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PREPARED STATEMENT OF REPRÉSENTATIVE JOHN MCCAIN

Mr. Chairman, I would like to commend you for convening this hearing on home health care. As you know, this is a matter of great importance and concern to me. In May, Congresssman Jim Kolbe and I held a field hearing in Sierra Vista, Arizona on the same subject. We heard testimony from providers, consumers and government regulators of home health care, and I would like to have their statements included in today's record.

Home health care is certainly not a new idea. For most of man's history, home health care was the only type of care available. Families did the best they could to care for the sick and aged, often relying on folk medicine, hard work and good luck. Philanthropic efforts, such as the Visiting Nurses Association, were instituted to try and help those who could not afford proper care. With the establishment of Medicare, this country went a long way in attempting to meet the health care needs of this nation's elderly. The preamble of the Medicare Act declares that access to quality health services is a right of all

Americans.

Ever since then, Congress has attempted to promote and encourage the development of Home Health Care. Language included in various reconciliation bills, the Tax Equity and Fiscal Responsibility Act of 1982 encourages and supports the use of Home Care. In 1982, Congress established the Medicare hospice benefit, providing home care for individuals who are terminally ill. And, of course, the primary purpose of the DRG prospective payment system was to move patients out of hospitals into less expensive community based home care services.

Unfortunately, there continues to be a bias towards

institutionalization.

to

I do not know why this bias continues exist. Every study, poll or scholarly study indicates a broad preference for home health care. Consumer satisfaction is high, costs are lower, and quality of life is improved in countless

ways.

It is my belief that many of the people who live in nursing homes today could be cared for in a home or community based setting at a lower cost and at a higher level of service. recommendations of groups such as the National Council on Aging

The

and the National Association for Home Care go a long way towards suggesting additional changes that can be made so that all Americans can make proper use of the Home Health Care benefit.

Congressman Kolbe and I also discussed the impact of DRGs on Home Health Care. Much has been made of the so-called sooner and sicker discharge procedures which have taken place since the implementation of the Prospective Payment System. Proper use of home care would certainly improve the quality of life for thousands of elderly people, or anyone else, recently discharged from a hospital.

Elderly Americans do not fear death, they fear the loss of control over their own lives. They fear growing old without the resources to pay for the health care they need to maintain proper quality of life. I applaud President Reagan's actions to study the problem of catastrophic health care and I believe home health care should be a major component of any such system, whether it be a Medicare Part C or a voucher system.

With the advent of the Gramm-Rudman-Hollings Deficit Reduction Act, there have been cutbacks in all areas of government. We must investigate the role of the Federal Government, especially the Department of Health and Human Services and the Health Care Financing Agency in implementing Home Health Care. Obviously the American family will remain the primary caregiver of Home Health Care. However, we must

determine how much and what kind of support the government should Especially in the common cases of families unable or

offer.

unwilling to provide care.

Finally, we need to know why past Congressional efforts designed to encourage Home Health Care have been so limited in their success. We all support the concept, why is the reimbursement rate so low? What more should we do? What more can we do without being fiscally irresponsible? What is the proper role of

private industry in this process?

Again, Mr. Chairman, thank you for calling this hearing. I look forward to an interesting session.

Mr. MCCAIN. Mr. Chairman, I would like to commend you for convening this hearing on home health care. As you know, this is a matter of great importance and concern to all of us. In May, Congressman Jim Kolbe and I held a field hearing in Sierra Vista, AZ, on the same subject. We heard testimony from providers, consumers, and government regulators of home health care, and I would like to ask unanimous consent that they have their statements included in today's record.

The CHAIRMAN. Without objection.

[EDITOR'S NOTE.-The referred hearing record titled "Home Health Care: The Arizona Perspective" held May 27, 1986, in Sierra Vista, AZ, committee publication No. 99-574 is available from the Select Committee on Aging upon request.]

Mr. MCCAIN. Thank you, Mr. Chairman. Home health care is certainly not a new idea. For most of man's history, home health was the only type of care available. Families did the best they could to care for the sick and aged, often relying on folk medicine, hard work and good luck. Philanthropic efforts such as the Visiting Nurses Association were instituted to try and help those who could not afford proper care.

With the establishment of Medicare, this country went a long way in attempting to meet the health care needs of this Nation's elderly. The preamble of the Medicare Act declares that access to quality health services is a right of all Americans. I believe that applies to home health care as well as hospitalization.

Ever since then Congress has attempted to promote and encourage the development of home health care. Language included in various reconciliation bills and the Tax Equity and Fiscal Responsibility Act of 1982, encourages and supports the use of home care. In 1982, Congress established the Medicare Hospice benefit, providing home care for individuals who are terminally ill.

I would like to point out, Mr. Chairman, this has been an enormously successful program, and one which has received widespread approval. Of course, the primary purpose of DRG's and the Prospective Payment System was to move patients out of hospitals into less expensive community-based home care.

Mr. Chairman, elderly Americans do not fear death. They fear the loss of control over their own lives. They fear growing old without the resources to pay for the health care. They need to maintain proper quality of life. I applaud President Reagan's actions to study the problem of catastrophic health care, and I believe home health care should be a major component of any such system, whether it be a Medicare part C or a voucher system.

