But the way DHEW now proposes to expand the medicaid home health care program will not accomplish these ends. Rather it will lead to the same conditions we have in the nursing home field-poor care and runaway expenditures. What happened in the last year is that the commercial interests in the health industry saw the direction in which money was about to flow, and naturally moved in that direction-to expand their programs in home health care. But they were frustrated in attempts to capitalize on public financing under medicare and medicaid because the Social Security Act requires that proprietary organizations can be certified as providers only if licensed under State law-and only 10 States license proprietary home health care agencies. This requirement of State licensure is found in title XVIII, the medicare title, but has always been regarded by DHEW as applicable to title XIX (medicaid) as well, for title XIX contains no other definition of home health agency. Suddenly in 1975, after a major lobbying effort at DHEW led by a national drug manufacturer who also runs the largest proprietary home health business, DHEW decides the licensing requirement is no longer applicable to the medicaid program. DHEW now proposes to force the States to certify as medicaid home health care agencies organizations they do not license. There is no requirement in these regulations for certificate of need programs, although Congress, in the National Health Planning and Resources Development Act, has recognized the necessity for such programs to prevent excessive and unplanned expansion of health care facilities. To make matters worse, the regulations would permit medicaid certification of single service agencies, also contrary to the provisions of the Social Security Act. This would encourage the growth of enterprises offering only services of home health aides, the most readily available pool of personnel since almost no training or experience is required, while neglecting the skilled professional services of licensed nurses and therapists.

These regulations will lead to the introduction of hucksterism in the field. Drug company representatives who regularly visit doctors and pharmacists and furnish them with free "samples" will simultaneously sell their home health services. Tie-ins between medical supply houses and home care operations are also to be expected-the history of the nursing home industry demonstrates the difficulties of preventing such abuses. Furthermore, by simply applying the promotion techniques used by business, proprietary home health organizations will likely draw patients away from the established governmental public health programs and voluntary agencies, depriving them of the medicaid funds necessary for development of a full program of comprehensive services.

A LOOK AT FLORIDA REVEALS RESULT

An example of what is likely to occur if these proposed regulations become effective can be seen from the recent experience in Florida which passed a home health licensure law which became effective July 1, 1975. Within weeks, the State Department of Health and Rehabilitation Services received applications from 66 proprietary organizations. This group of applicants exceeds in number the total medicare-medicaid certified proprietary home-health agencies in the entire country and almost equals the number of presently certified public and nonprofit agencies in Florida. Fortunately, Florida has a licensure law with some important safeguards, most notably a certificate of need requirement so that local authorities will have the opportunity for sensible planning and screening before these applicants can begin to operate. But under the proposed regulations, the 40 States without licensure laws will not have that opportunity. Any applicant meeting the very minimal requirements of the proposed regulations will have to be certified as a medicaid provider.

No research has been conducted on the role of proprietary organizations in home health care or their effect on public and voluntary agencies. Florida offers an excellent opportunity for a study of this sort. Instead of rushing headlong into uncontrolled proliferation of home health providers, DHEW should pause to conduct studies in Florida and other States to evaluate the effectiveness and costs of the proposed regulations.

The National Council of Senior Citizens is concerned with the fact that the States have not fulfilled their obligation to provide home health services under their medicaid program. We support the clear statement of the proposed regulations that the States are required to provide home health care to all the cat

egorically needy age 21 and over and to the medically needy to whom skilled nursing services are available. We believe this obligation should be enforced by action of Congress and DHEW, using both the carrot and the stick. Congress should appropriate the full $6 million authorized in the Special Revenue Sharing Act of 1975 for the expansion and establishment of nonprofit and public home health agencies. DHEW should make funds available for the same purposes from other appropriations for research and development. At the same time, DHEW should include in its regulations a baseline number of recipients receiving home health care under medicaid and enforce this regulation with appropriate penalties, after allowing a reasonable period for the States to achieve compliance.

Home health care holds great promise for improving the health of our citi zens and keeping elderly persons in their communities with friends and family, instead of being placed in institutions. This promise can be realized only through joint Federal-State cooperation, through carefully planned programs which make a range of necessary home health services readily available to those whose health needs can best be served by such service.

Mr. HALAMANDARIS. We will now hear from John Byrne, president of National Association of Home Health Agencies, and executive director, Visiting Nursing Association of St. Louis, Mo.

