The primary health care nurse traditionally prepared at the graduate level represents a most cost-efficient and under-utilized provider professional. Primary health care nurses are exquisitely prepared to diagnose and manage minor acute illness within a joint practice model with physicians. In 1979, a HCFA funded study demonstrated that a visit by a primary health care nurse costs half as much as a visit of the same nature executed by a physician. In addition, the quality of care given by the nurse as reflected in client satisfaction and recovery was equal to or superior to physician management.1 These nurses were also proven to be more effective in networking services, ordered fewer costly procedures, and emphasized self-reliant behavior, counseling and health education.2 The competency, cost-efficiency and efficacy of nurses is extensively documented. Direct access to primary health care

nurses and for the matter, to all nurses, has been denied the consumer because of the absence of reimbursement.

Where reimbursement is at all available,

it is usually contingent on physician prescription or supervision. This becomes absurd as we realize that nurses are licensed under their own autonomous practice act in every state in the Union. It seems, at least figuratively, restraint of trade to have one professional serve as gatekeeper to the services of another. It needs to be emphasized that I am not proposing to offer new services or to extend existing services to new populations, rather I appeal to you to seek formalization of nurses' rights to serve as a substitute for more costly provider professions. Nurses have admirably fulfilled this role in rural health and with underserved populations such as children and aged. In addition, we support authorizing maximum flexibility to hospitals in granting privileges and organizing its professional staff. Granting staff privileges to health-care professionals other than those defined as physicians is one key to containing health care cost. We believe such initiatives will serve to permit the substitution of nurses for more costly providers, while at the same time not comprise in quality of care. Volumes have been published citing the efficiency and cost-benefit of nursing as an alternative to higher cost care (Fagin, American Journal of Nursing, 1982, p. 56).

Health Care Settings

While strides have been made in support of alternative health-care

settings for the Medicare population, we have not gone far enough in providing other than costly institutional care. Provisions are necessary to expand the

use of community health services and home care as alternatives to long-term or acute care institutions. Careful monitoring is needed to assure that these options fill the gap as legitimate substitutions and do not create new or expanded benefits. A bill recently introduced by Senators Inouye and Packwood seeks to authorize the establishment of Community Nursing Centers under Medicare and Medicaid. The proposal builds upon the historically demonstrated capacity and concern of community based nursing organizations, such as visiting nurse agencies and departments of health.

Services would be offered

on an inclusive per capita fee basis to well children, to those in need of home care, as presently authorized under Medicare, and to individuals, who without the services of Community Nursing Centers would require institutional placement. Through such a commitment the Community Nursing Center unifies existing services and promises to impact costly admission and retention of patients

in hospitals or nursing homes. Assurances to safeguard against both underutilization and over-utilization of services would mitigate against any income maximizing techniques.

Health Care Reimbursement

Finally, are our recommendations for a reimbursement system that truly addresses quality care outcomes while containing costs.

We strongly oppose increasing Medicare user's co-payment as we believe that budgets should not be balanced on the backs of those least able to bear the costs.

The prospective payment system, currently under discussion by HCFA, is a logical mechanism to contain cost. Further, a case-mix reimbursement system is a useful model to implement prospective payment. However, NJSNA is fearful that implementation of a case-mix model without addressing nursing

intensity resource use on a patient-specific basis will jeopardize patient care, since adequate nursing resources may not be allocated. A result of seven years of funding, the methodology on Relative Intensity Measures of nursing care (RIMs) developed in New Jersey with HCFA funding, provides a workable allocation statistic.

The DRG model as conceived by Medicare includes no sensitivity to the intensity of nursing resource use on a patient-specific basis. It will never achieve the control it desires without this patient-specific measure of nursing. Thrity-five percent of a hospital's budget is concentrated in the department of nursing; 55% of the manpower budget exclusive of hospital based physician cost is devoted to nursing service personnel.3 Nursing reports a yeoman's share of hospital finance, and while it is costed out on a per diem basis and quite arbitrarily patient-to-patient, maximum budget control is impossible. The relative intensity measure methodology (RIMs) is the only allocation statistic of its kind and is currently pending incorporation into rate setting for 1984. In summary, the New Jersey State Nurses Association supports a Medicare program that gets quality care to the aged and selected populations. We believe that nursing can offer excellent cost-efficient resources as health-care providers in settings where nursing is reimbursed to the fullest, without constraints of health care gatekeepers.

We believe that the prospective payment system holds promise for costcontainment, while offering quality care, but are adamant that nursing intensity resource-use must be addressed as a separate cost unit.

References

1. Joseph Romm, et al. Survey and Evaluation of the Physician Extender Reimbursement Experiment: Productivity and Cost, Washington, D.C.: Health Care Financing Administration, 1979.

2. Virginia Cleland, "Perspectives for Nursing: Old Dreams, New Visions", Perspectives for Nursing: A symposium, Hyattsville, Md; US Deparment of Health and Human Services, Health Services Administration, Bureau of Health Division, Division of Nursing, August 1980.

3.

Russell Caterinicchio and Pearl Morrison, "Case-Mix Reimbursement", The New Jersey Nurse, Sep/Oct 1980.

22-020 0-83--13

PREPARED STATEMENT OF DORIS FULLERTON, PRESIDENT, PRACTICE Insight, INC., AND PRESIDENT, HERE TO HELP, INC.

Congressman Rinaldo and Members of the Advisory Council,
I am Doris Fullerton, President of Practice Insight, Inc.,
a management consulting firm serving physicians and den-
tists and President of HERE TO HELP, INC., a medical claim
service which assists individuals, attorneys, estates and
small businesses to obtain the maximum reimbursement un-
der their policies. I have been the Administrator for
multi-physician medical groups for over fourteen years.
I have taught courses and seminars in Medical Office Man-
agement for physicians and their office personnel.

Over the years I have witnessed numerous insurance reimbursement problems for health claims. I will address only the problems of the elderly at this time.

Many of our Medicare clients are covered by additional health insurance policies but are not aware of the benefits or limitations of each policy or what should be claimed from which carrier.

Some of our clients have so many health problems that they
simply cannot sort out or deal with the maze of forms and
bills. Many are procrastinators who readily pay their
bills but become confused when it comes to forms. They
do file their claims on top of the refrigerator or in

a desk drawer. Others simply cannot remember what has been filed, reimbursed or paid. Very few Medicare beneficiaries have the insight or perseverance to investigate or challenge unwarranted Medicare denials.

Our clients come to us because their claims are so complex that they cannot reasonably expect their physicians or hospital business office personnel to assist them further. They

cannot deal with the red-tape, the "lost claims", the low reimbursements, the appeal process and the general Many have multiple insurance policies.

confusion.

I feel that much of the confusion Medicare beneficiaries have could be avoided if they were able to have their questions answered knowledgably by personnel in their physician's offices who have a keen understanding of the Social Security system and Medicare as well as a working knowledge of supplemental insurance plans. I have personally spoken to numerous physician's office personnel who do not understand Assignment of Benefits, do not know current deductible amounts for Part A or the definition of a Benefit Period. These people care very deeply, as I and my staff do, about our senior citizens whose lives they touch each day. Their contact is more frequent and intimate than a visit to a distant SSA office. I encourage physicians to take responsibility for providing continuing education for their professional receptionists and other staff members.

I propose that the Social Security Administration conduct seminars and workshops specifically for medical office personnel regarding updates and revisions in Medicare and

other SSA programs.

Medicare was designed to meet the health care needs of the individual. Has it done that?

Better utilization of Home Health Care Services would provide a substantial savings to the Medicare program and help to preserve the dignity of the recipient. The services of