Senator MUSKIE. Our next witness is Thomas M. Tierney, Director of the Bureau of Health Insurance, Social Security Administration. Mr. TIERNEY. Thank you, Mr. Chairman. Senator MUSKIE. I would like to say with respect to Mr. Tierney, that he is testifying before the subcommittee for the third time in about a year, and he has been a most forthcoming witness, and we are delighted to have him back today. We are particularly appreciative of his patience, his understanding, as well as his insight into Medicare and its problems. Although we on the subcommitte may occasionally disagree with the positions he takes as a representative of the administration, we find our exchanges to be fruitful, and we know that his participation this morning will be no different. By the way, for the record, I should like to note that we have already received a letter from Mr. Tierney indicating that he is taking steps to follow up on our hearing of 2 weeks ago, and without objection, I include his letter as a part of this record. [The letter referred to follows:] DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE, Hon. EDMUND S. MUSKIE, DEAR SENATOR MUSKIE: Enclosed for your information is a copy of a letter which I sent today to Mr. Raymond W. Daum, director of finance, Abbott-Northwestern Hospital. In accordance with your request, I will keep you fully advised with regard to the results of our further investigation. Sincerely yours, THOMAS M. TIERNEY, Director, Bureau of Health Insurance. [Enclosure] DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE, Mr. RAYMOND W. DAUM, Director of Finance, Abbott-Northwestern Hospital, DEAR MR. DAUM: At the close of the hearing held by the Subcommittee on Health of the Elderly on June 26, 1974, I assured the chairman, Senator Muskie, that the Bureau of Health Insurance would see to it that Medicare reimbursement regulations are being fully complied with in the review of claims submitted in behalf of associates of the Minneapolis Age and Opportunity Center, Incorporated, and Abbott-Northwestern Hospital. As a first step in filling that commitment, I have directed that a team of qualified personnel from here in the central office go to Minnesota on Monday, July 1, to undertake a full review of all of the claims submitted to date. In addition, I have asked our Regional Representative from Chicago, Mr. Robert Green, to arrange a time to meet with you and the appropriate other persons involved in your effort at a time which you find convenient to discuss not only past procedures but, perhaps even more importantly, to develop a full and joint understanding for the future. The hearings which Senator Muskie conducted were certainly most helpful in calling attention to the benefit limitations prescribed in the Medicare law as well as the appropriate interpretation of those limitations in actual practice. Some of the language employed in the various communications to date has been unfortu nate and perhaps misinterpreted. I want to assure you, as I did the chairman, of our continuous interest and efforts to eliminate any such misinterpretation. Mr. Green will be in touch with you within the next few days. If you or your associates feel that I can be helpful in any way as your discussion progresses, please let me know. Sincerely yours, THOMAS M. TIERNEY, Director, Bureau of Health Insurance. Senator MUSKIE. I understand you have a brief statement, Mr. Tierney, which we would be happy to receive. STATEMENT OF THOMAS M. TIERNEY, DIRECTOR, BUREAU OF HEALTH INSURANCE, SOCIAL SECURITY ADMINISTRATION; ACCOMPANIED BY DR. M. KEITH WEIKEL, COMMISSIONER; LUCILLE REIFMAN, ASSOCIATE COMMISSIONER, MEDICAL SERVICES ADMINISTRATION, SOCIAL AND REHABILITATION SERVICE: AND DR. CLAIRE F. RYDER, CHIEF, AMBULATORY AND HOME HEALTH SERVICES SECTION, HEALTH RESOURCES ADMINISTRATION Mr. TIERNEY. Thank you very much, Mr. Chairman, I have a brief statement. Mr. Chairman, this statement incorporates the Department's position on the GAO Draft Report on "Development of the Medicare and Medicaid home health care programs," which was forwarded to the committee on June 11, in response to your request. We concur in the recommendations of the report which we believe presents a generally fair and objective appraisal of Medicare and Medicaid coverage in the home health care area. It discusses, in appropriate perspective, both administrative problems and accomplishments in effectuating the home health care benefit within the statutory limitations under which we have to operate. A number of measures have been taken or are in process to implement GAO's recommendations; these are summarized below. Among the Department's fiscal year 1975 management objectives is an interagency objective which will include the development of a policy paper defining the near- and long-term strategic goals of the Department with respect to home health care as an alternative to institutional care. In addition to the Social Security Administration, the Social and Rehabilitation Service, the Office of the Assistant Secretary for Health, and the Office of the Assistant Secretary for Planning and