STATEMENT OF JOHN BYRNE, MHA, PRESIDENT, NATIONAL ASSOCIATION OF HOME HEALTH AGENCIES, AND EXECUTIVE DIRECTOR, VISITING NURSING ASSOCIATION OF ST. LOUIS, MO.; ACCOMPANIED BY DON TRAUTMAN, CHAIRMAN, LEGISLATIVE COMMITTEE, NATIONAL ASSOCIATION OF HOME HEALTH AGENCIES

Mr. BYRNE. Thank you.

I am John Byrne, the executive director of the Visiting Nursing Association of Greater St. Louis, Mo., and president of the National Association of Home Health Agencies; and I am speaking on behalf of the National Association of Home Health Agencies.

I think since we have filed our prepared testimony, I will summarize and make a couple of quick statements and ask that the statement and attachments of the association I represent be included in the record.*

Mr. HALAMANDARIS. That will be fine.

Mr. BYRNE. My background is hospital administration and health planning. During the 3 years I have been associated with home health, I think the most frustrating thing we have to deal with is the lack of definition regarding what we are trying to do, and in line with that, and Nancy Tigar referred to it, the lack of marketing— that is, to define what is the need. I think these two must be faced soon, because you cannot build a program without knowing and doing either, since you just do not know how to finance it, the kind and number of personnel and other required resources.

The question was asked: What are the limitations and expansion of home health services?

I can speak from a little experience in the State of Missouri. Over the past 4 years, through the division of health and the Governor's office, a great deal of effort and moneys have been given toward

See appendix 4, item 3, p. 215.

expanding home health services to all of the counties. When the program started some 3 years ago, barely 50 percent of 110 counties were covered. With seed money flowing from the division of health, and efforts by the staff there, and from the Missouri Association of Home Health Agencies, 92 percent of the Missouri counties now have home health services available.

With regard to the proposed regulations, in answering the unmet needs, I think the fallacy and one of the great problems in home care is meeting the management, accountability, and clinical challenges. This, we feel, cannot be met with a one-service agency.

I think we will have to umbrella the counties, particularly the rural counties with expertise from the larger agencies, and consolidate rather than proliferate.

Don Trautman, to my immediate left, is the chairman of the legislative committee of our association. He would like to make some observations, and then we will be happy to answer questions.

Mr. TRAUTMAN. Some statements alluded to problems today in which the causes need to be clarified.

Specifically, 24-hour care of individuals is not available, because private duty nursing is excluded under medicare and many medicaid programs.

The medicare program was not intended to pay for private duty nursing; 24-hour care in the home is expensive. The limitation of intermittent visits is placed on the home health services program because of the concern for overutilization and high cost.

ONLY 30,000 EMPLOYEES AVAILABLE

At another point it was estimated that there were only 30,000 employees available under medicare.

Under medicare reporting requirements, agencies are required to report in terms of full-time equivalents. So looking at the medicare statistics of 30,000 employees, you are looking at over 35 million hours of service.

Another point I would call to your attention is the final regulations promulgated for the redefinition of "skilled nursing." The Secretary of HEW stated that this could not be extended to home health care, and that this would be under study by the Department.

The result of this is that when these regulations go in effect Novermber 24, 1975, the sterile irrigation of a catheter will be a skilled care in a nursing home, but unskilled level of care in home health.

There are some weaknesses in surveillance under the existing medicare regulations that do need addressing. We will have to improve the accountability of home health services, even under the existing regulations. I would like to cite some examples for your consideration.

One would be a requirement that there be an annual policy review, including administrative and clinical record review, conducted by a group of local professional people outside the agency.

Second, there should be dollar amounts developed for each standard that would penalize continuing violations and reward outstanding performance.

Third would be to permit only certified home health care agencies to use the terms "home health agency" and "home health service" in their names and promotional materials, and this would eliminate a lot of confusion.

Fourth is to require all home health agencies to post their most recent survey report.

NO FISCAL REVIEW PROCEDURES

Also, there are some specific problems with medicaid and the proposed regulations. Even if you were to accept the argument that the medicaid regulations were similar to medicare in quality, you cannot overlook the fact that there is no fiscal review procedure spelled out in these regulations.

This leads to no definition of allowable costs, and no defined fiscal review procedures.

We would suggest that the medicaid regulations require local professional participation in the governing party, advisory groups, and evaluation groups.

Another suggestion is in the form of a question. What about States that have a rate review requirement for home health services, but no licensure law?

With your help, there are some things that we in the profession can do. We think the following item deserves as much support as possible.

