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their hospital or

SNF care or the overly broad HHS inter

pretation of when these in patient services are deemed to have


ANCA believes that the requirement can be completely eliminated,

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a three-year HCFA demonstration project in Oregon and Massachusetts

and evaluation report by Abt Associates, Inc. The record shows 11kely Medicare savings would result from elimination of the


We know of no other public or private health plan

which finds value in such a requirezent.

The current restriction is arbitrary, unnecessary and burdes

The removal of the requirement would recognize the legitimate


needs of beneficiaries who require only skilled nursing services.

There are also those who "gane" the program by arranging for unnecessary (and costly) hospital stays in order to become eligible "Spell of Illness! Definition

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 (e.s., transfer of medical records, treatment plan) and the financial

disincentives (e.g., no cost sharing is required after the bospital

deductible until the 61st day).

AHCA recommends eliminating inconsistencies in the "spell

of illness" definition so that a "spell" ends when a beneficiary

is neither under Medicare 10 patient hospital aor SNP coverage followed by the requisite tine 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"


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 111ness.

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 participa

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only for purposes of ending a Medicare spell of illness.


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 CFA policy adversely affects beneficiary coverage

por durable medical equipment (e.g., oxygen therapy, alternating pressure mattresses, and pacemaker bonitors). The durable medical

equipment is available to beneficiaries at home or in an institution,

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available to a beneficiary who is neither under Medicare inpatient

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monitoring care, providng routine medical services, and appro

priately involving the supervisory physician if major medical

problems develop.


has already recogized the value of physician

assistants and nurse practitioners to augment physicians in

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titioners, 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

We hope that you will provide the charted course


so Medicare

nursing home benefits can finally become what beneficiaries need

and think they have.



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:


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

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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.

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