ITEM 4. LETTER FROM HON. PATRICIA SCHROEDER, REPRESENTATIVE IN CONGRESS FROM THE FIRST DISTRICT OF COLORADO; TO JOHN A. SVAHN, ADMINISTRATOR, SOCIAL AND REHABILITATION SERVICE, HEW, DATED SEPTEMBER 20, 1975

DEAR MR. SVAHN: I am writing to express my concern about the August 21, 1975, proposed regulations that authorize medicaid reimbursement for proprietary home health agencies regardless of State licensing procedures.

Although the purported purpose of the regulation is to "greatly expand availability of home health care services in American communities," I do not think that the reimbursement of proprietary providers is the only means of accomplishing this goal.

Implementation of Public Law 94-63, the Health Revenue Sharing and Health Services Act, over the President's veto will provide funds for the establishment and initial operation of public and nonprofit private agencies in areas where such services are not otherwise available.

In many States, such as Colorado, where there are 30 home health agencies certified by the State, providers are available, but services have been curtailed by the restrictive interpretation of home health services.

What is needed to more adequately serve the needs of the elderly, sick, and disabled, is to lift the "skilled nursing" criteria, expand services without the limitation to posthospital illness and those who are "homebound," and increase funding.

In my opinion, HEW's proposed regulations amount to a major policy change which should be made by the legislative branch, not by administrative discretion. I urge you to reconsider these regulations and not interfere with the States' right to choose whether to permit the participation of for-profit home health agencies. Sincerely,

PATRICIA SCHROEDER,
Congresswoman.

PROPRIETARY AGENCY PROBLEMS

(as reported from throughout the United States)

There are proprietary (as well as private, nonprofit) home health agencies which endeavor to and do provide quality health care services. However, there is a growing list of dubious practices to which some of these agencies have succumbed:

(1) Location:

-Overlap of services with existing services,

-None are located where other home health agencies do not exist,

-No evidence of "increasing supply to 50 percent of counties now without services,"

-Neglect or no concern for ghetto or rural areas.

(2) Time abuses: Subsidiary proprietary agency chain takes a tax loss on per hour aide service and advertises at a cut-rate as compared to voluntary and public agencies charges. They then recoup some losses by establishing a "minimum 4-hour visit." Since this amount of time is often not required, there is waste of staff time and taxpayers money. Study has revealed that not only is visit time inflated but patients are kept under care longer than the average need for services experienced by other agencies.

(3) Patients are "dropped" when they no longer have full third-party or private reimbursement.

"The agency (proprietary) has made no contact with the VNA or health department. Two nurses from the VNA/HD staff were interviewed regarding employment by the proprietary agency. One asked about relationship of this agency's service to VNA/HD. “Oh, that is no problem. We take care of the paying patients and the VNA/HD takes care of the poor patients."

This policy leaves the public and voluntary agencies to struggle with the complexity of health and social needs; funding for services; and staffing for limited areas.

(4) Broad evidence of service and administrative abuses comparable to nursing home pattern:

"When the 100 visits run out just have the Doctor reorder care," -Agency-employed-physician who writes orders supplementary to those prepared by the patients private physician in order to secure Medicare reimbursement

-Inflated costs because of use of expensive fleet-rental cars and extravagant office establishment

-(See attached newspaper list of proprietary nursing homes "bilking abuses" most of which could also be practiced by unscrupulous operators of home health agencies)

(5) Collusion of private agency with medical equipment firms to pirate referrals made by physician to VNA. Physician mailed orders for patient care to VNA. Meantime private home health agency phones patient after delivery of medical equipment; secures name of physician and tells patient that her physician will be called for orders and told that patient had requested private agency for home health services. Patient and family very upset and confused; refused private agency care when nurse arrived since VNA had phoned and made plans to provide care as ordered. Two abusive phone calls followed from private agency-very traumatic to patient and family.

(6) Excessive visits. Not only lack of concern for rehabilitation of patients but evidence of attempts to make or keep patients dependent on agency. Examples illustrate poor health care as well as negation of results of expensive institutional care.

-"In accordance with instructions from the physician our nurse has been encouraging self help for this patient and had reduced the frequency of service. The patient requested that we do not return when the other (proprietary) agency on a door-to-door campaign offered to visit her daily." -"Patient purchased care (bed bath by aide) from proprietary agency until funds were exhausted and she was summarily dismissed from service. VNA was asked to provide free service. Found patient with 'frozen shoulder' after months of neglect and inattention to healing arm fracture, whereas physical therapy should have been instituted from the first."

(7) Limited coordination with other community resources for patient and family. Lack of planning and coordination with other groups for community health care.

(8) Minimal team services.-"One staff member, whoever admits the patient, is the same one to provide all the care that the patient needs." No specialized therapist or other consultants available to provide a broad range of services when needed by a patient.

(9) Excessive utilization of expensive medical equipment.

