of integration, of community integration of care for the indigents, which ties in with chronicity because our population is aging. A person may take care of an acute illness financially but you let him get a chronic illness and to the average individual it is not so long before he is out of the picture so far as his financial ability to pay is concerned.

We have an aging population as a community problem and we want to discuss the beginning of taking care of chronic illness at Gallinger Hospital particularly.

Now along with that—and I want to emphasize this, Mr. Chairman, because it is very important that there be instituted checks to see that this service that the Congress and the Commissioners are making possible for indigents does not go to the wrong people. In other words, we must have someone to check these people who come in, to see whether or not they are really indigent, whether they are residents of the District, and whether they are hospitalized under the law which Congress has set up. That means a system to check to see whether they are really entitled to medical care.

Along with it goes also, and then I will turn the meeting over, if you please, sir, to Gallinger and let them go along with the picture, a provision for the treatment of children with crippling and other illnesses at the Gale School Medical Clinic. This has a relationship to public service in that it is a Health Department clinic, and as such is located in the center of the city so that it could take care or relieve the medical shortage that occurs in the north central area, where we have the greatest centralization of population, the greatest amount of illness, and the greatest amount of underprivileged conditions in the entire city. Congress made possible the establishment of Gale School and we do feel that that, along with Gallinger, with proper balances and checks to see that all people who are asking for assistance are entitled to it, these additions will complete the picture so far as we are concerned.

I shall be very happy for Dr. Stebbing and Dr. Fazekas to tell us about Gallinger. Then I would appreciate greatly if Mr. Sanderson could tell you about the over-all picture and also to have Dr. Oppenheimer give you a few words on the Gale School set-up, if that meets with your approval.

Dr. STEBBING. Mr. Chairman, I might tell you what clinic we now have, begun some years ago when we had no clinic at all. It often happened that patients who were ready for discharge from the hospital needed follow-up care. Those patients were told to return and see the doctor who had seen them in the hospital, who could give them that continuous care. From that simple beginning such clinic as we have started and there has never been any budgetary recognition of a clinic as such at Gallinger Hospital.

We have at present that small beginning which sees approximately 18,000 persons a year. They are all in specialized subjects such as orthopedics, surgery, vascular diseases, genito-urino diseases, and diseases of that kind. There is no general medical clinic where a patient applies for the first time and receives a thorough work-up.

If we had such a general medical clinic, a patient who applied for admission to the hospital and who was seen not to be an emergency case but one that should be worked up before admitting to the hospital, could then be worked up in the clinic and then if hospitalization was found to be necessary it would be very much shorter.

Nearly all of the hospitals of any size have a fairly large out-patient department. I have some comparative figures from other cities which will give you an idea.

For instance, Los Angeles County Hospital has 3,624 beds, twice as many as we, but they have 282,993 clinic visits a year.

The University of California has a 314-bed hospital and has 101,778

visits a year.

Charity in New Orleans has 3,530 beds and has 275,935 clinic visits. Coming closer to our own area, the University of Baltimore Hospital has 505 beds and 72,736 clinic visits.

Boston City Hospital, less than twice our size, 2,537 beds, has 317,681 clinic visits for a year.

I have a few others but those are representative and run more or less in the same order.

Mr. YATES. How many visits do you have a year?

Dr. STEBBING. We have 18,000 in our out-patient figure.

Mr. YATES. Is that the figure to be compared with the other figures to which you have just testified?

Dr. STEBBING. Yes. We have been counting as out-patient visits those persons who come to our emergency room and are treated. There are approximately 3,000 a month there.

Mr. FURCOLO. A month?

Dr. STEBBING. A month. If they were added into the clinic visits, we would have out-patient visits of approximately 60,000 a year. Many of those would still be emergency-room visits even though we did have a clinic, but on the other hand many of them are suitable for clinics and should not clutter up the emergency room.

Now as to the detail of what we propose to do, I would like to have Dr. Fazekas speak on that subject, unless there are some questions you would like to ask me.

Mr. FURCOLO. How do those patients get in in the first place? Are they sent by doctors or do they just walk in?

