The Honorable John Melcher Page 2 Pharmacists play an important role in assuring high quality health care in all health care settings. While we understand that in adult day health care centers participants would bring their prescribed medications with them and thus the center would not generally be required to dispense medications, pharmacists perform numerous non-distributive professional functions that are valuable and necessary in the adult day health care setting. Pharmacists provide in-service educational programs to the center staff on the proper storage and administration of medications. Pharmacists work with the center staff to maintain an accurate patient medication profile. This profile record allows the pharmacist to periodically review the participant's medication regimen, monitoring for drug interactions, duplications of therapy, and over or under-utilization of the prescribed medications. The consultation of the pharmacist also can be very effective in preventing adverse drug reactions. Pharmacists also can counsel the participants in the center to help them understand the purpose and proper use of their medications and health care equipment, such as ostomy supplies, braces, and respiratory therapy devices. Such counseling assures not only that patients receive optimal benefits from their medications and health care equipment, but that they do not suffer from serious problems that could result from the inappropriate use of medications and equipment. Some adult day health care centers are affiliated with long term care facilities and thus are required to meet the government-regulated standards for pharmaceutical services. APhA believes that the government's recognition of the need for pharmaceutical services in long term care facilities, such as nursing homes, should extend to all adult day health care centers. We therefore believe that all elderly and disabled participants in adult day health care centers need and deserve to have the professional services provided by pharmacists. For the reasons we have set forth in this letter, APhA respectfully urges that you explicitly include pharmaceutical services in any legislation addressing long term care, including adult day health care centers. Thank you for the opportunity to provide comments on this issue. We stand ready to assist you and your staff with further detailed information about the services that pharmacists can provide in adult day health care centers. Sincerely, John F. Schlegel, harm.D. President JFS/kac Item 2 Statement of the Hon. Leon E. Panetta on Adult Day Care The Mr. Chairman, I am delighted that you are today convening this hearing on the important subject of adult day care. As you know, I am the sponsor of a measure in the House, H.R. 550, that is a companion bill to S. 1839 that you have introduced in the Senate. "Medicare Adult Day Care Amendments" are intended to help more of our nation's senior citizens and chronically ill stay in their own communities rather than being unnecessarily placed in nursing homes and other institutions away from their own homes and communities. I am very pleased that you have introduced the Medicare Adult Day Care Amendments in the Senate, and am very thankful for the opportunity to present testimony on adult day care as part of this hearing. The need which this legislation attempts to address is part of a persistent yet neglected national problem that will not just disappear over time: the lack of a comprehensive national long-term health care policy. By now, the parameters of this problem have become familiar to most policymakers. The aging of the population over the next few decades - - will due to both demographics and longer life expectancies impose increasingly greater strains on an already overburdened system. The present structure of health care delivery and financing does not make effective use of total health care dollars. Entire segments of the population receive second-rate services. The United States is the only major industrialized nation in the world without a national health care policy. I think it is especially important in the context of this hearing that senior citizens today spend the same percentage of their personal incomes on health care as they did before the existence of Medicare. Moreover, Medicare provides coverage mostly for acute care situations and largely frowns upon preventive health care services. Those requiring long term custodial care must either be wealthy enough to pay the exorbitant costs of such care out of pocket, or destitute enough to meet Medicaid eligibility requirements. The middle-income segment of the population follows the all-too-familiar "spend down" path, whereby they must deplete their lifelong savings before becoming eligible for any public assistance. While pending Medicare catastrophic legislation would create some provision for the elderly to hold on to their resources, their savings are usually sufficient to cover only a short period of care; thereafter they become the responsibility of the state, under whose jurisdiction they remain indefinitely. Those critics who abhor the thought of Medicare coverage for preventive care because of "the expense" should play the scenario out a little bit further: today's Medicare patient unable to afford the relatively inexpensive costs of preventive or custodial community care is tomorrow's broke nursing home patient financially dependent on Medicaid. people of savings they have worked very hard over their lives to earn and build up. We should not shy away from shifting Medicare's focus to encompass preventive care because in the long run we will realize savings. The "spend-down" requirement deprives many I believe it is high time that we begin to look at alternative means of caring for our nation's ill and elderly. We need to broaden our perspective on the health care issue. Over the past few years we have enacted significant reforms in the Medicare program which have resulted in more efficient delivery of currently covered services. These changes