practice of medicine and all physicians will have to devote more of their time to meet demands for the information of justifying their medical decisions; Whereas, it has yet to be proven that the creation of the PSRO will reduce healthcare costs and improve the healthcare delivery system; Whereas, the government will spend millions of tax dollars on a project with unproven merit-$34,000,000 in 1974 alone to establish the PSRO; Now therefore be it Resolved that the YMBC of Greater New Orleans, Inc. urge repeal of that section of Public Law 92-603 that created the Professional Standards Review Organization; Be it further Resolved that copies of this resolution be forwarded to all members of the Louisiana Congressional Delegation, the News Media and Medical Authorities. Approved by general membership of the YMBC of greater New Orleans, March 21, 1974. ELLIS JAY PAILET, President. [From the Times Picayune, Apr. 20, 1974] THE IRON FIST (Editorial in Indianapolis News) When Medicare and Medicaid were adopted back in 1965, assurances were given that these programs would not lead on to government control of medicine. That guarantee, indeed, was written into the legislation. The bill explicitly said nothing in its language "shall be construed to authorize any Federal officer or employe to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided." This had a pleasantly soothing sound, and people who warned against potential government takeover were dismissed as cranks. Less than 10 years later, those early warnings of government coercion are all in the process of coming true. The bureaucrats of the Department of Health, Education, and Welfare are deploying a massive network of "Professional Standards Review Organizations" to control the private practice of medicine down to the last detail. And the pretext, exactly according to the crank scenario, is that such control has become essential because of Medicare and Medicaid. As just about everyone knows by now, these programs have run far ahead of original estimates and are costing the nation billions of dollars in tax money. (Another warning which was blandly ignored back there in 1965.) And in an effort to get these costs under some kind of control, the Federal planners have come up with their PSRO scheme to regulate everything and everybody which is or "may be" financed with government medical dollars. PSRO is a vast bureaucratic pyramid allegedly relying on doctors themselves but controlled by the Secretary of HEW. Among other things, it will maintain computerized files on doctors and patients, establish "norms" of standardized medical care, and hand out punishments to medical practitioners whose treatments vary from the lowest common denominator. HEW will also have access to medical records as it sees fit, thereby violating at its whim the confidential relationship between doctor and patient. Justification for all this is simplicity itself. As the HEW official in charge of imposing the controls has put it: "The government is paying for a significant amount of medical care. It wants to see that the care being received is appropriate." Which is another way of saying that, within the velvet glove of federal subsidy, there always lurks the fist of federal control. [From the St. Louis Globe-Democrat, Tuesday, April 23, 1974] SMOKESCREEN HAZARD TO HEALTH Your medical records-from general health history to psychiatric diagnoses— may now be examined by government bureaucrats. You and your personal physician may no longer decide that you should be admitted to a hospital-the government can decide that. And the bureaucrats can throw you out of a hospital despite the advice of your physician. Your doctor may be fined $5,000 for deviating from federal procedures which describe exactly what may and may not be done regarding your own, unique health situation. You and your physician will be part of a computerized file system which will establish certain "norms." These are among the consequences of a law-already in effect-that estab lishes a massive network of "Professional Standards Review Organizations" (PSROS). The PSROS are now being deployed by Big Brother as a result of a little-considered amendment tacked onto a bill in 1972. PSROS were presented as a way for doctors to examine the services performed by other physicians and to determine that these conformed to regional standards of medical practice. Yet the boards are primarily window-dressing; the law repeatedly states that procedures will be conducted "in accordance with the regulations of the secretary" of the U.S. Department of Health, Education, and Welfare. The secretary's powers are listed 96 times in the law. When HEW awarded its first PSRO's contract this month (the program took effect Jan. 1 and will not be fully implemented until 1976), the administrator of the program