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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,
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
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"
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
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,
available to a beneficiary who is neither under Medicare inpatient
monitoring care, providng routine medical services, and appro
priately involving the supervisory physician if major medical
has already recogized the value of physician
assistants and nurse practitioners to augment physicians in
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
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:
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 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.