Evaluation, will participate in the objective. Earlier this year, SSA established a Home Health Coordinating Committee in the Bureau of Health Insurance to make a full-scale review of the home health provision under Medicare. As part of the review, they will be soliciting input from all major organizations interested in home health care as well as from the home health agencies presently participating in the Medicare program. In short, the Bureau of Health Insurance intends to broadly reassess the statutory and administrative dimensions of this area of coverage to make sure that its policies and Medicare procedures are as supportive of home health care as the law permits. The following recommendations of the GAO Draft Report relate specifically to the Medicare program. Recommendation: That SSA increase its effort to assure more effective and uniform interpretation of existing instructions to intermediaries and home health agencies regarding the various coverage requirements for home health services. We concur. The Home Health Services Coordinating Committee will review all substantive and procedural issuances relating to home health services for areas of potential clarification or further emphasis and will identify, through reviews of adjudicative results, those intermediaries and home health agencies who appear to need additional training in the coverage requirements of the home health benefit. Recommendation: That SSA review screening guidelines used by intermediaries and, where significant differences exist in service limitations, explore the possibility of requiring intermediaries to apply more uniform screening guidelines. We concur. The committee will review the screens or parameters now used by the intermediaries and will determine whether they are consistent with program guidelines and with the characteristics of medical practice in the various intermediary services areas. Where they are found to be out of line. SSA will take appropriate steps to have them corrected. Recommendation: That SSA explore the possibility of further clarifying program benefits, especially the limits on the duration of benefits in an effort to reduce confusion on the part of beneficiaries. We concur. SSA will expand the explanation of home health benefits in the forthcoming revision of "Your Medicare Handbook" which we plan to send to each Medicare beneficiary in August or September of this year. At the same time, SSA will review all other informational issuances and will expand or clarify them where needed. Also, the Home Health Services Coordinating Committee will make a special study to determine the need for additional communication vehicles to better reach beneficiaries and other groups within the general and professional public who act in an advisory of assistive capacity to beneficiaries. Recommendation: That SSA encourage and, where considered feasible, assist home health agencies in their efforts to increase the medical profession's awareness and support of the home health care program. We concur. The committee will explore the extent to which this kind of assistance can be rendered by the Medicare program. The degree to which this effort would be legitimate on Medicare's part will have to be studied since it is SSA's strong conviction, first, that home health agencies themselves must work toward achieving professional community acceptance and. second, that efforts undertaken by SSA or the Medicare program on the agencies' behalf could be counterproductive to this acceptance. Recommendation: That SSA establish regulations, as authorized by the advance approval provision of the Social Security Amendments of 1972, to specify limited coverage periods, according to medical condition, during which a patient would be presumed to require a covered level of posthospital home health care services. We concur. As a matter of fact, SSA expects that these regulations will be ready for issuance under the Notice of Proposed Rulemaking Procedures in the very near future. Recommendation: That SSA determine whether implementation of the advance approval and waiver of liability provisions is effective in minimizing the problem of denials, and, if necessary, advise the Congress that the amendments need modification to correct the problem. We concur. The Home Health Services Coordinating Committee will, after the amendments have been in operation for a period of time, make an analysis of the effectiveness of the advance approval and waiver of liability provisions. Depending on the outcome, SSA will take whatever followup steps may be appropriate. The following recommendation and comments relate specifically to the Medicaid program. Recommendation: That SRS impress upon the States that the home health care program generally is a less expensive alternative to institutional care and, because of this, it is intended to be used as such when home health care would meet the patient's needs and reduce program costs. We concur. The Social Security Amendments of 1972 tighten requirements for the admission of patients to skilled nursing facilities and, as a result, the demand for