Education, and Welfare is authorized to conduct experiments and demonstration projects with the use of certain institutional and homemaker services as substitutes for the more costly skilled nursing and home health benefits covered under Medicare. However, even in the case of the experiment provision the benefits would be limited. One example of an experiment which might be conducted under this provision could involve Medicare payments for the services of homemakers for a short period of an individual who does not require institutional services upon discharge from a hospital but is unable to maintain himself at home without assistance. The purpose of this particular experiment would be to determine whether such coverage would lower the use of more costly, covered, institutional care. The primary responsibility for developing the experiment program rests with the Health Resources Administration. A Request for Proposal (RFP) has been issued for the development of an experimental design for the conduct of a nationwide research study which, once implemented, will produce data and information necessary for recommending alternative Medicare reimbursement methods. Mr. TIERNEY. Senator, it is, I guess, a very good example of a difficult situation that we have been talking about here all morning. I am sorry I did not hear everything you read about the double amputee with diabetes. They feel they have to keep urging her to watch her diet and to take care of herself. Now, that is obviously a very needed thing, but if you want to read the law very technically, and the regulation very technically, you do not need a skilled person to do that urging, and this in itself is not in a sense a skilled service. It is urging a very unfortunate person to follow some procedures. When you say to me, "Should not that be paid for?" maybe it should, but it does take a broader definition, I think, Senator, than we construe the law to permit. Senator PERCY. I have a number of illustrations in my letter, and I will very much look forward to your reply. I very much appreciate your being here. Senator MUSKIE. Our next witness this morning is Dr. Jeoffry, Mr. Tierney. We have two more witnesses, and I regret to say that I have an appointment at 1 o'clock with the Secretary of the Treasury that I have to keep, and I know from the testimony, that these two doctors who are scheduled to testify have some important points to make, so I would appreciate it if you would undertake to make sure that those high-priority points are made in this next half hour. I do want to thank our past witnesses this morning. Senator MUSKIE. Our next witness this morning is Dr. Jeoffry Gordon of the American Public Health Association. Dr. GORDON. Thank you, Mr. Chairman. Senator MUSKIE. I see you have a prepared statement, and if you would, I would appreciate your making the best of your time. Your prepared statement will be included in the record.1 I regret that the rest of my afternoon will be devoted to business on the Senate floor, and I cannot possibly come back, so let us see how we can best use this time. 1 See p. 1433. STATEMENT OF DR. JEOFFRY GORDON, SAN DIEGO CALIF., Dr. GORDON. I would like to respond to Senator Percy's comments at the beginning, by saying my work is generally with young people, adolescents, and I am here representing the American Public Health Association and the Visiting Nurse Association of San Diego County, and that I find myself involved with this because I have a great deal of difficulty in working with the "now" generation, because of their definite, what I believe to be egotistical, rejection of their parents. I think the people would rather take a vacation than devote the energy to taking care of their parents. I think it is an attitudinal problem, and certainly legislation will not change that. I would like to make a few points that came up, and ask that my full statement, and the resolution of the American Public Health Association be inserted in the record.1 Senator MUSKIE. It will be, of course. Dr. GORDON. Thank you. Let me just say a couple of things. One is that with regard to fiscal intermediaries, this does not apply when you ask for prior authorization for services. The State health departinent in California will authorize these, but at the bottom of the authorization, it says that this authorization for care may be subsequently denied by the intermediary according to their guidelines. So even after you pass one hurdle, determining that there is needed skilled care, they can retrospectively take the money away from you after the care is provided. That is a problem. Second, I think our Visiting Nurse Association can say that it has been having difficulty in getting money out of Baltimore, and that the reimbursements have been falling 6 months behind. We had a cash flow problem-we had to borrow $40,000 to meet our payroll because we were not getting the money due to us out of Baltimore. So, there are problems from both ends. I think working with Social Security is much more understanding than the elusiveness of the intermediaries formed by the private insurance agencies. PROBLEMS OF FUEL CRISIS I would like to call