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Senator MAGNUSON. Doctor, have we made any progress at all on "NP" cases? Is it still 50 percent?

Dr. ENGLE. Fifty percent of our beds. Yes, sir, we have significantly reduced our waiting list in psychiatry, and treat far more patients.

Senator MAGNUSON. But every other bed is still NP?
Mr. DRIVER. And that is our big waiting list.

Senator MAGNUSON. We have made some progress in other diseases, other illnesses, but here we seem to stay at a plateau.

Dr. ENGLE. We think we have made a lot of progress in recent years, as Mr. Driver has indicated, much of our waiting list has been. in the psychiatric area. We have been able to reduce this, and treat far more patients than we have treated in previous years.

Senator MAGNUSON. Outpatient care?

Dr. ENGLE. The emphasis is on treating people on an outpatient basis as rapidly as possible, yes, sir.


Senator MAGNUSON. Is there anything new in the research field that we don't know about since last year or just recently?

Dr. ENGLE. We can ask Dr. Wells, our Assistant Chief Medical Director for research and education.

Dr. WELLS. In the psychiatric area, from a purely practical standpoint, I don't think there is anything contributing to answering the problems involving the number of beds or number of patients treated that has come in from the research side. However, we have a very large number of research projects that do involve our psychiatric patients, to improve care, and help to improve turnover.

But as far as the general attack on the problem as such, I think it is only fair to say that progress is at something of a plateau.

Senator ALLOTT. On that subject, Mr. Chairman, I visited last fall the Fort Lyon facility.

Would it not be of help to this committee if we had some comparative tables on the releases from these mental hospitals? They were telling me of the figures, which I have forgotten now-but I am sure that it shows-well, you have indicated it here in your testimony-that the idea of putting a mental patient in a hospital and keeping him there until he dies is receding, and that with your new drugs and better medical assistance, the turnover is much more rapid.

I wonder if some figures on 10 years ago, for example, or for the last 10 years, on the total case load, might not be of assistance?

Mr. DRIVER. We have that by hospital.

Senator ALLOTT. I would not think we would need it by hospitals, Mr. Driver. But I think it would be of some assistance to the committee to assess the problem.

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Senator MAGNUSON. Are we doing enough research in this field? Dr. WELLS. I think we would like to do more research in this field. The main thing we lack is good researchable ideas, and the kind of people that can offer valid projects. We are into a great many studies, drug therapy and other forms of psychotherapy and so on. But the amount that we spend, which is in excess of $4 million a year, probably represents about what we can do at the present time in terms of ideas and people.


Senator MAGNUSON. Well, as you people know, I have always had a little different opinion about your research projects. However, we will talk about that later, when we hear some other testimony.

I notice that your budget on this item is up a little this year from last year. I wanted to inquire-in many cases some of this money is being used on a joint research project or several research projectsin conjunction with a university or other people, is that correct?

Dr. WELLS. Yes, that is correct. A great part of this is used in one way or another in conjunction with the university people. But it is not contracted out; these are not extramural programs.

Senator MAGNUSON. You have $9.2 million available to medical schools, of which the VA hospitals are affiliated.

Dr. WELLS. That is right. This is money that comes to the VA through the medical school, largely from the National Institutes of Health.

Senator MAGNUSON. You do have some joint projects, do you not? Dr. WELLS. Oh, yes.

Senator MAGNUSON. In the State of Washington, I live just down. the street from the VA hospital in Seattle. At the university you have a joint project with heart and blood deseases.

Dr. WELLS. Yes, sir, several projects jointly there.
Senator MAGNUSON. Right on the campus grounds.


Senator ALLOTT. Before you get off of that, this gentleman has some figures he was going to give me, I think, in response to my question.

Mr. ROSEN. Yes, sir.

The release rates, patient turnover rates in the psychiatric hospitals are going up. In the first quarter, 1965, 9.4 percent was the release rate. First quarter of this fiscal year, 1966, it was 9.9 percent. And each quarter, comparing one year with the next, there was an increase.

In the third quarter of this fiscal year, it is 10.2 percent compared with 9 percent in the third quarter of last fiscal year.

Senator ALLOTT. With respect to the mental patient, the release rate is going up all the time.

Mr. ROSEN. Yes, sir.

Senator ALLOTT. And yet we still have 50 percent of the bedsSenator MAGNUSON. That is because of increases in numbers and the backlog that is still being reduced.








Mr. MONK. From 1954 to 1964 we just about doubled the number of patients treated and discharged, in about the same number of beds. Now, we can put those figures into the record-the exact figures.

But in magnitude, we just about doubled it.
Senator ALLOTT. I think that would be helpful to us.
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Senator MAGNUSON. Last year-your estimate is $6.2 million for outpatient visits.

When you say VA physicians, do they work in and out of the hospital or are they associated with the hospital?

Mr. DRIVER. They are in the clinics.

Senator MAGNUSON. These physicians come to the clinics?
Mr. DRIVER. Right.

Senator MAGNUSON. What about a physician visiting a home?
Mr. DRIVER. As Mr. Stratton indicated-

Senator MAGNUSON. Do you take care of that?

Mr. DRIVER. In examining the pensioners who are unable to leave home, the hometown physician is authorized to go to his home and examine him, and he files his report to us, and gets paid by us.

Senator MAGNUSON. What do you pay him-the going rate for a home visit?

Mr. DRIVER. A negotiated fee.

Dr. ENGLE. Our rates are substantially under the rates in the community.

