry of Anp'oved loternships and Renidencien, 1971-72" Hang, Rnback, and Martin, "Distribution nf Fhysiriann in the United Status, 1971'' AMA. TABLE 11.-STATE PERCENT OF TOTAL RESIDENT GROWTH 1960-65 1965-70 Connecticut 0. 0071 0.0200 Maioe -.0023 .0013 Massachusetts .0844 .0183 New Hampshire -.0029 .0021 Rhndn Inland .0052 .0081 Vermont .0029 .0074 New Jersey .0521 .0252 New Ynrk - .2444 .1939 Pennsylvania .0789 .0472 Illinnin .006t .1032 Indiana -.0275 .0143 Michigan .0443 .0159 Ohm -.0139 .0443 Wincnnsin .0078 .0090 Iowa -.0036 -.0015 (ann .0246 .0066 Minneanta .0181 .0130 Minsisnippi -.0149 .0215 Nebranka ~.0071 .0085 North Dakota .0052 -.0027 SnnthDaknta -.0029 .0005 PAGENO="0679" 669 TABLE 11.-STATE PERCENT OF TOTAL RESIDENT GROWTH-Continued 1960 1965 Delaware .0013 .0011 District of Columbia .0359 .0136 Florida .0417 .0384 Georgia .0225 .0123 Maryland .0200 .0327 North Carolina .0265 .0143 South Carolina .0094 .0192 Virginia .0158 .0229 Wont Virginia -.0019 .0064 Alabama .0330 .0151 Kensnc~g .0001 .0054 Missouri .0162 .0001 Tennessee .0233 .0133 Arkansan -.0097 .0034 Loaisiaaa .0110 .0057 Oklahoma .0048 .0036 Tenon .0511 .0541 Ariznaa .0006 .0227 Colorado .0200 .0058 Now Islenicn .oito .0097 Utah .0061 .0015 California .1154 .1260 Hawaii .0026 .0028 Dregnn .0042 .0044 Washington .0249 .0094 Saarcen: AMA, Various Directories of Agprnoed Interonhipa and Renidnrcien. TABLE 12-CHANGE IN ALL RESIDENCIES, BY STATE Lacela Percentage change 1960 1965 1970 1360-65 1965-70 1960-70 Csaancticnt 669. 000000 691. 000000 842. 000000 0. 006492 0.040320 0. 023266 Maine 48. 000000 41. 000004 51.000000 -.031034 .044617 .006081 Massachusetts 1,582.000000 1,843.000000 1,981.000000 .031012 .014546 .022746 New Hamgohiro 78. 000000 69. 000000 85. 020000 -. 024222 .042591 .008631 Rhodo Icland 122.000000 138.000000 199.000000 .024953 .075957 .050145 Vnrrnnnt 66.000000 75.000000 131.000000 .025896 .110001 .070959 Newiersey 621.000000 782.000000 072.000000 .047181 .044460 .045821 Neal York 5,970.000000 6,720.000000 8,189.000000 .024133 .040147 .032109 Pennsylvania 2,442.000000 2,686.000000 3,042.000000 .019230 .025205 .022213 Illinois 1,789.000000 1,808.000000 2,517.000000 .002115 .074285 .037573 lodiasa 469.000000 381.000000 492.000090 -.039203 .058816 .009799 Michigan 1,815.000000 1,952.000000 2072.000000 .014660 .012003 .013331 Ohio 2,258.000000 2,215.000000 2,5~9.000000 -.003838 .028488 .012196 Wisconsin 617.000000 641.002000 700.040000 .007001 .020370 .013996 Iowa 382.000000 371. 020004 300.020000 -.005827 -.006002 -.005914 Kansas 331.000000 407.000000 457.000000 .042205 .023445 .032782 Minnesota 1,250.000000 1,300.000000 1.404.000000 .008804 .014576 .011686 Mississippi 1,121.000000 1,075.000000 1.237.000000 -.008345 .028471 .009895 Nebraska 197.000000 175.000000 239.000000 -.023405 .064319 .019514 North Dakota 16. 000000 32. 000000 12. 000000 .118698 -.178124 -.028358 Sooth Dakota 16. 000000 7. 000200 11. 000000 -. 152391 .094009 -.036776 Dnlavsare ..~ 69.000000 73.000000 81.000000 .011334 .021016 .016164 District of Colombia 851. 000000 962. 000000 1,065.000000 .024824 .020551 .022685 Florida 585.000000 714.000000 8,004.000000 .040059 .070550 .055499 Georgia 559. 000000 629. 000000 722. 000000 . 023877 . 027963 .025918 Maryland 977. 000000 1,039.000000 1, 286. 000000 .082381 .043578 .027862 North Carolina 628. 000300 780. 000000 888. 000000 .024849 .028724 .026785 Soath Carolina 139. 000000 168. 000000 313. 000000 .038625 .132523 .084558 Virginia 571.000000 620.000000 793.000000 .086602 .050452 .033389 West Virginia 180.000300 174.000000 222.000000 -.006757 .049931 .021191 Alabama 194.000000 296.000000 480.000000 .000173 .067329 .077701 Kentucky 326.000000 358.000000 392.000000 .084887 .022331 .088607 Misooari 143.000000 193.000000 194.000000 .061801 .001034 .030971 Tennessee 648.000000 713.000000 883.000000 .021580 .020508 .024055 Arkansas 181.000000 158.000000 177.000000 -.035595 .032284 -.002232 Louisiana 682. 000000 786. 000000 759. 070200 . 009778 . 0t1733 .010755 Oklahoma 277.000000 292.000000 319.000000 .080603 .017845 .014287 Tenon 1,305.000000 1,463.000000 1,071.300023 .023120 .050427 .036684 Ariaooa 96. 000000 98. 000000 209. 000000 .003132 .223705 . 108532 Colorado 532. 000000 594. 000000 638. 020000 . 022292 .014394 .018336 New Menico 57. 000000 91. 000000 t0~. 000000 .098078 .125021 .811468 Utah 171.000000 190.000000 201.000000 .021296 .011320 .016295 Galiforsia 3, 099. 000080 3, 456. 000000 4, 407. 000000 . 022040 .040818 .035839 Hawaii 120.008060 128.000008 143.000000 .012991 .030849 .028881 Oregon 255.800000 268.000000 301.000000 .009994 .023496 .016723 Washington 381. 800000 458. 000000 529. 000000 .037500 .029243 .033363 Sourcon: AMA, Vaninun Directorieo of Approved Interoohipa ood Rasidoocieo. PAGENO="0680" 670 TABLE 13.-CHANGE IN ALE. U.S. RESIDENCIES, BY STATE 1960 1965 1970 1980-65 1965-70 1960-70 Connecticut 367.000000 346.000000 365.000000 -0.011715 0.010749 -0.000546 Maine 21.000000 10.000000 26.000000 -.030360 .076317 .021587 Massachusetts 1,039.000000 1,153.000000 1,263.000000 .021040 .018392 .019715 New Hampshire 61. 000000 47. 000000 50.000000 -.050809 .046520 -.003328 Rhode Island 30.000000 54.000000 62.000000 .072808 .028015 .050173 Vermont 42. 000000 50. 000000 103. 000000 .035486 .155509 .093853 Newierney 144.000000 202.000000 170.000000 .070034 -.033906 .016737 NewYcrk 3,110.000000 3,428.000000 3,585.000000 .019662 .008997 .014315 Peorsyleania 1.419.000000 1.~46.000000 1,697.000000 .003777 .032530 .010052 Illinois 992.000000 1,017.000000 1,132.000000 .004990 .021657 .010289 Indians 317. 000000 262. 000000 310. 000000 -.037394 .034210 -.002230 Michigac 1.265.000000 1, 150. 000000 922. 000000 -.018882 -.043232 -.031133 Ohio 1,081.000000 1,038.000000 1,121.000000 -.008085 .015504 .003640 Wisconsin 351.000000 383.000000 455.000000 .017603 .035053 .026291 Iowa 267.000000 303.000000 238.000000 .025620 -.047145 -.011432 Kansas 203.000000 240.000000 225.000000 .034054 -.012825 .010343 Minnesota 906.000000 946.000000 1,021.000000 .008678 .015376 .012022 Mississippi 640. 000000 522. 000000 669. 000000 -.041731 .050875 .003505 Nshraska 77.000000 86.000000 146.000000 .022355 .111657 .066071 North Dakota ~.oooooo 12. 000000 4. 000000 .319508 -.197258 .029186 Sooth Dakota 2.000000 1.000000 6.000000 -.107258 .430969 .071773 Delaware 15. 000000 13. 000000 19. 000000 -.020214 .078052 .023920 District at Colnrohia 545. 000000 552. 000000 634. 000000 .002556 .020087 .015241 FIori~a. 401.000000 415.000000 641.000000 .006887 .090842 .048024 Cearnia 371.000000 394.000000 422.000000 .012102 .013826 .012964 Maryland 504.000000 582.000000 660.000000 .029197 North Cacahaa 514.000000 558.000000 645.000000 .016563 .025473 .020402 .027333 .022962 Sooth Carolina 9t. 000000 85. 000000 185. 000000 -.013549 .168290 .073527 Virginia 358.000000 353.000000 533.000000 -.001691 .085902 .041185 Went Virginia 49.000000 36.000000 77.000000 -.059798 .164227 .046236 Alabama 113.000000 184.000000 269.000000 .102422 .078914 .090605 Kontucky 157.000000 184.000000 223.000000 .032247 .039t96 .035716 Misnoasi 100. 000000 135. 009000 132. 000000 .061859 -.004484 .028152 Tesnesaee 441.000000 488.000000 537.000000 .020461 .019321 .019891 Acka~sac 139,000000 103.000000 126.000000 -.049216 .031310 -.009771 Lasisiara 570.000000 528.800000 544.000000 -.016225 .005988 -.005180 Oklahoaro 200.000000 182. 000000 217.000000 -.027286 .005804 .003763 Tn 976.000000 973.000000 1,294.000000 -.000616 .058679 .028605 Arizons 20. 000000 41. 000000 118. 000000 .079258 .235424 154709 Calarain 329. 000000 414. 000000 551. 000000 .047034 .058040 . .052920 New Mends 36.000000 35.000000 007.000000 -.005618 .290441 .115085 Utah 127.000000 140.000000 167.000000 .019682 .035900 .027759 Colitncnia 2,649.000000 2,778.000000 3,689.000000 .009555 .058365 .033672 Hawaii 90.000000 91.000000 107.000000 .002212 .032024 .017452 Oregon 200.000000 208.000000 220.000000 .017385 .00t828 .009577 Washington 309. 000000 359. 000000 433. 090000 .030451 .030194 .034315 Snorceo: AMA, Varloon Directories ot Approced Interochips and Renidenciec. TABLE 14.-CHANGE IN ALL FOREIGN RESIDENCIES, BY STATE 1960 1965 1970 1960-65 1965-70 1960-70 Connec'icat 170.000000 191.003000 343.000000 0.023568 0.124222 0.072715 Maine 3.000000 1.000000 5.000000 -.197258 .379730 052410 Massachusetts 379. 000000 447. 000000 554. 000000 .033555 .043050 .038693 New Hampshire Rhode Island 3.000000 55. 000000 7.000000 9.000000 45. 000000 92. 000000 .184664 -.039339 .051547 153759 .116123 .052792 Vermont 13. 000000 16. 000000 9.000000 .042402 . 100099 -.036105 New Jersey New York Peensyleania Illinsis 333. 000000 2, 170. 000000 542. 000000 533. 000000 365. 000000 606. 000000 2,378.000000 3,890.000000 536. 000000 780. 000000 578. 000000 1,081.000000 .014889 .018475 -.002224 .016343 -. . 106715 . 103437 .077919 133391 .059808 .060105 .037073 .073272 Indiana 8.000000 11.000000 56.000000 .065763 . .384711 .214814 Michigan 363.000000 462.000000 792.000000 .044832 .118710 .081140 Ohio 722. 000000 635. 000000 988. 000000 -.025353 .092438 .031863 Wisconsin 109.000000 81.000000 112.000000 -.055912 .066956 .003643 Iowa 31.000000 27.000000 83.000000 -.027252 .251823 .103498 Kannas 56.000000 72.000000 91.000000 .051547 .047953 .049749 Minnesota 218.000000 190.000000 255.000000 -.027120 .060614 .015800 Mississippi Nebraska 231. 000000 30. 000000 221. 000000 331. 000000 27. 000000 10. 000000 -.008812 -. 020852 .084144 180164 .036625 104042 North Dakota 9. 000000 16. 000000 3. 000000 .121955 -. -.284515 -. -.104042 Sooth Dokata 5.000000 1.000000 1.000000 -.275220 0 -.148660 Delaware 23. 000000 19. 000000 37. 000000 -.037490 .142588 .048691 District of Columbia 192.000000 209. 000000 325. 000000 .017113 .092314 .054043 PAGENO="0681" 671 TABLE 14.-CHANGE IN ALL FOREIGN RESIDENCIES, BY STATE-Continued 1960 1965 1970 1960-65 1965-70 1960-70 Florida 107. 000000 162. 000000 276. 000000 .086491 . 112446 .099392 -.066971 Georgia Maryland North Carolina 74.000000 349.000000 51. 000000 82.000000 339.000000 43. 000000 69.000000 .020743 501.000000 -.005797 78. 000000 -.033549 .081254 .126485 -.058255 .036815 .043404 .258925 South Carolina 2.000000 27. 000000 20. 000000 .682933 .015015 Virginia West Virginia Alabama 112.000000 61.000000 21.000000 116.000000 57. 000000 11.000000 130. 000000 .007043 62. 000000 -.013473 40. 000000 -.121312 .016959 .294594 .001627 .066557 -.015964 Kentucky Missouri 74. 000000 8.000000 70. 000000 5.000000 63. 000000 -.011052 11.000000 -.089718 .170805 .032358 .001059 Tennessee Arkansas 94.000000 1.000000 57. 000000 4.000000 95. 000000 -.095207 12. 000000 .319508 . .245731 .282089 170856 Louisiana 19.000000 18. 000000 92. 000000 -. 010755 . Oklahoma 13. 000000 18. 000000 17. 03u000 .067249 -.011367 Texas Arizona 106.000000 46. 000000 142.000000 19. 000000 285.000000 .041277 71. 000000 -. 162087 .149506 .301670 044360 Colorado 87.000000 78.000000 46.000000 -.021603 -.100288 New Mexico 1. 000000 11. 000000 30. 000000 .615394 .222210 .405116 .034220 Utah 10.000000 5.000000 14.000000 -.129449 123015 California 84.000000 168. 000000 268. 000000 .148698 . .055866 Hawaii 18.000000 12. 000000 31. 000000 -.077892 .209027 Oregon Washington 18.000000 38.000000 19.000000 38.000000 37.000000 .010872 45. 000000 ~ 0 .142588 .034394 . 017051 Sources: AMA, Various Director len of Approved Internships an d Residencies. GLOSSARY FOR TABLE 15 1.0 Represents total physicians. 2.0 Represents general practice. 3.0 Represents total medical specialist. 4.0 Represents cardiovascular disease. 5.0 Represents internal medicine. 6.0 Represents pediatncs. 7.() Represents total surgery specialist. SO Represents general surgery. 51(1 Represents obstetrics and gynecology. 10.0 Represents ophthalmology. 11.0 Represents orthopedic surgery. 12.0 Represents otolaryngology. 13.0 Represents urology. 14.11 Represeists total other specialist. 15.0 Represents anesthesiology. 16.0 Represents psychiatry. 17.0 Represents pathology. 18 0 Represents radiology. PAGENO="0682" 3 ~ E ~, ~ I i PAGENO="0683" ~ ~ ~1~i~P ~ ~ -.4 Q ~ P I -1 - . PAGENO="0684" ~i:1 i~PPi~ ~ *1 I I I I I I Iii I II~I I - ~ - ~ ~ ~oo lcD I I I I I I cDcDcDcDcD *I.1. F, ~ - -~ ~ - cD cD ~ - ~ I I ~II 1cD*11IlI*I . IF~ I I II IIcD I lcD II f~L9 PAGENO="0685" 675 TABLE 18-GEOGRAPHICAL DIVISION OF MEDICAL SCHOOLS PROVIDING PHYSICIANS FOR GRADUATE TRAINING,' 1955-60 Division of medical ochool Division of training NEWE MIDA ENCO WNCO SOAT ESCD WSCO MOUT PACD Total NEWE MIOA ENCO WNCO SOAT ESCO WSCO MOUT PACO AR 47.8 24.2 7.8 3.2 11.3 1.4 2.2 0.3 1.9 1,761 5.8 67.9 9.1 2.8 8.8 2.1 1.7 .4 1.3 5,670 2.7 9.9 65.2 7.1 5.9 3.4 3.0 .7 2.1 4,877 2.9 7.0 16.3 50.2 5.8 5.8 6.4 1.4 4.1 2,299 2.8 10.7 5.8 3.3 64.4 6.5 3.8 .5 2.0 3,562 .9 2.6 3.7 2.2 9.2 71.1 9.0 .2 1.0 1,105 1.2 3.8 5.4 4.4 6.8 5.7 71.0 .6 1.2 2,513 3.1 11.9 17.2 17.2 8.3 2.7 9.3 24.5 5.6 731 2.7 10.7 18.1 12.8 6.9 2.8 4.5 3.4 38.1 3,563 1.4 13.1 10.1 14.6 13.9 11.8 15.3 2.4 7.5 4,823 Total 5.5 21.1 20.5 10.5 15.1 7.4 11.0 1.8 7.0 30,904 1 The location ot the 2d listed post medical nchool training on the A.M.A. recordo. TABLE 19-GEOGRAPHICAL DIVISION OF MEDICAL SCHOOLS PROVIDING PHYSICIANS FOR GRADUATE TRAINING,' 1961-65 Divi Oivioion of training NEWE MIDA ENCO WNCD oion of m edical ochool SOAT ESCO WSCO MOUT PACD Total NEWE MIDA ENCO WNCO SOAT ESCO WSCO MOUT PACO AR 43.6 28.8 7.0 3.3 11.6 1.3 1.0 5.9 67.8 7.2 2.8 10.9 2.3 1.4 1.6 9.3 69.6 5.9 6.5 3.2 1.7 1.5 6.0 15.3 54.7 6.0 5.4 7.4 2.1 11.6 5.4 2.5 67.5 5.8 3.6 .3 2.9 2.7 2.6 9.0 74.9 6.2 .3 2.7 4.3 4.5 5.3 5.6 75.3 2.2 10.8 18.2 11.4 11.6 3.5 8.6 2.9 12.7 18.2 12.1 8.5 2.0 4.1 1.3 12.3 20.2 15.2 14.5 13.4 13.2 0.8 2.5 990 0.4 1.4 3,377 0.6 1.6 2,814 1.4 2.4 1,341 0.6 0.9 2,047 0 1.4 692 0.9 1.2 1.456 29.2 4.4 455 2.9 36.6 2,228 2.2 7.6 3,183 Total 4.6 21.2 20.4 10.6 16.0 7.8 10.6 1.9 6.9 18.583 1 The location of the 2d listed pont medical school training on the A.M.A. recordo. TABLE 20.-GINI COEFFICIENTS FOR 48 STATES BY SPECIALTY, 1970 Total phyoiciann 0.1489 General practice 0980 Total medical opecialiot 2166 Cardiovascular disease 2640 Infernal medicine 2285 Pediatrics 2051 Total surgery specialiot 1323 General sorgery 1318 OB-Gyn 1631 Ophthalmology 1315 Orthopedic surgery 1558 Otolaryngslogy 1418 Urolsgy 1214 Total other specialist 2157 Aaestheoiolagy 2255 Poychiatry 3145 Pathology 1487 Radiology 1133 Test specialty 0000 Source: J. N. Haag, G. A. Ruback, and B. C. Martin, "Distribution of Phyniciano in the United Stateo, 1970," AMA (1971). PAGENO="0686" > > C * - ~-. . . -~- . C - ~ > C 0 * -.~- .~__~-*~-*..0 0 C C 9L9 PAGENO="0687" HHHfl ~) ~ C, LL9 PAGENO="0688" 00 C) C) c~ c~ C) C) (0 ~ 00 00 C) - Cc (Cc (0 C-, (0 -J (0 00 Cc C) CO N.) C) C) (N (C C) .~ ~ > ~=:~ C) ~0 C-, > C,, .C) C) C) C) C) C) C) C) C) C) C) C) C) C) C) C) C) C) C) C) C) C) C) C) (0(0(0(0 (0(0 ~ C) C) SL9 PAGENO="0689" S 0000.o.o.000.o.. I C" C" 00 -`C) p 0 C 6L9 PAGENO="0690" GSO Mr. Roy. Thank you, Dr. Weber, for a very fine p~pe1'* J)r. Dorsey. STATEMENT OF JOSEPH T. DORSEY, M.D. 1)r. DORSEY. Thank you. Dr. Roy. Tl~e. steady decline in the supply of primary care physicians that has taken place in this country has lead to the single most critical re- source deficiency in our system. Rather than read the statement that I have submitted for the rec- ord. I think what I will do is to make several observations from the personal experience that we have had in Boston ab Harvard Gorn- niunitv health Plan, both in recruiting physicians into the primary care disciplines, attempting to develop an adequate primary care service J)rogram and attempting to construct training programs for people interested in primary care. Most of the comments in my submitted statement have already been addressed by previous speakers, aiid I do not feel the need to repeat the comments they have made. I think it is remarkable that all of us and representatives of the AMA would agree on the diag- isis. There is a deficiency of primary care physicians, with deficits being most felt in rural American and in the inner cities of Amer- ica. There are now a half a dozen studies, most of which have come out over the last 15 years, from Baltimore, Boston, Chicago, Los Ange- les, and New York, plus a 1934 study from Philadelphia, which all provide precisely the same information. As changes have taken place in medicine in the direction of greater specialization and greater institutionalization of care, those areas that are characterized by low socioeconomic status have lost their primal-v physician manpower pool. There are two particular points that were briefly mentioned, which I would like to emphasize. First is, that the remaithng pool of gen- eral practitioners averages almost 10 years older than other physi- cians in practice. if you turn to the last page on the statement that I submitted, one can see that despite the increase in the extent to which primary care is provided by internists and pediatricians, over half of the available physician primary care pool is still in general practice. Emphasizing this fact, things are going to get worse before they ~ret better. Many of those people who have given service to their communities are not going to be around 10 years from now. A second interesting fact is, that general practitioners tended to select office practice locations with little regard for the socioeconomic conditions of the neighborhood in which they located. Physicians trained as internists and pediatricians, and to an even greater ex- teiit. J)hvsicians trained in nonprimary care specialties, have tended to locate their office in neighborhoods at the favorable end of the socioeconomic spectrum. Thus, the poor, in addition to participating in the nationwide loss of primary care capacity, have been doubly affected by the failure of the modern day replacement for the general piactitioi~eI' to locate in poor neighborhoods. In the comments I submitted, I made remarks regarding the defini- tion of primary care; why there has been such a decline in the num- PAGENO="0691" 681 ber of primary care physicians and various methods that have been used for estimating the need in the field of primary care. I am going to turn to the bottom of page 3. where the first corn-. ments regarding the experiences related to prepaid group practice are mentioned. One methodology that has been used is based on an analysis of the exl)erie.nces of existing prepaid group practice plans. Patients eni-oll in these relatively self-contained systems; they are covered only for services obtained through the closed panel of physicians as- soeia.t.ed with the plan. Under these circumstances, the volume of demand for services in the various clinical specialties can be deter- mined. Utilization rates in widely disparate prel)aid group practices are, more remarkable for their degree of similarity than for the dif- ferences noted. The medical group is responsible for providing virtually the full range of services covered for their members. The medical director mnst re.ci-uit physicians in numbers and types that reflect the pat- te~n of specialty utilization demanded by enrolled members. If there al-c inadequate numbers of primary care physicians, it is the medi- cal group's problem to conduct a recruiting program which will as- Sure specialty balance and/or to devise pi-ogrammatic ways to meet t-he. need with existing staff. TTsing this approach, Mason, in an article in the JAMA, reported on staffing patterns in a number of prepaid group practices. The ratio of all full-time equivalent physicians ie~ 100.000 enrolled inem- be.