your attention to something in my statement having to do with the recent fuel crisis. The American Public Health Association conducted a study, and it pointed out that 80 percent of those surveyed showed they had tremendous problems with fuel allocation during that time. This goes back to the question of rural health care. Our county is mostly rural. Our nursing staff drives 50,000 miles per month; it makes our overhead a little high. You ought to try doing that when gasoline stations are closed-because the nurses use their own cars-and we have no bulk allocation. There was a lot of trouble serving rural health needs during that time. I draw your attention to the fact that the fuel office made no determination, except for emergency care, that money should be delegated to health services. That was a tremendous burden at that time, and in some ways, continues to be a burden. 1 See pp. 1433, 1437. I think that the spinoff from some of the discussion you have had about skilled nursing services is that it is relatively easy to make a definition of emergency, such as threatening to end life, or to lead to permanent pain and disability. That is a bureaucratic determination. But as a practicing physician, you make a different kind of determination, for example, that if there is a 20-percent probability an emergency could exist. I think a lot of the custodial and maintenance care that is not allowed to be reimbursed, is in that order of magnitude. If a skilled person versus the patient reviews the status of that patient, the vital signs, and does not treat him per se, that observation may be crucial in avoiding emergencies, and maintaining the patient. Yet under all of the limitations of guidelines, and so forth, it is virtually impossible to persuade an intermediary that that kind of preventive emergency care is appropriate and reimbursable. Senator MUSKIE. We did not, in this morning's discussion, go to preventable care. Dr. GORDON. It is not prevention of disease. It is prevention of deterioration. We can prevent a lot of deterioration with goodness and care that would not come within the realms of skill. Again, I am surprised in your discussions that your level of specificity was not always at the level that Senator Percy read from his letter. Skilled nursing care was a big controversy back home. If a person is not able to maintain bowel control, not only is it discomforting, but it is not considered reimbursable to maintain the patient in his own home and send in a person to relieve the fecal impactions. As I said, monitoring to prevent emergencies is not skilled nursing. Mr. Tierney brought up insulin syringes. I do not know who will do it if the person has trouble getting homemaker services because they are not reimbursable. Someone has got to do it. That is our big problem. Finally, I would like to go back to the whole concept of the practicing physician, in the statement of the American Medical Association, which is very good, but in my experience. it is quite to the contrary. There is a lot of frustration. I would like to call your attention to the legislation of S. 3286 for national health insurance, for instance, in title 20, section D, which requires a physician-authorized certification and treatment be established before reimbursable services are provided. This section goes on to talk about physician overutilization and the provision of mechanisms in dealing with overutilization. This mechanism is also in the current legislation. However, it is my impression that this kind of physician control really encourages underutilization. It is my observation that the physician never has time to do everything. The nurse can initiate the cure and then call the physician for a treatment care plan, but the nurse is discouraged from doing this because it is not a reimbursable service. I would strongly recommend that this inappropriate underutilization can be overcome by changing the language of the proposed legislation to provide that the treatment plan be submitted by the second patient visit, rather than by the first visit. This change would allow one cushion visit on the nurse's knowledge. I have a lot of bones of contention with the medical profession because they do not make house calls very much. As part of a team, the nurse could make the house calls. HOMEMAKER EVALUATES SITUATION In San Diego, we have garnered a lot of revenue-sharing money to make homemaker services available, which generally is nonreimbursable under health insurance legislation. We found that the homemaker goes in and tidies up, and many of them make referrals for nursing care and physician care that would not otherwise be made. Through this mechanism, we find there are large numbers of patients who have needed skilled nursing care but who were not getting it because they are under the aegis of a physician. I think this is a major problem. We have gone through great lengths to try to work with physicians in our community, and I do not know how far to go in my public testimony, but our local medical society has a hospital-based pathologist as a part of this home nursing care committee. On the other hand, our association has currently