however, take long-term intensive hospitalization in a rehabilitation facility with a rehabilitation program being on a comprehensive basis. Patients who have had injuries to the cervical spinal cord take an average of 9 months' total time for an intensive rehabilitation program to bring them to their maximum physical and mental status.

A recent compendium developed by the Academy of Physical Medicine and Rehabilitation to establish standards for PSRO utilization review calls for not only the inpatient intensive rehabilitation program but also for outpatient intensive comprehensive rehabilitation programs for the spinal cord injuries.

I could personally attest to the fact that too early discharge from a hospital or rehabilitation center or the lack of proper inpatient care and outpatient rehabilitation followup can result in contractures or tightness of the joints, bed sores, bladder infections, or other complications that can destroy any potential for independent living.

The functional training for patients having spinal cord injuries lower in the back is much less and they can be rehabilitated in approximately 3 to 4 months' time providing an intensive comprehensive rehabilitation program is available.

According to the National Center for Health Statistics, there are over 51,000 new cases of spinal cord injuries each year.

I would also like to discuss briefly another type of case that we see that we feel needs intensive rehabilitation care. That is the person who has suffered a paralytic stroke. We feel that both intensive inpatient comprehensive rehabilitation care and outpatient comprehensive care is important to enable that person to return to dignified living and to living in his own environment; that is, his own home.

There is need for long-term therapy to enable the person to walk, to learn to talk and to care for himself, and this is done with a comprehensive program.

This takes weeks and maybe months in a rehabilitation facility, and followup, outpatient care of a comprehensive nature is an important continuation of the total rehabilitation program.

Strokes are a common disability and particularly in the older age person. Therefore, as we approach our older years, we are ever threatened with this disability. I think statistics now are 1.6 million persons in America who have had strokes.

Lack of inpatient comprehensive rehabilitation programs and outpatient followup comprehensive rehabilitation programs usually results in additional return to the hospital for further care. This is medically preventable with good rehabilitation and can cost millions of dollars in unnecessary expenses.

Other disability categories we feel that require not only inpatient but outpatient rehabilitation programs are rheumatoid arthritis, multiple sclerosis, hip fractures, amputations, and several other severely handicapped categories.

We strongly urge in any legislation reported by this committee there be included specific recognition of an outpatient rehabilitation service benefit to remedy this problem; any legislation which purports to cover catastrophic illness must include such service.

Mr. ROBERTS. The final two points in our testimony we will summarize, the third one being inclusion of a definition of rehabilitation services. The provisions that we have outlined regarding inpatient and

outpatient service in our full testimony should be augmented by a clear and comprehensive definition of rehabilitation services.

There is a great deal of confusion which attaches to the word "rehabilitation," particularly because of its strong association with the vocational rehabilitation movement.

A national health insurance bill should cover all items which are legitimately within the realm of medical rehabilitation. We feel that the only way to avoid confusion in administration for the Government, for intermediaries, or providers is through the inclusion of a definition in the law and we have provided such a definition in our full testimony. Finally, we submit that to make these items effective, there should be specific recognition of rehabilitation facilities as eligible providers of service. This should be accompanied by appropriate standards.

Rehabilitation facilities are accredited by the Commission on Accreditation of Rehabilitation Facilities commonly referred to as CARF. This provides a standard setting and a review mechanism which is comparable to that provided by the Joint Commission on Accreditation of Hospitals.

We suggest that while the establishment of standards for rehabilitation facilities be left to administrative discretion, that CARF accreditation raise the same presumption of capability for rehabilitation facilities which the Joint Commission on Accreditation does for hospitals under medicare.

We have prepared a series of amendments which would accomplish the objectives outlined above. These were drafted to relate to the text of the Kennedy-Mills bill. However, the text would generally be applicable to any other bill which adopts the medicare benefit structure. These amendments are submitted to the committee with the hope they will be helpful in your considerations of the issues we have outlined. We will be happy to provide any other material we can in addressing these issues.

Thank you very much for the opportunity to present our views. Mr. BURLESON. Thank you, Doctor. Thank you both. You would like the suggested amendments made a part of the record?