~s ranged between 94 and 1O~. In the p1ac.tic(~s surveyed, primary en ic was given by family pract~t.ioners. internists, and pediatricians or some conibination thereof. A remarkably consistent i~5-6O percent of the full-time equivalent staff was made up of primal-v care prac- titio~iers. I believe that. this estimate of need is as reasonable as one can cui-rent.lv obtain, but, in projecting this experience nationally, one mu~t take into account several other characteristics of prepaid gloup practIces. I indicated a number of cautions we should have in pro- jectiiig these figures nationally. They aie in `the record, and I will skip over them at the moment. In comparing the overall PPGP staffing pntt.ei-ns with national physician/population ratios, it is probably best t.o focus on the pool of non-Federal physicians and osteopaths. whose professional ac- tivity is patient care, in an office or hospital setting, and who are not in training. The most. i-ecent data fi'oin the National Center for health Statistics indicate that the Nation had a maximum of 48.8 primary care physicians per 100,000 population in 1971, of which 58 Percent were general practitioners. I would like to clarify one diseiepanev between the figure I used and the figure you used iii your introduction to your bill, Dr. Roy. You said the figure for primary care physician manpower is (~0 per lOft000. Tile only difference is, you added in obstetric-gynecology, ami I assume you know more about whether they should be included than I would. `\I" BOY That represents a personal bias. Di-. Doi~srv. The national figures as they now stand would repre- 3S-OOS--74-pt. 1-------45 PAGENO="0692" 682 sent inadequate staffing for primary care in PPGP's (52-61 primary care physicians per 100,000 population) even before taking into con- sideration the younger age of PPGP patients and the presumed or- ganizational efficiencies. Since the national figures are highly influ- enced by the remaining pool of general practitioners, their relative age should be carefully recalled as one thinks ahead to the next decade. In the methodologies that have been used, one gets wide divergence of estimates about the number of primary care physicians required in this coutrv. Wheii one is faced with the need to make national polic'v. one has to deal with the fact that the demand for physicians' services are very elastic and the fact that there is no objective defini- tion of what. nee(l is made up of. Ihere is a well-accepted principle in the hospital literature that the very supply of inpatient hospital capacity creates the demand for that service. I would suggest that the same thing could take place if we accept very high estimates of the need for primary care physi- cians, very high estimates for the number of total physicans. There are many problems we do not attend to in medical practice today, that many of us feel should be better attended to: Patients' emotional pi'oblems. their need for more in the way of health main- tenance services and a variety of other activities. But I think the country has to establish some outside limits in terms of what per- centage of its resources it is going to allocate into a particular area, ~:hether that area happens to be hospital beds or primary care physi- cians. I think Dr. Bunker's writing has pointed out that, if one does not (10 this in a particular specialty, the physicians who are practicing in that specialty are. able to deal in the gray area and that they are able to keep themselves active and busy. The, system, in many ways, sets the incentives that the individuals are going to face. when they make career decisions. I do not think we should blame hospital administrators or particular chiefs of service for the situation. I think that, as long as the system is geared as our academic. institutions are, to have as their highest priority the rewarding of people who work in the basic sciences and rewarding people who work in the clinical sciences, that is where physicians are going to be attracted. Xs long as the country remains largely on a fee-for-service reim- bursement system, that system of unit pricing will go a long way towards distorting any attempt to rationally allocate our manpower resources. I think the same thing happens when one deals with hos- pital beds. In contrast, the i'ate of reimbursement for services in the field of primary care, the aniount of prestige attached to the areas and the type of educational ~)rOgra.ms that have been available to physicians entering in primary care have been considerably less attractive than those that have been available for people who are interested in going into some of the subspecialties. The experiences we have had in recruiting physicians into a pre- paid group l)i'aCtiCe have been of interest., and may provide some PAGENO="0693" 683 clues to other features `that could be built into programs that would help attract physicians into primary care. First of all, attractive practice settings-physicians who have com- pleted training programs in which their colleague relationships with other members of the staff have become important, are not likely to be attracted into isolated practice settings. 1 think the ability to develop group practice settings ~ii modern facilities would be one step towards attracting more people into pri- mary care. Secondly, I think, to the exent that our clinical departments in academic settings take on a greater ainoiuit of responsibility for th~ development of training programs for primary care physicians. there will be created a home for many practitioners that will enable thien~ to have ties to academic institutions, and that., in itself, I think, will help to make the field of primary care more attractive. Thirdly, I think, with respect to these very particular and very severe iieeds of low income communities, it is more likely that, if we can develop a service program in which low income communities are represented as part of a more broadly mixed population of peo- ple being served by physicians in primary care, the likeJihooci of retaining the services of primary care physicians for the low in- conic members will be enhanced. llegarding training programs. I think, particularly, in large urban centers \vithl highly specialized medical institutions tied to ac~tdemic cemiters, I believe the importance of developing special training pro- grams for internists and pediatricians who are interested in primary care should not be overlooked. Specialists in these two clinical fields have found themselves mor~ and more playing the role of primary care practitioners. However, this has been a de facto situation that has grown out of the corn- rmnuiit.v's need for primary care, rather ft an a rationally 1)1 anned de- velol)nient in which a phvsicians early career decision was nurtuied ali(l brought to maturity through an appropriate primary care train- mg l)rOgiam. .\Iost of our residencies in internal me(licine and nediatr~cs are heavily hospital and subspecialtv orielite(l. 1ieco~riiizin~ this fact ahi(t responding to increasing concern from time conununitv and interest froni young I)hysiCianS. the. Departments o~ Medicine affiliated with harvard Medical School, with support from tIme l~obert Wood John- Soil Foundation, have initiated separate tracts within their depart- meiit.s. which am-c designed to meet the Sj)ec.iIiC tlaiiiiimg requirements of time budding primary care physician. Time tracts are of 3 years duration. with approximately 50 percent of the trainees time spent in ambulatory practice settiinrs. rflie train- ees work nuder the direction of senior staff chiuiicians who serve b~Ii as l)1eceptors and as role models. In contrast with fully hospital- based programs, greater emphasis is placed on developing sensitiv- itv to patients' 1)ei'somiah amid emotional problems, oil viewing the patient as a member of a family and a community, on recognizing and making use of the full range of resources in the health care system. on time natural history of patients with chronic disease who PAGENO="0694" 684 bye in the community, on preventive checkups, on the common prob- lems which present commonly in the primary care physician's office. seminar programs deal with issues in the delivery of health care, ~the physician as a member of a health care team, and the broader social role of the. physiciar~. As the physician matures, he takes on tile role. of primary care physician, works with nurse clinicians and becomes the contact physician under supervision for a panel of patients. By 1975, we anticipate extending the program into the Department of Pediatrics. For institutions with strong clinical departments in medicine and pecliat~ics, and with chiefs of service who are recep- tive to encouraging the development of a primary care tract for a ~0Ili011 of the department's trainees, this pattern allows one to use the stien~ths of the existing training system. Furthermore, in Boston, all our organized ambulatory programs ii~c intel I11S~S and pediatricians to provide primary care. Thus, the tm eee hiiis not only available role models but a ready-made prac- tice setting into \vhicll he can move on completion of his training. Ua~vard Medical School and its teaching hospitals have long epitomized the institution whose orientation was to research and SlJld~~C(~Olt~ training. If these institutions can make a meaningful an~ I enl edantive coniinitment to primary care training, it seems rca- Sollitnie to bmw that other medical centers will also be able to do so. The dnancing of primary care training programs represents a very special problem. Tile costs of training cannot be borne by patients who USC the anibulatory se.~tings. Research funds which have helped support inpatient training efforts are generally not available on the alllI)ulalory side. Incomes of physicians iii primary care practice t&ii'l to be at the. lo\vel end of the spectrum among practicmg phy- snn~uis and the time of clinician faculty members must be reimbursed. ilecaure improving access to pu1~~~.y care services represents the Nc. 1 pIloritv of the Robert WTood Johnson Foundation, we have hccii successful in securing funds for a group of 1~ trainees, in priniary care. for 1974-75. We are applying for funding for 1975-77 now. In addition to estal)lishiflg a good training program, we hope to develop inure accurate cost estimates than are now available for tl1c,se~ who must formulate national policy regarding the funding of resbiencies. in tOfld~lUSiOIl, tire average citizen is affected clay in and day out by the (lecline m primary care physicians. While he may some day i~eed to worry about adequate insurance coverage for a costly hos- pitalization~ i~e is faced every day by the need for well child services his children, Pap smears and family planning services for his w fe a nd checkups to help him with his hyper~ension or fear of an early heart attack. When he finds himself paying a high insurance premium and still unable to readily obtain satisfactory, routine office serv~ce5, the frustration becomes intolerable. We jiced a clearly stated national policy committing ourselves to producing adequate numbers of primary care practitioners. From this c~inimitment will follow the funding, development and implementa- t~ on of training programs, the establishment of practice settings which will attract and retain physicians in primary care and a na- PAGENO="0695" 685 tional resurgence of interest in the provision of dignified, high qual- it,y and humane primary care services. [Dr. Dorsey's prepared statement follows:] STATEMENT OF JOSEPH L. DORSEY, M.D. NATIONAL ShORTAGE IN THE SUPPLY OF PRIMARY CARE PHYSICIANS-INTRODUCTION My name is Dr. Joseph L. Dorsey. I am the Medical Director of the Harvard- Coinnuinity I-Iealth Plan, an HMO of the prepa]AI group practice model, serv- ing some 37,000 enrolled members in the greater Boston area. I also practice as an internist in the HCHP Medical Group. The problem our American people face in obtaining adequate primary care services has been of interest to me for a number of years. As a Master's De- gree candidate in the School of Public Health at Yale, I studied the loss o~ primary care Physicians from the inner city of Boston in my thesis (1,2). My interest in joining the staff of HCHP in its formative years grew in large measure out f the Plan's commitment to developing an organizational struc- ture ~vhicli would offer residents of the Boston coiiirnuiiity high quality and well-organized primary care services, would give pliysieia us an attra ctive prac- tice setting to encourage them to serve as primary care providers, and would later be used as a site for the training of physicians who desired careers in primary care (3,4). TRENI)5 IN SUPPLY OF PRIMARY CARE PHYSiCIANS The steady decline in the supply of J)rilnary care physicians that has taken place in this country over the past 40 years has led to the single most critical resource deficiency in our system. It might lie worth pausing for a moment to indicate what is included in the d'tinitinn of "primary care" physician. The term is used in different ways by different people hut, in functional terms, there is general agreement that the primary care physician is the person who does the following: 1. He serves as the usual and appropriate point of entry for most people into the medical care system; he is the physician of first contact. 2. He is the source of care for most basic health services, including preve~i- tive checkups, management of acute eptisodes of disease, longterm foilowup of many chronic medical conditions. 3. He is the source of referral to surgical and medical specialists when prob- hems arise requiring their specialized skills. The primary physician will usually coordinate the services of these referral consultants and other health agen- cies whose services his patient may require. 