Dr. STEBBING. Most of them just walk in. Occasionally they are sent by private doctors to whom they have made one visit perhaps and the doctor has found that the patient is going to require other visits and is unable to pay for the first visit, so the private doctor tells him, "You had better go over to Gallinger and get the rest of your treatment there."

Mr. YATES. May I ask another question with relation to the figures to which you have just testified? Do the counties in which the county hospitals serve in the other cities, to which you have testified, have the same sort of indigent-patient care with private hospitals as you have in the District?

Dr. STEBBING. I do not really know the answer to that question. Mr. YATES. Do not the private hospitals in the District have their out-patient care, too, as part of the indigent care for the District? Dr. STEBBING. Yes, the private hospitals of the District do have care for tax eligibles on a contractual arrangement with the District of Columbia.

Mr. YATES. So that strictly speaking if you were offering a fair comparison you should include those out-patients in your total number as well, should you not, inasmuch as it is part of the same service? Dr. STEBBING. They should be so included.

Now many of those patients should be attending clinics at Gallinger, not all of them, however, but it is perfectly ridiculous for us to dis

charge a patient from Gallinger Hospital who lives in the southeast and tell him to go to Georgetown or George Washington for his follow-up care. In the first place, there is the long distance he has to travel and in the next place they are going to repeat a lot of expensive tests that we have already done on them.

Mr. YATES. What will be the effect of your proposal on the plan now existing for the care of indigents through private hospitals? Will that be reduced as a result of that?

Dr. STEBBING. We think it should be reduced both in the interest of the patient concerned and in the interest of economy. It will not be entirely eliminated because there will still be patients residing in Georgetown or in the far northwest who should attend those hospital clinics for the sake of their convenience, their inability to travel on public transportation, and so on.

Mr. YATES. If the out-patient service is set up as you propose, it will have the effect of cutting down the number of patients who will be taken care of by the private hospitals?

Dr. STEBBING. We think it should.

Mr. YATES. If that is done, how will the private hospitals be able to obtain sufficient funds to keep going? As I remember, the reason for the installation of the indigent service with the private hospitals was to supply them with funds because of failure of private funds, community fund drives, and other things of that nature.

true?

Is that not

Dr. STEBBING. The point they made was that they were taking care of tax eligibles and always had done so because we were not equipped to do so and therefore they should be paid for taking care of them. There will be suitable clinic cases for those other hospitals who are not tax eligibles.

Mr. YATES. That has no bearing on the District's relationship with them, does it?

Dr. STEBBING. No, it does not; but it does not mean that that clinic will have to fold up as soon as their work is taken away from them. Dr. SECKINGER. There are still funds available. There will be $635,000.

Mr. YATES. I knew that was available except that they had asked for a greater appropriation than that. If this service is proposed, certainly there will be no need for a greater appropriation but possibly a lesser appropriation.

Dr. SECKINGER. Somewhat so and it will stabilize things probably so far as pyramiding cost is concerned.

Commissioner MASON. What is the percentage of nonresidents who get treatment at these private hospitals as well as ours?

Dr. STEBBING. I do not believe there are many nonresidents who are treated at out-patient clinics. There are some in the emergency room. As soon as they appear at the clinic, they are refused treatment. Commissioner MASON. Who refuses treatment?

Dr. STEBBING. The Permit Bureau. The private hospitals do not have representatives of the Permit Bureau present. I believe they should have.

Commissioner MASON. My question was aimed at this: A large proportion of the people who are treated at Georgetown, for instance, George Washington, and the other contract hospitals, are actually residing in nonresident areas.

Dr. STEBBING. Yes.

Commissioner MASON. And I have never been able to prevent it. Somebody ought to do something about it because our taxpayers are paying for it.

Dr. STEBBING. I have always believed that there should be representatives of the Permit Bureau at the contract hospitals to check the cases that are admitted to their clinics that are charged to the District. Dr. FAZEKAS. Mr. Chairman and members of the committee, there are many things needed at Gallinger Hospital. One of its most outstanding deficiencies is the fact that it does not have a medical outpatient department. I cannot see how we will ever have an integrated program for the patients with chronic disease or how we can ever begin to practice preventive medicine in the District of Columbia unless you give its only community hospital an out-patient service.

