BOOKS CONTAIN "PROPRIETARY INFORMATION"

Mr. BROWN. I would have to think about that. It would depend on why you wanted it. If you were interested-just bear with me for a minute. If you were interested in opening up our books, and then coming in front of the committee here and just throwing numbers around, then I would say no, I would not be interested in that; however, you are welcome to come to look at the books, provided you respect the fact that that is proprietary information, and as far as that, it is a for-profit business that provides services, and sometimes services to other home health services-you are welcome to come and look at the books.

Mr. HALAMANDARIS. Did you say "proprietary information?"

Mr. BROWN. I think that the books of a private corporation are their own information. I mean, it is subjected to the IRS inspection, and things like that; however, you are welcome to come and look at the books to determine whatever it is that you want to determine.

Mr. HALAMANDARIS. Is there a supervisor over you that might countermand that offer?

Mr. BROWN. Yes, sir, and I would certainly-the caveat is that I would have to go back to the president of the company and to the board, but I would think-I really do not think—

Mr. HALAMANDARIS. If you check with your superior, and get back in touch with us, we would appreciate it.

Mr. BROWN. Thank you.

Mr. HALAMANDARIS. We appreciate your cooperation.

Mr. WEINER. Mr. Wilsmann made the comment, and I think a very good comment, that you would like to make sure the "schlock" operators are kept out.

How do you define good care in such a way that you would keep the "schlock" operators out?

Mr. WILSMANN. In the survey of the agency, for certification, we have a couple of States in the Union that do absolutely excellent work.

In the State of Wisconsin, no way on God's green earth is a "schlock" operator ever going to get in.

In the State of Nevada-and there are only three agencies out there, two of which are mine-they do a tremendous job.

I think when the State of Florida finishes with their regulations, their survey will be an outstanding survey.

We do have examples in place. We had them in place in a number of locations since the inception of title XVIII.

It has been onstream at least 9 years in a number of locations, and I would suggest that it is that kind of thing that we build on, and certainly not duplicated. Use the same agency, that single State agency, with the availability of the reimbursement under 1964, to do it in all 50 States. Don't duplicate it. Do not spend any additional money; the mechanism is there, and let us take the best of what is being done, and duplicate that 50 times throughout all of our 50 States. That is how you keep the "schlock" operator out.

Mr. WEINER. I have an additional question. Could you tell us if you asked the intercession of the Department of Health, Education,

and Welfare regulations? Did you approach HEW and ask for these regulations?

Mr. WILSMANN. I have been in every Department of HEWSSA-long before I became part of the Upjohn Co.

NOT AN 8 A.M. TO 5 P.M, JOB

I have been working on this problem for 912 years, because you do not deliver home health care with RN's and LPN's dealing at a level of care requirement that is way below that-that is the aide level. You do not deliver home health care 8 a.m. to 5 p.m. 5 days a week.

You heard my testimony. That is what motivated me, and if you can imagine at the time I left my other businesses to come into this, I had two manpower franchises, and one Allstate franchise. I was running three credit agencies; two in Illinois and one in Indiana. I had a public accounting practice in Joliet. I had another one in Oak Park. I was in more businesses, making more money than you could shake a stick at.

I have not yet recouped from that comedown, if you please, to open this agency, April 12, 1965-on stream fully from October 1, 1966. My total position in this, which then the Upjohn Co. bought from me with the same motivation, was to provide proper quality home health care on a 24-hours-a-day basis, 7-days a week availability at the lowest price conceivable to that ultimate consumer.

Mr. WEINER. During the months of July and August of this year, were you in touch with HEW before they issued these regulations?

Mr. WHLSMANN. The first time I looked at these regulations was immediately after the first draft. At that time, Jim Dwight was the Administrator, and he would not sign off on them, because he knew there was something wrong.

Jim wanted to include those 500 to 700 single service agencies, and he did not know quite how to do it. I met with Jim, almost a year to the day prior to the time they were finally printed in the Federal Register.

He asked me to review them. He could not pick out what was wrong with them-and what was wrong with them? He had included the same restrictive language you find in 1861 (o).

MOST OFFER SINGLE SERVICES ONLY

The reason those 500 to 700 agencies have not been certified for title XVIII-and I think, Val, this is a question you ought to look at-the reason those 500 to 700 have not been certified is because they are a single service. There has been no other not for profit in that locale that they could contract to provide the ancillary or the auxiliary services, and that is the reason they are not certified today. We need those people. We are well short of what we should have to deliver appropriate home health care, and certainly those are already in place.

We want them there. We do not want to put them out of businesswe want them involved. So I came down deliberately, at Jim's

request, to review the original draft of the home health regulations for the title XIX, a year before they ever went into the Register.

Mr. WEINER. Earlier today, HEW testified they had received 1,000 comments on the regulations.

Mr. WILSMANN. I think that is an understatement. I would guess they are something well in excess of 2,000.

Mr. WEINER. The implication was that these are comments that came in from the field.

I wonder if you can tell us what Upjohn has done in terms of developing grassroots support by encouraging letters to HEW?

Mr. WILSMANN. In every location we have offices, we went to the people involved in the control of title XIX programs, in position there, and asked them to please comment on the new regulations— study the regulations, and comment on them.

We did not provide them with material saying that we would like them to comment this way or that way.

We simply asked them to look at them so they would get a representative feeling from the field, where the rubber meets the road, and we did that through all of our 200 offices throughout the country.

Mr. HALAMANDARIS. Thank you, gentlemen. We appreciate the testimony.

As some of you know, we are doing a study of the comparative quality and costs of for-profit home health care. If any of you would care to contribute further data, we would welcome your help.

