lack of sensitivity to the patient in the home and to the supportive benefits of home health services will seriously affect the delivery of these services. Thus, it is very important to have both consumers and other health professionals as an integral part of the standards setting and review mechanisms of PSRO's. Health maintenance organizations have the potential, by virtue of their more organized, continuous system of care, and their larger pool of available manpower, to substitute the less expensive home health services for institutionalization for chronic disease and other disability. Also, within the HMO context, the incentive is not solely to use home health services but, because of prospective reimbursement, to save money!

With regard to the long term care services program in the Kennedy-Mills bill, it is encouraging to see the enumeration of the various home health services which would be covered by this proposal. These services should certainly all be available under some public program of one sort or another. However, I think that it is important that, in addition to home nursing care, physical and occupational therapy and other services such as health education, nutrition, and homemaking should be made available and reimbursable under a home health package. Intermediate care and long term nursing home care are, of course, important, but should be viewed as a second order of priority and considered as an alternative to home health care rather than vice versa. Finally, day care and foster home care, as well as social work services and food programs such as "Meals-on-Wheels," can be most beneficial to certain classes of elderly and homebound, but perhaps they should be funded through other financing mechanisms. When we are asked to define which services should be covered under home health care, it might be preferable to turn that around and specifically define which services should not be covered. We believe this would provide more latitude to the provider in effectively planning and implementing a course of treatment and being sure that those needed services will be covered.

Finally, I would like to make a statement with regard to the role of fiscal intermediaries and their control of health services. I think that, in the general context of this discussion, it is very important to separate out, and to make independent of each other, considerations regarding cost containment and considerations of quality of care. Fiscal intermediaries, almost unanimously, in my experiences both as the president of a visiting nurse association and as the former director of the University Hospital outpatient department in San Diego, have been overly conservative and restrictive in their interpretation of the needs of patients, especially where long term care is concerned. It is apparent, from their behavior, that the considerations of cost containment far outweigh considerations of the necessity of care, even when these determinations are made by physicians. Little attention is paid to the needs of the chronically ill, and rather than seeking means of providing services in the least expensive but highly responsive way, such as with home care, they prefer to reject the claim outright. The insurance mentality is somewhat parallel to that of the gambler who plays the odds. Unfortunately, chronic illness is not compatible with this philosophy, for there is no gamble involved: the care for the chronically ill must be covered. Thus, it is important that those who are charged with determining quality of care should not work for fiscal intermediaries. The delicate balance between cost considerations and those of quality can jeopardize consumer-oriented assessments in regard to care. Whether such review takes place within a PSRO or through some other mechanisms we would discourage the role of the carrier in that process.

If we can be of any additional assistance to you in your endeavors, please feel free to contact us.

Sincerely,

JEOFFRY GORDON, M.D., M.P.H.

ITEM 2. LETTER FROM R. BERNARD HOUSTON, DIRECTOR, DEPARTMENT OF SOCIAL SERVICES, STATE OF MICHIGAN; TO SENATOR EDMUND S. MUSKIE, DATED JUNE 28, 1974

DEAR SENATOR MUSKIE: Michigan is vitally concerned with barriers to health care for the elderly, especially with regard to alternatives for long-term institutional care. We are sending these comments to you as chairman of the Subcommittee on Health to the Elderly, and would appreciate having them entered into the record of your subcommittee hearing scheduled for July 9, 1974.

We feel that home health care is one viable alternative to institutional care, but certain financial factors must be considered. Our experience indicates that home health care is not necessarily a less expensive alternative to institutional care if continuous nursing attention is required. In providing home health services, the Visiting Nurse Association rates are currently $22.50 per nurse visit and $19.50 per day for supervision. This compares to the nursing home average rate of $19 per day, which is based on an even mix of patients receiving either skilled or basic care. These figures illustrate that a patient requiring daily attention may receive more care in an institutional setting and at less cost than he would receive in his own home.