home health services should increase as more careful appraisals are made of alternatives to both skilled nursing and intermediate care facility services. SRS will emphasize to the States the importance of careful appraisals of alternatives to institutional care, and the use of home health care whenever indicated. Recommendation: That SRS clarify for the States the specific home health services which are eligible for Federal financial participation and define these services for the States. We concur. SRS plans, in revising Medicaid home health regulations, to include more definitive requirements that will aid in assuring uniformity and preventing misinterpretation. Recommendation: That SRS clarify for the States the fact that their payment rates for home health care should be established at a level that will encourage utilization of the home health care program. We concur. While we do not have the authority to require States to adopt a certain level of payment for home health care, SRS will emphasize to them the importance of realistic payment rates as a means of encouraging more frequent use of home health care services. Recommendation: That SRS encourage and assist home health agencies in their efforts to increase the medical profession's awareness and support of the Medicaid home health care program as an alternative to institutional care. We concur. In responding above to GAO's first recommendation relating to Medicaid, we mentioned the Social Security Amendments of 1972. These amendments also require that, in prescribing institutional care, the physician must certify that this represents the best means of treatment for his patient. SRS believes that physicians, in making these certifications, will have to become more and more aware of, and knowledgeable about, the home health services that are available. In addition, the Health Maintenance Organization Act of 1973 requires participating HMO's to make home health service available to their members. So that, here again, physicians should become increasingly aware of the benefits of home health care. While we believe that the implementation of these legislative provisions should lead to significant improvement in physician awareness and support of home health care, SRS will look for steps that it could take to further encourage such support. LACK OF UNDERSTANDING IN MEDICAL PROFESSION Mr. Chairman, there is a point that you brought up in your questioning, and I would just like to clarify it, if I may. We feel very strongly, and I think Mr. Ahart maybe felt to some extent, that one of the real problems, in increasing utilization of home health services in this country for a long time has been the lack of the medical profession's understanding or acceptance of the concept of this being a good way to take care of people. Often, Mr. Chairman, when Government proceeds on a sales effort, if you will, or if it be regarded as mandating the use of a service, it is always looked upon as an effort to cut costs, or in some way to cut down or change the patterns of practice, and such an effort could be quite counterproductive from that point of view. That is the only reason I do not want you to have the impression, we think that we have no responsibilities in this area. We want to make sure we do it in a way that will answer what we think is a very basic problem, and that is getting the doctors of the Nation to say yes, this is a good way to get treatment. I really think they have not said that yet. Senator MUSKIE. On that point, if I may interrupt, if this is a good approach to health care needs, are you saying that the medical profession is not making an organized effort through the AMA, or through whatever association, to form a judgment on this approach, of what needs to be done, to make it more universally applicable and used? In other words, have they accepted any professional responsibility for making this a more viable adjunct to health care? Mr. TIERNEY. I think I have seen statements of the AMA encouraging the development of more sophisticated, and I do not mean to put words in their mouth, but more totally reliable home health services, and encouraging doctors to utilize them. That is quite different, Mr. Chairman, from 200,000 doctors across the Nation, who have had little experience with it, never used it, and had frankly looked at it in the old days as kind of a service for the poor. It is a real job to get them to realize that this is a viable, reliable, and good way to take care of people. That is something that the home health agencies have as a continuing and ongoing problem of selling. Senator MUSKIE. Are there examples of local medical groups, State medical groups that are undertaking, organizing positive programs to develop this kind of a program? Mr. TIERNEY. Do you mean of doctors? Mr. TIERNEY. I am not aware of any. Dr. RYDER. I would like to indicate, Mr. Chairman, that I am involved particularly in this area of concern for home health services, and I think, Mr. Miller will remember back years ago that the American Medical Association has taken a positive stand for home health |