Without objection, that will be included with the other materials. [The prepared statement and amendments referred to follow:] STATEMENT OF CHARLES L. ROBERTS, EXECUTIVE VICE PRESIDENT, INTERNATIONAL ASSOCIATION OF REHABILITATION FACILITIES

I am Dr. Charles L. Roberts, Executive Vice President of the International Association of Rehabilitation Facilities. IARF is the primary national organization of rehabilitation facilities. Our total membership of 700 includes 300 medical rehabilitation facilities providing services to both inpatients and outpatients. My testimony today will be addressed to the need for inclusion of comprehensive rehabilitation services in any national health insurance legislation reported by this Committee.

It is fundamental to an adequate national health insurance program that medical rehabilitation be covered as an integral part of the medical care system. As various proposals for national health insurance are considered by this Committee, attention should be focused on the role and function of rehabilitation medicine and its relation to other levels of care. Partially because of escalating health care costs, increasing attention has been given to the need for preventive medical services to reduce the need for acute care. Rehabilitation can serve much the same function for persons who are disabled from disease, traumatic injury, stroke, or other causes. Comprehensive rehabilitation services provided in a timely manner to restore a patient to a maximum level of function will reduce the likelihood of further acute medical care. More important, it can restore a disabled person to a productive and personally satisfying position in society.

There are millions of disabled people in the United States, and the number grows as medical science improves its ability to save lives. Their needs are manyfaceted and of long duration. These handicapped individuals include those afflicted with spinal cord injuries, deafness, visual impairments, loss of limbs, stroke, various congential defects, heart disease, cancer and renal disease, and other legacies of disease or traumatic injury. The inadequacy of traditional medical care to meet the needs of such handicapped individuals has resulted in the development of a new medical specialty known as "rehabilitation medicine" and the growth of rehabilitation facilities to provide it.

Rehabilitation facilities provide services for inpatients, outpatients, or both. Some are units of acute care hospitals. Others are free-standing community facilities. The unique feature of the rehabilitation facility is that it brings together in one place and under single direction all of the medical and related services that a patient needs to help him overcome or decrease his disability. In a rehabilitation facility, the physician, the nurse, the physical therapist, the occupational therapist, the speech pathologist and audiologist, the psychologist, the social worker, the counselor, and oher professionals combine in an integrated program of service. Medical rehabilitation, under the direction of a physician, is directed to the advancement of levels of function and independence. This encompasses the reduction of disability and dependence, and the promotion of optimum psychological, social, economic and personal adjustment. Rehabilitation care should be provided as an uninterrupted program.

The following specific services may be included in an integrated and coordinated rehabilitation program: diagnostic services; physical therapy, occupational therapy, speech therapy, respiratory therapy, and other medically necessary therapies; audiology; prosthetic and orthotic devices, including testing, fitting, or training in the use of prosthetic or orthotic devices; medical social services; psychological counseling (including family counseling); nursing care provided by or under the supervision of a registered nurse; drugs, biologicals, supplies, appliances, and equipment, including the purchase or rental of equipment; and such related services as are medically necessary for the health and restoration of the patient, and are ordinarily furnished by a hospital, rehabilitation facility, skilled nursing facility, or home health agency.

The bills which have been introduced to establish a national health insurance system do not adequately recognize medical rehabilitation as an integral part of the health care system.

Most of the national health insurance bills pending before the Committee incorporate, by reference or directly, the benefit structure of the Medicare program on the assumption that the services and providers of such service recognized by Title XVIII represent an adequate system of coverage. With respect to rehabilitation, this is simply not the case. Perhaps because it is a relatively new field, rehabilitation did not receive proper attention at the time the Medicare law was passed and, although some progress has been made in subsequent amendments, the Medicare program continues to be inadequate in its coverage. Based on experience with Medicare, we suggest to the Committee that language be included in whatever bill is reported to cover the following points:

1. recognition of comprehensive inpatient rehabilitation services;

2. coverage of comprehensive rehabilitation services provided on an outpatient basis;

3. inclusion of a definition of "rehabilitation services," which will eliminate confusion and cover truly comprehensive rehabilitation programs; and 4. recognition of rehabilitation facilities as eligible providers of services.