Senator MAGNUSON. I think the physicians feel a responsibility in these cases.

Dr. ENGLE. We spend about $7 million a year systemwide dealing with 40,000 hometown physicians.

Senator MAGNUSON. This home visit program is increasing all the time; is that right?

Mr. DRIVER. That is right. Now, this is associated with age. It is also associated with the fact that, for example, when we increased the discharge rate in the mental hospitals, many of those patients are out and stay out, because they get outpatient care in a clinic.

Senator MAGNUSON. It seems to me this is very valuable because you get a stubborn fellow-and he says "I want to get into the hospital." Nobody pays any attention to him except maybe the American Legion man calls on him, or the VFW man. If he gets a hometown physician to take a look at the patient-this alleviates a lot of problems.

Mr. DRIVER. If we can take care of him even in our own clinic, we keep him out of the hospital bed.

Senator MAGNUSON. Right. In many cases this provides a bed, available for somebody you really know has to come there.


Senator ALLOTT. On this unconnected service disability, what are we now doing with respect to actually determining whether these people qualify? How thorough are the admissions, how thorough is the registrar, or whatever you call him at the hospital, with respect to their financial ability to take care of themselves?

Mr. DRIVER. We have an application form, which he has to fill out, including a listing of his assets and liabilities. Under prescribed formulas we have in all of these hospitals, when his net worth, including an evaluation of his liabilities, reaches a certain figure--if he applies for hospital care, we tell him how much we estimate the care will cost. We then sit down, and counsel him in terms of our evaluation of his ability to pay. And then say-now, in the light of this you, Mr. Veteran, have to make the decision as to whether or not you will sign an oath certifying you cannot afford to pay. So we lead him through an evaluation of his economic status, and his medical care costs. But in the final analysis, under the law, he makes the decision about whether he can afford to pay.

I might say that in reviewing these cases, we find very, very, very few which offend us, where the man insists on going in. Most of them, by and large, without any question, would qualify before any jury

Senator ALLOTT. Are clear cut?

Mr. DRIVER. Absolutely.

Senator ALLOTT. Well, I suppose the one exception is the thing that bothers you. I remember a man whose estate I probated a few years back, who was worth half a million dollars net when he died, and the year before he went into the veterans' hospital and had a gall bladder operation at the expense of the Government.

Mr. DRIVER. We have some, I think, absolutely bona fide cases where the individual concerned feels he is going to get the best care in the world there, and he is going to sign no matter what.


Senator MAGNUSON. What are you doing on the artificial kidney centers?

Dr. ENGLE. We now operate eleven artificial kidney centers. The 1967 budget has money in it for the establishment of 17 additional


Senator MAGNUSON. That would be 28 altogether?

Dr. ENGLE. Right. It includes money for Seattle, most importantly.

Senator ALLOTT. I thought the most important one was for Denver.
Dr. ENGLE. And Denver.

Senator MAGNUSON. We feel a little priority should be given out there because we started the whole business.

Dr. ENGLE. I am aware of this.

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Senator MAGNUSON. The plan is to get as many as you can, isn't it?

Dr. ENGLE. Right-within the limitations in terms of the training of people, the necessary equipment.

Senator MAGNUSON. Of course, the cost of the machines is now coming down. I visited the one in Spokane just over 2 weeks ago, at St. Luke's Hospital. They have their old machines stowed away, and somebody out there, some versatile mechanic, has invented a new machine for them that is going to run about $6,000. They have three now.

Of course you know about the one in Seattle. They are going to have & ward where they will to try to take care of 20 patients on one large sophisticated machine.

The reason you went into this is because when availability of treatment was so scarce, we all felt you had a responsibility for the vet that had this trouble, as against an average person that had it?

Dr. ENGLE. Well, I think that it is an important new area, an area where research has paid off. As with other things, it is our intent to give to the veteran patient the best available in medical care. And I think this is just one of the many examples of new programs that we are attempting to implement.

Senator MAGNUSON. You still have a problem of getting enough trained people?

Dr. ENGLE. Yes, sir. It is a highly specialized field. As you know, Dr. Scribner was a pioneer on this. He started work on this many years ago when he was with the Veterans' Administration. Tremendous progress has been made.

Senator MAGNUSON. I found in Spokane, Doctor, that they had 17 patients there on a Saturday. Many of them were there with their wives. The wives had taken a 60-day training course in the hospital. Then when they go home they act as the nurse for their husband, and save that expense. They claim they can do a good job. One wife said, “We have more dedication to do well than anybody else," and I suppose they would.

They had a priest there that was taking lessons. And the standing joke around was-he had no wife to take care of him.

However, they are doing remarkable work in having members of the household take this specialized course and work the machines. That might be something we can be thinking about. They could come up to the veterans hospital and get the training. I suppose it would not clutter things up any; would it?

Dr. MUSSER. We have a pilot study of this home procedure.

Senator MAGNUSON. There are two or three wives that go up there and help around the hospital when they need them on other things.

Dr. MUSSER. It takes very unusual people in the family, though, to make this go year after year. There is the problem of infection and other circumstances. It makes it a situation where unless you have unusually dedicated and intelligent people, you may do more harm than good.

Senator MAGNUSON. I am pleased you are expanding the program in the VA.

DENVER ARTIFICIAL KIDNEY CENTER Senator ALLOTT. That is the only thing I wanted to remark about. I have had this rather critical situation in Denver.

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