(10) Rare and sporadic staff supervision of unprepared workers.-Patient, after funds exhausted in care by proprietary agency was dropped from this service and referred to voluntary agency. Home health aide had been giving daily bed bath with no evident concern for extensive and long term vaginal hemorrhage. No evidence of this pathology having been reported to the physician or counsel to patient or family to secure medical care.

(11) Limited or no emphasis on staff education, training, and inservice education.

(12) Focus on technical care with minimal concern for patient and family health education and instruction in patient's care.

(13) Discrimination in patient selection, e.g., diagnosis, length and seriousness of illness, socioeconomic group, etc. Nonprofit agencies are then overloaded with the seriously ill and those needing more intensive and expensive care without funds.

(14) No evidence of regard for other family health needs in conjunction with individual patient care.

(15) Lack of administrative responsibility for 7 day/week service when employee fails to show.

(16) No provision for standardized evaluation of services and overall program including the amount of funds being utilized for direct patient services as opposed to administrative cost or profits.

ITEM 5. LETTER AND ENCLOSURE FROM MAXINE A. THOMAS, R.N., EXECUTIVE DIRECTOR, SALT LAKE COMMUNITY NURSING SERVICE (UTAH); TO SENATOR FRANK E. MOSS, DATED OCTOBER 1, 1975

DEAR SENATOR Moss: Attached is a copy of our letter, submitted to Social and Rehabilitation Services, DHEW, in response to August 21, 1975, Federal Register.

We devoted considerable time and study to the proposed regulations and feel. as outlined in our letter, the regulations are thoughtlessly and irrationally put

together. Of more importance, we are most concerned that programs are being established through regulation rather than congressional enactment.

Very truly yours,

[Enclosure]

MAXINE A. THOMAS, R.N.

Mr. JOHN A. SVAHN,

SALT LAKE COMMUNITY NURSING SERVICE,
Salt Lake City, Utah, October 1, 1975.

Acting Administrator, Social and Rehabilitation Service, DHEW,
Washington, D.O.

DEAR SIR: The following comments are made in regard to the Social Rehabilitation Service of DHEW published proposed rules for "Medical Assistance Programs, Home Health Services," in August 21, 1975, edition of the Federal Register:

The proposed rules for home health services for medicaid assistance programs sets up a separate, unequal set of standards for agencies to be certified for medicaid reimbursement from those certified for medicare. We firmly believe that uniform Federal standards for certification of home health agencies must be required.

The proposed regulations provide only for minimum services for medicaid recipients, with necessary services as physical therapy, occupational and speech therapy services to be optional. Medicaid recipients are entitled to the same services as other citizens and must not be discriminated against as a separate group. If the goals of the medicaid program are to develop alternatives to institutional care, maximum not minimum services are needed.

The proposed regulations do not establish fiscal or management controls to prevent overutilization. There is no provision for quality control.

Any changes to improve home health services must be made by legislation, not by regulation. Much testimony has been provided special Senate committees urging expansion and improvement of home health services benefits. Extending home health services cannot be attained on a piecemeal basis as these regulations propose.

We reaffirm that local control of services must be preserved and strengthened. Local responsibility is essential to meet the unique needs of local communities. The proposed Federal regulations usurp this responsibility.

We strongly urge that the proposed regulations not be implemented.
Sincerely yours,

MAXINE A. THOMAS, R.N.,

Executive Director, Salt Lake Community Nursing Service.

ITEM 6. LETTER AND ENCLOSURES FROM FLORENCE MOORE, EXECUTIVE DIRECTOR, NATIONAL COUNCIL FOR HOMEMAKER-HOME HEALTH AIDE SERVICES, INC., NEW YORK; TO JOHN A. SVAHN, ACTING ADMINISTRATOR, SOCIAL AND REHABILITATION SERVICE, HEW, DATED OCTOBER 3, 1975; SUBMITTED BY DR. ELLEN WINSTON* DEAR MR. SVAHN: Regarding Proposed regulations on medical assistance programs, home health services, published in the Federal Register, August 21, 1975, the National Council for Homemaker-Home Health Aide Services appreciates the opportunity to comment on these proposed regulations.

The stated purpose of expanding the availability of home health services to medicaid recipients is commendable. The clarification that medicaid, unlike medicare, is not bound to "skilled" nursing and "prior institutionalization" is very helpful. Allowing participation in the medicaid program of an agency providing either nursing or homemaker-home health aide service will facilitate expansion of those services.

Before discussing, on a point-by-point basis, some of our concerns in these proposed regulations, we wish to point out our major overriding concerns and to recommend steps toward alleviating the problems.

At least an attempt has been made in the regulations to outline standards, including standards for home health services (although they are based on title XVIII standards an inadequate base to start with). No attempt has been made, however, to provide for the expansion of mechanisms to assure that the standards are adhered to. This is the most glaring problem posed by these *See statement, p. 100.