With help, time, and money, we can develop administrative procedures which are required to maintain continuity of care and quality while using part time employees. We can develop minimum data base requirements and procedures necessary to evaluate appropriateness, adequacy, effectiveness, and efficiency of home health services. [The prepared statement of Mr. Byrne follows:]

PREPARED STATEMENT OF JOHN BYRNE

Chairman Moss, Chairman Pepper, and members of the Senate and House subcommittees on Long-Term Care, I appreciate the opportunity to appear before you today to discuss the impact of the proposed August 21, 1975, medicaid regulations on the future quality of home health services.

My name is John Byrne. I am executive director of the Visiting Nurse Association of Greater St. Louis, and president of the National Association of Home Health Agencies. I am speaking on behalf of the National Association of Home Health Agencies.

With me is Don Trautman, chairman of the Legislative Committee of our Association. Both Don and I will be happy to answer any questions the committee may wish to ask following our statement.

I ask permission to have our written statement with attachments* included for the record and proceed with our oral statement.

The impact of the August 21, 1975 proposed medicaid regulations is impor tant. This set of regulations makes a major policy change that lowers standards for home health service while Congress is developing changes designed to maintain quality while increasing the use of home health services.

The prime purpose of the National Association of Home Health Agencies is to support the delivery of high quality cost effective services to those who would benefit from such services. It is the policy of our association that no distinction should be made between agencies on the basis of sponsorship, i.e., between official, nonprofit, and for-profit agencies.

*See appendix 4, item 3, p. 215.

It appears that home health agencies are facing the same dilemma nursing homes faced in 1967. We want to avoid the problems that developed in the nursing home field during an accelerated growth period. These problems were the result of an increase in quantity at the expense of quality which took about 8 years to identify. We cannot stand by silently and permit a similar development in home health services.

SHOULD RAISE STANDARDS, NOT LOWER THEM

The proposed regulations include a provision to certify single-service agencies as home health agencies. This lowers standards by catering to those who are not willing or interested in being responsible and held accountable for the delivery of a comprehensive range of services. Why change one comprehensive service agency into seven different single-service agencies? This is diametrically opposed to the concept of organized and coordinated home health services. We should be raising the minimum requirements, not lowering them.

Quality is important. It must assure the user: (1) that he will receive services when he needs help, (2) that he will be trained to help himself when he is able, and (3) that he will be able to care for himself as long as possible. Quality eliminates the costly dependency trap.

Quality must guarantee that the user's needs will be routinely reviewed by a group of health workers. Subtle changes need to be noted and the treatment modified to avoid the development of serious problems.

Quality must be practical and include the user in planning the home treatment program. The home treatment program must put the recipient's needs above that of the budget or the profit-and-loss statement of the organization.

Quality includes using the most appropriately qualified person (not necessarily the cheapest) to treat the problem. This includes efficient utilization of staff by matching the task to the level of the worker. It takes quality to make the best use of staff, to match needs to level of worker, to know when to seek consultation of another, or when to turn the primary responsibility of treatment over to a more qualified person.

We don't expect a carpenter to be a nuclear physicist just because he helped build the physicist's office. By the same token we should not expect a homemaker to know when the patient's overall condition requires the skills of a registered nurse to plan and supervise the services, just because she is providing housekeeping services.

Quality home health service is all of these melted together into a cohesive organization called a home health agency, an organization that uses the best available to do the job right.

Quality is important to home health because: (1) it can help reduce the long-term cost of caring for a person, (2) it requires nursing and rehabilitation staff to work together, side by side, in the home to help the patient, (3) it stimulates development of innovative solutions and encourages redesign of the service systems, and (4) it tells you when to stop treating, start teaching self-care and finally when to let go.

Our association's specific recommendations on the medicaid regulations can be summarized in two groupings.

First, we urge immediate adoption and final publication of the medicaid regulations as recommended in our September 30 letter to the Commissioner of the Social Rehabilitation Service. This involves deleting sections 249.150 and 249.151 and making the following changes to section 249.10 (a) (4) and (b)7. -Home Health aide services provided by a qualified agency must be clearly defined.

-Include all medicare home health services as required medicaid services and add nutrition counseling, therapeutic diets, and medical social services as the services which may be provided at State option. -Add a requirement that the State agency conduct a public hearing in the local area to determine that there is no home health agency service available before permitting the State agency to reimburse for services provided by other than a medicare certified home health agency.

-Require that in order to participate under a State title XIX plan as an agency qualified to provide home health services, such agency must be certified under title XVIII of the act to provide such services.