A Public Health Official Looks at Recent Legislation*

1965 Heart, Cancer and Stroke Programs

Title Xl , vIII

a public health official looks at • • •

recent legislation * by Donald P. Conwell, MD f we are to accept the responsibility all of us have to improve patient care for all citizens, we must include pharmaceutical services to chronic disease patients in whatever setting they may be found. With this concept in mind, I should like to discuss three laws, three problems and three solutions. The three laws are-

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1. Title 18 of the Social Security Amendments of 1965, known to most of us as medicare

2. Title 19 of the Social Security Amendments of 1965, known as the welfare amendments. 3. The Heart, Cancer and Stroke Legislation

The medicare legislation is very familiar because of the most effective manner in which the Social Security Administration has informed not only the "65 and over members" of the community but also the "providers of service" as to their responsibilities in this area. Basically, the bill provides for care for any person 65 or over, in 'case of catastrophic illness and introduces the concept of continuous care from hospitalization through extended care to the home with home health services. Part B provides for physician services in any 'Of these settings with laboratory and additional home health services included through a three-dollar monthly payment on the part of each 'Citizen electing to participate in this portion of the program. Title 19 probably has the most important long-range effects of any health legislation passed during 1965. It will o Presented to the Academy of General Pract-ice of Pharmacy at the American Pharmaceutical Association annual meeting on April 26, 1966 in Dallas; Texas.

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upgrade ho~pital, physician, extended care, outpatient service and diagnostic services not 'Only for those who are 65 and over but for various age groups already eligible for care under existing programs. It indicates the concern the Welfare Administration of the Department of Health, Education and Welfare has in providing quality care for its beneficiaries. It also requires an increased awareness by the state government to the need for increased personnel, funds and training to give better care to its citizens. The heart, cancer and stroke legislation win increase the number of centers for training health professionals and hopefully will begin to break the "walls of Jericho" that have too long separated our teaching institutions from the other hospitals and health facilities in the community. These laws, although federal in origin, are really a result 'Of U.S. citizens' realizing they have need of better patient oare and voting to support men who would provide these services from taxes of our national government. As citizens, we have brought this about and, as citizens, we must make sure the funds, thus allotted, are used to the maximum for improving the health of all citizens no matter what their race, creed or origin! 'B ut such exciting legislation also brings problems. Three of these seem to require immediate action and thought on our part. The first of these is the fact that the nurse is one of the 'key persons in our scheme of health services at the present time. In the material presented to support the Nurse Education Act of 1964,

Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION

there was a statement that to maintain 'Our present level of nurse services in our health facilities, we would need to double the supply of nurses that we have in the United States by 1970. This ·w as the estimate when legislation passed last year had not been considered. N ow we have at least three new programs that win require nurses in increasing numbers for effective implementation and the enormity of our problem is quite apparent. It means that we will have to find ways of using our present supply of nurses more efficiently and also find ways of giving the same type of service without providing nurses with three to four years of optimum training. IMedicare legislation requires a transfer agreement between an extended care facility and a hospital for the transfer 'Of patient information. The law states that it should be from nursing home to hospital but it would be futile to develop this one-way street when the more effective method would be to make patient information available to the extended care facility at the time the patient enters that fadlity. Luckily, the interpretation that has ·b een put on this part of the l:aw does indicate the need for hospital information's being given to the extended care facility upon entry of the patient. What does this mean? Hopefully, it means that hospitals and extended care facilities will be able to plan effectively f'Or the transfer of patients and patient information at a maximum level' of efficiency; it also means that the two groups will search out their mutual areas of concern and helpfulness for the benefit of the

patient in the community and not just the personnel in either of the institutions. The final problem is implementing the requirement that a utilization plan be developed for each institution involved in the care of medicare eligibles. This can be developed on an institution by institution basis but we hope it will most frequently be done by a community planning group which will use most efficiently the time and skills of those who serve in this capacity. We have seen three laws and three problems. Hopefully the three solutions I offer can be implemented effectively by pharmacists working at the community level. In regard to shortage of personnel, we can only hope that we will be able to ,a dapt from other disciplines some of the technics that they have already developed. As an example, the American Occupational Therapy Association has developed a very excellent program for training occupational therapy aides to be certified by AOTA. There are 12 such training programs at the present time and the association has acceptedresponsibility for the quality of the course and effective supervision of such aides when they .are trained. The physical therapists have realized that they will have to change their concept of providing direct service to patients to incorporate the idea of the therapist working as a consultant and as a trainee of persons who will perform the direct service. This technic of stretching personnel has already been successfully done in Idaho, Kentucky and North Carolina. Perhaps pharmacists could work up a similar program. The second problem is that of training personnel. The Ohio State University college of pharmacy has begun to solve this problem by de-

ADMINISTRATION and COORDINATION

PERSONNEL

RESEARCH and TRAINING

FACILITIES and FUNDS

veloping Pharmaceutical Services for Nursing Homes, a course for community pharmacists presented for the first time in September 1965. This course was designed to bring community pharmacists and nursing home administrators together to explore their mutual dependency and to develop technics for working together effectively in the community. Copies of this conference proceeding, which is suitable for a basic training program, are available from the pharmacy extension services of Ohio State University for $2. It is well worth the investment. Again in the area of training, the division of chronic diseases has developed a syllabus that attacks the problem of servicing the ,chronically ill and aging at a broader -level. This syllabus, available on request through

Donald P. Conwell, assistant to the chief for training, division of chronic diseases, USPHS, received his AB (1941) and MD (1943) from Vanderbilt University and his MPH (1951) from Harvard University school of public health. After two years in the Army Medical Corps, Conwell joined the Institute of Tropical Medicine in Antwerp. In 1952 he became assistant professor in tropical medicine and public health at Tulane University and in 1956 director of the preventive medicine bureau for the Kentucky State Health Department. In 1958 Conwell became medical officer in charge of division of foreign quarantine and in 1964 assumed his present position.