4. He serves as the constant figure over the span of years to whom the ra- tient can turn far help and advice regardless of the nature of the problem. Most peop'e find it easier to think about the primary care physician iii terms of yesteryear's general practitioner. The basic concept of the physician who looks after the patient in a personalized and continuous manner over time is embodied in the modern day definition of the primary care physician. With the decline of general practice that followed the second World War, primary care services have been provided to an increasing degree by physi- clans with specialty training in family practice, internal medicine, and pedia- tries. But the gradual increase in the numbers of family practitioners, internists, and pediatricians in the past quarter century has not nearly offset the 1ss of general practitioners (5-8). In 1931. there were 90 general practitioners and parttime- specia1ists who provided primary care per 100.000 population: by 1957, the number had fahleii to 48: by 1970, to 27. The first chart atta~hed shows that when one adds in the numbers of internists and pediatricians to the totals, the decline is only niodestly affected-from 94 primary care physi- cians in 1931 to CO in 1P57, and to i~0 in 1970. A number of national commissions dating hack to the micl-1960's indicated the serious nature of the problem and the priority it deserved (9-11). The consequences of this shortage are evident In every urban and rural setting in this country. Much of the sense of alienation and depersonalization PAGENO="0696" 686 people feel when they talk about the health care system flows from their inability to locate a kind and competent primary care practitioner. Much of I lie excessive use of hospital emergency rooms by patients with nonurgent problems is brought on by the lack of an appropriate alternative (12). Pa- tients often find themselves making a preliminary diagnosis on their own in order to select a subspecjaljst as their lioint of entry into the system. REASONs FOR DECLINE ~\unierous reasons have been advanced for the decline in general practice. .A~. intilicine became niore technically complex and scientifically oriented, JiJivs~cians in training found specialization an increasingly more attractive career pattern. As the role of the hospital and other institutions grew, the ileed for a physician to Possess specialty skills to remain in the mainstream of clinical medicine increased. Neither the training opportunities, nor the prac- tue settings that evolvd in the Ilast quarter century have been sufficiently ultlraetive to nlaiiitain the supply o~ generalists. Two additional critical facts that have emerged in virtually every study on he ~upilv and distribution of general practitioners should l)e mentioned. Fir~r of all, the remaining pool of general practitioners is. on the average, con- saliruibly older than are physicians classified as specialists. Hence, the cur- rer~t I)rollem will most assuredly be magnified over the next decade. Secondly, general practitioners tended to select office practice locations with 1i~rle regard for the socioeconomic conditions of the neighborhood in which they located (13). Physicians trained as internists and pediatricians, and to ~ui1 t~ cmi greater extent physicians trained in non-primary care specialties, have teIl(le(I to locate their offices in neighborhoods at the favorable end of the ~4(tuoeeonoa1ic spectrum (1). Thus, the poor, in addition to particinating in the nationwide loss of primary care capacity, have been doubly affected by the failure of the modern day replacement for the general practitioner to loc To in poor maghborhoods. ESTIMATES OF NEED 1~ i-~ difficult, if not impossible, to get a consensus among medical care ex- !err~ about the precise level of need for primary care P~1ysicians (14). (rio method for estimating the number required is outlined in a 1072 paper fro!!! the New England Journal of Medicine by Schonfeld, Heston, and Falk U~ing data from national surveys on the incidence and prevalence of dis( rises and conditions that would lead people to seek primary care, the authors interviewed private practice internists and pediatricians on the clinical faculty at Yale Medical School to establish estimates of the amount of phy- S~]flhI Iliac that would he re(lulired to adequately manage patients with these pr 1 ruis. They then calculated the numbers of I)hySicians that would be re- i r'e.l to provide the quantities of time estimated. lr~ccring time results nationwide, they calculated a need for 133 primary (`~ 1' J1y~icians PG inttrnists and 37 pediatricians) per 100,000 population, corn- jarel with the existing maximum estimates of the present supply of physi- cia n~ in these specialties, namely 50-GO per 100,000 population. On top of these eSt~nu:ites, one would need to add the physician time involved in preventive services. This method of estimating need produces a relatively high estimate of marilow-er lice-I, It has loth the obvious advantages and disadvantages that fr~loxv form surveys of clinicians. The main advantage is that the projections are l:i~od on professionally determined estimates of real need and are not to existing ratios, which are a reflection of derna~d, as the main focus for pr ~cetin~ need. The disadvantage is that the projections of required time innuts are based on sc)ft data and do not reflect l)hysicians' and patients' ac- tu~ 1 1 elmavirr patterns in seeking health care. A second metluodelegy is based on an analysis of the experiences of existing prp Id cr~uip practice plans. Patients enroll in these relatively self-contained they are covered cily for services obtained through the closed panel of physicians associated with the Plan. TInder these circumstances, the volume of demand for services in the various clinical specialties can be determined. Triliz~tion rates in widely (hiSparate prepaid group practices are more re- triarkable for their degree of similarity than for the differences noted. PAGENO="0697" 687 The Medical Group is responsible for providing virtually the full range of services covered for their members. The Medical Director must recruit phy- sicians in numbers and types that reflect the pattern of specialty utilization demanded by enrolled members. If there are inadequate numbers of primary care physicians, it is the Medical Group's problem to conduct a recruiting program which will assure specialty balance and/or to devise programmatic ways to meet the need with existing staff. Using this approach, Mason, in an article in the JAMA (16), reported on staffing patterns in a number of prepaid grou~ practices. The ratio of all full time equivalent physicians per 100,000 enrolled members ranged between 94 and 102. In the practices surveyed, primary care was given by family practi- tioners, internists, and pediatricians, or some combination thereof. A remark- ably consistent 55-60% of the full time equivalent staff was made up of pri- niary care practitioners. I believe that this estimate of need is as reasonable as one can currently obtain but, in projecting this experience nationally, one must take into account several other characteristics of prepaid group practices: 1. The Plans are highly specialty oriented. Most have few, if any, general Practitioners on staff. Problems which might be cared for by a general prac- titioner in communities with adequate numbers of general practitioners are likely to receive care in a PPGP both by other primary care providers and by other non-primary care sepcialists. Hence the, estimate of primary care practioners, may be low for those communities with substantial numbers of general practitioners. 2. The population over age 65 is significantly under-represented In most PPGP's. People over age 65 use 2-3 times as much service as people under age (35. Hence, the total physician/population requirement would be higher if projected nationally, although I doubt that the proportion of primary care i~hysieians would be significantly altered (17). 3. I'PGP's represent a distinct financial and organizational structure within which its primary care physicians operate. Considerably fewer surgical proce- diires are performed on PPGP members; a much higher proportion of care is provided out of hospital and there are fewer days of hospitalization even when the utilization figures are age adjusted. The distinctive financial, bene- fit, reimbursement and organizational characteristics of PPGP's must all be rec- ognized when extrapolating their experience nationwide. 4. The ~gures from PPGP's refer only to that segment of the physician man- power pool which is a) out of training. b) not involved in teaching and re- search, and c) not engaged in other activities such as industrial medicine, public health administration, etc. PPGP c0MPAflED TO PRESENT NATIONAL FIG'URES In comparing the overall PPGP staffing patterns with national physician/ population ratios, it is prohal)ly best to focus on the pool of non-federal phy- sicians and osteopaths, whose professional activity is patient care, in an offiec' or hospital setting, and who ore not in training. The most recent data from the National Center for Health Statistics (IS) indicate that the nation had a maximum of -15.8 primary care physicians per 100,000 population in 1971. of which 58% were general pratitioners. These figures would represent inaucquate staffing for primary care in PPGP's (52-61 primary care phy- sicians per 100.000 l)opulaticn) even before taking into consideration the younger age of PPGP patients and the presumed organizational efficiencies. Since the national figures are highly influenced by the remaining pool of gen- eral practitioners, their relative age should be carefully recalled as one thinks ahc~d to the next decade. CFRRENT STEPS What is hein'~ done to correct this situation? Frankly, in relation to the marnitude of the problem, not much in a free-for-service system, the sur- gical specialties anmi suhsrecialties prove extremely nttraclive to young phy- sicians. Dr. P~iinIcer will discuss this problem in detail. Suffice it to say, both voluntary and rovernmental efforts will lie needed to modify the existing pat- tern of incentives to increase the flow of trainees into primary care specialties. In many oreas. the ro~e of professional nurses has been expanded to Include a direct involvement in the delivery of primary care. Nurses who are trained as nurse practitioners or nurse clinicians can provide excellent well child services, prenatal services, and a broad range of primary care services for PAGENO="0698" 688 adults. A number of training programs for physicians' assistants are also preparing their graduates for primary care roles. It is clear that "mid-level practitioners' of both types will play an increased part in meeting our nations primary care needs in the future. It is less clear, however, what quantitative impact nurses and physicians assistants will have on the need for primary care physicians. A number of medical seliools and hospitals have developed family practice training programs during the past decade. The AMA's November, 1973, Rej~rt on Medical Education iii the United States (19) indicated that ". . . the num- ber of approved residencies has increased from 70 in 1971 to 172 in 1973. There were ~4J first year, (3~3 second year, and 35-1 third year residents, for a total of 1,771 residents in training in 1973. Eighty-six percent of first year positions were filled." in June. 19T3. the AMA House of Delegates approved a report on "The Distribution of Physicians by Medical Specialty" which emphasized the need for more primary care physicians. The report noted that ". . . the ~~ercentage of residents in training in primary care specialties (39%) is lower than the percentage 110W in practice in those specialties (40% ) ." It is clear that the 1)ractict' situation will heconie worse unless increased numbers of graduates enter the primary care residencies. it concluded that: "The AMA should adopt immediately, publicize widely and promote vigorously a goal to have at least 50% of all medical graduates enter residency training in the primary care specialties (especially family practic'e) in the coming years." Particularly in large urban centers with highly specialized medical insti- tutions tie(l to academic centers, I believe the importance of developing spe- ciai training programs for internists and pediatricians who are interested in prilliry care should not he overlooked. Specialists in these two clinical fields hive found themselves more and more playing the role of primary care prac- titioners. However, this has been a de facto situation that has grown out of tin' coinniunity's need for primary care, rather than a rationally planned de- velopment in which a physician's early career decision was nurtured and brought to maturity through an appropriate priniary care training program. Most of our residencies in internal medicine and pediatrics are heavily ho~-.~ irl nd suhspecialty orient ed. Recognizing this fact and responding to increasing concern from the com- munity and interest from young physicians, the Departments of Medicine affili- ated with Harvard Medical School, with support from the Robert Wood John- son Foundation, have initiated separate tracts within their departments, which are designed to meet the specific training requirements of the budding primary car' physician. The tracts are of three years' duration, with approximaely 50% of the trainee's time spent in ambulatory practice settings. The trainees work un- der the direction of senior staff clinicians who serve both as preceptors and as role models. In contrast with fully hospital-based programs, greater em- phasis is placed on developing sensitivity to patients' personal and emotional jrolienis. on viewing tie patient as a member of a family and a community, on recognizing and making use of the full range of resources in the health cro cyst en, on the natural history of patients with chronic disease who live in the community, on preventive checkups, on the common problems which present commonly in the primary care physician's office. Seminar programs deal with issues in the delivery of health care, the phy- SiCiOfl as a member of a health care team, and broader social role of the physician. As the physician matures, he takes on the role of primary care physician, works with nurse clinicians and becomes the contact physician un- der supervision for a panel of patients. By 1lt7~i. we anticipate extending the program into the Department of Pedia- trics. For institutions with strong clinical departments in medicine and pediatrics, and with chiefs of service who are receptive to encouraging the development of a primary care traet for a portion of the department's trainees, this pattern allows one to use the strengths of the existing training system. Furthermore, hr Boston. all our organized ambulatory programs use intern- ists and pediatricians to provide primary care. Thus, the trainee has not only available role models hut a ready-made practice set~ng into which he can move on completion of his training. Harvard Medical School and its teaching hospitals have long epitomized the PAGENO="0699" 6S9 institution whose orientation was to research and subspecialty training. If these institutions can make a meaningful and substantive commitment to pm- mary care training, it seems reasonable to hope that other medical centers will also be able to do so. The financing of primary care training programs represents a very special problem. The costs of training cannot be born by patients who use the ambula- tory settings. Research funds which have helped support inpatient training efforts are generally not available on the ambulatory side. Incomes of physi- cians in primary care practice tend to be at the lower end of the spectrum among practicing physicians and the time of clinician-faculty member must be reimbursed. Because improving access to primary care services represents the number one Iriority of the Robert Wood Johnson Foundation, we have been sucessful in securing funds for a group of 12 trainees in primary care for 1974-75. We are applying for funding for 1975-77 now. In addition to establishing a good training program, we hope to develop more accurate cost estimates than are now available for those who must formulate national p~1icy regarding the funding of residencies. Already at the State level, a number of legislatures have tied their con- tinued support for financing medical training institutions to assurances that the institutions will train adequate numbers of primary care physicians for their state. The average citizen is aff~ted day in and day out by the decline in primary care physicians. While he may some day need to worry about adequate need for well child services for his children, Pal) smears and family planning ser- vices for his wife, and checkups to help him with his hypertension or fear of an early heart attack. When he finds himself paying a high insurance pre- niium and still unable to readily obtain satisfactory, routine office services, the frustration becomes intolerable. We need a clearly stated national policy committing ourselves to ~srodu~ing adequate numbers of primary care practitioners. From this commitment will follow the funding, development and implementation of training programs; the establishiiient of practice settings which will attract and retain physicians in primary care and a national resurgence of interest in the provision of thgni- fled, high quality and humane primary care services. BIBLIOGRAPHY 1. Dorsey, J. L. "Physician Distribution in Boston and Brookline, 1940 and 1961." Medical Care 7 :429-440, 1969. ~. Dorsev, J. L. "Manpower Problems in the Delivery of Primary Medical Care." NEJM 2S2 :871-872, 1970. 3. Dorsey, J. L. `Development of Primary Medical Care Programs by Un!- versiy Teaching Hospitals: Issues Related to Patient Care Services." Trans. Assoc. of Amer. Physicians 83:73-77. 1970. 4. Dorsey, J. L. "The Prepaid Group Practice Plan in the Education of Future Physicians: Initial Effors at the Harvard Community Health Plan." Medical Care 11 :12-20, 1973. Donabedjari, A., Axeirod, S.J., Sevearingen, C., and Jameson, J. "Medical Care Chart Book." Ann Arbor: University of Michigan School of Public Health, 1972. Chart E-21. (3. White, K. L. "General Practice in the United States." Jour. Med. Ethic. 39 :333-345, 1964. 7. Fabs. I. J. and Peterson. 0. L. "The Decline of General Practice." Public Health Reports 83 :267-270, 1968. S. Overpeck, M. D. "Physicians in Family Practice, 1931-67." Public Health Reports 85 :485-4~4, 1970. 9. "The Graduate Education of Physicians. Report of the Citizens' Commis- sion on Graduate Medical Education (The Mihlis Commission). Chicago: AMA, 196(3. 10. "Health is a Community Affair." National Commission on Community Health Services. Cambridge: Harvard University Press, 1966. 11. "Meeting the Challenge of Family Practice." The Ad Hoc Committee on Education for Family Practice of the Council on Medical Education, AMA. Chicago: AMA, l9O~. 12. Weinerman, E. R., Ratner, R.S., Robbins,, A. and Lavenhar, M. A. "Yale Studies in Ambulatory Medical Care: V Determinants of Use of Hospital Emergency Service." AJPII 56: 1037-1056, 1966. PAGENO="0700" 690 13. Marden, P. G. "A Demographic and Ecological Analysis of the Distribu- tion of Physicians in Metropolitan America, 1960." Amer. Jour. of Sociology~ 72 :290-300, 1966. 