boasted, "PSROS is potentially the most important piece of health legislation ever enacted, here or anywhere in the world. . . . The program has the potential now to be the backbone of all care rendered in the country to all citizens in any setting-hospital inpatients, office outpatients, and nursing homes." The idea of federal bureaucrats in Washington setting "standards" for physicians regarding patient care is not much different than if the bureaucrats set "standards" for parents regarding their children's care. Who is better able to supervise the persons they care for-Washington functionaries or the family physician, the paper-pusher or the parent? One reason the government is so interested in PSROs is the scandalous bureaucratic mess that followed the adoption of Medicare and Medicaid in 1965. These programs were "sold" with the assurance that they would not lead to federal control of medicine; in fact, the legislation stated that nothing in its language "shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided." But now the government is arguing that PSROS and controls are necessary because of Medicare and Medicaid-thus justifying the federal control denied by the earlier programs. "The government is paying for a significant amount of medical care," said the HEW official in charge of the controls. "It wants to see that the care being received is appropriate." Notice how the velvet glove becomes the iron fist? As would be the case with impending national health insurance proposals, and has been the case with virtually every federal program, the government's involvement with funding programs becomes the rationale for controlling them. With PSROS, subsidizing medical care has led to controlling medical care. The PSRO legislation surely is, as an article in the Wall Street Journal calls it, "the most radical health legislation in this country's history." There is no other way to describe a law that imposes federal controls, grants the right to inspect an individuals highly personal medical history, fines doctors $5,000 plus the loss of the right to treat Medicare and Medicaid patients for deviating from federal procedures, and allows PSROS the right to order patients out of a hospital or deny admission altogether. Again, is your care a function of Big Brother or of your own physician? How could Congress pass such a bill? The answer is: Unknowingly. The PSROS section was Section 249F of the 1972 Social Security Act amendments, which lingered on for 160 pages. The section was inserted by the Senate after the House had passed the bill, and was passed by the House as part of a HouseSenate compromise bill without hearings and without most members even knowing the section existed. There are more than 40 bills submitted in this Congress calling for repeal of the embryonic program. Eighteen state medical associations have formally urged repeal, and an equal number will soon consider such a resolution. Those who think that national health care would be a great thing should ponder the lesson that PSROS already demonstrate: When federal funds for medical care are involved, controls over that medical care are close behind. It's true of medicine just as much as it's true of highways, education, flood insurance, welfare or anything else. CONGRESS OF THE UNITED STATES, HOUSE OF REPRESENTATIVES, Washington, D.C., November 28, 1973. AN OPEN LETTER TO THE HOUSE OF DELEGATES OF THE AMERICAN MEDICAL ASSOCIATION Last year, as part of a thick, complex bill amending the Social Security law, Congress adopted, almost without notice, a provision which will completely alter the practice of medicine in the United States. That section, creating Professional Standards Review Organizations, will require you to practice according to computerized standards, rather than using your best medical judgment in treating your patients. It will deprive your patients of their right to privacy. It will impose severe fines for medical innovation. Some of you have ured AMA participation in implementation of PSRO so you can control the administration of the law. But PSRO is the law of the land; it is the working of Conress and its implementation is the responsibility of the Department of Health, Education and Welfare. Even if you help implement the law, you will not control it. The only way to avoid the law's bad effects is to repeal it. The PSRO section is bad law; it will be bad for the doctor and bad for the patient. It should be repealed. Unfortunately, although many of us in Congress want to work for the repeal of PSRO, we have been handicapped by the AMA's failure to continue its active opposition to the law. Some of us have already introduced bills to repeal PSRO, but if we are to be successful we need your help. We strongly urge the House of Delegates to pass a resolution specifically calling for the repeal