level of care, in other words, less nursing home, more home health

care.

Are there studies that show that that might be a possibility?

Ms. MOON. A lot of research has been done, but the findings are difficult to interpret. For one thing we don't have a system of care that in each area provides both a lot of nursing home beds and ample home health care services to compare how people would like to participate. And it is not clear, if you expand home health coverage, whether you are going to replace nursing home services or whether you are going to provide services that are needed but not now received. These complications make a prediction about the costs of making services more widely available difficult.

There is probably little doubt that in a world in which there was adequate nursing home coverage, and adequate home health care coverage, that there would be better and more efficient care. There are many people in nursing homes probably could be better treated at home.

Mr. SAXTON. And, if you will excuse me, people who would much rather be treated at home.

Ms. MOON. Absolutely. There are also people who are treated at home who might be better off from a cost standpoint in institutions if they need a lot of care, but not by their own preference, Howev

er.

Mr. SAXTON. Thank you, Mr. Chairman.

The CHAIRMAN. Thank you. Mr. Volkmer.

Mr. VOLKMER. After reviewing the home health benefits on the Medicare working paper of AARP, I find some disturbing language on page 11. If you could address that-the deficiencies within some of the home health care agencies and what could possibly be done and recommendations about correcting those deficiencies. The paper discusses New Jersey and Region 2 providers. Sixty percent New Jersey providers and 25 percent of Region 2 providers were deficient on patient services.

Ms. MOON. Again, the issue is that there were a number of deficiencies found that ought to be corrected. Are those deficiencies serious enough to deny participation in Medicare by home health agencies? If they reflect modest problems, or if they are deficiencies that home health agencies want to-and work to-correct, we don't believe that agencies should be denied participation. They should be carefully monitored to insure that those deficiencies are corrected, however.

HCFA now has only limited options in dealing with this situation. They can sanction and drop the provider from participation, but they do not have intermediate sanctions that they can use.

Mr. VOLKMER. And I notice there seems to be a stepping away from the idea of State licensure or State regulation also. Is that correct? Is that a correct impression, a moving away from it instead toward it?

Ms. MOON. That we would recommend that?

Mr. VOLKMER. No, no. I'm just saying that seems to be what is going on out there.

Ms. MOON. There are moves in some areas to streamline accreditation or make such activities voluntary. But I don't know of any organized movement.

Mr. VOLKMER. That there is really no movement. You don't know anything within the State legislature groups, the national associations or State legislatures or anybody like that that is looking at a model law for licensure or anything like that?

Ms. MOON. I am not familiar with those efforts but I know that many States are becoming concerned about quality of nursing home care, as well as home health care. So I would not be surprised to learn that there is some movement.

Mr. VOLKMER. And the other thing I would like for you to address is, it is my impression, let's put it this way, what is occurring, is that there is also a difference in reimbursement between the type of agencies; is that correct or incorrect?

Ms. MOON. There are differences.

Mr. VOLKMER. In other words, a public service agency like a county agency, et cetera, will get less reimbursement than maybe a for-profit agency or one connected with a hospital.

Ms. MOON. That's right. There are reinbursement differences among providers.

Mr. VOLKMER. And yet they may be providing the same type of service, and yet one will get less reimbursement than the other within the same area.

Ms. MOON. I believe that is correct.

Mr. VOLKMER. Thank you very much.

The CHAIRMAN. Thank you, Mr. Volkmer. Mr. Fawell.

Mr. FAWELL. My question would be along the lines that Congressman Saxon was putting to you. I was reading quickly through the AARP Home Health Benefits on your Medicare workpaper. Insofar as the home health care services are concerned, to show an acute illness, a person has to be homebound, and apparently those services just aren't going to be available for a very long period of time, maybe 2 or 3 weeks, and then, by and large, they are cut off. Is that about correct?

Ms. MOON. On a daily basis, they are not supposed to be given for more than 2 to 3 weeks. After that, you can receive what is called intermittent care, perhaps 3 to 5 times a week, for example. Mr. FAWELL. And how long can the so-called intermittent care continue?