14. For a through discussion of the advantages and disadvantages of various methods of projecting manpower requirements, see: Donabedian A., "Aspects of Medical Care Administration: Specifying Requirements for Health Care. Cambridge: Harvard University Press, 1973. 649 pp. 15. Schonfeld. H. K., Heston, J. F., and Falk, I. S. "Numbers of Physicians Required for Primary Medical Care." NEJM 286:571-576, 1972. 16. Mason, H. R. "Manpower Needs by Specialty." JAMA 219:1621-1626, 1972. 17. Stevens. C. M. "Physician Supply and National Health Care Goals." In- dustrial Relations 10 :119-144, 1971. IS. "health Resources Statistics, 1972-73." Report form the National Center for health Statistics. 1973, p. 194. 19. "Medical Education in the United States, 1972-73." JAMA 226:896, 1973. r~ Prlar-; Care Physicians Per 100,000 Population and by `Lype o~ Practice cU.S.A., 1931, 1957, 1970). `Co 80 0 Co 0 an an an 0 S~ecia1jsts who liit their practice to physicians who are in general practice General Practitioners internal medicine and pediatrics and or part-time specialties. 60 20 Sources; (1) For 1931 and 1957; Mary 0. Overpeck, "Physicians in Family Practice 1931-1967,' Public Health Rep~y~ 85 (June 1970), Table 2, p. 488. (2) For l970:~ 3, 8. Haug, C, A. Roback, and 5. C. Martin, Distribution of Physicians in the United States, 1970 (American Neai'cal Aasociation; ~i~o,' i971)7~ie 6,"~. 54. 3 Internists 60 Pediatricians 3 1931 1957 1970 PAGENO="0701" 691 Mr. PREmi~. (presiding). Thank you. Dr. Bunker, you may proceed. STATEMENT OF IOHN P. BUNKER, M.D. Dr. BrNKER. Mr. Chairman, thank you for inviting me to speak today before the subcommittee. My prepared remarks cover material already touched on by other witnesses, and I will skip over these. I hope the full testimony can be accepted for the record. Mr. PRE1'1~n. Without objection, it will be put in the record. Dr. Bt~KER. I would like to call attention to some of the forces which determine the flow of physicians into one or another me~1ical specialty and to the question of why the resultant distribution does iiot meet the Nation's needs. In a free market such as ours, medical manpower is unplanned and uncontrolled. Up to the very recent past, the medical profession has made no attempt to determine how many physicians are needed in each specialty, nor have our medical schools or teaching hospitals. Clearly, there are acute shortages in some areas, such as general prac- tice and pediatrics; and it is probable that there is an excess of physicians in other specialties. A particularly well-known example is that there are more neiiro- surgeons in Massachusetts for a population of 5 million than there aie in England and Wales for a~ population of 50 million. But many other specialties also have a relative oversupply of physicians; and indeed, there are, overall, far too many specialists in comparison to generalists. In the absence of planning, there ~re identifiable forces which de- termine th~ quantity and variety of graduate specialty-residency- training. The physician, himself, usually has a clear career goal at the. time of graduation from medical school or during internship. Having paid for much of his education, he understandably feels free to choose a medical specialty and a place of practice based pri- niarily on his own personal preference. The young physiciaifs choice is, of course, limited to the spectrum of hospital appointments offered. rihe appointments offered are de- teimnined, in turn, primarily on the basis of the service needs of the hospital. Nowhere does the ultimate national need for trained prac- titioners enter into the decision. The service needs of the teaching hospitals are very large. Teach- ing hospitals provide 25 percent of the hospital care in this country, and they provide a large majority of the highly specialized care, such as kidney dialysis, open heart surgery and the care of premature infants. It is the young physicians in post graduate training who 1)1ovide almost all of the physician manpower and much of the skill necessary to carry out these complicated procedures. some of their activities are, of course, educational, but much is not, and indeed, a great deal of these activities could be performed by less trained personnel. The director of Stanford University Hospital has said tha,t h~ believes lie could provide those services by hiring fully trained phy- PAGENO="0702" 692 sicians at less cost than what he has to pay for his very large house staff. I think this service problem is a central one, and I believe it must be solved if we are going to wrestle successfully with the prob- lems of maldistribution and the problems of the foreign medical graduate. For this reason I was particularly pleased by the provi- sions of H.IR. 14~7 that. take account of the service problem and provide what. would appear to be reasonable financial recognition for the lIosl)itals. One might. reasonably anticipate that whatever kinds of doctors are trained, their services will he needed. To a certain extent this is true, fey it is now clear that there is an almost unlimited demand for medital services of all varieties. But though demand may be un- 1 muted, our iesources. and particularly our physicians, are limited; therefore, it. is essential that priorities be established to use these sea re resources and manpower in the most. effective and efficient man- ner possible. \o such comprehensJve assessment of medical specialty needs has been made. hut one can appreciate the magnitude of the problem by eonsideiing the fact. that the number of residency positions offered iii this country far exceeds the total annual number of medical grad- u~tes. For example. of the nearly 17.000 surgical residencies cur- lelitly offered, only about 12.000 are filled. Many of these pesitions are tilled by graduates of foreign medical schools; but it is ap- parent that. the medical specialties could easily absorb all new phy- sic~ans. leaving none. for general pI'ac.tice. One of the problems as- soiated with the training of foreign graduates is that having brought t.heni here, rather than training them in general practice, where they miLrht provide useful service, either here or in their own coun- trv-we train them primarily in the specialties. Ifow many specialists should be trained must be determined in li~rht of the needs of a. practice. of medicine which is in the process of profound reorganization. The education of residents must be geared to the long-range medical needs of the country and not sim- ply on the basis of the short-term needs of the hospital for an extra paIr of hands. Four years ago, I called attention to the fact tknt there are pro- I)ortionately twice as man surgeons in the United States than there are in England and Wales, and that they do iwice as many operations. This data is available. Mr. Piiryra. That will be included in the record (see p. ~398~. 1.)r. BUNKER. Within the United States, we now know that there are s~niilar large variations in surgical manpower and in operations. In Kansas and in Vermont, for example, two States for which de- tailed information is available, there are two, three, and four-fold variations in the rates at which common operations such. as ton- si I lectonuv, appendectomy, hysterectomy, and cholecystectorny are performed when one community is compared to another; and it is observed that the highest operation rates occur in communities where there ewe the most surgeons. I should point out, that operation rates were based on place of residence, thus excluding any effect of travel to medical facilities away from home. PAGENO="0703" 693 These data suggest either that some populations receive too imich care or that otliets receive too little, and some observers have dra ~vn the COIICiUSlOll that there must be a large numl)er of unnecessary operatioiis. But exactly how flinch surge.1y is needed for good health is not known, for no one has vet collected the kind of outcome data reqinieti for this j iidgnieiit-data first reqiiited~ inteiestiii~lv, l)v Florence Nightingale over 100 years ago, and icquesteci again by Boston oltho1)edic surgeon, E. A. Codman, early in this century. Studies to (levelop this kind of comprehensive data on cost-elfee- ti veness and risk-benefits are planned but. they will be t n ie coiisum in~ an(l laborious. T~ntil such data are available, there will continue, to be concern that demands for medical and surgical care may exceed fiee(l. 01, in CCOIIOI111C I)aIiaflce. that t he u~iiai checks and balances. of tl~e fiee market do iiot. apply to the medical care `industrv." The, pl'i1ic~p~il d~litcultv is, of course, that the COiiSllIllel, when lie is the average ci icnt, is not an informed (0115111 ar. lie hiii~ 11~) ~a-uy of tel hinc good 1!le(licllle from bad or whether iiiOie care is better than less. lii an ~itteml)t. to circunivent this difficulty, B. A. Brown, profes- sor of bio4atisties at. Stanford. and I have recently studied phvsi- cians as informed consumers of surgical services. (Bunker. J. P. and Brown. B. `\V. The Physician-Pat ieiit as an Iiifornied Consiiiiier of Surgical Scribes. N.F..J. Med. 2~0, l()~ [-P ~55. 1974.) The study was carried out. iii California and iii it, we compared ph~sicrans and their fari~i 1 es w;t ii lawv'rs. in inisters and lmsh icss mcii. I \vollld like to suinilit that ~mi t biilii F paper for the record if I may. ~\ ii. Iio ms. Wi tI lout obj ectio~ is, that will be inc I i~ded the record. [See p. 712.] l)i. l3cxnma. In this study oF utilization of surgical service 1w physicians and other piofessionals, it was our Iìypothesis that phv- sicians, cognizant of the risks, as well as of the bend-its of stirgeiv, would undergo fewer operations. (1on tia iy to our predict ion, however, we found that phvsicia US and their' families had as many as or more than the other profes- siorial grolI~)~. l'a rticula~ly startling was the observat.~on that lIore thai~ half the wives of male physicians in Santa Clara County will have tuidergane luv~terectomv by the age of (i~. Many of these. hysterectomies must have been for co11veii~e~~e~ amid I Suspect that mdiv would be called unnecessary by cOiiVe!~t.1O11~~j medical ciite~ia. But to the extent that they were denmanicled hi informiied patient. they must be considered to repiescut. a perceived need. I would suggest, however, that. some of such surgery is at best ~t luxury and indeed. I Suspect that a gOOdi deal of surgery is of ii luxury var~etv. W1~ethier. ~it.h the advent of national health insurance and time re- moval of financial barriers to medical care, we cani uiroril to provide medical and surgical care at. this level for' all seemmis unlikely. In the absence of quantitative data on whirhi to est mate nat ioi~aj needs for surgical care. it is difficult to say how many surgeons an needed to piovicle it. `We do have some reason as suggested above, PAGENO="0704" 694 ~to rs'~c~me that demands for surgical care by an increasingly iii- for:iied 1)llb~1C, will continue to grow. I )r. Lee has already sug~ested the combination of national health isnidnce and easn~ ~bnsumer knowledge will increase the de- nieuls for highly speciilzed care particularly in surgery. re provide surg~cai care, even at the current high rates which r~tinn in this country, there are probably already too many surgeons ~s certain tiìat surgeons are being trained at too great a ~ate. `ITe dinpeons themselves now recognize this and have begun to `nFecrive action. Such self-regulation is a welcome first step I cii is unlikel that this alone will be adequate. I say this simply en r *e basis ti~at one cannot expect any special interest group VOillfl- tiiid : to make large peiso~~l sacrifices, whether the group consists .~1sIologista, padiologists. surgeons, or any other specialty. i~icdical profession as a whole must assess the relative contri- nt aclt spec~e tv arid judge where the need is greatest. To Ii admini4rat mc nhecilanisms, and to set priorities, will ye- mm a coulrimssldi Icadmy representative of the medical profession, I v:clliiitt i~istmtut~ons and the. public. l~me cllarhre to tills mimI 1551011 must ill(h ude tile separation of mc Ir prloclt s horn thmi needs of hospital service and, therefore, In :!dS~' C ooinin:ited w~tli tothl medical manpower planmiuig. mr 1)11111 (~ounc:l on Post~iaduate Physician Training, such as sed mu ii.L. 14ml~l. v;oul(l appear to be an appropriate aaency me on ti~is Import cur respcimsibility ai~d I strongly endorse tiPs mi ant piece of legisiatioli. nailk you very much. ~i)c. Bunkeis prepared statement and the articles referred to in,. a STATEMENT OF JoHN P. BUNKER, M.D. SPECIALTY MALDISTRIBrTION OF PHYSICIANS Mr. Rogers, members of the Subcommittee, I wish to thank you for inviting :re to speak to you today on the subject of suecialty maldistribution of :ihysiciahls. I would like to address my remarks to some of the forces which determine the flow of physicians into one or another medical specialty and the question of why rue resmiltaimt distribution does not meet the nations I fee market 50(11 as ours, medical na ulower is unplanned and uneon- troiled. [p to the very recent past, the medical profession has made no at- tenrit to determine how many l)hyslcialls are needed in each specialty, nor have our medical schools or teaching hospitals. Clearly, there are acute sb rtages in some areas. such as general pratice and pediatrics; and it is IrI:.ml~e that there is an exress of physicians in other specialties. A par- ticularly well known example is that there are more neurosurgeons in Massa- chusetts for a population of five million than there are in England and Wales for a population of fifty million. But many other specialties also have a relative oversupply of physicians: and indeed, there are overall far too many specialistS in comparison to generalists. In the absence of planning, there are identifiable forces which determine the quantity and variety of graduate specialty (residency) training. The liy~eian, himself, usually has a clear career goal at the time of graduation from medical school or during internship. Having paid for much of his education. lme miderstanclably feels free to choose a medical specialty and a iltee of practice based primarily on his own personal preference. Time young physician's choice is, of course, limited to the spectrum of hos- pit 1 appointments offered. The appointments offered are determined, in turn, PAGENO="0705" 695 primarily on the basis of the service needs of the hospital. Nowhere does the ultimate national need for trained practitioners enter into the decision. The service needs of the teaching hospitals are very large. Teaching hospitals provide 25% of the hospital care in this country, and they provide a large majority of the highly specialized care, such as kidney dialysis, open heart surgery, and the care of premature infants. It is the young physicians in post graduate training who provide almost all of the physician manpower and much of the skill necessary to carry out these complicated procedures. One might reasonably anticipate that whatever kinds of doctors are trained, their services will be needed. To a certain extent this is true, for it is now clear that there is an almost unlimited demand for medical services c~f all varieties. But though demand may be unlimited, our resources, and par- ticularly our physicians, are limited; therefore, it is essential that priorities be established to use these scarce resources and manpower in the most effec- tive and efficient manner possible. No such comprehensive assessment of medical specialty needs has been made, but one can appreciate the magnitude of the problem by considering the fact that the number of residency positions offered in this country far exceeds the total annual number of medical graduates (of the nearly 17,000 surgical residencies currently offered, only about 12,000 are filled). Many of these positions are filled by graduates of foreign medical schools; hut it is apparent that the medical specialties could easily absorb all new l)hysicians, leaving none for general practice. How many specialists should be trained must be determined in light of the needs of a practice of medicine which is ia the process of profound reor- ganization. The education of residents must be geared to the long-range medical needs of the country, and not simply on the basis of the short term needs of the hospital for an extra pair of hands. The large service element present in medical sI)ecialty training is reflected in the fact that interns' and residents' salaries currently are derived pri- marily from patients fees. If the primary purpose is to train for the national need, new sources of funds must be found. Dean Robert Ebert of Harvard has suggested that house staff salaries be paid by the Department of Health, Education and Welfare, and he further suggests that this `would make it possible to exercise some degree of control over the numbers recruited by various specialties." I believe that only when the public pays for medical education can it expect to have a voice in what kinds of physicians are trained and where they practice. My personal concern with the problems of over specialization began while chairman of the National Halothane Study, a study o~ anesthetic and surgical deaths sponsored by the National Aeadern~' of Sciences ten years ago. One of the most important observations of this study was th~it there were large unexplained differences in postoperative death rates among the 34 participat- ing institutions. This observation suggested that there are large variations iii the quality of surgical care: another possible explanation is that there are large differences in the selection of patients-that some hospitals may care primarily for very sick patients with serious surgical illness, hut that others may specialize In less urgent surgery in good risk patients. That the distribution of surgery may vary widely, and by iniplication that tIle indications for which surgery is carried out may also vary, is strongly suggested by other data now available. Four years ago I called attention to the fact tht there are proportionately twice as many surgeons in the Fnited States than there are in England and Wales. and that they do twice as many operations.' Within the United States we know that there are similar large variations in surgical manpower operations. In Kansas 2 and in Vermont,3 for example, two states for which detailed information is available, there are two, three, and four fold variations in the rates at which common operations such as tonsillectomy, appendectomy, hysterectomy, and cholerystectomy are performed when one community is compared to another; and it is nl:served that Bunker, J. P.: Surgical manpower: ~ comparison of operat!ons and surgeons in the United States and England and Wales. N EngI J Med 2S2 :1~l-144, fl170. `Lewis. C. E. : Variations in the incidence of surgery. N Engi J Med 251 :SSO-S~4, 19~9. Wennberg, J. E., Gittelsohn A. : Small area variations in health care delivery. Science 182 :1102-1108. 