I would like to discuss each of these briefly.

1. Recognition of comprehensive inpatient rehabilitation services.-The Medicare Act and the several bills which this Committee is considering, including H.R. 13870, include under the definition of a hospital "an institution which is primarily engaged in providing, by or under the supervision of physicians, to inpatients . . . rehabilitation services for the rehabilitation of injured, disabled or sick persons;" This definition clearly covers rehabilitation services for inpatients. A similar definition, however, appears for a skilled nursing facility and the lack of any standard to distinguish among levels of rehabilitation care has caused confusion and, in some cases, retroactive denials. This problem has been mitigated greatly by the issuance of an intermediary letter by SSA in April, 1972 which contains the following language:

"A patient would be deemed to require a hospital level of care if he requires a relatively intense rehabilitation program which requires a multidisciplinary coordinated team approach to upgrade his ability to function as independently as possible." Section 3101.9, p. 3-33.6 of Revision Transmittal No. 255.

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To avoid confusion in the future, it would be helpful to have this definition included in the statute or its legislative history.

2. Coverage of comprehensive rehabilitation services provided on an outpatient basis. This is a serious deficiency in the Medicare Act and warrants special attention in any national health insurance bill. Neither the Medicare Law, nor H.R. 13870, nor other bills modeled on Title XVIII provide coverage for comprehensive rehabilitation services on an outpatient basis. There is specific coverage of "outpatient physical therapy services" and "speech therapy services" and for certain components of a comprehensive rehabilitation program when provided under the auspices of a home health agency. But, these provisions do not provide coverage for comprehensive services to a patient who may no longer require the level of care of a hospital or skilled nursing facility, but who is a long way from being restored to maximum function. For example:

Trauma to the cervical spinal cord which leaves the patient completely paralyzed from the neck down, with the exception of limited shoulder motion, is a disability for which there was only limited programming and little hope a few years ago. At present, based on factors of age, motivation and physical endowments, many individuals suffering from such injury return to active productive lives. Ironically, patients with a lower lesion, that is less severe residuals of injury, may require longer hospitalization because they do have potential upon which to build. Those with very limited potential may be discharged soon after life saving procedures have been completed. Individuals with lesions at level C4 and C5 may be hospitalized from 2-6 months or an average of 4 months. Patients with lesions at C6, C7 or C8 may be hospitalized from 6-12 months or an average of 9 months. A recent compendium developed by the Academy of Physical Medicine and Rehabilitation, to establish standards for P.S.R.O. utilization review, calls for goal oriented outpatient rehabilitation provided daily or three times a week for a six week period. I can personally attest to the fact that too early discharge to a nursing home or lack of proper outpatient rehabilitation follow-up care can result in contractures, decubiti, and bowel and bladder infections that can completely destroy any potential for independent living. The functional expectations for patients having spinal cord lesions in the dorsal and lumbar column is better and the average length of stay reduced to 3 months; however, the outpatient rehabiiltation requirements are about the same. According to the National Center for Health Statistics there are over 51,000 new cases of spinal cord injury each year.

We strongly urge that in any legislation reported by this Committee there be included specific recognition of an outpatient rehabilitation services benefit to remedy this problem. Any legislation which purports to cover catastrophic illness must include such services.

3. Inclusion of a definition of "rehabilitation services."-The provisions that I have outlined regarding inpatient and outpatient services should be augmented by a clear and comprehensive definition of rehabilitation services embracing the items set forth earlier in my statement. There is a great deal of confusion which attaches to the word "rehabilitation," particularly because of its strong association with the vocational rehabilitation movement and programs. A national health insurance bill should cover all items which are legitimately within the realm of medical rehabilitation and we feel that the only way to avoid confusion in administration for the Government, intermediaries or providers is through the inclusion of a definition in the law.