We must investigate the role of the Federal Government, especially the Department of Health and Human Services and the Health Care Financing Agency in implementing home health care. Obviously, the American family will remain the primary care giver of home health care. However, we must determine how much and what kind of support the Government should offer, especially in the common cases of families unable or unwilling to provide care. Finally, we need to know why, and I hope our witnesses will help us today, we need to know why past congressional efforts designed to encourage home health care have been so limited in their success. We all support the concept. Why is the reimbursement rate so

low? What more should we do? What more can we do without being fiscally irresponsible? What is the proper role of private industry in this process?

Again, Mr. Chairman, thank you for calling this hearing. I look forward to an interesting session.

The CHAIRMAN. Thank you. Mr. Bonker.

STATEMENT OF REPRESENTATIVE DON BONKER

Mr. BONKER. Thank you, Mr. Chairman.

I believe the hearing that we are conducting today is indeed timely. Given the fact that we are seeing a greater demand for home health services, and considering the recent GAO report on the Medicare prospective payment system which has documented an increase in the number of older patients being released early from hospitals, the effectiveness and availability of quality home care becomes a matter of extreme importance.

It is obvious that we are going to have growing problems in this area. The prospective payment system will put a lot of pressure on the hospitals to discharge patients earlier. I believe that the ideal approach is to strengthen our ability to provide quality home health care.

The statistics demonstrate that the certified home health agencies grew from 1,275 to 5,447 between 1966 and 1985, or to look at another way, from 1974 to 1980, Medicare expenditures for home health increased at an annual rate of 34 percent. Since 1980, Medicare expenditures for home health have increased steadily. So we not only have the human problem associated with the dramatic increases in the need for homecare, but we also have responsibility, to make sure our Medicare and Medicaid dollars are being expended wisely.

In my own State, home health providers who are reimbursed under the Medicare and the Medicaid Programs must comply with State certification standards. However, those who serve private clients may operate without such certification. Obviously Mr. Chairman, you have touched upon a terribly critical issue. I am hopeful that as a result of this hearing and having testimony from the ABA and others, we can find a proper basis upon which to develop some oversight, perhaps monitoring or auditing of health care, that could be part of an ongoing certification and review process. I will be anxious to hear what our witnesses have to offer today.

Mr. Chairman, I have a statement I would like to submit for the record.

The CHAIRMAN. Without objection, your statement will be submitted in the record.

[The prepared statement of Mr. Bonker follows:]

PREPARED STATEMENT OF REPRESENTATIVE DON BONKER

GOOD AFTERNOON. I WOULD LIKE TO COMMEND CHAIRMAN ROYBAL FOR CONVENING THIS HEARING. AS CHAIRMAN OF THE SUBCOMMITTEE CHARGED WITH OVERSIGHT OF CONSUMER INTERESTS ISSUES THAT EFFECT THE ELDERLY, I BELIEVE THAT IT IS INDEED APPROPRIATE THAT WE BEGIN A CAREFUL EXAMINATION OF THE THE QUALITY OF HOME CARE SERVICES.

WE ARE FAMILIAR WITH THE STATISTICS THAT CHRONICLE THE AGING OF OUR POPULATION, AND SPECIFICALLY THAT SEGMENT OF THE OLDER POPULATION WHO BECAUSE OF INCREASED AGE AND FRAILITY WILL REQUIRE MORE INTENSIVE SERVICES. AMONG OTHER THINGS, THE EXPANSION OF OUR OLDER POPULATION HAS LED TO A PROLIFERATION IN THE NUMBER OF ORGANIZATIONS INTERESTED IN INVOLVING THEMSELVES IN THE "SENIOR

MARKET".

IN MANY CASES, THESE ORGANIZATIONS BEGIN OPERATIONS WITH MINIMAL STANDARDS AND WITHOUT ANY CONSISTENT METHOD FOR

MONITORING THEIR ACTIVITIES.

AS THE COMMITTEE POINTED OUT IN ITS RESEARCH FOR THIS HEARING, THERE HAS BEEN A RAPID

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AND LARGELY UNCHECKED

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GROWTH IN THE HOME CARE INDUSTRY. THIS HAS OBVIOUSLY LED TO INCREASED CONCERNS NOT ONLY ON ISSUES RELATED TO FINANCING, BUT EQUAL CONCERNS REGARDING QUALITY OF CARE. IN MY OWN STATE OF WASHINGTON, HOME HEALTH CARE PROVIDERS WHO ARE REIMBURSED UNDER THE MEDICAID AND MEDICARE PROGRAMS MUST COMPLY WITH STATE CERTIFICATION STANDARDS, BUT THOSE WHO SERVE PRIVATE PAY CLIENTS MAY OPERATE WITHOUT ANY CERTIFICATION AT ALL. AS LONG TIME MEMBER OF THE COMMITTEE, I AM CONCERNED THAT THE WELL-BEING OF OUT OLDER CITIZENS IS BEING COMPROMISED.

CLEARLY, WE WILL CONTINUE TO SEE MORE DEMAND FOR HOME HEALTH SERVICES. COMBINED WITH AN INCREASE IN THE NUMBER OF OLDER PEOPLE, THE GAO HAS DOCUMENTED THAT THE MEDICARE PROSPECTIVE PAYMENT SYSTEM IS LEADING TO AN INCREASE OF OLDER PATIENTS BEING

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