1973. PAGENO="0706" 696 the highest operation rates occur in communities where there are the most surgeons. (I should point out that operation rates were based on place of residence, thus excluding any effect of travel to medical facilities away from home.) These data suggest either that some populations receive too much care or that others receive too little, and some observers have drawn the conclusion that there must be a large number of unnecessary operations. But exactly how much surgery is needed for good health is not known, for no one has yet col- lectecl the kind of outcome data required for this judgment (data first re- quested, interestingly, by Florence Nightingale over 100 years ago). What we need are quantitative regional and national data on the costs, risks, and benefits of surgery. There are already abundant data on the costs of surgery, and a good deal is known concerning the risks, at least in terms of mortality in the immediate postoperative period. But there are relatively few data concerning those who are discharged alive from hospital. Some die in other hospitals or nursing homes and are lost from the records. (The financial importance of this is suggested by Social Security records which show that as much as 25~ of Part A hospital Nedical payments are on behalf of patients who are dead a year later.) For those who live, there are virtually no reliable and comprehensive data on how many are relieved of their presenting disability or diseoiiitort. and how many have recovered to their pre-perative or pre-illness level of function consequently, it is usually not pussible to assess the balance of benefits to risks as operation rates are e~- tended ti incluue increa sing numbers of marginal procedures. Such an assessment has been un(lertaken, however, for one common and important ol)eration, appendectomy. The study was carried out in the Federal Republic of Germany.' Appendectomy rates were reported to he two to three times higher than those of other countries, and the mortality at- tril cited to nppendjc~tis was ciso found p be three times as great as in most other countries. Three-quii~ters of the appendices removed were found to be normal from this finding, the authors rule out time possibility of an in- creased prevalence of cl~sea~e and conclude that time most probable reason for Germany's high mortality rate is that appendectomy is carried out snore often than elsewhere. They imply. in short, that when appendectomy is carried out at higher rates for increasinrly tenuous indications, the risk of operation eventually exceeds the risk of time disease. A similar conclusion has recently heemi drawn by Duncan Neuhauser of the Harvard School of Public I-Iealth. On the basis of the mortality of elective heraiorrhaphy. the risk of strcngulation and the mortality of emergency opera- tion after strangulati n. Yeuimauser predicts that in the hands of the average surgeon, the risk of elective herniorrhapliy at the age of 65 or above is four times as great as the risk of not onerating. The question that Neuhauser raises is of special interest and importance at present, in view of the fact that the number of herniorrhajhies in the Medicare population has doubled since 1965. The evidence is strong that some cperaticmns are performed with a frequency In excess of doeurneatalle cost-benefit usefulness. How general is the phe- nomenon? Do more total operations actually lead to an increase in overall population mortality? There is some evidence to SupJ)Ort this conjecture. In the Vermont study (Vide supra). Wennlerg has observed a positive statistical association between onerntiin rates and overall death rates, and together with Wennberg. I have recently raised the question as to whether the high operation rates in the United State'~nid Canada may not help to explain the high age- specific mortality rates which are of so much concern on this side of the Atlantic~ Some. but by no means mill, of the difference can be attributed to the greater incidence of accidents, homicide and suicide in this commtry. Is it possible that some of the remaining difference may he accounted for by the now well established differences in numbers of discretionary operations? Discretionary operations all carry a discrete and measurable risk of death. The operative and postoperative mortality for all operations in the United `Tirhtner. 8.. Pflanz. M. : Appenlectomv in the Feieral Republic of Germany: ept- demblory and niodleal cu"o patterns. Med. Care 9 :311-laO, 1971. Bunker. .T. P.. Wennlerc. J. W. : Operation Rates, Mortality Statistics and the Quality of Life, N.E.J. Med. 289, 1249, 1974. PAGENO="0707" 697 States is approximately 1.4 percent (National Center for Health Statistics, unpublished data). For discretionary operations one might conservatively as- siime a mortality of 0.5 iercent, which if assigned to operations performed in the United States in excess of those performed in England and Wales, would account for a third to a half of the discrepancy in age-specific death rates. There are, to date, no national or international published data on post- operative deaths adequate to test this hypothesis. And even if the hypothesis is found to be correct, it does not necessarily mean that fewer operations (than performed in the United States) are better. Death is, after all, only one index of the public health-or lack of it. It is to the improvement in the quality of life-to the relief of disability, discomfort and disfigurement-that elective surgery is primarily directed. But the costs of surgery, measured in lives as well as dollars, are large, and must be entered into cost-benefit analysis of surgical care. In addressing itself to the costs and benefit.s of surgical care, the medical pro ssion will, first (If all, need Letter data. It will need (1(101 ltd iliiW:ll;itilifl oil which to estimate and balance the risks of each operation against the risks of nonoperat lye treatment.. br opera tiens sub as apjendetcoaly. in which the considerations are largely limited to life and death, the analysis is relatively straightforward. For iliany discretionary irocedules tile (luSt i~ ti is mire dith- cult to ~ljproacli ; is the likelihood that the operation will lead to a more cuifortable, useful and rewarding life sufficiently great to justify accepting risk; of death of one in a thousand, one in a hundred or greater? S 1111515 to develop this kind of c niorehensive dat a n ci st-effectiveness and risk-bench ts are planned, but they will be time eonsnhi;ng and Ia tori~ii s. Until such data are available, there will continue to be concern that demands for medical and surgical care may exceed need. or, in eeononuic parlance, that tic siisiiiil cheeks rid ha lanees of (lie free rita rlcet do 11 It alq Iy to the niedical care `findustry." The princilal difficulty is. of ceuI~se. that tine consumer, when lie is the average pal lent, is not an infornied consumer. lIe lies no way of tell- ing el rued ;eine fr ru had, or whet Per more Ca re is bet ter than less. 111 ill altenipt to eitvunivent (iris (hifhleUlty. B. \V. BrOvn. Prcfes~. r of blo- st itlstics at Stanford. and I have recently studied jliysicians as informed con- siil;~crs of surgical 5~ es.'1 The study was carried out in California a rid in it we compared physicians and their families with lawyers. nilnisters, and business rica. Vie expected tli;t physicirns. cognizant of the risks as well as of tie l'nietits it' surgery, would undergo fewer operations. Contrary to our predic- tiori. however, we found that physicians and their In niiiils had as many as or more than the other professional groups. Particularly startling was the observation that more than half the wives of male physicians in Santa Clara C unty will have undergone hysterectomy by tI age of 65. Many of these hysterectomies rimust have been for (`onVefli'n°e. and I suspect that many would be called unnecessary by conventional mile(lic;i I criteria. But to tie extent that they were demanded by an informed patient, they mnirist he considered to present a perceived need. I would suggest, however. that some of such surgery is at liest a luxury. arid, indeed. T suspect that a good deal of surgery is of a luxury variety. Whether. with the advent of nat lull I!ea Itli insurance and the removal of financial harriers to medical care, we can afford to provide medical and surgical care at this level for 01t seems uth ilcely. In (lie absence of quantitative data on which estiniate national needs for surrial care, it is difficult to say how many surgeons are needed to provide it. We dl hive some reason. as suggested above, to assume that demands for sur;rie;ml care l)y an increasingly informed pull in. will continue to grow. But to rovide surgical care. even at the current lii ghi rates wi' nh are nita ned iii this country, there are probably already too many surge ins, a rid it is eer- thin that surgeons are being trained at too great a rn to. TTie siirn.tens them- selves nw recognize this and have begun to take nerrot iv act ion. Siali self- reumlation is a welcome first step. lut it is unlnkely tilat I ids alan will In adeinil te. I say this simply on the basis that one c; nnot expect any special interest group voluntarily to make large personal sacrifices. The medical profession as a whole must assess tie relative contrnl)ulion of Bunker, I. P. afl(1 Brown, B. W.: The Physician-Patient as an Informed Consumer of Surgical Services. N.E.J. Med. 290, 1051. 1974. 3S-M9S--74----pt. l-46 PAGENO="0708" 698 each specialty and judge where the need is greatest. To establish adminjistra- live itiecliartisins, and to set priorities, will require a commission broadly rejiresentative ot the medical profession, the teaching institutions, and the public. Tire charge to this commission must include the separation of teaching priorities from the needs of hospital service, and therefore must be closely eourdiiiarecl w'ii h total medical manpower planning. A National Council on ostgr:iduate Physician Training, such as proposed in HR 14651 would appear to lie an ri1l~rprrare agency to take on this important responsibility, and I stri laly end me his important piece of legislation. ~i'iiCi1AL :\L~.xpo~-z:[l-x COMPARISON OF OPERATIONS AND SURGEONS IN TIlE LNITED STATES AND iN ENGLAND AND WALES (By John P. Bunker, M.D.) X1sirrreL-IIlere are twice as many surgeons in proportion to population in the Friited States as in England and Wales, and they perform twice as many operations. Fee-for-service, solo practice and a more aggressive therapeutic lipraicli a~~ear t a nrriliute to the greater number of operations in the Uiiir `1 Stai'~. M. re fr'qricllt use of consultation, closely regulated and stand- ardiri sumierri Iraciaccs and restrictions in facilities and numbers of surgeons c' t e cit rjlut e a i lie lower rates of operations in England and Wales. a as i srrigerv are not sufficiently precise to allow determination of whether American surgeons operate to often or the British too infrequently. A)elr'ra in ri iraica ma Iir)ov'er needs requires better information on ii ot- a ii ch `~ `r. ice trea men rae rt lie health requires and must also take in:o a' `tint the r. ci nodhil manpower needs of the country. pLv~ieians' services in the Fnitefl States has many causes, of with ho lIIehirr-iuflt use of the physicians' time rind inequities in their distribu- tion may have a greater roie than any alleged deficiency in their actual num- bers. The dIsprOportionate ge graphic concentration of physicians in wealthy set IllS f the country is common knowledge. Harder to identify, anti there- fore less well appreciated, is the pOSSibility of the maldistribution of physi- cians among the medical specialties. Evidence is presented herein that serious maldzstribution dors exist in that area of medicine with which I am most familiar-the operating room and its proprietors, anesthesiologists and sur- geons. It Las long been the goal of anesthesiologists in the TJnited States to provide all anesthetic c-are required for surgery, obstetrics rind dentistry. In its efforts to achieve this goal, the growth of anesthesiology as a medical specialty has been dramatic: in 194() there were 100(1 physicians specializing in anesthesia; and in IhIJO there are over 9000. But despite such rapid growth, it is estimated that anesthesiologisrs can personally provide anesthesia for less than half the paf~ents undergoing surgery, and they can hardly login to offer anesthetic care for obstetric's and for tientril surgery. There is no evidence that further rapid expansIon is apt to occur, and therefore there is little prospect that the shortage in anesthesiology manpower will diminish with time. Although it is widely acknowledged that there is an acute manpower shortage in anesthesia, not much attention is given to manpower problems in surgery. It is assumed that there are probably enough general surgeons,2 although there may he a shortage in some of the surgical specialties. But no serious thought seems to have been given to the possibility cf an overall excess. Certainly, there is a marked imbalance in the ratio of anesthesiologists to surgeons, but * .Af1dre~5 reprint roqii~ste to Dr. ltirnk"r at the Department of Anesthes1a~ Stanford uriverslrv Medical (`enter. Stanford, Cal. 9430a. Aided by a grant from the Jos!ah Macy, Jr., Foundation. 1 FIn. It. The Doctor Shortage: An economic diagnoais. Washington, D.C., Brookings Institution, 1967. `Knowles. J. H. : The quantity and quality of medical manpower: a review of medicine's current efforts, J Med Edue 44 :81-118, 1969. PAGENO="0709" 699 is it possible that the imbalance is due more to an excess of surgeons than to a shortage of anesthetists? Evidence in support of this hypothesis will be de- veloped by a comparison of anesthetic and surgical manpower and practice in the United States and in England and Wales. There were 9024 physicians engaged full-time in the practice and teaching of anesthesia in the United States in 1967 ~ for a civilian population of 197,430,000, and in England and Wales, also In 1967, there were 2298 physi- cians specializing In anesthesia' for a population of 48,391,000, 4.6 and 4.7 per 100,000 population respectively. At that time there were 74,746* physicians devoted to the full-time practice of surgery or its specialties in the United States ~ as opposed to 8,924 t in Great Britain 4~~39 and 18 per 100,000 popula- tion respectively (Table 1). There were, in addition, 10,850 physicians in gen- eral practice in the United States engaged in part-time surgical practice.5 Thus, whereas the ratio of physicians engaged full time in the practice of anesthesia to population Is almost exactly the same, there are proportionately more than twice as many surgeons in the United States as in England and Wales. There are also proportionately more operations performed in acute, short-stay hospitals in the United States than in England and Wales. From sample sta- tistics, collected by the National Survey,5 it is estimated that 14,000,000 opera- tions were performed In the United States in 1965, a rate of 7400 per 100,000 population, and from sample statistics collected by the Ministry of Health for the British Hospital In-Patient Enquiry,7 it is estimated that approximately 1,700,000 operations were performed in England and Wales in 1966, an opera- tion rate of 3770 per 100,000 population. Comparison of these overall operation data must be made with caution, since there were many differences in how they were collected.t Comparisons of individual procedures, however, can be made with considerably greater confidence and indicate rates for many opera- tions that are two or more times as great for the United States as for England and Wales (Table 2). All anesthesia in Britain is administered by physicians, over 90 per cent of whom are specialists or in specialty training, whereas in this country less than 50 per cent of all anesthetics are administered by an anesthesiologist, or by a physician in specialty training. Eckenhoff attributes this discrepancy ti, the greater operating-room efficiency and speed of surgery in Britain. Al- though marked differences in organization and efficiency of operating-room care do exist, the principal reason why the American anesthesiologist cannot keep up with his British colleague is that he has twice as much work to do. Why are there proportionately more than twice as many surgeons in the United States, and why are twice as many operations performed? Socio- economic, organizational, philosophical, geographical and population differences between the two countries all appear likely to be involved. Traug. J. N., Roback, 0. A.: Distribution of Physicians, Hospitals, and Hospital Beds in the U.S.. 1967. Chicago, American Medical Association, Department of Survey Research, 1968. `Annual Report of the Ministry of Health for the Year 1967. London, Her Majesty's Sta ~ecrv (OlI~'~, I These figures arbitrarily include surgeons in training. If only fully trained, practicing surgeons are considered, there are proportionately five times as many surgeons in the United States. t For example, the United States data are based on up to three operations for each Datient discharged, whereas the British (lata are based on a single operation per patient. This difference tends to inflate the UnIted States data, possIbly by as much as 30 per cent. On the other hand, the British figures include diagnostic procedures (cystoscopy, bronchoscopy, breast biopsy and so forth), whereas the United States figures do not, and In this case it Is the British data that are inflated. It is estimated that approxi- mately 4,500,000 diagnostic procedures are performed in the United States annually, enough largely to offset the multiple-operation effect. ~ Medical Mailing Service, Inc., Chicago, Illinois. Personal communication. `National Center for Health Statistics. Personal communication. Ministry of Health: Report on Hospital In-Patlent Enquiry for the Year 1966. London, Her Majesty's Stationery Office, 1968. Eckenhoff, J. E.: Shortage of anesthetists: real or artificial? Amer J Surg 117 :607- 600, 1969. PAGENO="0710" 700 TABLE l.