Mr. HALAMANDARIS. We will now hear from another panel made up of Dr. Ellen Winston of the National Council for HomemakerHome Health Aide Services; Miss Nancy Tigar, assistant director, Council for Home Health Services, National League of Nursing, New York, N.Y.; Eva Reese, director, Visiting Nursing Service of New York, N.Y.; Ms. Helen Rawlinson, director of home care, Blue Cross Association of Greater Philadelphia; Ms. Janet E. Starr, executive director, Coalition of Home Health Services, Syracuse, N.Y.; and Mary Ann Pfau, coordinator of ambulatory and home care nursing services of the American Nurses Association, Kansas City, Mo.

Welcome to the subcommittees, ladies. We will hear first from Ms. Ellen Winston.

STATEMENT OF DR. ELLEN WINSTON, NATIONAL COUNCIL FOR HOMEMAKER-HOME HEALTH AIDE SERVICES, NEW YORK, N.Y.

Dr. WINSTON. My name is Ellen Winston. I present this testimony in my capacity as chairman of the Social Policy and Legislation Committee of the National Council for Homemaker-Home Health Aide Services, a national, nonprofit 501(C) (3) membership organization with offices in New York, N.Y. I am accompanied by Mrs. Florence Moore, executive director of the national council.

The national council was incorporated in 1962 and has worked steadily toward its goal which is availability of quality homemakerhome health aide service in all sections of the Nation, for individuals and families in all economic brackets, when there are disruptions

due to illness, disability, social and other problems, or where there is need of help to achieve or retain independent functioning and selfsufficiency.

The national council is a membership organization composed of 608 members of which 256 are agencies providing homemaker-home health aide service; 55 are organizations, and 297 are individuals— 1974 year-end figures-all of whom are committed to promoting quality inhome care.

Homemaker-home health aide service helps families remain together or olderly persons to remain in their own homes, when a health and/or social problem occurs, or to return to their own homes after specialized care. The trained homemaker-home health aide, who works for a community agency carries out assigned tasks in the family's or individual's place of residence, working under the supervision of a professional person who also assesses the need for the service and implements the plan of care.

The need for a variety of inhome services for the ill, aged, and disabled individuals has been documented many times before congressional committees. Homemaker-home health aide service, an essential home health service, is one of the most urgently needed of these inhome care programs.

A homemaker-home health aide service should be of good quality to be safe, effective, and efficient for the recipient, and it should be administered responsibly to protect the workers involved.

There are already trends developing, especially under title XIX and also under title XX of the Social Security Act, which threaten the quality of this service. For the August 21, 1975, medicaid regulations to be implemented now and in their present form would add further concern about the quality of homemaker-home health aide services.

These regulations need to be held in abeyance until careful study of their impact, not only on the quantity, but also on the quality of homemaker-home health aide service has been made.

We suggest that such a study will reveal a need to tighten up and to clarify existing medicaid regulations involving home health aide and related personal care services before new ones are implemented, and especially before regulations with the potential impact such as those of August 21, 1975, are put into effect.

Some needed changes in the proposed August 21, 1975 regulations are detailed in this testimony.

STRIVES FOR INCREASE IN SERVICES

Since its inception in 1962, the National Council for HomemakerHome Health Aid Services has worked toward an increase in the number of homemaker-home health aide services across the country for the thousands of families and individuals who need this inhome service to help them remain independent and in their own homes. It is most reassuring to know that this need is being recognized too by congressional committees such as the two subcommittees holding these hearings.

Removing any doubt about medicaid not being bound to skilled nursing and prior institutionalization is a very useful contribution

in the August 21 proposed regulations. This will remove a major barrier to the receipt of inhome services by many very needy individuals.

However, on other points in these regulations further change is needed. Experience of agencies across the country has demonstrated time after time that both the personal care tasks and the home management tasks are needed by individuals with a health problem who wish to remain at home rather than to have to go into an institution. Therefore, we are glad to see the following phrase in 249.150i (1) listed among the duties of the aide: "household services essential to health care at home." We strongly recommend that in this section and others which refer to home health aide services, the terminology be changed to homemaker-home health aide services. This will assist in the integrated delivery of needed service to the recipient with a health problem and make this intent clear to provider agencies. There are still a number of programs which have two paraprofessionals going into the home, one to provide personal care and another to attend to tasks essential to the operation of a home, such as shopping, cooking, and cleaning. It becomes much more costly from every standpoint to send two people into the home when one trained, supervised paraprofessional can undertake all the practical services required.

Homemaker-home health aide services should be of good quality and should include protection of the workers. A concern that there be good standards for this inhome service predates by many years the formation of the National Council for Homemaker-Home Health Aide Services. In fact, it was in part to help assure quality homemaker-home health aide service that 26 national health and social service organizations and eight Federal Government departments recommended that the council be established. Basic standards for the service were developed in 1965 and updated in 1969 and each of these efforts involved broad representation from the field nationally. Based on these standards and a national social policy statement adopted in 1971 the national council developed a national approval program and currently is taking steps to develop it into one of accreditation. This program is available to an agency under any auspice and set in motion in 1972 objectively reviews the practices that an agency actually follows. The review is undertaken by a national peer review committee which makes recommendations to the board in regard to the approval status sought by the agency and recommends improvements to the agency to strengthen its service.

The two components essential to this process are, first, basic national standards and, second, an objective third party review. We submit that it is essential for each agency in the country regardless of auspice to participate on a regular basis in a recognized objective third-party review.

I might point out that many agencies are extending service to a 24-hour basis, and not an 8-to-5 basis as has been pointed out here today.

"MONITORING OF PERFORMANCE"

The August 21 proposed regulations do specify some standards and refer to "monitoring of performance." We would like to comment on the key standards and to share some of our experience in