Ms. MOON. Technically, that can go on as long as the individual needs acute care.

Mr. FAWELL. But if it is a chronic problem-for instance, you have indicated that is not acute. How do you make that determination?

Ms. MOON. Those kinds of distinctions are difficult to make, that the home health care program and Medicare in general has struggled with that issue. But when someone may have care needs who is very frail, for example, but does not have a specific medical problem, the person would not qualify for home health care under Medicare.

Mr. FAWELL. It strikes me that homecare is being interpreted as an extension of the hospital, and we are not going to really allow it to go along very long. Is that a fair statement?

Ms. MOON. I think that is a fair statement. Medicare home health benefits are not intended to be a long-term health benefit in

the way in which people often see a need for home health care. It is not a long-term care program.

Mr. FAWELL. It is not meant to be in lieu of the nursing home, then, the idea of being able to remain in your home with maybe visitations two, or three or four times a week. Even though it would be much less expensive for everyone, at this point we are not really concerned about having that in lieu of nursing home services.

Ms. MOON. That's right. I also should point out that Medicare covered services are only for medical treatment, for skilled nursing care, for therapy and so forth, and not, for example, for visiting aides. Aides who help older people live independently at home do not technically provide medical care and therefore are not covered by Medidcare.

Mr. FAWELL. Thank you.

The CHAIRMAN. Thank you, Mr. Fawell. Mrs. Meyers.

Mrs. MEYERS. Medicare, then, pays primarily as long as there is a medical necessity, but the kind of health care that is provided in many States does have to do with the title 19 waiver, and frequently the health care that is provided there might be really more for hygiene or for assistance with diet, in other words, to help with bathing and cleanliness and feeding and that sort of thing.

Now, as I recall, in order to have a waiver and provide the service in the home rather than in the nursing home or in an institution of any kind, this service has to be provided for at a 5-percent saving, does it not?

Ms. MOON. My understanding is that it must be in lieu of nursing home care, and it must be less expensive than nursing home

care.

Mrs. MEYERS. In many States, I think homemaker services are provided by a different agency, for instance, than home health services, and yet the kind of services where we are talking about just helping people with cleanliness, with feeding, could probably be provided by the same kind of person, a well-trained person that also provided homemaker service. Do you think that is true?

Ms. MOON. I think that is probably true. There is certainly a need for good coordination of different kinds of services that must come together to truly allow an individual to remain independent at home. Without reasonable medical services, as well as homemaker services, that is just not going to be possible. Homemaker services enhance the quality of life rather than provide medical care, but they are nonetheless critical for making a home-care system workable.

Mrs. MEYERS. Well, I certainly don't want to blur the distinction of what is really good medical care, and what is a true health or medical need and what is not. On the other hand, I think that sometimes we may not be efficient in what we are doing because we call one person a homemaker, and it is provided by a social agency, and we call another person a home health aide, and they are provided through maybe the Department of Health and Environment, and one goes on Monday, and one goes on Tuesday.

In just trying to provide the best kind of services that we can for the dollar, I guess what I am asking, what would be your thinking

about trying to combine some of those services, or are they being combined in some States? I don't think they are in mine.

Ms. MOON. I am not sure about the combinations that are actually occurring. The main issue of concern comes back to what we heard about from the previous witness in terms of homemaker services. When you have homemaker aides who are poorly paid, it is going to be difficult to get them to to have the kinds of training necessary to provide other more sophisticated services. If, on the other hand, you use more skilled people to provide homemaker services, you may be caught in the bind of it becoming a more expensive program.

The efficiency that you could get from combining the services and developing a better, more comprehensive care, may very well outweigh that potential problem, but I think those are the kinds of issues to consider in assessing whether or not services ought to be combined.

Mrs. MEYERS. In the bill that I passed in Kansas that provided for licensing of home health agencies, the criteria for training was set at the same level as that level of training for aides in nursing homes, and I think it made for a kind of fairness, and maybe it does help upgrade salaries somewhat.