-PTTYSTIUANC ENGAGED TN E'LL-T[ME PATIENT CARE AND CLNECAL TRAINJNin GENERAL SURGERY, AND SURGICAL SPECIALIES, 1967 Surgen~ sac 9~it ct nt~t,' I'rse-: r*'nrc"aipja-,'asa Sit, 636 lI'ntac' 5 tticPaiie silT 4,349 `-saint tinily 16-i cet:ts,jrstt',l'avs 1p640 Isnacis 921 7,745 Surgt'citu EraS ii'! a'. `n..i1.5~2 Cnrn U~4t O'lc"r nt-tr,ccc,cc.n ccnpstsl (sill-tins,' st'itf Na tnni-rr.r- 475 Rat cc .~a cat a,: rio ocr ,i'ear 39~5 lairs Gtli,'t' 42 Tnal E1C4 Alan'.' tfraan TL!~4. p oUr. "1)iot~innriansf Tim-i `Loac. It' itctyc,n1 }{ospitLi Retain tim' United Stat's, to': sa:aao..r,ca': Pr- "rol "a. rho ImtrCU] oral i:. `a'Ia':i'a,aritiot, ant research Eu] not inUitselt. 2 AiD a el It ~n T.. is Ga, 1 art 4. ~saae in, Annual Report oft lie Di nist ry of Dealt h fur year IceS'." TPBLE 2.-COMPAIATIVE RATES FUR SELECTED OPERATIONS' Rate per 100,000 popalatien United Stales of Ametica (l9ES) Englaed and Wales (1956) Opotatoe Male Female Male Female Thpromac'natares 1.1 68.5 8.7 42.3 aDds! 75rn0-ír,o~-, 503.0 51.1 294.0 29.2 Appsrae, 217.0 110.0 220.7 223.5 ChaLc,s''eP~ 94.5 273.0 32.2 89.9 All operaaans on c-os 2~0.3 223.3 180.6 193.0 EuroPa a' inn: 55.3 92.5 4L2 63.1 Ton ;iVaca on aD ar e `Scat DeasiJectoasy 63°. 5 Lit. 0 322.7 321.9 Adeocueriaais wrhnat unsuac,a- 2W 7 15.2 09 9 25.6 Hemortbraicecaorray 162.0 137.0 60.5 31.4 Circumcincs 96.7 1106 Hyslorearra:c- (i sPa nay °ahnrsl, total and espaal) 516.0 213.2 Al! spacanans on breast 10.9 273.0 5.8 171.7 Partial naaatecsrmy .. 6.5 196.0 3.0 100 6 Cemple:opianpla) sasiecsnmy 15.8 1.8 27.2 Raaical rtaasrsalnn, 51 0 .5 25.1 Other epstaGacr at a'east 4.4 18.0 .5 i8. 8 `Calculate! from sample :ra9atmas fran JO. PaTio Haalth Seraice anal tram Regietrar Generate Office, Hospital In- Patient E'aJ),',. U.S. fcgurea Lao t an op to 3 aperatiane per potient (with eerepliae et appeedertarny, tot which appee- aector's a `:;aaaa sal. if ``it:::,, strip Ane'eaa Jars tar Enp asi arid Wales tanad on 1 aperatiee pet patient, mhich in either `moat ~,ci:na npera.ioas, ````car nteationed'', or epeaatcon `Related to principal diageesie." SOCIOECONOMIC DIFFERENCES The key to an understanding of differences in medical manpower appears to lie in the British National I-iealth Service (NHS). Surely, a socio-economic systems different in organization and philosophy as the NHS should present differing demands for medical and surgical sen'ices, and on their utilization and quality. These possibilities have been considered in the past by many others, but it has been difficult to sort out the effects of this vast "experiment" In delivery of medical care from the effects of the many dramatic changes in the practice of medicine that have occurred. Social reorganization of medicine occurred with dramatic suddenness in Great Britain and was nationwide. So many changes took place simultaneously that it has been difficult to assess the effect of individual factors. In the United PAGENO="0711" 701 States, by contrast, social reorganization of medicine has occurred slowly, re- gionally and piecemeal. Specialized regional programs have been Introduced, some as controlled experiments in delivery of patient care, and many of these programs can provide the basis for meaningful comparisons of the effects of some of the relevant factors. What are the effects of insurance In comparison with no Insurance, of prepaid in comparison with indemnity insurance and of group practice versus solo practice? These are perhaps the principal issues to consider, and a good many data can be brought to bear on them. Insurance, by itself, appears to increase the utilization of physicians' services, presumably in response to previously unmet medical needs. In a study of medical services conducted in 1953, Odin Anderson9 reported operation rates for insured persons that were double those for uninsured, with an even greater differential among low-income families. In attempting to explain these differ- ences, Anderson considered it "very likely there is a higher proportion of so-called `elective' surgery among the insured persons, and a higher proportion of `emergency' or `must' surgery among the uninsured persons." `i'he effect of insurance in increasing rates of operations vanishes when one goes from indemnity to prepaici insurance, and it is now well established that rates of operations for prepaid group-health plans such as the Health Insurance I'lan (HIP) in New York City, the group-practice option of the Federal Em- ployees Health Benefits Program and the Kaiser Foundation Health Plans are approximately half those of the usual Blue Shield fee-for-service insurance plsn.1° `~ Such prepaynient plans, however, are by their nature group-practice plans, and it is not clear how much of the effect Is related to the method of 1J~ment and how much to the organization of physicians' services. The effect of method of payment on the volume of medical and surgical services provided has acquired considerable notoriety. Fee-for-service invariably results in the provision of more services than provided by capitation or salaried plans ul4 and has led to claims that fee-for-service encourages unnecessary operations.'~'" That the method of delivery of services may be of great Importance is sug- gesteil in two recent reports of experimental programs in which comprehensive ambulatory health-care facilities were established and an examination made of their effects on utilization of health facilities. In one, the Tufts Neighbor- hood Health Center at Columbia Point in Boston, surgical admissions fell Over the first two years of study to 24 per cent of the Drestudy level.1' In the other, a randomized, controlled clinical comparison was made between comprehensive, family-oriented pediatric care (experimental group) and con- ventional, hospital-based care (control group). Operation rates were three times greater for the experimental than for the control group during the first six- month period, but were consistently lower (50 to 70 per cent) than control (luring the subsequent four six-month periods covered by the report.'7 Method of payment was appently not a subject of special consideration In either of these studies. However, by offering ambulatory, group-practice care without charge. prepayment was, in effect, also provided, and we are still left without clear evidence on the effect of group practice separate from that of prepayment. `Anderson, 0. W., Feldman, 3. 3.: Family Medical Costs and Voluntary Health Insur- ance: A nationwide survey, New York, Blakiston Division, McGraw-Hill Book Company, 1956. 10 Prepayment for Medical and Dental Care in New York State. R. E. Trussell, F. van Dyke (directors of study). New York, Columbia University School of Public Health and Administrative Medicine, 1962. U Perrott, G. S. : Utilization ot hospital services. Amer 3 Pub Health 16 :57-64, 1966. "Falk, I. S., Senturia, 3. 3.: The steelworkers survey their health services: a pre- liminary report. Amer 3 Pub Health 51 :11-17, 1961. ~S Roemer, M. I.: On paying the doctor and the implications of different methods. 3. Health Hum Behav 3 :4-14, 1962. 14 Lees, D. S., Cooper. M. H. : Payment per-item-of-service: the Manchester and Salford experience 1913-28. Med Care 2 :151-156, 1964. 15 Carter, H.: The Doctor Business. New York. Doubleday and Company', 1958. 1~ Bellin SS. Geiger HJ. Gibson CD: Impact of ambulatory-health-care services on the demand for hospital beds : a study of the Tufts Neighborhood Health Center at Columbia Point in Boston. New Eng 3 Med 280 :808-812. 1909. 17 Alpert JJ. Heagarty MC. Robertson L. et al: Effective use of comprehensive pediatric care : utilization of health resources. Amer J Dis Child 116 :529-533, 1968. PAGENO="0712" TABLE 3.-CERTIFIED AMERICAN BOARD OF SURGERY OR OTHER SURGICAL SPECIALTIES, EXCLUDING THE AMERICAN COLLEGE OF SURGEONS I Colon and rectal surgery General surgery Neurosurgery Orthopedic surgery Plastic surgery Thoracic surgery Obstetrics and gynecology Ophthalmology Otolaryngolsgy Urology 128 1 2,848 57 1 465 1 2,967 7 338 1 353 5,914 3 3,920 3 2,051 10 1,347 Total 138 3, 775 576 3,341 442 568 6, 605 4, 285 2, 256 1, 487 Ii of the difficulties in the attempt to assess surgical manpower is that there is no authoritative, published listing of surgical specialists. The AMA "Distribution of Physicians, Hospitals, and Hospital Beds in the U.S." lists all physicians on the basis of their principal area ot activity-general practice, or individual specialty--but dons not include information about specialty certification, nor does it include information on part-time specialization. The specialty boards can provide enact information on the total number of diplomas issued, but many do not ksep records of how many surgeons are alive or prac- ticing. Furthermore, there is no record of how many diplomates in 1 specialty may be certilied in a 2d specialty. The surgical specialties present a special additional problem, since fellowship in the American College of Surgeons is considered equivalent to board certification as a criterion of training. The data presented in tables 3-6 wore prepared for this article from the magnetic tape files of the Medical Mailing Service, Inc., Chicago. They are based on physician data obtained by the AMA through July 16, 1969. Tables 3-6 are mutually exclusive and, added together, comprise all practicing surgeons in the United St3tes. 2 General practice with some specially practice. Surgeons in governnrent Surgeons in private Surgeons not in private practice service practice - ________---- ~ ________ - -.-.-- Full-time Ariminis- Veterans Full-tinse Part-time Other medical tralive Admsnis- Specialty specialty specialty S Intern Resident full-tinse school medicine Research Air Force USPH tratioa Total 20, 331 3 4 1 1 67 222 134 6 15 272 41 112 5 15 52 1 8 18 1 10 9 59 77 4 6 170 10 32 43 12 11 1 33 1 2 60 42 27 49 3 34 4 105 279 14 16 256 11 3 14 67 95 3 20 102 39 22 7 28 46 6 4 65 9 30 1 21 44 4 2 41 4 23 83 1 213 575 766 39 72 1,006 119 268 23,473 PAGENO="0713" 703 Total hospital admissions rise with indemnity insurance and fall again with prevaid group-practice insurance plans. That is, they vary in parallel with opera- tion rates. It has been assumed that the increases in hospitalizatiu and operation rates with indemnity insurance reflect a response to previously unmet needs, although a second interpretation offered is that insurance is an invitation to unnecessary hospitalization an(I unnecessary operations. There are also at least two explanations for the decrease in admissions and operations with prepaid group plans. It is reasonable to consider that intensive ambulatory care may lead to improvement in general health, and hence to a decrease in the need for hos- pitalization. But, of course, it can be argued that in the absence of a fee, there is less incentive to perform procedures that are desirable, if not absolutely neces- sary. Other suggestions are that patients may accept group practice for routine care but go elsewhere for their operations, or that a younger and healthier group of patients participate in prepaid programs. The careful studies of Shapiro have effectively ruled out these proposed alternate explanations, at least for the l-Tealth Insurance Plaii in New York City, and the recently reported experience in the Neighborhood Health Centers for low-income famihies.'~ ~ where the popu- lations could be closely controlled, provides additional contrary evidence. The group-practice effect is also reflected in a smaller proportion of surgeons needed in group practice, as well as a smaller number of operations performed. Roemer and I)uBois `~ write that `SIt is significant that the ratio to population o~ surgeons, anesthesiologists and ophthalmologists in the United States as a whole is much higher than the ratio of these specialists found for the population of pre- paid group-practice plans. (Solo surgeons seem to he either not working at full capacity or doing more surgery than is necessary--both of which points are prob- ably true in some degree.)" 18 Shapiro 8: End result measurements of quality of medical care. Milbank Mem Fund Quart 45 :7-30, 1967. ~ Roemer MI, DuBois DM: Medical costs in relation to the organization of ambulatory care. New Eng J Med 280 :988-993, 1969. PAGENO="0714" 1ABLE 4.- FELLOWS OF THE AMERICAN COLLEGE OF SURGEONS, EXCLUDING ALL DIPLOMATLS OF ANY SURGICAL BOARD Surgeons in private Surgeons not iii private practice practice --- ------------------ -- Full-time Full-time Part-time Other medical Specialty specialty specialty 2 Intern Resident full-time school Colon and rectum General surgery - - Neuro-sorgery Orthopedic suigery Plastic surgery Thoracic surgvry Obstetrics and gynecology Ophthalmology Otolaryngology Urology Total 3,562 I General practice with some specialty practice. Surgeons Err government service Admisis- Veterans trative adurinis- medicine Research Air Force USPH tration Total 32 2 2,732 624 2 34 18 21 1 13 5 29 3, 419 36 1 3 1 3 1 45 197 2 2 2 1 2 1 207 18 1 1 1 1 22 45 2 1 2 2 52 268 43 2 3 3 2 1 322 65 1 2 68 48 3 2 1 54 121 8 2 1 1 1 1 1 136 684 42 31 29 3 19 8 36 4,419 ~ _____ ____ - PAGENO="0715" 705 ORGANIZATION OF CARE Whatever the relative contribution of insurance, prepayment and group prac- tice, it is clear that the British National Health Service embodies all three, and all probably contribute to the observed differences between the two coun- tries. That the NHS is a form of group practice might bear brief additional comment. The essence of group practice I take to be the ready availability and routine, or nearly routine, use of medical consultation. And, of course, the con- sultant system is the very essence of the NHS. The British surgeon is a true consultant. He sees patients only as they are referred to him by the general practitioner or internist, anti he is entirely hospital ltused.* The Aiiwc'icaii SUF- goon, by contrast, may function as consultant exactly as his British counter- l)art, he may accept patients without referral, or he may ic the primary physician-general practitioner, referring the patient to himself for surgery and thus creating his own demand. The question of referral is an important one, for surgeons and nonsiirgeons are apt to have very different ideas of indications for surgery. That the in- ternist and surgeon have different points of view is inherent in their specialty training, and this difference is reflected at its worst when surgeon and in- ternist isolate themselves from each other, the int~rnist often seeing himself as the patient's protector against surgery. But when two differing I~oints of view are brought to bear on the problems of single patient. it is very much to the pa- tient's advantage. The essence of medical referral, or consultation, then, is the solicitation of more than one physician's opinion, and the advantage of the experience of more than one specialty. Consultation is the way of life under the British National Health Service and is reflected in the specific designation of all specialists as "consultants." The registrar in specialty training is instructed from the outset to make fre- quent use of other specialists, and of course it is the assumed duty of the general practitioner to refer the sick to the hospital consultant for the treatment of all but simple illnesses. The system, if anything, works too well, and the problem of too early and too frequent referral by the general practitioner is a troublesome one. In the United States, by contrast, the physician or surgeon in residency training, allowed greater responsibilty and independence than his British counterpart, may be reluctant to seek help lest he lose that responsi- `bihity for the patient's management. The surgeon in private practice may be reluctant to seek consultation, again for fear of losing his patient, perhaps now also for economic reasons. An example of the quantitative effect of consultation is provided by experi- ence of the United Mine Workers Medical Care Program. When a plan for reimbursement of surgical fees was offered to the United Mine Workers some years ago, there seemed to be an excessively large number of surgical pr~e- dures performed-that is, an excessive number of surgical hills were submitted. The Mine Workers Fund was concerned with the large amount of what ap- peared to be unnecessary surgery, particularly gynecologic operations and appendectomies. When a requirement was added that all operations be endorsed by preoperative specialist consultation, the number of operations fell by as much as 75 per oent for hysterectomies, 60 per cent for appendectomies and 35 per cent for heiuorrhoidectomiesY° Quality control or peer review has long been of concern to the medical pro- fession. Efforts to standardize the quality of medical care date hack to Cod- man.