have been encouraging. Now, we should be exploring ways of redesigning our health care system to meet the "big picture" human and fiscal needs of years ahead. An oft-discussed and much lauded approach is to maximize the amount of time the individual spends in a community setting, either with their families or on their own. Aside from the obvious human benefits of avoiding institutionalization, such a strategy makes fiscal sense as well. Measures designed to maximize a senior's independence and self-sufficiency should not be viewed as unnecessary luxuries but as sound investments. Given the proper array of support services, countless senior citizens would be able to remain in the community for an extended period of time, reducing their dependence on publicly financed institutional care. The time has come to start putting into place the various components of a comprehensive system of long term care alternatives. Already communities across the nation are responding to the need as families and specialists are working together to implement creative solutions to the problem of caring for the aged. Adult day care is a particularly encouraging alternative that has attracted widespread attention. Adult day care, as you know, is a community-based group program designed to meet the needs of functionally impaired adults through individually tailored plans of care. It is a structured, comprehensive program that provides a variety of health, social and related support services in a group setting on a less than 24-hour care basis. A multidisciplinary group of professionals including a physician, a registered nurse, a physical, occupational and/or speech therapist, and, if needed, a dietician work together to deliver the optimal configuration of services to meet the individual's needs. Adult day care offers a number of unique benefits. It is costeffective as compared to both institutionalization and home health care. The centers provide respite for primary care givers, reduce the incidence of acute illness through ongoing monitoring of health symptoms and preventive health care, and have been successful in avoiding or delaying institutionalization. In addition, clients, many of whom live alone, receive the vital psychological benefits of mental and social stimulation not available to them when confined to the home. A 1982 evaluation of adult day care centers in California found that 87% of seniors who participated in the programs maintained or improved their level of functioning. This statistic is especially significant given the fact that 63% of the participants were eligible for institutionalization according to Medicaid Field Office Criteria. Clearly, it is possible to avoid both the costs and the trauma of institutionalization provided that the proper community-based services are available to those in need. Adult day care centers are cost-effective means of delivering those services. Because the care is provided in a group setting, day care centers can capitalize on the efficiency of providing care to more than one individual without having to act as a residential facility as well. Participants' needs are evaluated, a comprehensive care package is developed, and the necessary services are provided in a focused, efficient and humane manner. Adult day care has grown quickly at the grassroots level over the last decade from approximately 300 programs in 1977 to over 1400 today. Despite the success of these programs, funding is difficult to come by. Some states have taken advantage of a Medicaid waiver program to provide coverage for certain low-income participants, but the Medicare-eligible population must pay out-of-pocket for these services. The result is that only the very poor or very rich can take advantage of this cost-effective alternative form of health care. Clearly, the need exists for some kind of adult day care coverage through the Medicare program. introduced the Medicare Adult Day Care Amendments. This legislation, reintroduced in the 100th Congress as H.R. 550, would allow certain Part B beneficiaries to participate in adult day care programs through their supplementary Medicare insurance plans. In order to be covered for this new benefit, it must be certified that participants would otherwise require a level of care furnished in a hospital, skilled nursing facility, or intermediate care facility if the adult day care services were not provided. In addition, no more than 100 days per calendar year would be covered, and utilization would be subject to a $5 per day copayment. This bill, which had 21 cosponsors in the 99th Congress, currently has 85 in this Congress. In addition, Medicare Catastrophic Legislation currently under consideration by the House and Senate includes a provision for a study on adult day care to be done by the Department of Health and Human Services. Specifically, the bill requires that HHS conduct a survey of adult day care services currently being provided throughout the United States. Based on the survey results, it then requires HHS, within one year, to report to Congress with recommendations for appropriate standards for the coverage of adult day care services under Medicare. Adult day care is a humane, cost-effective alternative form of health care of the sort that we as policymakers should be encouraging. Amid current talk of revising Medicare so that it can better meet the long-term health care needs of our nation's seniors, this hearing is an important occasion for providing information on a cost-effective, humane alternative to nursing home placement. We owe the American public the wisest and most efficient allocation of their hard-earned tax dollars; we owe elderly Americans the respect to allow them to live out their later years in the least restrictive, most dignified environment available. Adult day care can and should be an important component of our overall longterm care system, and the federal government should play a role in enabling the elderly to make full use of this and other community-based forms of care. |