Ms. MOON. If it upgrades salaries and it upgrades the status of the profession, that can probably only help in attracting skilled workers who will do a good job.

The CHAIRMAN. Thank you, Mrs. Meyers.

Dr. Moon, I would like to thank you for a very excellent testimony. I would also like to thank Dr. Shelah Leader, who is the primary author of the report upon which you based your testimony. I think that together you brought to this committee a lot of information, very useful information. I want to take the privilege at this time to say that I hope that you would be open for further questions. There are some questions that I would like to ask, and that would probably be in the next few days. I would like to call you on it, and then complete the questioning for the record in that

manner.

Ms. MOON. We would be happy to provide that additional information.

The CHAIRMAN. Thank you very much.

Ms. MOON. Thank you.

The CHAIRMAN. The second panel is made up of Mr. John H. Pickering, chairman of the American Bar Association's Commission on Legal Problems of the Elderly. He is accompanied by Mr. Charles P. Sabatino, the associate staff director of the Commission on Legal Problems of the Elderly and primary author of the American Bar Association report; also Mr. Hadley Hall and Ms. Joan Quinn.

I'm going to ask Mr. Pickering to start the discussion and proceed in any manner that he may desire.

STATEMENTS OF JOHN H. PICKERING, J.D., CHAIRMAN, AMERICAN BAR ASSOCIATION'S COMMISSION ON LEGAL PROBLEMS OF THE ELDERLY, ACCOMPANIED BY CHARLES P. SABATINO, J.D., ASSOCIATE STAFF DIRECTOR, COMMISSION ON LEGAL PROBLEMS OF THE ELDERLY; HADLEY HALL, R.N., PRESIDENT, VISITING NURSES ASSOCIATION OF SAN FRANCISCO, BOARD MEMBER, NATIONAL ASSOCIATION FOR HOME CARE; AND JOAN QUINN, R.N., CHAIRWOMAN, NATIONAL INSTITUTE ON COMMUNITY-BASED LONG TERM CARE, NATIONAL COUNCIL ON

AGING

STATEMENT OF JOHN H. PICKERING

Mr. PICKERING. Thank you, Mr. Chairman. I have a prepared statement which I ask be incorporated in the record, and I shall summarize it in the interest of saving your time.

The CHAIRMAN. I thank you, Mr. Pickering, and without objection, that will be the order. Will you proceed, then?

Mr. PICKERING. I am John Pickering, chairman of the American Bar Association Commission on Legal Problems of the Elderly. On behalf of the commission, I wish to thank you for allowing us to appear before you today and for incorporating the report on home care quality prepared by the Commission into your committee print entitled, "The Black Box of Home Care Quality," which is being released today.

Our commission prepared this report with funds provided by the Department of Health and Human Services through the Administration on Aging. Neither my testimony, nor the report, have been approved by the American Bar Association. House of Delegates or Board of Governors, and thus neither reflects the official policy of the American Bar Association.

As you know, of course, the American Bar created our commission because of concerns about the legal problems of the elderly, and it is in that spirit that we come to you today to applaud your committee's examination of quality because your committee's inquiry into the quality of home care is timely and urgently needed. You are aware that the elderly portion of our population is growing rapidly, and so is the need for home health care.

While home care services bring enhanced opportunities and disabled persons to live longer and live independently, they also bring enhanced risk, unreliable services and outright neglect. These risks are magnified by a number of factors discussed in our commission report, not the least of which, of course, is the inability of the elderly to look out after their own interests and the complexity of the field ranging all the way from common char services, literally, to technical health support services such as dialysis in the home. Now, there is no comprehensive, consistent, overall regulatory scheme to control or to measure the quality of care. At the present time, to the extent it is regulated, it is done so primarily by the conditions imposed by various paying entities such as Medicare, Medicaid and many State programs. Some 33 States and the District of Columbia require licensing of some home care services. However, this patchwork of overlapping uncoordinated and limited oversight mechanisms result in significant fragmentation in accountability.