Michigan also limits services under Medicaid to patients who require skilled nursing care. Reimbursement for supportive services which do not require skilled nursing supervision or participation-but which are necessary for the recovery of a home-bound patient-are provided, but under titles IV-A and VI rather than title XIX.

In order to provide a consistent strong commitment by the states on alternatives to institutional care, the Federal Government should either remove the ceiling on Federal funds designated for services programs or increase the title XIX Federal financial participation, as with family planning services. These actions would encourage approaches that enable patients in institutional settings to return home and still receive basic supportive services, such as homemaker services and supervision.

In the area of day care, Michigan supports the concept of day hospital programs and day treatment services as set forth in the policy statement issued by the Medical Services Administration of HEW. However, enabling Federal legislation or regulations are required to clarify whether such related non-medical services included in these programs would be covered under title XIX.

We appreciate the opportunity of providing input to the Subcommittee on Health of the Elderly and hope our comments have been useful. Sincerely,

R. BERNARD HOUSTON, Director.

ITEM 3. STATEMENT FROM THE COUNCIL OF HOME HEALTH AGENCIES AND COMMUNITY HEALTH SERVICES OF THE NATIONAL LEAGUE FOR NURSING

We commend the legislators for their efforts in studying the feasibility of developing a broad program of health legislation to effect modifications in the organization and methods of delivery of health services. Efforts must be made to increase the availability and continuity of care, enhance its quality, and emphasize the maintenance of health as well as the treatment of illness. By improving the efficiency and the utilization of services and strengthening professional and financial controls, the mounting cost of care will be controlled while providing fair and reasonable compensation to those who furnish it.

Home health care is an integral and essential part of a coordinated health care delivery system in the community. In any community these health services may be offered by a visiting nurse association, a health department, a home care unit of a hospital, a private agency or other health care facility.

The Council of Home Health Agencies and Community Health Services of the National League for Nursing is the national representative of over 1,400 of the 2,200 home health agencies certified for Medicare and Medicaid reimbursement. In this testimony, we propose certain changes in the home health portions of the "Comprehensive National Health Insurance Act of 1974" designed to eliminate existing legislative barriers to appropriate health services to all Americans. We submit the following recommendations for changes in S. 3286:

Part A, Scope of Benefits Section 2011(b) (2). This section refers to limitation of 100 visits per year for home health services. We recommend the limitation be deleted.

Rationale: There are many other provisions built into the law to prohibit abuse, i.e., eligibility criteria such as: "intermittent nursing, physical therapy or speech therapy, etc.," "PSRO review services," "physician certification ... accompanied by supporting material . . . as may be provided by regulations." We strongly urge that covered services be determined by the patient's needs rather than limited by an arbitrary number.

Part D, Administration of Program Section 2041 (a) (2) (D) (i). Change to read ". . . such services are or were required because the individual is or was confined to home or is ambulatory and can be most appropriately served in his own home ... and needs nursing care on an intermittent basis, or physical or speech therapy, or homemaker/home health aide services on an intermittent basis. The latter services to be rendered under the supervision of the appropriate professional staff member. . . ."

Rationale: Since ambulation may be an essential part of the medical care plan the use of the phrase "confined to home" as the sole basis of eligibility is in conflict with the intent of this proposed legislation as stated in Section 2002 "... Neither the Board of the Social Security Administration, nor any of its agents, shall make medical judgments with respect to a patient's health care; this function is reserved solely to the physician and his peers. . . ."

Furthermore, in recognition of the homemaker/home health aide as a generalist in personal care, this service should be added to any health insurance package as an extension to professional health services. These services enhance the appropriate utilization of the professional, thereby promoting cost effective

measures.

Payment for Home Health Services Section 2041(f) (1) (A). Change to read "the certification and plan referred to in subsection (a) (2) (D) of this section are formulated and submitted in timely fashion following the first visit by such agency."

2041 (f) (1) (B). Delete.

2041 (f) (1) (C). Change to read "there is compliance with such other requirements and procedures as may be specified in regulations, taking into account the medical severity of such conditions, the degree of incapacity, and such other factors affecting the type of care to be provided as the Administration deems pertinent."

Rationale: The nature of home health care delivery is such that written certification prior to the first home visit is logistically impossible. Referrals for care most often come by telephone, always followed by written confirmation through U.S. postal system.

Change

Section 2042 (b)(1). Change to read "The Administration, after consultation with providers of services . . . third party payors for health care. . . "institutional" to health services wherever it appears in this section. Rationale: Third party payors are increasingly including home care in their benefit package. Home Health is a mandated benefit in HMO legislation. Therefore, any comprehensive piece of health legislation should promote this trend. Part E Miscellaneous Provisions Section 2051(k). Utilization Review-Change to read "a. . . facility or a home health agency... by the institution or agency ... if it provides :

(1) for the review of admissions to the institution or the agency, the duration of stays therein or care provided and the services (including drugs and biologicals) furnished (A) with respect to the medical necessity of the services, and (B) for the purpose of promoting the most efficient use of available health facilities and services;

(2) for such review to be made in the case of the institution, by either... the Administration. In the case of a home health agency, such review to be made by a committee representing both providers and consumers. The provider representation shall consist of a physician, a public health nurse, a social worker and a representative from each of the therapeutic services provided by the agency.

Home Health Services Section 2051 (m). Change to read "the term 'home health services' means . . . and in need of nursing care on an intermittent basis, or physical or speech therapy, or homemaker/home health aide services on an intermittent basis as such individual's home."

Rationale: The attachment of the label "skilled" to nursing has become a major barrier to the delivery of care under Medicare. The practice of nursing is an art, a science and a skill as is practice of medicine, physical therapy or ocupational therapy. The limitations placed on the definition of nursing care has resulted in great variance in interpretation of covered services. Greatly needed care has been withheld; patients, families, nurses and SSA/BHI personnel have suffered pain, frustration and expense without return to taxpayers.

Section 2051 (m) (4). Change to read "part-time or intermittent services of a homemaker/home health aide provided under the supervision of the appropriate professional staff member."

Rationale: Again, in recognition of the homemaker/home health aide as a generalist in personal care, this service should be added to any health insurance package as an extension to professional health services, which enhance the appropriate utilization of the professional, thereby promoting cost effective

measures.

Section 2051 (m) (6). Change to read "in the case of a home health agency which is affiliated or under common control or makes arrangements with a hospital . . . or such hospital; and"

Rationale: If these services are limited to hospital-based home health agencies, then such services are denied to patients under home health care provided by a nonhospital-based home health agency.

Home Health Agency Section 2051(n)(1). Change to read "is primarily engaged in providing nursing. services.

Rationale: delete "skilled" to conform to recommendations for change in 2051 (m).

Section 2053. Use of State Agencies to Determine Compliance by Providers of Services with Conditions of Participation.

(c) Change to read, "The Administration which are accredited by the Joint Commission on the Accreditation of Hospitals in the case of institutions; and home health agencies which have an agreement with the Administration under section 2043 and which are accredited under the National League for Nursing/American Public Health Association accreditation program."

Rationale: The National League for Nursing/American Public Health Association accreditation program meets the requirements as stated in Section 2054 (a). We have spoken to the home health care portions of S. 3286 at great length in an attempt to eliminate existing barriers to the delivery of home health services. We strongly believe that the concepts of continuity of care and health maintenance as well as treatment of illness must pervade the entire health care delivery system if a national health insurance plan is to fulfill its purpose. It is to this end that we submit these recommendations.