4. Recognition of rehabilitation facilities as providers of service.-Finally, we submit that to make these items effective, there should be specific recognition of rehabilitation facilities as eligible providers of service. This should be accompanied by appropriate standards. Rehabilitation facilities are accredited by the Commission on the Accreditation of Rehabilitation Facilities which provides a standard setting and review mechanism which is comparable to that provided by the Joint Commission on the Accreditation of Hospitals. We would suggest that, while the establishment of standards for rehabilitation facilities be left to administrative discretion, CARF accreditation raise the same presumption of capability for a rehabilitation facility which the Joint Commission on Accreditation does for hospitals under Medicare.

We have prepared a series of amendments which would accomplish the objectives outlined above. These were drafted to relate to the text of H.R. 13870. However, the text would be generally applicable to any other bill which adopts the Medicare benefit structure. These amendments are submitted to the Committee

with the hope that they will be helpful in its consideration of the issues I have outlined. We will be happy to prepare any other material which will be helpful in addressing these issues.

CHILDREN'S SERVICES UNDER NIH

I wish to call the committee's attention to one other problem to which our suggested amendments are addressed and that is the unique position of children under a national health insurance program. The precedence and experience for rehabilitation coverage established under medicare are only partially applicable to the provision of services to children. Particularly in cases involving congenital defects and disabilities caused by illness or traumatic injury in the early years of life, a comprehensive rehabilitation program can have enormous positive consequences. The effectiveness of such a program depends upon the coordinated and integrated delivery of medical services in conjunction with educational programs and social services. A major facet of such a program is the effective involvement of the family and training and counseling of the family to produce such involvement to ensure that the care delivered by health professionals can be augmented and supported in the home. The alternative to such coverage may well be reoccurrent utilization of high-cost acute care facilities.

While the previously listed diagnostic categories represent approximately 75 percent of the hospital admissions for rehabilitation they do not deal specifically with the problems of children. Consider, if you will, the needs of the spina bifida or cerebral palsied child; limited in function from birth and requiring a long course of physical restoration services such as physical and occupational therapy, speech and audiologic services, medical social services, psychological testing and counseling, orthotic devices and services. Except for occasional surgical intervention such services are most easily and economically provided by an outpatient rehabilitation facility.

The coverage of comprehensive rehabilitation services, whether delivered on an inpatient or an outpatient basis, and the recognition of outpatient facilities as eligible providers of service under a national health insurance program are badly needed. The alternative is intense economic hardship for the disabled, a loss of potentially productive citizens and high costs resulting from reoccurrent utilization of acute care facilities which might well be avoided through the application of timely and effective rehabilitation services. We trust that this committee will give its attention to this extremely important issue and we would be happy to develop for you any additional information or suggestions which you feel would be helpful in this process. We would be happy to answer any questions. AMENDMENTS TO H.R. 13870 PROPOSED BY THE INTERNATIONAL ASSOCIATION OF REHABILITATION FACILITIES TO PROVIDE FOR COVERAGE OF COMPREHENSIVE REHABILITATION SERVICES WHETHER DELIVERED ON AN INPATIENT OR OUTPATIENT BASIS 1. On page 31 (c) line 16 after skilled nursing facility insert the following: , or rehabilitation agency.

2. On page 31 (c) line 22 after skilled nursing facility insert the following: or rehabilitation agency

3. On page 33 strike line 1 through 16 and insert in lieu thereof the following: "(G) In the case of outpatient rehabilitation services, (i) such services are, or were required because the individual needed rehabilitation services, (ii) a plant for furnishing such services has been established, and is periodically reviewed by physicians, and (iii) such services are, or were furnished while the individual is, or was under the care of a physician; or" 4. On page 33 following the word "services" in line 17 insert the following: ; including rehabilitation services,

5. On page 36, beginning on line 7 with the words "For purpose," strike through the words "therein defined" on line 15 and insert in lieu thereof the following: "For purposes of this section, the term 'provided of services' shall include a clinic or public health agency if, in the case of a clinic, such clinic meets the requirements of Section 2051 (o) (4) (A), or if, in the case of a public health agency, such agency meets the requirements of Section 2051 (0) (4) (B), but only with respect to the furnishing of outpatient rehabilitation services as therein defined."

6. On page 61 strike lines 20 through 25 and on page 62 strike lines 1 and 2 and insert in lieu thereof the following: