Section 10 also provides for the use of a wage index based on general wage levels (including fringe benefit costs) in the areas in which the hospitals are located so as properly to adjust such component to the general wage level (including fringe benefit costs) prevailing in the respective areas. If, in a given area, the wage level for hospitals is significantly higher than the general wage level in such area, then the general wage level in such area shall be deemed to be equal to the wage level for hospitals in such area, but only during the first year. How this discrepancy will be dealt with the second year is not clear. The plight of the health care employee has only recently begun to be alleviated. These employees have been forced to accept the unilaterally determined substandard wage package for decades. With the advent of collective bargaining, many hospital employees have upgraded their salary and working conditions. Some hospitals have been more progressive in these areas than others. ANA would hope that the employees who have obtained greater economic and general welfare status would be protected from salary cut-backs (correlative to the general wage level in the area) past the first year. Section 11 creates a Hospital Transitional Allowance Board. Clarification is needed as to this Board's relationship to Health Systems Agencies. In reviewing applications for transitional allowances for a qualified facility conversion, the Hospital Transitional Allowance Board appears to be duplicating an HSA function. Section 20 sets out criteria for determining reasonable charge for physician's services. No mention is made of reimbursement for non-physician providers. In hearings on the Social Security Amendments of 1972, Senator Curtis called attention to the untapped potential for utilizing the services of nurse practitioners in rural settings where the physician shortage is especially acute. Senator Curtis at that time called attention to a paper entitled "A New Look at the Visiting Nurse," by R. Paul Hoff, M.D. of Seward Clinic, Seward, Nebraska. Doctor Hoff's article pointed out both the opportunities available in utilizing the services of nurse practitioners and the problems involved for the nurse in obtaining third-party reimbursement for services rendered. The inability of the nurse to obtain third-party reimbursement under Medicare/Medicaid was cited as a major obstacle to utilization of the nurse practitioner in easing the physician shortage. Such future problems could be avoided by changing the title of Section 20 to read, "Criteria for Determining Reasonable Charge for Professional Providers." This section could specify reimbursement for non-physician professional providers. As regards professional nurse providers, care would be rendered by licensed registered nurses within the scope of their practice as defined by State law. We believe this bill represents a significant effort to deal with the complex issue of Medicare-Medicaid administrative and reimbursement reform and we hope our suggestions are helpful in achieving that objective. Thank you. ANNE ZIMMERMAN, R.N., President. THE NATIONAL ASSOCIATION FOR MENTAL HEALTH, INC., Hon. HERMAN E. TALMADGE, Chairman, Subcommittee on Health, DEAR SENATOR TALMADGE: The Mental Health Association strongly supports your action to improve the administration of Medicare and Medicaid, and to prevent abuse of those plans. Therefore, although we are not competent to pass judgment on all the details, we endorse S. 3205 in principle. We also urge the Subcommittee on Health, while it is taking up amendments to Titles XVIII and XIX of the Social Security Act, to consider S. 3642, introduced July 1 by Senator Stafford, and now before the Committee. We also urge the Committee to consider S. 3708, introduced on August 3, 1976, by Senator Brock. S. 3642 would amend Titles XVIII and XIX by removing the discrimination against the mentally ill now incorporated by law in both Medicare and Medicaid. S. 3708 would amend Title XVIII to make Community Mental Health Centers qualified providers of Services under Medicare. We are enclosing a statement on this subject, and hereby request that this letter and the accompanying statement be inserted in the hearings on S. 3205 when they are printed. Thank you very much for your courtesy. Sincerely, HILDA ROBBINS, Chairperson, Public Affairs Committee. AMENDMENTS TO MEDICARE AND MEDICAID, TITLES XVIII AND XIX OF THE SOCIAL SECURITY ACT, RECOMMENDED BY THE MENTAL HEALTH ASSOCIATION MEDICARE Medicare, Title XVIII of the Social Security Act, discriminates against mentally ill persons. It discriminates directly by setting forth more restrictive limitations on the coverage of mental illness than on all other forms of illness. It discriminates indirectly by failing to recognize Community Mental Health Centers per se as primary providers of health care. Direct discrimination In Part A, hospital insurance, which is provided automatically to all Medicare eligibles, Section 1812 (b) (3) sets a lifetime limit of 190 benefit days in a psychiatric hospital. There is no lifetime limit on time in other hospitals. Section 1812 (c) provides that anyone who is a patient in a psychiatric hospital at the time his Medicare coverage begins shall have his first benefit period reduced by the number of days already spent in the hospital. No such reduction applies to patients in other hospitals. In Part B, the supplemental medical insurance available on payment of monthly premiums, Section 