ITEM 4. EDITORIAL COMMENT BY WILLIAM REICHEL, M.D., ON DAY CARE PROGRAMS IN THE UNITED STATES; FROM THE AMERICAN GERIATRICS SOCIETY NEWSLETTER

Geriatric day care alternatives are beginning to appear in greater numbers in the United States. In 1973, the Administration on Aging and the Medical Services Administration funded four demonstration projects to study the cost effectiveness of day treatment settings as compared to the more traditional long-term institutional services. These projects included the Burke Day Hospital of White Plains, N.Y., the Levindale Day Treatment Center of Baltimore, Md., the On Lok Day Care Center of San Francisco, Calif., and Montefiore Day Care Center of New York City. The above centers and 11 others in the country, including those in Puerto Rico and Hawaii, vary considerably in size, setting, agency, sponsorship, and source of funding. All share similar goals, trying to provide either maintenance and/or rehabilitation for the chronically ill and disabled older person. The Burke program in White Plains is unique as a day hospital which is involved in providing direct medical care with physicians connected directly to the service as staff members. Day care centers do not include the same degree of medical service and stress social aspects of treatment and other health care supports from various levels of nursing personnel.

The British experience with day treatment alternatives demonstrates the feasibility of both long and short-term maintenance in the community. There, the concept of day hospital has been implemented within many sections of the country. In the United States, we have seen rather a growth of day care centers and it is probable that day hospitals will develop slowly in comparison to day

care.

The Levindale program in Baltimore has operated the longest of the four programs dating back to 1970. The Burke Day Hospital, established in 1973, is unique as an American day hospital. The editor of the Newsletter believes that we will see the growth of the day care movement throughout the Nation as more and more day care centers develop as alternatives to institutional care. Nursing homes or

other institutions should be prescribed specifically by the physician in the same manner in which digitalis and penicillin are prescribed. The American Geriatrics Society strongly supports the development of additional alternatives to institutional care for the elderly patients of this Nation.

ITEM 5. STATEMENT AND ENCLOSURES FROM THE NATIONAL COUNCIL FOR HOMEMAKER-HOME HEALTH AIDE SERVICES, INC.

INTRODUCTION

The National Council for Homemaker-Home Health Aide Services, Inc., a national, nonprofit 501(c)(3) membership organization, with offices at 67 Irving Place, New York, N.Y. 10003, is pleased to have this opportunity to present a statement on the long-term care section of S. 3286, because the decisions reached on this aspect of a national health insurance plan will have such far reaching implications for the constituency we represent for many years to come.

The National Council's goal is availability of quality homemaker-home health aide service in all sections of the Nation, for individuals and families in all economic brackets, when there are disruptions due to illness, disability, social and other problems, or where there is need of help to enhance the quality of daily life.

MEMBERSHIP

The National Council is a membership organization composed of 545 members of which 264 are agencies providing homemaker-home health aide service; 50 are organizations; and 231 are individuals. (1973 year-end figures.)

DEFINITION OF SERVICE

Homemaker-home health aid service helps families remain together in their own homes when a health and/or social problem occurs or return to their own homes after specialized care. The homemaker-home health aide carries out assigned tasks in the family's place of residence, working under the supervision of a professional person who also assesses the need for the service and implements the plan of care.

DEFINITION AND SUPPORTING STATEMENT ON HOME HEALTH SERVICES

We commend to you the definition and supporting statement on home health services, developed by units of and approved by the boards of four national organizations with direct provider agency members: The American Hospital Association, National Association of Home Health Agencies, National Council for Homemaker-Home Health Aide Services, Inc., and the National League for Nursing. The governing council of the American Public Health Association has also endorsed these concepts. A copy of this material is attached to the original of this statement.1

Homemaker-home health aide service is listed in this definition as one of an array of home health services. Frequently it is the cornerstone service which makes possible the delivery of other health services in the home. In other situations it may be the only service which is needed to help someone remain in his own home or return home from the hospital or other out-of-home care.

While we could testify about many aspects of the long term care section of S. 3286, it is from the vantage point of homemaker-home health aide service, a vitally important home health service, that the National Council primarily addresses this statement.

OVERALL VIEW OF CURRENT NATIONAL HEALTH INSURANCE BILLS

The current bills on national health insurance would perpetuate rather than reform the present health system and would greatly extend the present overutilization of costly in-patient care, especially hospital care, as compared with

1 See p. 1518.

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