Figure I-Comprehensive patient care wheel prepared by the division of chronic diseases of the Public Health Service of the Department of Health, Education and Welfare.

state health departments, is entitled Development of Community Programs for the Chronically III and Aging. It will help any community group develop a plan of action which does not require the expenditure of a hundred thousand, or even a thousand dollars to discover the resources of the community which can solve its problems. The plan would seem to be particularly appropriate for the community pharmacist to help his community come to grips with the total problem of health services, not just those of pharmacy or nursing home patients. And finally, the schools of pharmacy for some months have been exploring ways in which they ·could introduce more of the public health concepts and responsibilities of the pharmacist Hopefully, into their curriculums. there will be a great increase in this type of content in the ·c urriculums of schools of pharmacy in the near future. But none of these will be successful unless we can put an of them into a concept that the total community can understand. In the Public Health Service we feel we have a concept of comprehensive patient care that can be used effectively in any situation. We have ,c alled it a Comprehensive Patient Care Wheel (see Figure 1). This diagram of a wheel is the product of a prolonged staff effort to plot the public health approach to the mobilization of community resources in the fight against chronic illness. In the four corners are listed the weapons available to us-personnel, facilities and funds, the technics of administration, coordination, research and training ( applied, rather than (continued on page 173) Vol. NS7, No.4, April 1967

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right to refuse to dispense under a reclassification plan should be consid~ ered in deciding whether there was an implied fitness warranty. However, this would probably not be a very important faotor in finding such a warranty. A serious problem of "pharmacy shopping" could arise if the obligation not to dispense were imposed on the pharmacist. Sensible patrons would not try another pharmacy if the pharmacist satisfactorily explained his reasons for refusing to dispense a drug. The pharmacist might be tempted to forego his ethical standards if he knew the patrons he refused were obtaining the drugs elsewhere. A patron might be able to obtain the drug from another pharmacist because that pharmacist had lower standards or did not know certain facts about the patient that were known by the first pharmacist. Requiring pharmacies to keep records of the dispensing of such drugs would only disclose the more flagrant abuses because considerable professional discretion would be involved in most cases. However, it would be a monumental task to examine in a meaningful way the records of all pharmacies in a given area. One approach to this problem would be to require the names of patrons who have been refused certain drugs to he circulated immediately to all pharmacies in the area through an infonnation exchange. The government inspector would probably circulate the names of chronic abusers as

state inspectors now do the names of exempt narcotic abusers. Once a patron has been turned down it might be rather difficult to obtain his name. The procedure followed when exempt narcotics are purchased could be adopted. Patrons then would have to identify themselves and sign a register before obtaining the drug. The plan could be regarded as successful if a majority of the refused patrons did not buy the drug elsewhere. A substantial number of injuries would have been prevented even though there were a large number of violations. Of course these violations could be decreased by rigorous enforcement of the law.

recent leg islation

nurse programs, coordinated home oare programs and the like) . Finally, in the outside circle, we have identified the various professional disciplines that contribute to the total care of the chronically ill patient; together they make up the chronic disease control' "team" in the community. Thus we have attempted to condense .and translate into a simple graphic presentation all the basic elements of chronic disease community programs at the community level; one way to view this is as focusing required professional skills through appropriate types of care down to adequately evaluated patient needs. This process applies to the whole range of chronic diseases. The measure of a community's readiness to cope with contemporary health problems is the extent to which this process is carried out wisely and efficiently, bringing to the chronically ill patient and his family the needed material and paramedical services at the right time and in the right place and at the right cost. •

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basic research, the field application of public health methods rather than laboratory study) . In what might be called the bull'seye of this chart ,a re the patient and his family. Public health, like the legendary "old family doctor," is concerned with the total patient and his total environment, the most vital element of which is his family. The patient and his family share a multiplicity of needs, which we have categorized in the surrounding space as physical, social, economic and emotional. The next circle can be thought of as the area of diagnosis and decisions; this is the stage at which the chronically ill patient is evaluated, reevaluated and finally referred to a suitable source of care and treatment. All communities should possess the sources named in the next circleinpatient care ( as in a hospital or nursing home) , outpatient care (clinics) and home care ( visiting

conclusion

Although ,there are certainly many variations of reclassification plans, the analysis of the basic plans would not be changed significantly by most of the variations. The basic question that must be answered about drug reclassification is-will reclassification

result in increased protection of public health? The proposed study to determine the number of injuries and to analyze the case histories of patrons injured by improper use of over-the-counter drugs should shed considerable light on drug reclassification and on the merits of various plans. Such a study should also be helpful in deciding what drugs should be placed in any reThe concern classification group. about drug reclassification should ibe

directed to this area and not to bhe issues of economic well-being of the pharmacist and the legal liability implica
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