1833 (c) limits reimbursement for treatment of "mental psychoneurotic, and personality disorders" to 50 percent of the doctor bills and related costs, after the deductible. Treatment of all other illnesses is reimbursed at 80 percent after the deductible. In addition, Section 1833 (c) places an annual ceiling of $250 on reimbursement for treatment of mental illness ($202 if the deductible is also for mental illness). No annual ceiling is placed on reimbursement for treatment of any other illness. Indirect discrimination The indirect discrimination lies in the failure of Title XVIII to recognize Community Mental Health Centers per se as primary providers of health care. This omission presumably stems from the fact that the centers did not exist in their present form prior to 1965, the very year Congress created Medicare. Today there are some 600 centers in operation and upon fulfillment of the program set up by Congress there will ultimately be 1500, one for every 150,000175,000 Americans. In the Community Mental Health Centers Amendments of 1975 (Title III of PL. 94-63) Congress mandated that to qualify for federal funding a Center must serve the 65-and-over age group, essentially the Medicare population, as well as all others. If a CMHC is operated as part of an accredited hospital, it qualifies under Part A as a primary provider of hospital care. If, however, the center is "free standing" it does not qualify unless it meets the same accreditation standards required of a full operable general hospital or a large state psychiatric hospital, standards far beyond any reasonable requirements for a facility treating only ambulatory patients. As a consequence, only seven percent of the free-standing CMHCs have been able to obtain Medicare reimbursement for inpatient treatment. Most mentally ill, of course, do not require hospitalization but are seen on an outpatient basis. Part B of Medicare will generally reimburse for outpatient treatment in a hospital setting. In other cases, however, reimbursement is available only on a fee-for-service basis and then, quite often, only if the patient is seen by a physician (rather than any other member of the mental health team) or, ludicrous as it may seem, only if there is a physician somewhere on the premises at time of treatment. The net result is that only twenty percent of the free-standing CMHCs qualify under Medicare as providers of outpatient services. The concern of the Mental Health Association is of course for the patient, not the provider, but it is manifest that it is the patient-or the emotionally disturbed elderly man or women who should be a patient-who suffers when the most logical, best qualified, and usually least costly provider is ineligible. It may also be noted that Congress to date has appropriated more than $1.3 billion to help establish Community Mental Health Centers and, as of this writing, is in the process of appropriating additional funds for the coming fiscal year. Recommended amendments To end Medicare discrimination against mentally ill persons, the Mental Health Association recommends amending Title XVIII as follows: 1. Repeal those sections of Parts A and B that place more restrictive limitations on mental illness than on all other forms of illness, specifically, Sections 1812 (b) (3), 1812 (c), and 1833 (c). 2. Insert language recognizing as primary providers of health care those Community Mental Health Centers which (whether or not actually receiving federal grants) meet the definitions and operating standards specified by Congress in PL. 94-63 and which comply with the implementing regulations issued by the Secretary of Health, Education and Welfare. S. 3642, introduced July 1 of this year and now pending in the Senate Finance Committee, would amend Title XVII exactly as we propose. Sections 1 and 2 of S. 3642 would insert language throughout Title XVIII to assure that qualified Community Mental Health Centers are recognized under Medicare as primary health care providers. Section 3 of S. 3642 would repeal Sections 1812 (b) (3), 1812 (c), and 1833 (c), as we are recommending. If the Committee cannot accept the revision of S. 3642, we hope that it will support S. 3708, introduced by Senator Brock on August 3, 1976, which "amends Title XVIII of the Social Security Act to include Community Mental Health Centers among the entities which may be qualified providers of services for Medicare purposes and to redefine terms used in such Title so as to reflect such inclusion." The Mental Health Association strongly supports this bill. Costs The Mental Health Association is fully aware of the skyrocketing costs of Medicare and is no less concerned than Congress. Fortunately there should be no additional cost and possibly some slight saving in recognizing Community Mental Health Centers per se as primary providers. Undeniably there would be some added cost in equalizing the benefits through repeal of the three sections listed above. The added cost of striking the 190-day lifetime hospitalization limitation should not be great because of the small number of patients affected. The same may be said of the provision requiring the initial benefit period to be reduced by time already spent in a psychiatric hospital. But the fact remains that there would be additional cost and it would seem prudent for the committee reports, if not the law itself, to make it plain that coverage is intended only for active treatment and not for custodial care. The most noticeable impact (and it would be noticeable only in actual dollars, not as a percentage of total Medicare costs) would follow repeal of Section 1833 (c) inasmuch as that would increase reimbursement for doctor bills and other outpatient services from 50 to 80 percent after the deductible, and would remove the $250 annual ceiling, making reimbursement for mental illness the same as that for all other forms of illness. Should the Congress feel that because of the current economic picture this is not the time to repeal Section 1833 (c) outright, several intermediate steps suggest themselves. One would be to limit this year's amendment to eliminating the discounting of doctor bills and the like so that reimbursement for mental illness would be at the same 80 percent as for other illnesses. Another would be to strike out the annual ceiling. This would not be as open-ended as it might seem, for fewer than five percent of all CMHC patients require more than twenty visits. Or, if that were unacceptable, raise the ceiling to $500 this year, which should cover the great majority of cases and defer until a later date its complete elimination. Here too, as a matter of cost control, it would be well to write into the committee reports or the law itself that Medicare is intended to cover active treatment of mental illness, not custodial care. Legislative history The intent of Congress in placing more restrictive limitations on mental illness coverage than on other coverage is not spelled out in either the House or Senate committee reports on HR. 6675, the 1965 bill creating Medicare. The only clue to Congressional intent is found in a single sentence in the House report (No. 213, 89th Congress, 1st Session) explaining the reason for reducing the initial benefit period of one who was in a psychiatric hospital at the time his Medicare a coverage began: "This provision is in keeping with the intent of the plan to cover only the active phases of treatment of mental illness and not to cover person who may have been institutionalized for many years." ... In the absence of any other explanations, it seems reasonable to deduce that the other restrictions in Title XVIII are for the same purpose "to cover only the active phase of treatment." That is precisely what the Mental Health Association is seeking. However, the existing restraints in Title XVIII not only preclude coverage of custodial care, in keeping with the intent of Congress, but also work to preclude adequate coverage of "active phases of treatment" of America's aged mentally ill, which is contrary to the expressed intent. There is no legislative history regarding failure of Title XVIII to recognize Community Mental Health Centers as primary providers. At the time Congress created Medicare, the network of CMHCs simply did not exist. Although construction grants were first authorized in 1963, it was not until 1965, the same year Title XVIII was enacted, that Congress authorized operating grants for centers. Thus they were an unknown, if not actually an unheard of, commodity. For a number of reasons, including until 1975 the lack of any Congressional mandate to treat the elderly, the matter did not get to the legislative stage in the intervening years. Recently there were discussions at the staff level but the subject did not get beyond that stage primarily due to inability to agree on specific criteria. Today this situation no longer obtains. In PL. 94-63, the Congress itself incorporated a detailed definition of a CMHC and set forth a number of specific requirements for its operation. Several of these requirements are especially germane a center, to be eligible for federal funding, must serve the elderly as well as all others; a center must set up a peer review system to insure quality performance by all staff; a center must have a system of utilization review in order to assure that each patient is getting the treatment he needs and that no patient is being seen more often or longer than necessary. Finally, the Congress in the preamble to Title III of PL. 94-63, declared: "The Congress finds that (1) community mental health care is the most effective and humane form of care for a majority of mentally ill individuals; (2) the federally funded Community Mental Health Centers have had a major impact on the improvement of mental health care . . . and thus are a national resource to which all Americans should enjoy access." In essence, the Mental Health Association is asking that Title XVIII, which reflects the views of Congress as of 1965, be updated to conform to the judgment of Congress in 1975. MEDICAID Title XIX of the Social Security Act, Medicaid, as it is now written, makes it unusually difficult for Community Mental Health Centers to serve the indigent with any hope of reimbursement through Medicaid. Yet the Community Mental Health Centers amendments of 1975, Public Law 94-63, in effect makes the centers themselves responsible for obtaining Medicaid reimbursements to offset the phasing out of direct Federal grants under P.L. 94-63. The Mental Health Association is fully committed to the concept of step-bystep decrease in Federal funding of the centers over the eight-year period set by law. It was our expectation-as well as that of Congress-that much, if not most, of the difference would be made up by increasing third-party payments, including not only patient fees and insurance proceeds but also-and most certainlyMedicare and Medicaid reimbursements. It is self-defeating to enact P.L. 94-63 on the one hand and fail to