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Mrs. CANDELARIA. Earlier you discussed the fact that you were far more fortunate than other people that perhaps did not know about many of the resources available. Will you elaborate on it?

Mr. WILLIAMS. In what respect?

Mrs. CANDELARIA. You said you were able to get around, and you did not let the idea of being in a wheelchair get you down, and you were able to do things for yourself, and a little garden you have out there kind of attests that you were able to get around.

Mr. WILLIAMS. Well, that is one of the things you had to learn to do to live, is do what you have to do with, and make use of it, and so it serves two purposes, it keeps you busy, it keeps your mind occupied, and it keeps your joints, in my particular case, in workable condition, I might say.

Mrs. CANDELARIA. You had experience with Medicare and again with home health care. If there was anything that you were able to do, or any kind of advice or opinion that you were able to give, what would they be, what kind of suggestion would you have for the improvement of those kinds of services for those people?

Mr. WILLIAMS. Well, I do not know too much about their present set-up, or the things they were trying to do, even at that time.

Now, when I first came out of the hospital, I was fitted with a leg brace, and Easter Seals helped out on that considerably.

What Medicare did not take care of, Easter Seal picked up the tab, and the thing I objected to on that was that the people, the man who made the brace and the handling of it was apparently trying to get rich off of one brace.

Mrs. CANDELARIA. You mean you had to pay for the brace? Mr. WILLIAMS. Well, in the end he billed me, for I think $180, and above what the brace is supposed to have cost, and one of the visiting nurses here who had quite a bit of experience around in such things, picked that up, and we took it back to him, and that is the last I ever heard of it.

After he had billed me about three or four times, I did not even realize really that it was a bill. I thought it was just a copy of some procedure report that he had to make out and send to Medicare and to other officials.

Mrs. CANDELARIA. You were on Social Security at that time, and I suppose you are still on Social Security ?

Mr. WILLIAMS. Yes.
Mrs. CANDELARIA. Was that adequate to take care of all your medical expenses?

Mr. WILLIAMS. No, it never is. I do not know anybody that had enough Social Security to fully take care of just their everyday needs, much less hospital and doctor bills. Doctor bills have gone clear out of sight, and as you know, hospitals have gone clear out of sight, and they are what Medicare and Social Security will take care of.

Mrs. CANDELARIA. Are you under Medicare care now?

Mr. WILLIAMS. Yes, the doctors in the medical centers are my doctors, and they keep in contact with me, and I have a kidney infection, and that gets taken care of. They just look after the infection in my kidneys, and they have to be watched very carefully, and I have taken just about all of the medication, which is very expensive, that is known to the medical profession, and he keeps changing from time to time, for instance, I have some here that the price of the medication was $60 for 40 pills.

Mrs. CANDELARIA. That is quite expensive.

Mr. WILLIAMS. And how are you going to make Medicare and Social Security meet those things?

Mrs. WILLIAMS. I do not know how anybody could believe that they would charge that much.

Mrs. CANDELARIA. Your telling us about it helps. It might start the ball rolling in the right direction to alleviate some of the conditions that exist.

Della, would you like to say something at this point?

Mrs. MIRABAL. I was going to ask Mr. Williams, do you feel that you are well informed, and that you knew where to get all of the services that you required?

Mr. WILLIAMS. No, I never was.

Mrs. CANDELARIA. Do you feel that it would be helpful to the people, who say they are not getting any services at all, if the people were informed where to get the services?

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Mr. WILLIAMS. Yes, and another thing that would be helpful would be for a depot or some center where unneeded equipment such as wheelchairs and walkers and trapeze from the beds over their heads to help them to turn over and move in bed, a lot of people have more trouble than you imagine, and I am one of them, but I have all of those things due to the fact my son was a welder, and I will show you those pretty soon.

The things that I have, that other people do not have made available to them, and if we had the center where those unneeded things could be collected, and then given to the people who do need them, that would be one of the things that would help a lot.

Mrs. CANDELARIA. You suggest that those things be given to the people without cost?

Mr. WILLIAM8. That is right. It would be strictly on a donation basis, people who do not need them anymore. Now, there are people who, for instance, they have hospital beds and things like that in their homes, and they are no longer needed. Well, a lot of times those go to the garage, storage, or thrown away, instead of getting to the proper places where they are actually available for somebody to use that needs them.

Mrs. CANDELABIA. Thank you, again, Mr. and Mrs. Williams. This is Fred Walters. He has a different kind of problem; would you care to tell us a little bit about your illness, and the number of years you have been ill?

Mr. WALTERS. Well, I have been ill with emphysema going on 8 years, and it is gradually getting a little worse. As long as I behave myself, I can get along pretty good, and I do not try to overdo and overwork.

Mrs. CANDELARIA. You are under Medicare and medication?
Mr. WALTERS. I sure am, taking three at a time of medicines.
Mrs. CANDELARIA. Are you covered by Medicare?
Mr. WALTERS. Yes.
Mrs. CANDELARIA. Do you find this is adequate?

