"3. Cannot be met satisfactorily in the physician's office, hospital, clinic, other ambulatory care setting, because of the unavailability of medical and other health related services for the person in such setting in or near his community." In a further attempt to define a level of care such as "skilled nursing care," the New York State Medical Assistance Program, stewarded by the New York State Department of Social Services (13), listed the following nursing practices: "A. No regular or specific needs B. Bed positioning C. Bladder and bowel training D. Catheter care E. Drugs, injectable F. Drugs, oral G. General nursing care H. Irrigations I. Dressing changes J. Ostomy care K. Transfer activities, supervision L. Skin care." The continuing trend to define skilled nursing care and levels of care by using mechanical procedures as criteria, is apparent. If the thrust of government agencies and fiscal intermediaries, in an attempt to control the budget, is to deprive the chronically ill aged of medical and nursing services rather than to provide them, then all the tools necessary for such deprivation are present. The following case illustrates the disintegration of the purposes of Medicare: The patient was an 86-year-old Negro male for whom inquiry to our extended care facility was made while the patient was in the local hospital. The information was transmitted to the medical department of the fiscal intermediary for opinion as to his qualification for "covered benefits" in the extended care facility. The attending physician documented (as noted below) the diagnosis, treatment plan and clinical course in the hospital and requested continuation of a rehabilitation program with restorative nursing services and physical therapy. In addition, the referring physician claimed a positive rehabilitation potential for the patient. "Diagnoses: Cerebral Arteriosclerotic Vascular Disease. Syncope as cause for difficulty on admission. Pneumonia now cleared. Iron deficiency anemia: disuse weakness of legs with inability to walk securely-poor equilibrium. Urinary incontinence-Foley catheter in bladder. Gouty arthritis of feet with pain on standing. Patient cooperating in rehabilitation efforts very well. He is eager to regain ambulation. With treatment of gouty arthritis I am reasonably confident patient will be able to stand and regain ability to ambulate with aid, and perhaps alone. Medication: 1. Lanoxin 0.125 mg. daily, p.o. 2. Feosol Spansules b.i.d. 3. Allopurinol 100 mgs. b.i.d. or t.i.d. 4. Irrigate Foley catheter with Suby solution daily, q12h. Therapeutic Goals: Regain aided and perhaps independent ambulation and return home." Covered care on this case was denied by the fiscal intermediary: "Even though it is quite obvious that this patient needs rehabilitation care it may not be covered under the Medicare program" (14). This situation clearly is an injustice to the insured aged patient and represents a denial of a reasonable clinical rehabilitation trial. Was this the purpose of the Medicare Law? CONCLUSIONS Although there may be significant deficiencies in the application of Medicare benefits at a local level by physicians and nurses, including the administration of extended care facilities, and although administrators and owners of extended care facilities are being scapegoated and often held financially responsible for professional decisions beyond their understanding and control, the substitution of bureaucratic and other proprietary controls (fiscal intermediaries) has caused great human suffering, legal and economic injustices, and serious inhibition of the scope and practices of the medical and nursing professions. Current application of the restrictive Social Security Administration rulings with respect to definitions of covered and non-covered care, with the literal interpretations by fiscal intermediaries, has made obsolete the decisions of local attending physicians and local Utilization Review Committees as to the need and definition of skilled nursing care. Such a shift in the venue of control has not made for clearer recognition of skilled services, nor has its application effectuated the laws of Congress. Money may be saved by the device of phasing out a desirable public health program. Several astonishing results of these developments are noteworthy: 1. The muffling of the local physicians by these new rules has occasioned no protest by the medical profession. Such indifference will exact its own price. 2. The art and true skills of nursing care (parenteral injections and the passing of tubes are not so considered here), the nurse-patient-family interrelationships, the spirit of the Nightingale and Oslerian practices (wherein the worth of the patient rather than mechanical nursing practice is revered), and family counseling are nowhere recognized in the new rules as a skilled service. Is it necessary to be reminded that the patient does not have to be insane to require skilled nursing psychotherapeutic support? The nursing profession is permitting itself to be constricted, to the public disadvantage, and yet no outcry. A high price for such unconcern about human feelings will be paid. 3. The lack of public protest regarding the denouement of the Medicare program reflects the persistent rejection of the aged and disturbances of family interrelationships, the indifference to the obvious modern dissolution of the family structure, and the denial of the dying and dead. Perhaps, after all, a "society gets what it deserves." Effective clinical implementation of Public Law 89-97 will require: 1. A reconfirmation of the values of the ill individual as a person with somatic, psychosomatic, organic, psychiatric and psychosocial disabilities, and the encouragement of the arts and skills of medical-nursing care supported by humane understanding, compassion and a desire to improve the life of the chronically ill aged in addition to the application of technological skills. 2. A reaffirmation that fragmentation and definition of health care facilities according to levels of care only reinforce concept that several levels of care are acceptable as if a compromise could be made with anything but the best and most skilled services for all those who need help. Can the idea of an "intermediate care facility providing minimum but continuous care for those not in need of continuous medical and nursing services" (15) really be defended on the basis of clinical realities? In the pursuit of economies we have created a chaotic system of health care which defies continuity of care for the chronically ill. 3. A realization that the general hospital and its professional staff must once again become the hub of all community health care activities. Medical schools and their faculties must reorient their curricula towards meaningful comprehensive care of the acutely and chronically disabled so that the physician can regain his lost position of leadership of the multidisciplinary team in its clinical rehabilitation efforts. 