DEFINITION OF OUT-PATIENT SERVICE

Mr. STOCKMAN. Will you explain just what that is?

Dr. FAZEKAS. The care of a patient with a chronic disease does not only mean that a patient should go to a medical clinic, have a drug prescribed to him by a physician, and then no other interest in the patient. Indigent patients are not medical curiosities; they are people who need total care. In addition to medicine, they should be given vocational guidance; they should be seen perhaps by a social service worker to help out with the family problems; they should be seen by rehabilitation workers who can rehabilitate them to do something that they are capable of doing, considering the condition with which they are afflicted.

Commissioner YOUNG. Mr. Stockman wants to know what an out-patient clinic is.

Mr. STOCKMAN. The doctor has used that term freely and I as a layman am not familiar with it.

Dr. FAZEKAS. I am telling you what a total out-patient clinic is. It is taking interest in the total care of the patient, not just in the administration of a drug to the patient when he comes to the clinic. You have to be interested in the person as a person.

FOLLOW-UP CARE

I think these other facilities which only the District Health Department can provide are equally as important to the patient as is the medical care he receives when he visits the out-patient department once every 2 or 3 weeks.

Now what does an out-patient clinic do for a patient? Now 60 percent of the patients at Gallinger Hospital have chronic diseases, diabetes, a large percentage of them have heart disease, a large percentage of them have neurological disturbances, and many of them have arthritis. We know we cannot cure these conditions. They are not like infectious diseases. All we can do is treat these people constantly to see that they get the best hospital and medical care because if we do not do that, then that patient will break down and come back in the hospital.

Take, for example, a patient who comes in the hospital with high blood pressure, cardiac involvement and failure. It takes 2 or 3 weeks

in the hospital to put that patient in the best possible condition. Now if that patient is not followed up, if he is not given post-hospital or out-patient care, you can be assured that within 2 or 3 weeks after his discharge from the hospital he will again become a hospital patient. That is exactly the condition that existed at Gallinger Hospital, only those patients were referred to the clinics who were interesting from the medical point of view. The other patients had absolutely no post-hospital care which is so important to keep these people well all the time.

You do not treat a private patient by paying attention to him only when he has to go to the hospital. The private physician follows his patient every so often to assure himself that his patient will not break down, and provides him the care he needs to remain well. I do not see why the indigent patient should be treated any differently. When I first came to Gallinger Hospital there was no system for referral of these patients to an out-patient department. Only those patients were sent to out-patient departments that seemed interesting to the residents from the point of view of academic medicine. To obviate this situation a Public Health nurse was assigned to see all patients before discharge and arrange that these patients should be sent to the various contract hospitals throughout the city and, in addition, provided the various contract hospitals with the findings on the patient while he was in the hospital to facilitate their work-up.

Every year since I have been at Gallinger, around March the contract hospitals would run out of funds and then our patients would not receive any posthospital care. There would be no clinics in the city to which they could go.

What we have tried to do at Gallinger for the past year is to set up a clinic that will take up this load. We set up a voluntary clinic in the Southwest Health Center where we see as many medical patients as we can that are discharged from Gallinger Hospital. Last Thursday night we saw 56 patients. Fifteen were new. Five of them had to be admitted to the hospital simply because there were no other facilities for taking care of these patients.

If we had an out-patient department at Gallinger Hospital, we could certainly do a much better job in preventive medicine than is being done today. We know our patients, we have their interest at heart, and we will give them total patient care, in addition to the medicine that is required to improve their condition.

At the present time we cannot follow patients discharged from our own hospital, no less do preventive work for our own community.

OTHER OUT-PATIENT WORK

What else can you do in an out-patient department besides followup care which is so important to keep these chronic patients as well as possible? You can do a diagnostic work-up on an ambulatory basis. Suppose a patient comes to your admitting office with high blood pressure? That patient has to be worked up. You must know the status of his heart and the status of his kidneys. What we do now is to admit that patient to the hospital for this work-up although hospitalization is not necessary, but we have to admit him because we have no other facilities for working him up. If we had an outpatient department with certain rooms set aside for diagnostic service,