APPENDIX I 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 follow-up steps may be appropriate. MEDICAID The following recommendations and comments relate specifically to the Recommendation: That SRS impress upon the States that the home health care program generally is a less expensive 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 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 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 APPENDIX I awareness and support of the Medicaid home health 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. APPENDIX 2 LETTERS AND STATEMENTS FROM INDIVIDUALS AND ORGANIZATIONS ITEM 1. LETTER FROM JEOFFRY GORDON,1 M.D., M.P.H., AMERICAN PUBLIC HEALTH ASSOCIATION; TO SENATOR EDMUND S. MUSKIE, DATED AUGUST 1, 1974 DEAR SENATOR MUSKIE: In fulfillment of the request by you and your staff, the following are some additional thoughts concerning home health care. Let me iterate, on behalf of APHA, our encouragement for the excellent and valuable work you and your subcommittee are doing in this important area. I want to take this opportunity to emphasize again the restrictive nature of current Medicare and Medicaid legislation and regulations regarding reimbursement to patients for home health services. The current philosophy, especially in Medicaid, supports only those services for patients who have rehabilitative potential. This omits reimbursement for services to many patients who, while not rehabilitatible, need the services in order to avoid institutionalization, to give them support during terminal illness, or to maintan a level of disability which continues to allow independent living. Services of this nature may be more difficult to justify on a technical review according to the needs of the patient but are, nevertheless, an important component of health services for the disabled and the elderly. If the concept was to create a health care system which provided health services of an appropriate and effective nature, then it is very appropriate that the full spectrum of home health services be made available according to the health needs of the patient without other artificial restrictions, and they should be fully reimbursable. In regard to realistic controls, the continuing requirements for coordinated patient care plans, the dialogue between the physicians and other providers of home health services, as well as the development of further utilization review activities such as professional standards review organizations, should be sufficient to prevent inappropriate utilization. Also, the limitation of the number of home health care visits to 100 per year is, in this context, also arbitrary, and even if it were extended to 200 visits per year on the basis of physical necessity, it is difficult to accept that it would be better to return a patient in excess of 200 visits to an institution rather than to continue less costs home care. A good example of a circumstance where this might occur involves cases of terminal illness where maintenance in the home is possible with home health services but, should they be discontinued, the patient would either deteriorate and thus require rehospitalization or would have to be transferred to a nursing home. Thus, home health services represent a more fiscally responsible approach to delivering care to the chronically ill, whether or not they are rehabilitatible. I would also like to expand upon my thoughts regarding the relationship of physicians to utilization of home health services. It is certainly appropriate for the quality care of the patient, as well as for the coordination of the many medical services available, for home health services to be under the control of physician authorization. However, I would argue that authorization prior to the first visit necessarily promotes appropriate utilization. Visiting nurses or other home health personnel often uncover basic medical needs in patients who are not currently under the supervision of a physician, and there should be latitude to allow an evaluating nurse to make decisions regarding the need for home health services in order to quicken and facilitate the initiation of reimbursable home care. This kind of outreach supplements the supply of physicians in reach 1 See statement, p. 1430. ing larger numbers of people and, in addition, may assist in reaching many patients whose physicians are unaware of the benefits of home health services. It is fully appropriate, then, that this first visit be made reimbursable without a physician's prior authorization. Within this context, it has been much to my surprise, and chagrin, to find, within the medical community, a great lack of knowledge as to the skills and competency of not only nurses but physical, respiratory, and occupational therapists, social workers and homemakers in providing support services for both the rehabilitation and general care of people with chronic illness. Physicians, I think, suffer as a result of the fact that they are generally trained in schools separate from other health professions and do not learn to work as part of a health care team. Rather, their hospital training often engenders the view that the rest of the health care staff is inferior, and are there to carry out the physician's orders rather than being a part of a coordinated team for patient care. Thus, when the physician goes into his own practice, his habits are already well ingrained and, in most cases, the skills of the other members of the health team are markedly underutilized. Many well-intentioned physicians attempt to assume the additional responsibility by themselves for managing family support problems for their patients. In reality, they often have neither the time nor the additional energy (after taking care of all their other patients) to devote the necessary attention to the family's total needs. In addition, as the technical basis for scientific practice for medicine expands, physicians have to devote much more energy to the complicated therapeutic techniques, leaving them even less time to spend caring for the human needs and the support in the home that patients require, especially when it involves maintenance of the chronically ill. Finally, it has become our model of medical education, and practice, that physician home visits are markedly decreasing. This, of course, has increased the efficiency, in many ways of private physicians and those in group practice, but has left large gaps in terms of many needed services, particularly to the homebound chronically ill patient. In my experiences as a physician, good medical care always involves a sensitivity to the family situation of the sick person. This is true whether the person lives in a wealthy family or poor family. Thus, consideration of the whole environment is one of the major components of quality medical care. For the reasons I have mentioned, physicians do not often have the opportunity to become involved to the extent that perhaps was once possible in family medicine in the home. I think it is, therefore, very appropriate for organizations such as the visiting nurse associations and the public health nurse components of various hospitals and public health departments to make their contribution to the health care team by making these home visits, evaluating the patient and the home environment, and helping physicians to design care plans. These activities are of great significance, especially in the care of the elderly and with the chronically diseased and disabled. Thus, it is my opinion that, while the overall care of the patient must continue to remain under physician supervision and coordination, it is important for regulations to be developed pursuant to national health insurance and other long term care proposals, as well as home nursing regulations, that give more discretion and weight to the opinions of trained public health and visiting nurses and other home health personnel in influencing the care plan for this category of patient. It certainly would be of high priority and of great import to educate physicians to use home health services more effectively. However, it is difficult to conceive of how to do this. The American Medical Association has a very strong and admirable policy with regard to home health services, yet it is difficult to implement that policy in terms of influencing the actual behavior of either local medical societies or individual physicians in their practice. I think the most effective means of having impact would be by influencing the type of education given to physicians, both in medical school and in their hospital training, through a more team-oriented approach and to raise the stature of the other health professionals, especially those within the nursing profession, in regard to the provision of coordinated patient care. Another aspect of physicians' involvement in home health care has to be the consideration of their activities with regard to Professional Standards Review Organizations and health maintenance organizations. Certainly PSRO's will have an important impact on the quality and cost of medical care. However, it is the concern of the American Public Health Association that, if the local PSRO committees are maintained under the sole influence of physicians, their |