Mr. WALTERS. No, not entirely adequate. We have a little insurance that we have had for several years. In fact, we have had the hospital policy, I imagine, since I have had the darn thing for 35 years.

Mrs. CANDELARIA, I see.

Mr. WALTERS. It does not pay much anymore. It is kind of outdated, but it helps.

Mrs. CANDELARIA. I see. Well, about 7 years ago, I met you under different kinds of conditions. At that time, you were bedridden, and you needed different kind of assistance than what you need today. Were there agencies available to assist you and to help in caring for you at home with your illness?

Mr. WALTERS. None whatsoever, except my wife, and that is what we do need, I think, out here in this district, is some home nursing care of some kind, so that he could help people. I do not claim to know what it is about, how to go about doing it, but one thing we do need out here is that. We are supposed to have it, but you never

see the people around. Mrs. CANDELARIA. You were never referred, your doctor never referred anyone to you to assist your wife with the care, home health care type things?

Mr. WALTERS. Not a bit, no, never, no.

Mrs. CANDELARIA. In your opinion, was the care something that you could have used, or was your wife able to take care of you adequately?

Mr. WALTERS. At that time, we needed help, because I was almost helpless, at that time. I would have to stop several times just to walk across the room, and I could not do nothing, not a thing. She had to do all of the work, inside and outside, and we have a pretty large lot up there, too large, and for one person to take care of, that is a lot of work.

Mrs. CANDELARIA, Plus caring for a sick person. Mr. WALTERS. That is another thing. I think we need somebody. Now, I cannot afford to pay wages, the going wages for stuff, but I know there are people that do things cheaper, like painting the eaves on the house and stuff like that, around the edges of the house, and it needs it bad, and I just cannot afford to have it done, but I know there is people out that set up in some community, where some older person, I do not care how long it would take them, to give me a flat price.

Mrs. CANDELARIA. So there are all kinds of needs by not only the elderly, but those not able to function because of some illness.

Jr. WALTERS. I know that. If I could do it, I would do it myself gladly, but that is what I say, there are probably some old people out here willing to do the job, if you just knew that they were there.

We need an information center, really, to let people know who does these things, and how to get it done.

JIES. CANDELARIA. I would agree with you. We have tried for many years in this area to develop some kind of multipurpose center, but hopefully now with the mental health coming in, something might materialize.

Mr. WALTERS. I hope so.

virs, CANDELARIA. Della, is there anything that you would like to ask Mr. Walters? With the kind of dedication we have from Della, that is almost unheard of these days.

Mrs. MIRABAL. Are you having any problems?

Jr. WALTERS. I cannot think of anything except that we should have an information center set up over there. The list of things that people will do, you know, they can do. I know there are a lot of people around the neighborhood that would like to work a couple of hours a day or something, but nobody knows how to get ahold of them.

Mrs. MIRABAL. The people need to be informed ?

Mr. WALTERS. That is what I say, we need an information center over there, as much as we need anything.

Mrs. CANDELARIA. Thank you, Mr. Walters. It has been a pleasure, and I am very glad to see you under different circumstances up and around.

Mr. WALTERS. I remember the last time, I imagine I looked quite a bit different.

Mrs. CANDELARIA. Thank you.

[Mr. Ramon Benegas did not appear on the video tape, although he was interviewed. Mr. Benegas is age 83, married, retired, and an invalid since 1956, 18 years ago. He has railroad retirement, Medicare, and no home health care assistance of any kind, sought assistance from HSSD, but was told he was making too much money. Mr. Benegas has rheumatism, has had a medical problem, and he has gained the use of his arms, unable to walk. Mrs. Benegas is age 65, and she has full responsibility for total care without outside help.)

STATEMENT OF JOSIE CANDELARIA, HEALTH PLANNER, MID RIO

GRANDE HEALTH PLANNING COUNCIL, ALBUQUERQUE, N. MEX.

Mrs. CANDELARIA. I have identified needs, and I have come up with several recommendations, Mr. Chairman, which were presented to our council. They were approved, but yet have not been adopted, and they will be a part of your record. I have submitted them to your committee.

Some of the problems in the area are that we have found that there is a need for doctor consumer education, of standards for agency licensure for providers which have been touched on, standards for home health aides, and certification of home health needs. This would also include insurance provisions for home health, that they be mandatory. I just thought I would mention that.

I have done something a little differently in the area of interviews, with the assistance of Dr. McCarthy, and also with the cooperation from the mental health centers that provided the manpower and equipment for us to go out into the community and take these interviews.

I also wanted to stress a point, that many people would love to be here again, people who are unable to come for many reasons, transportation, illness, and what have you.

We interviewed a total of four, three we video taped. The fourth one, we were not able to tape for the simple reason that it is the classic experience of insecurity of the elderly. Anyone that comes into their

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home, they feel is a threat to their security, and that is what happened with the fourth person.