of PSRO and committing the all-out efforts of the American Medical Association to that end. Ben C. Blackburn (R-Ga.); Edward J. Derwinski (R-Ill.); Steven D. Symms (R-Idaho); John H. Rousselot (R-Calif.); David C. Treen (R-La.); Robert J. Huber (R-Mich.); Philip M. Crane (R-Ill.); Sam Steiger (R-Ariz.); Dan Kuykendall (R-Tenn.); Harold V. Froelich (R-Wisc.); Tom S. Gettys (D-S.C.) ; G. V. Montgomery (D-Miss.); Andrew J. Hinshaw (R-Calif.); H. R. Gross (RIowa); John E. Hunt (R-N.J.); L. A. Bafalis (R-Fla.); Jack Brinkley (D-Ga.); La Mar Baker (R-Tenn.); Earl F. Landgrebe (R-Ind.); E. G. (Bud) Shuster (R-Pa.); Roger H. Zion (RInd.); Clair W. Burgener (R-Calif.); Robin L. Beard (R-Tenn.); Joel T. Broyhill (R-Va.); William H. Hudnut III (R-Ind.) Louis C. Wyman (R-N.H.); David W. Dennis (R-Ind.); Floyd Spence (R-S.C.) ; William M. Ketchum (R-Calif.); John R. Rarick (D-La.); Charles Thone (R-Nebr.); Trent Lott (R-Miss.); James M. Collins (R-Tex.); William J. Scherle (R-Iowa). AMERICAN SPEECH AND HEARING ASSOCIATION, Senator HERMAN E. TALMADGE, Chairman, Subcommittee on Health, Senate Finance Committee, Dirksen Senate Office Building, Washington, D.C. DEAR SENATOR TALMADGE: This letter presents the American Speech and Hearing Association's general view of the Professional Standards Review Organization concept embodied in sections 1151 through 1170 of the Social Security Act (as amended). We ask that it be included in the record of the Subcommittee's May 8 and 9 oversight proceedings. The American Speech and Hearing Association (ASHA) is a national scientific and professional society, made up of some 18,000 speech pathologists and audiologists. The speech pathology and audiology profession is the primary discipline concerned with the systems, structures, and functions that make human com munication possible; with the causes and effects of delay, maldevelopment, and disturbance in human communication; and with the identification, evaluation and habilitation of individuals with speech, language and hearing disorders. Speech pathologists and audiologists considered "qualified providers" under Medicare and Medicaid regulations must hold a Master's degree in their field of specialization and have completed a "fellowship year" of supervised clinical in ternship. These standards are also among those set by ASHA for the achievement. on the part of potential service providers, of the ASHA Certificate of Clinical Competence in speech pathology or audiology. Qualified speech pathology and audiology providers render their clinical services in such settings as hospital speech and hearing clinics, freestanding outpatient speech pathology and audiology clinics, university outpatient clinics, outpatient rehabilitation centers (e.g.. Easter Seal agencies), Veterans Administration hospitals, Head Start programs, and private practice. ASHA has commented twice previously on the general subject of peer review to the Senate Finance Committee: first, in February 8, 1972, testimony to the full committee (Social Security Amendments of 1971: Hearings on H.R. 1, pp. 2573-81), and again in a "Statement of the Coalition of Independent Health Professions on Peer Review Systems" (ibid., pp. 3363-64). In its 1972 testimony, ASHA said, at p. 2580, that it "supports the concept of accountability and believes that all providers of medical and health care services should be held accountable for services rendered." The Association's testimony went on to say the "peer review' should be just that. Local and regional peer review committees comprised of speech pathologists (or audiologists) should be established nationwide to review speech pathology (or audiology) services provided to Medicare recipients and other consumers. ASHA, however, does not support a peer review concept which incorporates evaluation by individuals who do not possess in-depth professional knowledge and skills of the speech pathology and audiology profession. Specifically, ASHA does not support a peer review system incorporating review of nonmedical, independent health care providers by physicians. Further concern is generated by peer review proposals that are one-sided physician evaluation of nonmedical health care services with no provision for evaluation of medical services by nonmedical health care providers." This position was echoed by the Coalition's statement, which questioned, at p. 3364, “how effectively and equitably one professional of a specialized background and education can evaluate the judgment and services of a practitioner engaged in another equally specialized field when the only common denominator is essentially the fact that both are providers of health care services?" ASHA has long acknowledged the public's right to the assurance of quality in the delivery of speech and hearing services-its nationally recognized