~' u-ho in 1914 implored the medical profession an(l its hospitals to make public all clinical "end-result~s"-a goal that. unfortunately, has not yet been achieved. "Tissue committees" to review specimens removed at operation and internal and external medical audit are more recent efforts at standardization in the United States. Lemhcke's papers on the methodology of the Medical Audit are of special interest and in particular his demonstration of the effect of such an audit in markedly reducing the volume of gyneeologic surgery per- fornied!~ But despite considerable improvement achieved by the Joint Com- mission on Hospital Accreditation. nationwide quality control of hospital prac- tice remains an unattained goal in the United States. *A ~m~ll proportion (approximately 4 per cent) of patlent~ ftre cared for outside the framework of the NTIS as private patients. ~O Draper, W. F.: Personal communication. 21 (`odman. F. A.: The nrodnct o~ a hospital. Snrg Gynec Obstet 18 :491-496, 1914. 22 Lemh~ke. P. A.: Medlenl nii~mir~' hv scientific methods: illustrated by major female pelvic survery. JAMA 162 :646-655, 1956. PAGENO="0716" Colon and rectum General surgery Neurosurgery Orthopedic surgery Plastic surgery Thoracic surgery Obstetrics and gynecology Opthalmology Otolaryngology Urology 1]? 7, 670 42 6 543 2 1,790 3 2 404 1 633 2 4 2,535 1 1, 173 1 935 1 1,451 4 1 127 26 221 5 1 8 30 3 18 15 1 31 3 39 11 1 2 5 1 11 4 1 13 15 2 36 TAUL.E 5. CEtt II FILD AMLI4ICAN BOARD OF SUI1GLI1Y DII UTIILII SPECIAL1 V BOARDS AND FELLOWS OF THE AMERICAN COLLEGE OF SURGEONS Surgeons in government Surgeons in private Surgeons not in private practice service practice ---------~_-~.~_ Full-time Adnrirrin- Veterans Full-time Part-tirrie Other medical trative adminis- Specialty specially specialty I Intern Resident full time school medicine Research Air Force USPI-I tratien Total Total 17,306 171 12 70 40 24 19 61 3 1 6 18 6 1 38 1 1 31 8 3 4 10 6 3 2 2 13 50 3 1 2 I General practice with some specialty practice. 57 13 304 872 75 40 246 38 349 19,300 177 8, 763 645 1, 933 447 841 2, 689 1, 230 1, 000 1, 575 PAGENO="0717" 707 By contrast, a large measure of quality control is apparently inherent in the British National Health Service hospital and consultant system, and peer review by tissue committees and medical audits has not been considered neces- sary. Curran believes that the high level of quality control in British hospitals can be attril)uted to the central role of the consultant: "The hospitals are organized in a hierarchic-al system that provides close supervision of all types of practice within the walls of these facilities. It is much tighter and more controlled than before the National Health Service was established. All patients are assigned to a consultant, the highest grade of the specialists. He supervises all care by lower-level doctors, from fully qualified staff physicians to residents ~Lfl(l interns iii traiiiiug. Another byproduct of the NITS that should be mentioned is the more efficient use of the surgeon's time, which is achieved in such a planned and regulated iiiedical service and which has recently been discussed by Eckenhoff.8 Perhaps the main element in this efficiency is the organization of operating-room ac- tivities around a single surgical team working together for a specific period ~ne team (surgeon, assistant [or assistants], anesthetist. nurse) one operating i'ooiii : and one "session'' (that is. morning or afternoon). How different from the erratic utilization in American operating rooms described by Eckenhoff! A second contributing factor to operating-room efficiency is the centralization of special surgery, such as neurologic and thoracic surgery, in the large specialty hospitals for special diseases and procedures. such as the specialty institutes in the Tjniversity of London. Whether or not one agrees that such disease- oriented centers are Ine(Iically advantageous, there can be little doubt they facilitate a more efficient use of medical manpower. DIFFERENCES IN SFRGICAL PhILOSOPHY Quite apart from socioeconomic considerations, there may be a genuine philosophical difference in attitudes of the two countries. In keeping with his national character, the American surgeon is more aggressive. He appears to hold higher expectations of what surgery can offer in the treatment of disease. -whereas the British surgeon is more modest in his expectations, possibly more realistic, but also possibly missing opportunities for surgical cure. Philosophical differences probably have their greatest quantitative effects in the large numbers of elective procedures for which indications may be equivo- cal. such as tonsillectomy. liemorrhoidectomy. cholecystectomy, hysterectomy. thyroidectomy and radial mastectomy (Table 2). Given the choice of adminis- tering or withholding therapy, whether the therapy is prescribing drugs or performing an operation, the American physician appears likely to choose active therapy. T1~e British surgeon. faced with time same choice and carrying a heavier work load, is ait. to avoid surgery if the indication is in question. `upe recently suggested that surgical attitudes that are conservative and often out of date. and emphasize technic. may encourage unnecessary surgery in the I nit ed States : he cites the treatment of goiter and carcinoma of the breast as examples of the reluctance to relinquish convenhonal surgical ap- 1rl('h(s.4 The rate for radical mastectomy fr the Fnited St:l tes, which is twice that reported in England and WThles (Table 2). presulflal)ly reflects the (lifforence in enthusiasm for this procelur(' evident in the current surgical literature of the respective countries. Fundamental differences in attitude or philosophy do undoimi tedly exist. but probably have loss quantitative effect on volume of surgery than method of payment and organization of services. GEOGRAPhIC AND POPILATION DIFFERENCES The relative concentration of a large population in the small geographic area of England and \Vnles should lend itself to a nero (filcient use of me(ii- cal manpower. and. conversely. proportionately more physicians and surgeons might be needed to provide service over the length and breadth of a large country such as the TiThited States. However, surgeons in the TTnited Stotes are not distributed in such a way as to meet geOgra~)hic needs. To the contrary, they ~ Curran. W. J. : Leral rerul~tlon end quality control of medical practice under the Britich Health Service. New Enr .1 Mcd 274 547-Da7, 19fi~. ~ Cope, 0. FnnecesSarv surgery and technical competence : irreconcilables In the graduate training of tie surgeon. Amer J Surg 110 :1I9-123. 196h. PAGENO="0718" 708 are concentrated in the heavily populated industrial areas to such an extent that trained surgeons in many of our prosperous communities have hardly enough work to keep busy, whereas there are acute needs for surgeons' services in other less populated areas. Furthermore, although it is true that Great Britain lends itself to a more efficient geographic organization of medical-care services, the- British themselves have by no means escaped the problems of too many physi- cians in more attractive and wealthy areas, and too few in parts of the country that are less favorably situated. The NHS has done much to redistribute medi- cal care by limiting the number of positions in the more desirable areas (a system of "negative inducement"), but acute shortages persist in some com- munities and continue to be a cause of concern. Differences in geographic needs may make a contribution to the differences in surgical manpower observed. between the two countries, but it appears to be a small one. Finally, hi attempting to assess the observed differences in operation rates and surgical manpower between the United States and Great Britain, one must consi(ler the possibility of differences in patient populations. A well advertised example of such a difference is the incidence of highway accidents, which is twic-~ as great in the United States as in Britain, and more surgeons are cer- tailily neded 1(1 care for the victims, Overall national accident rates, including th~e tar industry, are only slightly greater for this country, however, and can account for only a siiiall part of the manpower differences observed. Specific surgical diseases may, and certainly do, occur with greater frequency in one country than in another. Pearson and his associates,25 comparing hospital popula- tions in New England, Liverpool and Uppsala, have reported cholecystectomy to he l'crrormed four times mare often in Lppsala than ta Liverpool, and twice as ften as in New England, the excess being attributed to prevalence of biliary-tract disease in Sweden. But regional differences in disease cannot rea- SOn:~hly be invoked to explain the consistently higher rates for the wide variety of orher procedures reported by them for New England and in the present report for the United States as a whole. ~ Pearson, R. J. C., Smedby. B., Berfenstam, R., et al: Hospital caseloads In Liverpool,. New England, and tppsala: an international comparison. Lancet 2 :559-566, 196S. PAGENO="0719" TABLE 6.-SURGEONS NEITHER CERTIFIED BY SPECIALTY BOARD NOR FELLOWS OF THE AMERICAN COLLEGE OF SURGEONS. Specialty Surgeons in private practice Full-time Part-lime specialty specialty I Surgeons not in private practice Colon and rectors General surgery Neurosurgery Orthopedic surgery Plastic surgery hor:c~c srJrOc'ry O~ stutrics 111(1 gynecology (phthalnicnlogy.~ Otoinrryngclrrgy Urology Other luturn Resident full-time Full-time Adininis- medical trative school medicine Research Surgeons in government service Vetorans ad nun is- Air Force USPH tration 2~3 178 12 1 2 1 3 468 5, 4C7 5, 514 827 5, 473 938 49 82 1,221 214 376 20, 195 414 7 463 79 12 79 24 25 1, 147 1,244 212 1,403 164 9 296 42 110 3,510 246 23 168 25 19 4 ii 532 135 5 126 45 11 1 17 353 4,834 2,898 59 2,381 543 64 623 35 20 11,595 2,125 168 1,095 135 36 200 62 46 3,903 1,248 251 687 15 19 178 19 65 2,571 1,151 172 772 103 9 213 23 101 2,580 Total 17,141 9,428 886 12,580 2,108 316 89 237 2,841 424 774 46,024 1 General Practice with some specialty practrce. Total 14 23 7 4 3 6 110 20 34 2 30 3 27 3 PAGENO="0720" 710 DISC 1 SSION The fact that we operate nearly twice as often as the English and Welsh, or' twice as often as we might under other political-economic circumstanees, does iiot necessarily force the conclusion that we operate twice as often as the Public health might justify. An alternate explanation might be that as a wealthier country, the Lnited States may simply be affording the luxury of surgical procedures that are desirable but not essential and that the British Public would be better served by more operations thaii are now performed in that country. For example. many British physicians believe that there are a large number of patients in need of surgery for cataract, and the long wait- ing lisi f c berm rrliapliy and prostatectoiny a ic (0111111011 gossip.~' Any dcci- soins abeut how niany surgeons we need in America must, of course, be based primarily on ho\v much operative treatment the public health requires. But this decision must also take into account the fact that with a limited total medical manpower 1)001. more physicians engaged in the practice of surgery means fewer for other pos'~ibly needier medical disciplines. Thus, we have tile paradox of a country that provides "luxury" surgery for the wel1-t~do but carlrit provide basic medical care for the indigent. That marked variability in surgical practices and presumably in surgical ,iudgnieat and philosoidiy exists must be considered to reflect absent or made- (juate data by which to evaluate surgical treatment, and specifically by which to compare operative with noiioperative treatment. Stated in other words, the indications for surgery arc sufficiently imprecise to allow a 100 per cent eauiat i0fl in rates of operation. The risk of operating can be documented with iliortairty data, but comparable controlled data on the risk of not operating are, for 111(1st surgical diseases, not available. This, of course, is one of the big pgob- l~~nis of surgery: that nobody has ever bothered to work out the natural history of any disease until what is regarded as an effective treatment for it has been found. Consequently. assessments of the natural history of disease must be~ made retrospectively and are grossly unreliable. Although currently available data may not be adequate to define precisely the indications and contraindications for many operative pTocedures, it can loassuriied that such wide variations in surgical practices must have marked effects on the public health. For example. a hospital that reserves operative treatment for the very ill can be expected to report very different postoperative death rates from those in another hospital specializing in minimally indicated operatrons in good-risk patients. It is well known that marked differences in ~ost o~ oral ive (lea th rates do occur from one liosici ta I to a nother,' ~ and in the past it has been assumed that these differences reflect differences in patient populations or in the quality of care. I believe that the decision whether or lit to operate may turn out to be an even more important determinant in explarning such differences in outcome. Lembcke.~~ in a classic paper. attempted to assess the indications for ap~en- decromy by correlating appendectemy rates with mortality rates for appen- clrc~lrs. He was able to demonstrate that higher appendectomy rates w~e as- sociated with higher, rather than lower, overall mortality from appendicitis and concluded that "considerably more operations of this type are done than necessary Comparable data for other surgical diseases are urgently 1)e(Ole{l. Mortality data alone, however, cannot provide an adequate basis on wll~ch to judge surgical success or failure, or on which to define surgical indica- tiins and contraindications. Quantitative tlata on other important surgical end- result indexes, such as complications, rehabilitation and relief of discomfort, are not available, but a substantial body of theory on the evaluation of the ~ Waiting lists In Great Britain are a public statistic. No such national data are available In the United States. American physicians are inclined to assume that prolonged delays In hospital admission do not occur In this country. A recent comparison of hos- pital care In two communities (Arbroath. Scotland, and Waterville, Maine) showed that w;iiting time was very similar, at least for these two communities. Siinpon. J., Mair. A.. Tliinas, R. G., or a! : Cu~tom and Practice In Medical Care A comparative study of two hospitals in Arbroath, Scotland, U.K. and Waterville, Maine, U.S.A. London, Oxford University Press. 1965. 27 Lee, J. A. H., Morrison, S. L., Morris, J. N.: Fatality from three common surgical conditions In teaching and non-teaching hospitals. Lancet 2 :785-790. 1957. 28 Moses, L. E., Mosteller, F.: Institutional differences in postoperative death rates. JAMA 203 :492-494, 1968. ~ Lembcke, P. A.: Measuring the quality of medical care through vital statistics based on hospital service areas: 1. Comparative study of appendectomy rates. Amer I Pub Health 42 :276-286, 1952. PAGENO="0721" 711 quality of medical care has appeared in recent years i8,30 and its application to t11'~ practice of surgery should receive a very high priority. The direct measurement of the quality of medical care, by death rates or by other criteria, is, of course, exceedingly difficult; consequently, studies of the quality of medical care have relied heavily on other kinds of information such as internal and external audits and the qualifications of the physician rendering care. Thus, in the Columbia University Study of Medical Care under three different insurance plans in New York State, prepaid group prac- tice (HIP) was found to be associated with fewer "unjustified' operations, and fewer operations were performed by "unqualified" surgeons than for in- demnity, Blue Shield insurance plans.'° On this basis, the quality of surgical care offered by HIP was judged to be superior. If the qualifications of the surgeon are considered a valid index of quality of care, the quality of surgery in England and Wales must be considered superior to that in the United States. Virtually all surgery in England and Wales is performed by consultant specialists and senior registrars,* or by house officers under their direct supervision. Furthermore, there are at least twice as many candidates as there are positions, thus providing an additional degree of quality selection. In comparison to the strict state control in Eng- land and Wales, regulation of surgery in the United States occurs at the local level or not at all. Individual hosiitals may require board certification. or equivalent training, but many do not. Of the 68,000 physicians listed in full-time or part-time private practice of surgery, less than two thirds are certified by a surgical board or are fellows of the American College of Sur- geons (Tables 3-6). There are no reliable national data specifying who does the surgery in this country, but it has been estimated that more than 50 per cent is performed by general practitioners or osteopaths. Whether fairly or or not, it Is to the "unqualified" surgeon that most "unnecessary operations" are attributed.