Mr. 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.

Mrs. 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.

Mrs. 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?

Mr. 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.1 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

1 See appendix 2, item 3, p. 1136.

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 legis lation 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, a 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 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 focated 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.

Just this week, a woman came into the Hope Medical Center, and when the staff told her that Medicare would not pay for services provided at Hope, she decided that she would travel to Albuquerque to see a physician. She had already met her deductible for the year out of part B and naturally was reluctant to incur additional out-of-pocket expenses.

By refusing to reimburse for services provided by the family nurse practitioner, Medicare is in effect telling Medicare beneficiaries that the insurance they have paid for is not valid at the only source of medical care available to them within 60 miles. The irony is even greater when it is realized that the cost of care is significantly less at the center than it is in Albuquerque-thus Medicare is seen to be driving up its own costs by not reimbursing nurse practitioners.

Torrance County, like other rural counties in New Mexico, has a large number of older persons. These older persons have stayed in their home towns while their children have moved to the cities. Yet we see Medicare denying coverage to these senior citizens where the care is most readily available.

Another irony about this situation must be mentioned. On one hand we have the Federal Government encouraging the development of new types of physician extender manpower and funding the training of such personnel-I've already mentioned the $750.000 University of New Mexico Medical School grant-but then, on the other hand, we have the Federal Government refusing to reimburse for their services.

RURAL HEALTH CARE FINANCIALLY RISKY

Providing health care in a rural area is a risky financial venture because of the sparse population density. There is not enough money in rural areas to support a physician at the salary level which they demand. Our experience has been that the total cost of a family nurse practitioner clinic is about $35,000 per year, and we feel that a clinic with this modest budget can become self-sufficient in a rural area without Federal subsidy. However, such clinics cannot hope to break even without receiving reimbursement which would go to other providers for similar services.

Both the clinic as well as the older residents of rural areas are being starved out of existence. Seventy percent of the patients pay the fees out-of-pocket and have no health insurance for outpatient care.

It is incumbent on Congress to move strongly in the direction of amending the Medicare laws so that physician extenders of all categories can be reimbursed. As an interim step, it is our understanding that the Social Security Amendments of 1972, section 222, title II, provided for a demonstration program of reimbursement under Medicare for services provided by nurse practitioners and physician assistants. This section has yet to be implemented, although we have heard that steps are now being taken to bring it about. We would like to participate in such a program of experimental reimbursement and, in fact, have been seeking such a solution for several years.

Senator DOMENICI. Would you say physicians assume the full responsibility?

Mr. JENSEN. Yes, they assume the legal and ethical responsibility; so she is totally backed up.

I believe that our organizational design meets both requirements stated in section 222, title II, of the Social Security Amendments of 1972, which are:

(1) The family nurse practitioner is legally authorized to perform in New Mexico.

(2) Physicians assume full legal and ethical responsibility for the necessity, propriety, and quality of care rendered by the nurse practitioner at the clinic.

Any assistance which this committee could provide would be greatly appreciated and should be directed to: Office of Research and Statistics, Social Security Administration, Washington, D.C. 20009.

I am enclosing a packet of materials for your files about our Hope medical project: 1

(1) Copy of the AMA publication, PRISM, article of October 1973, describes the operations and organization of the Hope Medical Center.

(2) Copy of the Albuquerque Tribune article of March 6, 1974. (3) Copy of a physician contract to supervise the family nurse prac titioner and to assume professional liability for her activities.

(4) Copy of a letter from the group insurer of professional liability in New Mexico regarding physician involvement at Hope.

(5) Copy of Hope Medical Center stationery, which shows the professional organization of the center.

In addition to these data, we prepare monthly financial statementsbalance sheet and earnings statement-which would be available to you upon request. Accounting is done on an accrual basis. Our direct patient expenses average about $2,500 per month. Average patient revenue is $2,200. Obviously we are extremely close to the breakeven point, and with the ability to serve Medicare patients and collect from Medicare, we could operate at better than breakeven.

Again any help that you could give us in having Hope Medical Center and our two new family nurse practitioner clinic sites of Tijeras Canyon and Pecos selected as sites for experimental direct Medicare reimbursement would be of great help.

In summary, if the needs of rural health care are to be effectively met, especially the needs of elderly rural residents, then it is incumbent that Congress continue to support the development of physician. extender roles, and that Congress amend the Social Security laws to allow Medicare reimbursement for such extender roles. I might add that some of the present congressional concern with national health insurance should be directed to seeing that physician extender roles are included and reimbursed under the NHI law whenever it is forthcoming and whatever form it takes. Thank you.

Senator DOMENICI. In terms of the operating statement of the Hope Medical Center, would it not be your observation, because of the failure of Medicare to pick up senior citizens expenses, that perhaps the senior citizens would otherwise use that facility who are going somewhere else?

1 See appendix 2, item 4 p. 1140.

2 Retained in committee files.