Senator DOMENICI. Thank you very much. We are going to have to move on to the other witnesses. The transcript of the three people interviewed will be made a part of the committee's record. Certainly it will not be as good as seeing it, but it is the best we can do under the circumstances.

We greatly appreciate your helping us, Mrs. Candelaria, on this point, and ask that your stay in touch, as we move through the legisIation throughout the next few months.

Mrs. CANDELARIA. Thank you very much.

Senator DOMENICI. Our next witness is David Jensen, executive director, Cooperative Health Services, Albuquerque. I understand you will be telling us about some ways we might fill the very, very serious vacuum in home delivery of services to the elderly, including nurse practitioners, paramedical type.

Mr. JENSEN. Essentially, practitioners.
Senator DOMENICI. You may proceed.

STATEMENT OF DAVID JENSEN, EXECUTIVE DIRECTOR, CO.

OPERATIVE HEALTH SERVICES, ALBUQUERQUE, N. MEX. Mr. JENSEN. Cooperative Health Services, a joint venture of Presbyterian Hospital Center and St. Joseph Hospital in Albuquerque, was formed in 1971 to pursue solutions to the broad problem of cost and availability of health care in both urban and rural New Mexico through the application of the resources from the private sector. During the past 3 years, Cooperative Health Services has developed four major programs aimed at improving health care for area residents. The programs, all operational, include two primary care clinics in medically underserved rural communities, à hospital-based home health care program, an emergency services system, and a prepaid, comprehensive health care plan-HMO—which is sponsored by our hospitals and their medical staffs.

Cooperative Health Services is not incorporated, but has organized four separate nonprofit section 501(c)(3) corporations to administer our programs which include the following: (1) Southwest Health Care Corp. (SWHCC), which administers

) clinics in rural, medically underserved communities. The clinics include the Bernalillo Medical Clinic and the Hope Medical Center in Estancia. Clinics in Pecos and Tijeras Canyon are planned to open in July 1974.

(2) New Mexico Health Care Corp. (NMHCC)-Mastercare, a prepaid health care plan sponsored by Presbyterian Hospital Center and St. Joseph Hospital and 230 participating physicians on their medical staffs. Mastercare is in its second year of operation and is a self-insured health care service organization.

(3) Bernalillo Health Care Corp. an emergency medical services system which operates Albuquerque Ambulance Service.

(4) Home Health Care--a hospital-based home health care agency, which is Medicare-certified.

Of primary concern to this committee are our activities in rural health care delivery. All our rural clinic personnel are employed by

the Southwest Health Care Corp. The Bernalillo Medical Clinic is staffed by a salaried physician and receives Medicare reimbursement. The Hope Medical Center is staffed by a family nurse practitioner, a type of midlevel medical practitioner, and is not presently eligible for reimbursement under Medicare, part B.

The Hope Medical Center operates as follows: The center is staffed by a family nurse practitioner, who functions under the standing orders and supervision of a panel of physicians in private practice in

a Albuquerque, 60 miles away. Mrs. Martha Schwebach, the family nurse practitioner at the Hope Medical Center, was the first family nurse practitioner in the United States.

The model was developed by Edward A. Mortimer, Jr., M.D., and others at the University of New Mexico Medical School in 1969 under HSMHA contract No. 110–69–241, “A New Manpower Model of Rural-Urban Linkage for Improved Health Services."

I am certain you have heard of the project. An exhaustive report covering the results of the $750,000 5-year project established the fact that high-quality medical

care is provided by such a carefully supervised nurse practitioner. The report went on to analyze many demographic, economic, and epidemiological aspects of the impact of delivery in this new model.

COOPERATIVE HEALTH SERVICES

In October 1972, Cooperative Health Services, a joint venture of Presbyterian Hospital Center and St. Joseph Hospital in Albuquerque, assumed management of the Hope Medical Center and placed the nurse practitioner under supervision of a panel of private physicians in Albuquerque. The model has worked well indeed. Not only does it provide high-quality primary care to rural areas, but the model is economically viable in sparsely populated areas which cannot support or attract a physician. We are pleased with our experience at Estancia, and we plan to open two new family nurse practitioner clinics in July 1974.

As I mentioned, we are at financial risk for the success of the clinics we manage. We are reimbursed for the nurse practitioner services by Medicaid and by New Mexico Blue Shield, as well as by commercial insurance companies.

The one stumbling block which has prevented us from breaking even and reaching older persons effectively has been the legal prohibition by Medicare for reimbursement of services when a physician is not onsite.

Since Medicare will not reimburse Hope Medical Center, most patients with Medicare pay out-of-pocket, and then must meet their deductible all over again when they are referred to one of our backup physicians or other Albuquerque specialists. Many retired persons are located in the area served by Hope Medical Center, but we have to tell them that Medicare will not reimburse us. It is all very confusing and inequitable, to say the least, leaving the elderly without accessibility to Hope Medical Center and to some degree, damaging the center's reputation and its prospects for breaking even.

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