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VETERANS' AFFAIRS

THE JOINT CONGRESSIONAL
COMMITTEE ON VETERANS' AFFAIRS,

Thursday, December 22, 1932. The committee met at 10.05 o'clock, a. m., in room 335, Senate Office Building, John McDuffie, chairman, Representative from Alabama, presiding.

The CHAIRMAN. If the committee will come to order, we shall now hear from the representative of the American Medical Association, Doctor Cary. Doctor, will you give your name, your address, and your connection with the association?

Doctor CARY. My name is Edward H. Cary; my address, Dallas, Tex.; I am president of the American Medical Association.

The CHAIRMAN. The committee will be very glad to have the benefit of your suggestions and the suggestions of your association.

STATEMENT OF DR. EDWARD H. CARY, PRESIDENT AMERICAN MEDICAL ASSOCIATION

Doctor CARY. Mr. Chairman, the American Medical Association is an organization composed of about 100,000 of the qualified doctors who practice medicine in the United States and, as an association, we have never opposed any of the benefits

The CHAIRMAN. May I ask you, Doctor-don't let me delay you or interfere with your statement, but you say there are 100,000 doctors in your association. What percentage of the doctors of the country is that?

Doctor CARY. There are about 120,000 active practitioners; yes, 150,000 registered throughout the United States that means of all ages and things of that kind. There are about 100,000 of these who are members of the American Medical Association. This is an organization, of course, that is made up of the membership of the State societies and county societies. Our county societies happen to be a unit of our organization.

As I stated, as an organization we have never opposed any of the benefits which the Government has given to the service-connected disabled soldiers, and we were in perfect sympathy with the hospitalization of all those who needed medical and surgical care, and it was in 1924 when this so-called section 202 (10) act was passed by Congress that we became very much interested in the possibilities that would accrue from that act. We recognize that there were a good many beds at least we have been informed that there were a great many beds that were vacant and that that act made it possible for the Veterans' Bureau to assign these beds to those who have not had service disabilities.

The CHAIRMAN. Are those beds in private hospitals?

Doctor CARY. No; in veterans' hospitals, but when that was opened up, of course, a great many

Mr. BOEHNE. Mr. Chairman, I wonder if the witness would like to speak a little louder. I can hardly hear him.

Mr. CHIPERFIELD. I should like to join in that request.

Doctor CARY. A great number of the nonservice men sought hospitalization following this 202 (10) act, and, as we understood it then, the demand for hospitalization then became very great, so great that Congress found it necessary to begin to build hospitals to take care of this demand. After a certain length of time the medical association as such became deeply interested in it, also the hospital authorities; the hospital executives throughout the country became deeply interested in it because we felt that potentially there were so many cases likely to develop in civic life that we would not be able to foresee the extent of the Government going into the hospital business, and from that time on we became alarmed as a group and, of course, as far as we could, protested here and there as to the Government remaining in the hospital business or at least continuing in the hospital business. This brought about a desire on the part of the Legion, some members of the Legion, representatives of the Legion, and I think they initiated a conference with us to see what common point we could cooperate on in this very apparently laudable undertaking on the part of the Government. We did have a conference and then that was followed with a second conference in which representatives of the Legion, representatives of the American Medical Association, and representatives of the hospital association conferred about this matter. There was a concordance of opinionpardon me just a second.

Later on, this conference was extended again, in which representatives of the Veterans' Bureau conferred with all of us. There was a concordance of opinion on the part of those, if I can properly call it that, in which we all felt that the hospitals as they had been developed were needed, many of them, for the care of nervous and mental cases, and that there were many of them needed for the care of those sick with tuberculosis; and in all probability there were many other chronic, totally disabled veterans who would have a just claim for hospitalization; and the chief objection which we offered, and I think it was more or less sympathetically received, was that the acute medical and surgical cases should not be hospitalized by the Government and that these acute medical and surgical cases, as far as possible, should be left at home or left where they could choose their own hospitals and their own doctors, and inasmuch as there are 4,797 private hos pitals located in 1,875 counties throughout the United States, making it easy for veterans to choose their service in these hospitals, we felt that the Government should not attempt to build hospitals all over the United States, because it is practically an impossibility to do a thing of that kind without very great cost and duplication of service. We felt that these hospials would be more accessible, well manned, than if the Government was to assume this responsibility of the veterans' care-I mean of the nonservice disabled cases. We thought it would be better for the Government to use these hospitals as they were located throughout the United States. We felt, too, that that

would give greater equality of service to the men. There are many of these patients, many of these individuals, when they are sick they are acutely sick, and if they need hospital service they need it immediately and they do not need to be transported for two or three hundred miles.