4. Cessation by the hospital of arbitrary and unrealistic definitions of acute and chronic illness and acceptance of the fact that since the majority of hospital in-patients are chronically ill, short-term and long-term management programs must be planned appropriately. The responsibility for care of the patient does not cease for the hospital at the time of discharge. If comprehensive care is to result in other than "lip-service," a meaningful cross-fertilization of administrative responsibilities and policies must be available at all levels of health care facilities, with the hospital providing leadership and inspiration. 5. Elimination of the distinction between proprietary and non-proprietary sponsorship. All these facilities are legal entities and can serve the public either well or ill. Serving the public need is the issue, and not status of sponsorship. Let the hospital help create the umbrella of health care services for the community. The responsibility for deciding whether care is to be covered or non-covered can be determined on the hospital premises, thus eliminating the potential of self-serving interests in subsequent care of the patient. REFERENCES 1. Public Health Law 89-97 (Medicare) Social Security Act, Federal Health Insurance for the Aged. "Conditions of Participation: Extended Care Facilities." HIR-11, 405.1101, General. February 1968. 2. Aetna Medicare Bulletin, ECF #144, May 1969. 3. Travelers Insurance Company, Bulletin N-100, H-103, HH-44, N-78, RH-2, May 1969. 4. Bureau of Health Insurance, Intermediary Letter #328, Department of Health, Education, and Welfare, Social Security Administration, June 1968. 5. MILLER, M. B.: Clinical implications of Medicare upon an extended care facility population (to be published). 6. MILLER, M. B.: Synthesis of a therapeutic community for the aged ill, Geriatrics 21: 151-163 (Aug.) 1966. 7. WORCESTER, A.: The Care of the Aged, the Dying and the Dead (2nd ed.). Springfield, Illinois, Charles C Thomas, Publisher, 1961. p. 6. 8. Coverage of Services, "Custodial Care," Social Security Administration Intermediary Manual, Section 3159.1.b., January 1968. 9. Public Health Law 89-97 (Medicare) Social Security Act, Federal Health Insurance for the Aged. Conditions of Participation: Extended Care Facilities, HIR-11, Sec. 405.1127, February 1968. 10. Travelers Insurance Company. Proposed release. 11. Travelers Insurance Company. Information on Medicare, N-100, H-103, HH-44, RH-2, May 1969. 12. State of New York, Department of Health, State Medical Handbook, "Policies and Standards for Nursing Home Care," item 140, p. 1, June 1, 1967. 13. New York State Medical Assistance Program, New York State Department of Social Services, Preliminary Form #Ma-NH-1, DSS. 14. Personal correspondence with Aetna Life and Casualty. 15. Am. Hosp. Assoc., Chicago: The Week for Hospitals 5: Sept. 26, 1969. Appendix 3 INTERMEDIARY LETTERS, BUREAU OF HEALTH INSURANCE, Department oF HEALTH, EDUCATION, AND WELFARE, Baltimore, Md., April 13, 1967. BUREAU OF HEALTH INSURANCE INTERMEDIARY LETTER NO. 211 Subject: Background statement on definition of custodial care. The Social Security Act prohibits payment to be made under the health insurance for the aged program for any expenses incurred for items of services where such expenses are for custodial care. We are enclosing for your information a background statement on the definition of custodial care as it relates to general hospitals and extended care facilities. (Since the application of the custodial care exclusion will present special problems in psychiatric and tuberculosis hospitals, a separate statement on the application of the exclusion in these hospitals is being prepared.) The Hospital and Extended Care Facility Manuals will be revised in the near future to incorporate the material contained in this paper. In the meantime intermediaries will want to get in touch with the administrator of each hospital and extended care facility and discuss the definition with him and stress the importance of having it called to the attention of the institution's utilization review committee and physicians making the necessary certifications and recertifications. In the near future, we will, after appropriate prior consultation, develop and issue to intermediaries procedural guidelines to be used in identifying custodial cases during the claims review process and instructions explaining how such cases are to be handled. Enclosure. ARTHUR E. HESS, Director, Bureau of Health Insurance. DEFINITION OF CUSTODIAL CARE The widespread and often loose use of the terms "custodial care" and "supportive services" makes it difficult to define them with any real degree of precision. Moreover, as has been frequently pointed out, all of the shorthand terms, such as "custodial care" or "supportive services," are not really descriptive terms, have a variety of meanings and lend themselves readily to different interpretations in particular cases. For this reason no attempt has been made to develop an abstract definition of "custodial care." Rather, attention has been focused on the effort to identify more specifically the type of particular services which, where they represent the primary focus or underlying purpose of the services, constitute care not intended to be covered. There can be no doubt that Congress in enacting Public Law 89–97 intended to provide beneficiaries with protection against the medical costs arising from an illness or injury which requires the type of care that necessitates the continuing attention of trained medical and paramedical personnel. This intent is reflected in the law in the conditions of participation for hospitals and extended care facilities which place a great deal of emphasis on the availability within the institution of a wide range of specialized medical services and the employment by the facility in adequate numbers of a variety of medical and paramedical personnel, the requirements relating to physician certification of the medical necessity for the skilled services furnished by a hospital or extended care facility, and the utilization review committee's periodic evaluation of the patient's continuing need for such services. |