placed nine nurses in various community hospitals to do discharge planning under contract, and through that mechanism, we have provided coordinated care. We are also trying to educate the physician, although it is an uphill job. So I would like to call these things to your attention. Finally, with regard to title 2 of the legislation, long-term care service program Senator MUSKIE. You are talking about the Kennedy-Mills plan? Dr. GORDON. Yes, I think that is very exciting, and I think your discussion about making these definitions is the crucial point. I think this committee can make some important decision about how much of this should come under health insurance, and how much under other Social Security or social programs. I am very familiar with the Older Americans Act of 1965, as amended, because it is very active in our community. I think some of these strategies can be financed under that mechanism, and therefore, the incredible inflation and the health care field will not be added to by trying to tag everything with Medicare and Medicaid. May I suggest that at the same time treatment strategies or maintenance strategies are tried under other legislation-I cannot say strongly enough on behalf of the association-that the underutilized home health services really have to be revised as well. PSRO LEGISLATION NEEDS EXPANDING We think that the 100-visit-a-year limitation is inappropriate. Most people use quite a bit less than that. We think 200 is inappropriate. We think it should be open ended in conjuction with utilization review. In addition, we believe that utilization review should not be conducted by the physician solely. The sensitivity of the care in the home is provided by the social workers and public health nurses who go into the home. So we think PSRO legislation ought to be expanded to include other than physician input, because it is just in this area that there is a terrible lack. That is why I do not belong to the medical society. That is a quick summary. Senator MUSKIE. Thank you very much. It would be useful if you would care to submit additional testimony concerning this whole question of finding another category of health-related home services that is quite specific in terms of definition. Dr. GORDON. I would like to make one point in that regard. The association is working on trying to define preventive services that might exist under health insurance. I would call to your attention that the insurance model is totally inappropriate for health maintenance, insofar as it involves risks that are unpredictable and out of the control of the persons so insured. Most maintenance and preventive strategy is within the control of the person. There is no risk involved, and it is not appropriate to put it under the insurance model. If payment is going to be done, it is best that it be done by provider mechanisms rather than patient disincentive. I think in this whole area, it cannot be solved solely through fiscal incentive in the insurance mechanism. That is why I think we are looking forward to a broader concept. Senator MUSKIE. That would not exclude the possibility of liberalizing the insurance program? Dr. GORDON. No, but I would like to take it out of the insurance model. The statement is that we do not want to restrict it to skilled services, because the definition of "skilled" is in error, but that we want to provide home health services to the extent they are necessary to support the well-being of our senior citizens. That is not an insurance statement. That is a statement of health care as a right, and that is a different statement than the kind of statements I heard this morning from these people who work for the Government. They want to save money. They aren't interested in maintaining the health of the people. It is expensive to maintain the health of the people, especially when a lot of providers take advantage of the system. But it should be public policy that we are here to protect the health of the people, and that is not an insurance statement. That is a statement of public policy, and the distinction is not made often. Senator MUSKIE. Should that kind of statement be included in the law? Dr. GORDON. If you can get certain segments of professional groups to approve it, yes. The American Public Health Association strongly stands behind that kind of statement. Senator MUSKIE. Thank you very much, Dr. Gordon. I apologize again for the shrinkage of time. Dr. GORDON. It is a pleasure. Senator MUSKIE. If there is anything you would like to submit along this line, we would appreciate it. Dr. GORDON. Thank you, Mr. Chairman. [The prepared statement of Dr. Gordon follows:] PREPARED STATEMENT OF DR. JEOFFRY B. GORDON Mr. Chairman and members of the committee, my name is Jeoffry Gordon. I am a physician and work as clinical coordinator of the Beach Area Community Clinic (a young people's free clinic) in San Diego, Calif., where I am also president of San Diego's Visiting Nurse Association. I am appearing before you today representing the American Public Health Association where I am a member of the association's action board. APHA's 50,000 regular and affiliate members 46-547 - 75 - 4 |