~°' CONCLUSIONS At the outset I asked why the ratios of surgeons and of operations to popu- lation are half as large in England and Wales as in the United States. The observation that prepaid group practice halves the numbers of operations and surgeons strongly suggests that the organization of medical care is a major factor. From this assumption a tentative hypothesis is proposed. Group prac- tice (whether privately organized in the United States or as a single large service in Great Britain) is a system that incorporates the wide use of con- sultation, and encourages a greater emphasis on ambulatory office care. There is evidence that these elements lead to a decreased need for hospitalization. including a decreased need for surgery. Increased use of consultation also appears to sharpen the criteria for surgery, resulting in a smaller number of operations where Indications may be equivocal. Group practice also provides the opportunity for the more efficient use of medical (and surgical) man- power. Finally, the method of payment appears to play an important, if unmeasured, part. Surgical fees in the United States, although perhnps not as large as a generation ago, are still much greater than those in other areas in medicine, and the opportunity for large incomes may attrn'~t a disproportionafo number of physicians into the practice of surgery. In addition. th~ "incentive' * The senior reristrar has received not less than fonr veers of snrric'il traininc. ~° Donahedian. A.: Evaluating the quality of medical care. Mllbank Mem Fund Quart 44 166-206. 1966. Cofler, F. A. Minutes of the Committee on Unnecessary 0peration~, American Surgi- cal Association, 1952-1960. PAGENO="0722" 712 of a fee for service may tend to increase the number of operations in cases In which indications are borderline. The converse must, of course, be con- sidered: that in the absence of such economic incentive, many procedures that are desirable but not essential may not be performed. Until new evidence is available, it is reasonable *to assume that there is a disproportionate number of surgeons in the United States, at least in relation to the total medical manpower pool, and it seems likely that some unnecessary surgery is being performed. Should anything be done? Many corrective torces are, in fact, already operative. The slow but steady gr'owth of group practice and of prepaid medical plans has already had some effect on surgical prac- tice. at least for the populations served. The growing power of large consumer groups, such as the Teamster's Union and the United Mine Workers, has been particularly effective in forcing standardization of medical care, including indications for surgery and qualifications of physicians undertaking surgery.~ The development of federally supported regional medical programs may also have an effect by encouraging the centralization and more efficient use of major therapeutic facilities and procedures. A final, important corrective force is the growth and maturation of surgery ItsCif as a specialty, and the influence of the surgical specialty boards, with the parallel decline of the general practitioner as part-time surgeon. But, al- though the boards have provided exemplary leadership in the establishment of standards of practice, neither they~ nor any other organization has accepted responsibility for determining or controlling specialty manpower needs. I am indebted to my colleagues in this country and abroad who have helped in the gathering of material for this review and who have offered in- valuable criticism of the presentation, particularly to Drs. Dean A. Clark, Stanley A. Feldman and Lawrence M. Klaimer for their continuing interest and assistance. Inclusion of data on rates of operation In Table 2 was made pOsSibi~ through the courtesy of Mr. Siegfried A. Hoermann, National Center for Health Statistics, Washington, D.C., and Drs. A. M. Adeistein and W. A. Wilson, General Register Office, London. TIlE PIIYSICIANPATIFNT AS AN INFORMED CONSUMER OF SURGICAL SERVICES (By John P. Bunker, M.D., and Byron Wm. Brown, Jr., Ph.D.) Abstract_The alleged overuse of surgical services in this country is often attributed to lack of consumer knowledge. Assuming that physicians possess such knowie{lge, we have examined their utilization of surgical services and (`Il1.,r~(j it with that of lawyers, ministers, and businessmen. Operation rates for ihy~jcjans and their spouses were found to he as high as or higher than rate~~ fur the other groups. Overall operation rates for physicians and for the other professional groups studied were estimated to be 25 to 30 per cent higher than for the country as a whole. We conclude that the physician-patient as in informed consumer places a high value on Surgical care. The results I)reserltetl srtggest that as the public becomes more fully informed, the demand fir ~o1r~ieai services will increase. (N Engl J Med 290 :1051-1Q~5, 1974) The trained physician should be the ultimately informed "consumer" of medi- cal and surgical services, for whom medical facilities are readily accessible, and for whom the cost of hospitalization and operation should not be an important ~ fl~ ~1j doterreut. In the present study we have examined the 1)ehe vior' of the physician as a patient and compared his utilization of surgical services with that of three other professional groups of equivalent education and affluence. To as~zure, as nearly as possible, conditions of unlimited supnly, the study was 00 i' r~ed out in a i~eegra~hic area of high physician and led_to_popu1a~ion ratis and high per capita income. Our purpose was to predict the impact of eun~i1rner eluention on deniand for care in a medical system in which financial harriers are removed, as seems likely under national health insurance. Our hy~tb~~js was that operation rates for most groups would he as high as or 1ii~lor than for the country as a whole hut that physicians, as informed con- s'niier~. er~~j~qnt of risks as w-ell as benefits, woul(1 undergo fewer operations than other groups. Falk, I. S.: Some e~eots of Insurance and of lahn' union attitudes on the practice and teaching of surgery. Yale 3 BIol Med 36 :27-42, 1963. PAGENO="0723" 713 MATERIALS AND METHODS A small number of commonly performed operations were selected as the basis for comparison: appendectomy, cholecystectomy, thyroidectomy, and hemorrhoidectomy in both sexes; inguinal herriiorrhaphy in men, and hyster- ectomy in women. These operations were chosen because of the wide variation in their reported rates. Mastectomy was also included, on the assumption that rates for this operation should be relatively stable among population subgroups. The following seven California groups were selected for study: active male members of the Santa Clara County Medical Society (1371), active Protestant ministers living in Northern California (1275), active male members of the Santa Clara County Bar Association (1423), male graduates of Stanford Business School living in Santa Clara or San Mateo counties (1223), women physicians practicing in California as indentfied by the Medical Mailing Service, Chicago, Illinois (1353), and women lawyer members of the California Bar Association, as identified by each of California's 54 county bar associations (755). Physicians were identified through their medical society, ministers through their directories, lawyers through their bar association, and businessmen through the Alumni Office of the Stanford Business School. On the basis of published rates for surgical operations, it was estimated that samples of ap- proximately 750 to 1000 respondents should generate rates for the several operations appropriate for statistical comparisons. The surveys were carried out by mail qu~tionnaire during the summer and fall of 1972 for physicians and lawyers, and during the spring and summer of 1973 for ministers and businessmen. Mail questionnaire was selected for economy and justified, at least in part, by Breslow's report of an accuracy of mail questionnaires closely equivalent to that of personal interview or telephone.~ Response rates for the first mailing ranged from 60 to 75 percent and reached 75 to 83 per cent after the second mailing. In the covering letter, physicians were asked to participate In a study "de- signed to provide baseline data on the utilization of surgical services in selected socioeconomic groups"; the other groups were asked to assist in a "study de- signed to provide information on how many operations are needed for good health." The questionnaire requested the following Information as appropriate for each group: year of birth; year of advanced degree: marital status: medical specialty; whether spouses, siblings or parents are physicians: whether, and at what age, respondent and spouse had undergone each of the specified opera- tions (for the non-physician groups, lay terms were included, e.g.. "appen- dectomy [gallbladder removal] ; iguinal hernorrhaphy Irepair of groin for hernia]" etc.) ; whether the major cost was covered by insurance, other opera- tions undergone by respondent within past 10 years: spouse's age; year of marriage: number of children and ages; how many of the children have under- go'ne tonsillectomy, and how many have undergone appendectomy. This article deals only with operation rates of adults. adjusted for age. The comparisons among groups were based on the proportion of subjects (respondent or spouse) in each group reported to have had the operation. Since an older subject has a longer exposure to the risk of operation and the groups differed in average age, all operation rates were adjusted to a standard popula- tion composed on one third under 40 years old. one third in their forties. and one third 50 and older. Standard errors of the age-adjusted operation rates were computed on the assumption of binomial variation for the operation rates reported by respondents in the three age intervals. Analyses were carried out using the multiple logistic model 2 to assess the effect on the age-adjusted operation rates of several possible interfering van- ahies. These included response to first questionnaire or to second, w-hether or not the subject had close relatives in the medical profession. and. for women. the number of children and their ages. The corrections had relatively little effect on the simple age-adjusted rates and hence only the latter are presented. To compare operation rates in this study with ITnited States national rates. rates age-specific to time of operation (rather than to age at survey, as In the ~reslow, L.: Alameda and Contra Costa Counties. Caflfornia. Mllhank Mem Fund 41 :~17-a25. 19R5. `Walker. S. H.. Duncan. D. B. : Estimation of the probability of an event as a func- tion of several independent variables. Biometrika 54 :167-179, 1967. 38-698 0 - 74 - 47 (Pt. 1) PAGENO="0724" 714 foregoing) were needed. These were obtained by counting the number of oper- ations reported in each age interval (five, five to nine, 10, to 14, 15 to 19, 20 to 24, 25 to 34 65-) and dividi~ng by the total person-years exposu,re pin the Interval contributed by all subjects In the group. These age-specific rates were then applied to United States population figures and added to get a total num- ber of operations for comparison with national figures for 1968, as provided by the National Center for Health Statistics (unpublished data, courtesy of Grace K. White, Chief, Hospital Discharge Survey Branch, Division of Heaith Re- sources Statistics). Fairbairn and Acheson have computed the cumulative probability of organ removal as a function of age from data collected in the Oxford area of Eng- land in the years 1962-65. For comparison, the age-specific rates described above, and the national age-specific rates, were used In similar fashion to obtain cumulative probability curves. Incidental apVendectomies were exe~luded by disregarding any appendectom~' reported in the same year as a hysterectomy, cholecystectomy or other opera- tion generally involving abdominal entry. Ninety-one per cent of the appendec- tomies so eliminated were in women, and 9 per cent In men, almost exactly the distribution of incidental or "second-listed" appendectomies reported by the National Center for Health Statistics. The effect was to drop appendectomy rates for women by about a third, and for men by 5 per cent. The correction is, of course, an arbitrary one and not precise. However, any error Is probably small, and it seems unlikely that it could affect the overall comparisons re- ported. RESULTS Rates for male physicians and for the other three professional groups were closely similar for four of the five individual procedures (Table 1, upper half). The fifth. thyroidectomy. was performed approximately twice as often In physicians as in lawyers or businessmen, but the difference was not statistically significant. Physicians' wives tended to have more operations than wives of the other three professional groups; they underwent appendectomy and thyroidectomy significantly more often than lawyers' wives (p<0.01); cholecystectomy sign!- ficantly more often than lawyers' and businessmen's wives (p.<0.01) and hysterectomy significantly more often than businessmen's wives (p<0.01). TABLE 1.-OPERATIONS REPORTED BY MALE PHYSICIANS, MINISTERS, LAWYERS, BUSINESSMEN FOR THEMSELVES AND THEIR SPOUSES' Operation Male respondents Physicians Ministers Lawyers Businessmen Appendectomy Cholecystectomy Herniorrhaphy Thyroidectomy Hemorrhoidectomy Any of the above Appnlectomy Cho~e-ystectomy Thyroidectomy Hysterectomy Hemorrhoidectomy Mastectomy Any of the above `23.0±1.3 21.7±1.3 20.8±1.3 1.8± .4 2.2± .4 1.9± .5 10.3± .9 12.4±1.1 8.7±1.0 1.4± .4 .9± .3 .7± .3 6.9± .8 6.3± .7 7.8± .9 36.1±1.4 35. 8±1.5 33. 3±1.5 20.4±1.3 1.2± .4 11.1±1.0 .6± .3 7.7±9 34.2±1.5 Spouses of married male respondents Wives of Wives of Wives of physicians ministers lawyers Wives of Businessmen a 22.3±1.3 2(1±1.4 16.4±1.5 5.9± .8 4.9± .7 2.9± .7 4.1± .6 2.9± .6 2.3± .6 22.6±1.3 20.9±1.2 20.4±1.6 3.6± .6 4.2± .6 5.4± .9 3.8± .6 2.3± .5 3.7± .8 U. 9±1.5 41.3±1.5 38. 6±1.8 22. 0±1.5 2.0± .5 4.0± .7 11.3±1.4 2.8± .6 2.5± .6 37. 0*1.6 I Operations ever recri ied per 100 respondents; standardized by age. 2 Rates are based on the proportions of subjects reported to have had the operation at the time of survey, grouped by ~ge at the time of survey, into 3 age groups (<40, 40-49, 50+). The overall rate shown is the age-adjusted rate, assuming a standard population with ~ in each age interval. The standard errors were obtained by taking the age-specific propor- tions to be binomially distributed proportions. Fairbairn. A. S.. Acheson. E. D.: The extent of organ removal in the Oxford area. J. Chronic Dis 22 :111-122, 1969. PAGENO="0725" 715 Table 2 shows the rates for female physicians and lawyers and their husbands. As with male physicians and lawyers, female physicians reported as many opera- tions as or more than female lawyers. For cholecystectomy, the difference was sig- nificant (p=O.02) and differences for several other of the operations showed sug- gestively low p values. Spouses of female physicians had higher operation rates than spouses of female lawyers for each of the five operations, though none of the differences was significant at the 5 per cent level. TABLE 2.-OPERATIONS REPORTED BY FEMALE PHYSICIANS AND LAWYERS FOR THEMSELVES AND THEIR SPOUSES Operation Female respondents Physicians Lawyers P value Appendectomy Cholecystectomy Thyroidectomy Hysterectomy Hemorrhoidectomy Mastectomy Any of the above Appendectomy Cholecystectomy Herniorrhaphy Thyroidectomy Hemorrhoidectomy Any of the above `23.8±1.3 20.7±1.7 0.15 4.0± .6 2.0± .6 .02 3.5±.6 2.4± .6 .18 15.1±1.1 16.0±1.4 .60 4.6± .7 5.4± .9 .51 2.1± .5 1.3± .5 .21 39.0±1.5 35.1±1.9 .10 Spouses of married female respondents Husbands of Husbands of physicians lawyers P value `18.0±1.4 14. 2±1.7 .07 2.4± .6 1.9± .7 .60 8. 1±1.0 7.4±1.2 .63 1.4± .4 .6± .3 . 12 6.6± .9 6.4s1.1 .87 30.7±1.6 26.3±2.0 .09 1 Operation ever receved per 100 respondents, standardized by age. Rates are based on the proportions of subjects reported to have had the operation at the time of surgery, grouperl by age at the time of survey, into 3 age groups (less than 40, 40-49. 50 plus). The overall rate shown is the age-adjusted assuming a standard population with ~ in each interval. The standard errors were obtained by taking the age-spscit proportions to be binominally distributed proportions. For all but two operations, the rates for male physicians and lawyers and their respective wives in Santa Clara County were similar to those for women physicians and lawyers and their husbands in the state as a whole. The ex- ceptions were appendectomy, which male physicians and lawyers in Santa Clara County underwent significantly more often then the husbands of women physicians and lawyers (p~O.O1) in the state; and hysterectomy, which the wives of Santa Clara physicians and lawyers underwent significantly more often than did women physicians and lawyers in the state (p