The CHAIRMAN. Thank you, Mr. Pickering. Mr. Sabatino, will you proceed in any manner that you may desire.

STATEMENT OF CHARLES P. SABATINO

Mr. SABATINO. Thank you, Mr. Chairman. I, too, would like to add my thanks for allowing us to appear before you today. I would only like to add to Mr. Pickering's comment one note of explanation about the report. The report includes a lengthy appendix comparing selected provisions of State licensure laws governing home care services. As you heard, 33 States and the District of Columbia have licensure requirements at this time. If one were to undertake a complete survey of all the regulatory provisions affecting home care services, and by home care I mean both the medically oriented services we associate with Medicare, and the nonmedically oriented services you would have to piece together State by State the requirements that flow not only from State licensure laws, but also from the Medicare conditions of participation, requirements under the States Medicaid Program, the States Medicaid waivers programs, the State social services block grant programs, the States Older Americans Act funded programs and any State or local direct funded home care programs.

On top of this you would need to factor in accreditation requirements for those agencies to which accreditation may apply, and also private insurance coverage requirements which play a relatively small role now, but may be increasingly significant in the future. If after piecing this regulatory patchwork together for even any one State, you could make a great deal of sense out of it, you would indeed be a rare individual, and you would find that relatively little of this patchwork really deals with the actual quality of services delivered.

Moreover, many services are untouched by quality controls all together. In most States you or I could set up a personal care or homemaker services agency with little more than a simply business license and a shingle to hang up outside our door. Recognizing these factors, in our report we chose to focus on licensure laws precisely because at the State level, it is the one source of public accountability that has the ability to cut across funding sources and organizational forms and service types.

However, the findings of the report show how little it has used this potential. Of course, on the Federal level the Medicare conditions of participation have been an effect of benchmark home care regulation. Most States have modeled their licensure statutes on the Medicare conditions of participation. Yet, as I think the report makes clear, the Medicare regulations have precisely the same shortcomings as the State licensure laws that we have looked at. They are narrow in the scope of home care covered. They look very little at the quality of services actually delivered, and they do little to give consumers the information and the tools they need to exercise any control over the situation.

With that, I let the report stand for itself and invite any questions you may have about the report. Thank you.

[EDITOR'S NOTE.-See appendix B for summary of State regulations.]

The CHAIRMAN. Thank you, Mr. Sabatino. Mr. Hall.

65-855 O 87 - 3

STATEMENT OF HADLEY HALL

Mr. HALL. Thank you, Mr. Chairman. I am here representing the National Association for Home Care, the Nation's largest association representing home care professionals and paraprofessionals with approximately 5,000 member organizations.

With your permission, I would request that the prepared testimony be included in the hearing record.

We in the home care field are pleased to participate in these hearings on quality because that is what we are all about. Home care services are provided behind closed doors in private homes to millions of people who by definition are the vulnerable members of society due to their inability to care for themselves. The care is rendered in a setting which is not subject to public scrutiny or view. The very nature of the services in the home places unique responsibility on all providers of care and on the Congress and the legislatures that affect that care.

We are proud of the record of outstanding services to the ill, elderly, and disabled in this country so far. Home care has enjoyed ever growing support by Congress and a largely unblemished reputation, but that is not enough. The major source for potential problems related to home care is the fragmentation of services, the fragmentation of eligibility, the fragmentation of coverage, the fragmentation of reimbursement, the fragmentation of standards and audit at every level of government.

The American Bar Association testimony has outlined the current status of the Federal programs and the standards for their complete absence, in some cases, of these services very well. We agree with the report and commend it to your careful review and consideration. Without repeating that, however, I would like to focus on just four items that the report perhaps doesn't enunciate as well as I would like to see.

They are the independent provider, cost, the split between the social and the health and the woodworking issue. The first, the independent provider-there are many people that believe that you can get something cheaper by talking about unit price, and in the home care field we often hear the argument that I can get X for $2, where somebody else $5, which is cheaper. We all know the story of going to an attorney that charges $150 an hour versus going to the attorney that charges $50 an hour. Which is cheaper, the $150 or the $50? Well, if you go to one attorney, he might answer your question in 2 hours, where the other attorney might take 20, and you still don't have a good answer.

We have to look at cost beyond the unit price. You have to look at unit price times utilization times length of stay. In home care you can't just look at unit price times utilization in a given period of time without adding up the periods of time, whether it is months or years.

Independent providers are the unit price mechanism. They are the low lawyer service. They do not, at any time in my experience, which is over two decades, prove that they are cheaper. In fact, they are more costly both in the short run and in the long run, and with your permission, Mr. Congressman, we will submit some information on the title 20 program in California that proves that very

The CHAIRMAN. Thank you.

[See appendix D: "Analysis of California's In-Home Support Service Program."]

Mr. HALL. The independent provider does not provide quality. In nearly every newspaper headline and abuse situation that we have seen to date, it has been an independent provider, sometimes operating out of a nurses' registry or some other kind of brokering firm that presents the abuse. We have seen very little abuse in the regulated programs like Medicare and Medicaid.

The second issue has to do with the social and health care split. In Medicare, we talk about the medical. Now, I have heard today even Members of Congress accept the conventional wisdom that Medicare was not supposed to be a long-term care program. That is simply not true. When Medicare was passed, home health had a 100 visits under part A and 100 visits under part B, and as an agency that did very well and subsidized Medicare, we found it difficult-we found it difficult to use more than 200 visits if were taking care of people in our community, some of them for as long as 20 years.

Now, they do have acute exacerbations or long-term illness from time to time and do require more services. It has been the Health Care Financing Administration and its predecessors that have interpreted what this Congress passed in 1965 repetitively to deny home care services and to support what they know and seem to understand, and that's institutional care. We cannot split the social from the health. People don't come that way. They come with a social context and a health context, and we have to address both needs.

If you will, sir, it is like trying to make an artificial distinction like learning the parts of speech rather than talking. You have got to address the person that needs meals brought to their home, otherwise they are going to be put in a nursing home or an institution where the meals will be brought to the home. What we need in this country in terms of dealing with the independent provider, in dealing with cost issues, in dealing with social and health issues, is a comprehensive, coordinated continuum of care that addresses needs with one set of standards, one organization delivering a comprehensive set of services with one audit. That does not mean that we don't have competition or more than one provider in a community, but it is my contention, sir, that must address it in this way.

The last point is the woodwork. There are many people that feel that if we add homemaker services to the Medicare benefit, that people would come out of the woodwork. They are in the woodwork now because we have put them there. We have put them there by denying them services to keep them out of nursing homes and hospitals. The fear that somebody would abandon their parent or loved one if Government somehow funded these services is a myth beyond my comprehension.

In my 20 years of experience in the same agency in San Francisco, I have yet to see the family that abandoned their parent or loved one because we came in to help. It is the reverse. We came in to help; they stayed and did more longer. When we were unable because of artificial requirements such as skilled or intermittent or some other thing, that's when the patient went to the nursing

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 Štate 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.