certification system for practitioners and accreditation systems for clinical service and graduate training programs are impressive measures of this acknowledgement, as is the Association's current push to expand its accountability program to create mechanisms for evaluation, review, and monitoring the effectiveness of clinical speech pathology and audiology service. With regard to this latter effort. a recently created Association task force, cooperating with state speech and hearing associations, is in the process of developing standards, criteria, and norms, applicable at the local level, for determining the necessity and appropriateness of speech and hearing services, and of designing the administrative models that will provide peer review, rather than physician review of these services. Organizations representing other nonmedical health professions, such as those in the Coalition of Independent Health Professions, have undertaken similar efforts. We believe these efforts should be encouraged, principally because they represent attempts to achieve a system of true peer review, wherein each health care professional is evaluated by members of his own discipline. I am enclosing a copy of section 730 of the recently published P.S.R.O. Program Manual [Office of Professional Standards Review, U.S. Department of Health, Education, and Welfare (March 15, 1974), Chapter VII, pp. 31-33], which appropriately reflects the involvement needs of “Non-physician Health Care Practitioners in PSRO Review." Aware as we are of the often transitory nature of federal regulations not based firmly in statute, we would hope that the thrust of this section (i.e., true peer review for nonphysician health practitioners) will be woven into the fabric of the PSRO law. We also believe that the PSRO needs and efforts of nonphysician health care providers-as well as the interests of the PSRO system generally-would be better served by a legislative mandate that brings direct nonphysician health practitioner input to both national and statewide professional standards review councils. Nonphysician membership on these councils constitutes a necessary step toward a national peer review system capable of objectively determining the appropriateness and necessity of all health care services. The American Speech and Hearing Association appreciates this opportunity to express its views. Sincerely, RICHARD J. DOWLING, Director of Governmental Affairs. [From the PSRO Program Manual, Chapter VII, Page 31, Mar. 15, 1974] Enclosure. 730 INVOLVEMENT OF NON-PHYSICIAN HEALTH CARE PRACTITIONERS IN PSRO REVIEW Health care is provided by practitioners of a wide variety of health care disciplines. Review of care provided by non-physician health care practitioners should be performed by their peers. Thus, while the PSRO retains ultimate responsibility for the decisions made under its aegis, it should seek the participation of all health care practitioners in the development of criteria and standards and the selection of norms for their professions, in the establishment of mechanisms to review the care provided by each type of practitioner, and in the actual review of that care. The PSRO's formal plan shall contain a plan for the involvement of non-physician health care practitioners in the PSRO's review system. 730.2 Definition Non-physician health care practitioners are those health professionals which (a) do not hold a Doctor of Medicine or Doctor of Osteopathy degree, (b) are qualified by education, experience and/or licensure to practice their profession, and (c) are involved in the delivery of direct patient care or services which are directly or indirectly reimbursed by the Medicare, Medicaid or Maternal and Child Health programs. 730.3 Development and On-going Modification of Norms, Criteria, and Standards 730.31 PSRO Responsibility. The PSRO is responsible for assuring, over time, that non-physician health care practitioners are involved in the establishment and on-going modification of norms, criteria and standards for their discipline. This is true both for PSRO direct development and when development is delegated to hospitals. 730.32 When care provided by non-physician health care practitioners will be assessed under any of the types of review to be performed by a PSRO or a hospital delegated PSRO review, non-physician health care practitioners of the appropriate discipline should work with committee (s) of the hospital or PSRO which are developing the criteria and standards and selecting the norms for these types of review. 730.33 Non-physician health care practitioners should work with the committee(s) of a hospital or PSRO fhich are responsible for on-going revision of norms, criteria or standards. This will assure the continual updating of the parameters as they relate to all involved health care disciplines. |