It is also true that when a man has this feeling that he can be hospitalized by the Government and not have to take care of himself, he will often await the time to get in, waste much of his time which might be utilized for getting well, and sometimes he takes a very great risk; and of course there have been many cases in all probability where disaster has taken place.

The CHAIRMAN. Doctor, if it does not interfere with your thought

Doctor CARY. No, sir; I shall be glad to answer any questions. The CHAIRMAN. This would be a very good place for you to give us the benefit of your suggestions or your knowledge with reference to the difference in the cost of care in the private hospitals and the Government hospitals.

Doctor CARY. We have gone into that, Mr. Chairman, two or three times, trying to find the basis of comparison. It is a very difficult thing to compare. I think much evidence could be brought in that would be apparently facts and yet be very misleading. That is the conclusion which I think all of us came to who are willing to be fair about it. It is very difficult to compare cost when you take the Government, for instance, dealing with a mass of figures and stating that it costs so much per day, compared with a patient who might have been acutely sick, taken to a hospital requiring a great deal of service, maybe a night and day nurse, an extensive operation, and maybe no very definite, no very great obligation on the part of the surgeon or hospital towards the Government, no definite arrangement which would lower those costs, and then take that and compare the figures of per diem cost with the mass, and it is rather misleading, to say the least.

Then, again, there is this fact-just to give you these gross figures gives you some idea of it-in the hospitals in this country that we call voluntary (which are not governmental in control, I mean by that county, State, city, or Federal) there are 332,000 beds and even though they have been 66 per cent filled

Mr. CHIPERFIELD. Doctor, would you repeat the number of beds? I did not get it.

Doctor CARY. Three hundred and thirty-two thousand beds, and although they are 66 per cent filled they cared for 5,322,898, while the Federal, State, city and all governmental hospitals had 641,524 beds, and they cared for 1,833,078 patients.

The CHAIRMAN. That is twice as many beds.

Doctor CARY. That is about twice as many beds.

The CHAIRMAN. And about four times as many patients.
Doctor CARY. About one-third the number of patients.
The CHAIRMAN. Yes.

Doctor CARY. That only indicates this, of course, that the turnover in one of the private hospitals, if you wish to call it that— it is charity, it is voluntary, and so on and so on, not State-the turnover in one of those hospitals is very much more rapid than the

turnover in any of the other hospitals; so that the per diem cost, when you compare the length of time that patients stay in a hospital, it then becomes a rather different problem. And I think that the records here show that the average stay in the government hospitals has been about 101 days.

The CHAIRMAN. What record is that?

Doctor CARY. The annual report of the Administrator of Veterans' Affairs for the year 1932.

Mr. TABER. What page?

Doctor CARY. Page 15. [Reading:]

Approximately 186,000 patients were under hospitalization during this fiscal year, of whom 142,216 were discharged after an average of 77 in-patient days. The average period of hospitalization for this year is lower than that recorded for the past several years, due to the increasing number of general or shortterm patients in proportion to the total discharges. In the fiscal year 1927, when the average period of hospitalization was 101 days, the general patients represented 60 per cent of the total discharges, whereas this type of patient formed 77 per cent during this year.

Mr. TABER. Of course, Doctor, that includes the neuropsychiatric cases, as well as the medical and surgical?

Doctor CARY. Yes; so do a great many of these other hospitalsMr. BOEHNE. I would like to ask a question, if I may. In which category do you place the State hospital for the insane?

Doctor CARY. That is a governmental hospital. This record here gives all the hospitals of the United States.

Mr. BOEHNE. Have you any idea how many beds are in State insane hospitals?

Doctor CARY. He [Doctor Woodward] will find that in a second. If I may go on [reading]:

A comparison of the number of discharges and average period of hospitalization in the various groups of hospitals utilized by the Veterans' Administration shows the following: Veterans' Administration hospitals, 65,167 discharges, or 46 per cent of the total, with an average of 101 days; naval hospitals, 33,143, or 23 per cent, with an average period of 45 days; hospitals at Veterans' Administration homes, 17,806, or 13 per cent, with an average of 76 days; and Army hospitals, 12,432, or 9 per cent, with an average of 57 days.

Mr. CHIPERFIELD. What is your deduction from those figures showing the period of residence or treatment in hospitals?

Doctor CARY. I realize-we realize, I will put it-that in these hospitals that are definitely housing cases of tuberculosis and nervous and mental cases that the stay should be long. On the other hand, it is also true, and I believe that the Government authorities here will state, that the individuals who come to them with acute medical and surgical cases remain very much longer than they do in civil hos pitals, because it is rather difficult to always cure those people. And then there is one other feature which I have often heard discussed, which is a perfectly human thing and bound to operate, the compensation for the individual when he is in a hospital is increased and that correspondingly makes it very difficult for the hospital, however well run and however beautifully manned, to terminate the case.

Mr. MILLIGAN. That is only cases of service-connected disability. Doctor CARY. I am speaking of any case-nonservice-connected disability.

Mr. MILLIGAN. I mean relative to compensation. I mean increase of compensation in hospital only applies to service-connected disabilities.

Doctor CARY. I am not familiar with the technique. Don't try to get me on the law; I am not a lawyer.

Mr. TABER. It appears, doctor, that patients at naval hospitals only have an average period of 45 days and the Army hospitals have an average of 57 days. Those Army and Navy hospitals, as I understand it, are not neuropsychiatric hospitals, so that that represents more of a picture of general hospitalization under Government care than the other figures do.

Doctor CARY. I would say so.

Mr. TABER. And in order to get any actual picture of Veterans' Administration hospitals we would have to segregate the neuropsychiatric case and the others.

Doctor CARY. Yes, sir. In Veterans' Administration hospitals general patients form 70 per cent of the total discharges, compared with the 86 per cent in naval hospitals. That is in next to the last paragraph on page 15 of the Administrator's annual report.

In reply to the question asked a few moments ago, under the head of "Nervous and mental" in all hospitals, public and private, there were 451,245 beds and 97,889 admissions. The average housed by them was 427,135 patients.

Gentlemen, we of course have been very greatly interested in Congress establishing a little different policy regarding this question of hospitalization. There are 126,000 empty beds in the voluntary hospitals; that is, where we said 332,000 beds in what I call voluntary hospitals, there are 126,000 empty beds. That is the latest_report. Even in this period of depression they are 56 per cent filled. In good times they are about 75 per cent filled. That is the average. The difference now and then is about that-so that there are always a great many beds in these hospitals.

Now, we have been deeply interested in this subject as doctors, and we also realize that the hospitals are greatly interested in it from the standpoint of economies that are attached to having patients leave their localities and go elsewhere for treatment and care. We have not complained, and can not complain, about the care of the patient who is utterly unable to pay.

Senator GEORGE. Whether service connected or not service connected?

Doctor CARY. We, as doctors, can not do that. We have lived a life of having to take care of people regardless or whether they are able to pay or not, and it is not a matter that we permit to get in the way of our conscience and service to humanity. We live that life and we feel the record is clean on that. But the medical profession is very deeply interested in having a man regardless of his connection, i. e., of nonservice disability origin, a man who is a veteran-deeply interested in seeing that the man who is able to pay for his medical service or surgical service, remain in his own locality, not having a place to go where he has free medical service and free medical care. We feel that that operates definitely as a disturbing factor in the practice of medicine. We feel that it operates apparently as an economic waste and an economic loss to the community and to the

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