since their hospital or SNF care or the overly broad HHS interpretation of when these inpatient services are deemed to have ended. The AHCA believes that the requirement can be completely eliminated, even under the statute's cost-effectiveness criterion. most thorough, objective examination to date on this issue is a three-year HCFA demonstration project in Oregon and Massachusetts and evaluation report by Abt Associates, Inc. The record shows likely Medicare savings would result from elimination of the We know of no other public or private health plan requirement. which finds value in such a requirement. The current restriction is arbitrary, unnecessary and burdensome. The removal of the requirement would recognize the legitimate needs of beneficiaries who require only skilled nursing services. There are also those who "game" the program by arranging for unnecessary (and costly) hospital stays in order to become eligible for Medicare SNF benefits. In addition, there are individuals receiving hospital care who would benefit as much from SNF care but who are not transferred because of the paperwork transfer of medical records, treatment plan) and the financial disincentives (e.g., no cost sharing is required after the hospital deductible until the 61st day). (e.g., "Spell of Illness" Definition AHCA recommends eliminating inconsistencies in the "spell of illness" definition so that a "spell" ends when a beneficiary is neither under Medicare inpatient hospital nor SNF coverage followed by the requisite time period. In general, the Medicare program limits the duration of covered services to the period between the beginning and ending of a "spell of illness" Under present law, a Medicare beneficiary must remain for 60 consecutive days out of a hospital or SNF in order to renew Medicare eligibility for these benefits. There are inconsistencies in the SNF criteria used to start and end a spell of illness. For purposes of starting a spell of illness and receiving benefits, the beneficiary must be in a facility which is licensed as an SNF, certified under Medicare as a SNF, and meets all of the program's requirements for participation as a SNF. However, for purposes of determining if a patient is no longer in a "skilled nursing facility", the program uses an overly broad definition encompassing many facilities not certified as a SNF nor eligible to be a SNF. Under Medicare's policies, many Medicaid intermediate care facilities are classified as providing skilled nursing care, only for purposes of ending a Medicare spell of illness. As a result, a beneficiary in an ICF, which is classified by Medicare as providing skilled nursing care for spell of illness purposes, might not receive Medicare coverage when he needs to go back to a hospital for SNF. Coverage would not be received because the spell of illness had been deemed not to have ended. A similar HCFA policy adversely affects beneficiary coverage for durable medical equipment (e.g., oxygen therapy, alternating pressure mattresses, and pacemaker monitors). The durable medical be equipment is available to beneficiaries at home or in an institution, other than those meeting the broad definition of SNF. АНСА recommends the Part B durable medical equipment coverage available to a beneficiary who is neither under Medicare inpatient hospital nor SNF coverage. Utilization of Physician Assistants and Nurse Practitioners Federally financed demonstrations have proven that physician assistants and nurse practitioners can perform cost effective and high quality services which traditionally have been provided by physicians. Physicians extenders have proven utility for monitoring care, providng routine medical services, and appropriately involving the supervisory physician if major medical problems develop. Congress has already recognized the value of physician assistants and nurse practitioners to augment physicians in rural clinics. Long term health care facilities are also appropriate settings for their utilization. Medicare requires periodic physician visits of long term care patients and periodic recertification of their continued need for care. AHCA recommends that physician assistant and nurse practitioners, acting under the supervision of a physician and within the scope of their license, be allowed to conduct Medicare required visits and recertifications. Thank you for the opportunity to present our recommendations for Medicare long term health care services. There are opportunities for new policies which would conserve program spending, improve service to beneficiaries, and enhance the provision of long term care. We hope that you will provide the charted course so Medicare nursing home benefits can finally become what beneficiaries need and think they have. JAMES E. CUNNINGHAM, PRESIDENT PREPARED STATEMENT OF LUCILLE A. JOEL, ED.D., F.A.A.N. I am Dr. Lucille A. Joel, President, New Jersey State Nurses Association, Professor and Director of Clinical Affairs, Rutgers University, College of Nursing, and Director, Teaching Nursing Home Project. The New Jersey State Nurses Association appreciates the opportunity to offer testimony on Medicare to the Select Committee on Aging. The New Jersey State Nurses Association endorses the concepts recently published on Medicare by Dr. Carolyne Davis, in the Federal Register: "To focus on patient care, to emphasize outcome rather than means used to achieve those ends, (and) to promote cost containment while maintaining quality care." (Jan. 4, 1983, Proposed Rules, p. 300) Although quality, access and cost create equal controversy in regard to the Medicare program, they all converge in the issue of reimbursement: Who is reimbursable; where can services be delivered; and what is the methodological model for reimbursement? We have become a reimbursable society. That which the third party payer subsidizes is mainly used. From the outset, let me assure you that I believe cost containment efforts are essential. The evolving solution to the problem of spiraling costs may be to paradoxically wed deregulation and competition among providers and settings and to require a more controlled approach to institutional reimbursement. Our testimony will focus on three major concerns which impact heavily on the Medicare program: Health Care Providers 1. Health-care providers 2. Health-care settings 3. Health-care reimbursement The New Jersey State Nurses Association strongly urges the federal government to maximize the opportunity for nurses to be major providers of health care services to the Medicare population. For nurses to emerge as dominant health care providers the Medicare program would have to address services reimbursed as health-care services, not medical services, as presently permitted. Nurses are licensed to offer health care services, which must be provided for under the Medicare program, not as medical staff to offer medical care, but as nursing staff to offer nursing care. |