enact implementing amendments to Titles XVIII and XIX of the Social Security Act on the other hand. As we have already noted, Sections 1 and 2 of S. 3642 would make the neces sary changes in Title XVIII to make it consistent with the 1975 centers amendments. Sections 4 and 5 would do the same for Title XIX, Medicaid. The Mental Health Association urges the Committee to incorporate the provisions of S. 3642 in the bill reported out as a result of these hearings. PREPARED STATEMENT OF LYLE H. NELSON, M.D. This testimony is submitted by Lyle H. Nelson, M.D. I am a family physician practicing in Crete, Nebraska, a village of approximately 5 thousand located near Lincoln, Nebraska. I am an assistant professor of Family Practice of the University of Nebraska College of Medicine. This testimony is submitted as an individual on behalf of approximately 131 physicians who practice in 61 counties with county populations of less than 10,000, which encompasses 5 percent of the state's area, thus representing about 10 percent of the total office practicing physicians in the state of Nebraska. There is no specific organization to speak solely for rural physicians. Most of us belong to the American Medical Association, American Academy of Family Practice, State and local Medical Societies. You must appreciate, however, that there is no way to organize such a geographically wide spread group of rural physicians. When we are gone our patients are without care, therefore, seldom do we as a group attend meetings outside of our local or state societies. Usually arrangements must be made with an adjacent practitioner so that one might attend such meetings without leaving a county without a physician. I, therefore, speak as an individual hoping to express the feelings of the 15.3 percent of all practicing physicians in the United States who practice in areas of non-metropolitan counties. These physicians number 41.9 physicians per 100,000 population in the rural areas of the United States and represent in Nebraska 1 physician for every 2,366 rural residents; corrected for semi- and retired physicians, this probably represents more closely one physician for every 2,500 rural residents. I am particularly interested in those parts of S. 3205 which may improve the chances of equal benefits to rural resident recipients of Medicare and Medicaid by equalizing the profile of rural physicians with urban physicians (Section 20-E). I doubt that it was the intent of Congress to have the Medicare and Medicaid program administrated in such a way so as to have differential of benefits based on the location of residents or practice. I am much in agreement with Section 20-E. page 52, which changes profile areas to only one profile per state. I strongly object to dropping the prevailing charge level to 50 percent from 75 percent. This approach to correction to a previous error by restriction of all physicians would serve only to cause much disagreement and argumentations to occur between rural and urban physicians. I would also request that the area of the nation with the lowest usual and customary rates be rewarded by improved re-imbursement systems (for example, a full 80 percent without discount up to the national means). This would discourage the current situation where doctors tend to relocate to an area of higher profiles, higher prevailing or customary charges in order to improve their collection standards. There are many instances within our state where well established family physicians in physician short rural areas have relocated. In almost every circumstance they have relocated to areas that have higher profiles and higher salary or customary charge levels. Regarding Section 20-F, item I, criteria for physicians shortage areas should be outlined more precisely by Congress to preclude the misuse of regulatory prerogatives by HEW agency. Numerous statistics have been accumulated by governmental agencies, AMA and definitions previously established should be utilized to provide outlines of physician shortage areas. I would suggest that the following criteria be considered: The National Statistics regarding physician-patient population ratios by county should be utilized. A rural community has been defined in previous studies as being one in which a county population of less than 10,000 is reported. Statistics show that less than 1 percent of the total nonfederal physicians in the United States practice in counties with less than 10.000 population, only 15.3 percent of all practicing physicians in the United States practice in areas of non-metropolitan counties. The national doctor-patient ratio is 41.9 physicians per 100,000 population in rural areas. In 1972 there were 167 physicians per 100,000 population in the United States as a whole or in other words, there was one physician for every 600 people in the general population but only one physician for every 2,500 rural residents. I would suggest that when the patient-doctor ratio in a community exceeds 1.5 times the national average patient-physician ratio, a shortage area is anticipated. In those areas where such ratio is 2 times the national average, a critical shortage area is in existence. In arriving at these statistics an effort should be made to delete from the statisties the non-practicing or semiretired physician. For example, (A) a county of 9.000 population with three actively practicing physicians, the patient-doctor ratio would be 3,000 to one, and a critical physician shortage is in existence. (B) |