in medicaid, but only in medicare. In fact, they are arguing that, therefore, we should have been accused of legislating when we originally promulgated the original regulations.

There is also the question of freedom of choice of providers, which Congress was very insistent on, and we have had as part of this program throughout. That is, that the individual recipient should have freedom to choose a home health agency without regard to whether the provider is proprietary or nonproprietary, except in the case of medicare.

Senator Moss. Did you not consider it more appropriate to have Congress determine whether or not to allow for-profit home health agencies to participate in medicaid?

Dr. WEIKEL. In the case of medicare, that obviously was considered, and that is the course of action that was taken.

With respect to medicaid, the other course of action was taken, because I think there has been significant congressional concern expressed about our lack of promoting home health agencies, of not having adequate participation of providers. We thought that this was one mechanism with which to expand home health services, and clearly follow what a number of committees are interested in.

FRANCHISING OF HOME HEALTH

Senator Moss. In your statement you mentioned the franchising of the home health services. What has HEW done about that problem! Dr. WEIKEL. Well, legally, as I understand it, there is nothing that HEW can do about the franchising, because it is the legal mechanism to get around the way the legislation and regulations are written.

It is a valid and legal mechanism to get around the not-for-profit prohibition, and that is of concern to me, because I do not believe we should have essentially what is three classes, nonprofit, profit, and disguised profit. I think we ought to call ourselves what we are.

Senator Moss. Mr. Franklin, you left the impression that GAO advocated home health care before profit operators, is that your testimony?

Mr. FRANKLIN. I did not mean to leave that impression. I was not aware that GAO had taken a stand. I mentioned that GAO had taken a very strong stand that home health care services must be opened up, and that we feel that one of the key ways of opening it up, is to have the proprietaries as an active participant in this delivery system.

I did not mean to say, Mr. Chairman, and I misspoke if I did, that we advocated, you know, something that GAO had definitely advocated. I did not agree that GAO had put it that way.

Senator Moss. Thank you.

Chairman Pepper, you may now take over.

Representative PEPPER. Thank you, Mr. Chairman.

Dr. Weikel, and Mr. Franklin, let me ask you first, do you believe that home care, as provided today, is sufficiently comprehensive to be a valuable tool to the elderly people of this country?

Dr. WEIKEL. In some areas, yes, but in many areas of the country, the answer is clearly no.

Representative PEPPER. Now, what needs to be done in order to make comprehensive health care and health home aide service, another necessary element, available to the elderly people of this country?

Dr. WEIKEL. Well, I think there are a number of items that have to be implemented.

First of all, one has to look at why we do not have more use of home health services. One of the reasons is the unfamiliarity of patients with services. We have to do more about acquainting patients with possible utilization of home health care. I have been speaking to some of the medical groups and major organizations in the country about that.

Most physicians do not have adequate details at least on the ways in which they could utilize home health care services to reduce institutionalization or to shorten the institutionalization time after the patient has been in the hospital or the nursing home, or to prevent. them from getting in in the beginning. That is a long-term process, one which we have a responsibility for, and about which we have begun to communicate with medical groups. Obviously, the question of reimbursement for home health services is important for making those services available.

REIMBURSEMENT PROGRAM

There is some dispute, as a result of some of the comments in the GAO report, as to whether our reimbursement program is adequate. Twenty-five States are reimbursing home health care on the basis of actual costs, or charges, if they happen to be lower.

The number of home health agencies is also important, and I think by having adequate reimbursement and by assuring physicians are aware of the availability of the services, the number of home health agencies will increase. Also, frankly, we have to develop the confidence of the physicians in the capability of our home health agencies, whether they be proprietary or nonproprietary, to deliver the services that we need.

One example that comes to mind is an experiment going on in Rochester, where they actually hire the surgical nurses to participate in the home health agency program. Since the physicians have confidence in those nurses and in their capability to take care of postsurgical cases, they found they were able to reduce hospitalization, to reduce the length of stay of the patient, because the physicians were comfortable in prescribing home health services.

Perhaps I could ask Dr. Ryder to make some additional comments in that area.

Dr. RYDER. There are several experimental programs around the country in which the Department is testing out the use of home health services in lieu of institutionalization, either shortening such institutionalization or preventing it to begin with.

In most of these programs, a medicaid waiver has been obtained, so that services which are ordinarily not paid for under this program are being paid for by medicaid funds. For example, there is a pilot program in Worcester, Mass., in which two groups of patients are being studied. Over the past 2 years, one group has received tradi

tional available services. The other group has been put through a special assessment, and has had a plan for in-home services developed, that is delivered by the community agencies there. A similar kind of program is under development in Connecticut. Both of these projects are already showing excellent results, and I think since the State medicaid agencies have been involved in both, there is a good chance that they will use the pilot project not only to prove the point, but then to carry it out on a statewide basis.

I think once States begin to report to each other, that they are having success in this area of providing home health in lieu of institutionalization, they will be more likely to include it in their

programs.

Representative PEPPER. AS I understand it, the main thing is that they have got to have the money, and then, with the money, we could provide the personnel to render the service.

Under medicare, there is no prehospital medicare or home aide care provided to the elderly, is there, at the present time? Dr. RYDER. Prehospital-yes, sir; under part B. Representative PEPPER. That is a doctor?

SERVICES AVAILABLE UNDER PARTS A AND B

Dr. RYDER. No, the same home health services that are described under part A are also available to those individuals who participate in part B, even though they have not been hospitalized.

Representative PEPPER. You mean you go to the doctor, and you pay 20 percent of the doctor's bill?

Dr. RYDER. In addition to the physician's care, the other services are available and reimbursable at the 100 percent level.

Representative PEPPER. And the doctor can prescribe

Dr. RYDER. The doctor would prescribe the services he wants the patient to get. He could do this in terms of having made a visit, or he could respond to a request by the patient, or the patient's family. Representative PEPPER. My understanding is that the sort of care provided by medicare is skilled care.

Maybe there is some variation in that, but I understand that skilled care under medicare is primarily care by a registered nurse or doctor.

Dr. RYDER. The patient must require the skilled care of a nurse, physical therapist or speech pathologist.

Representative PEPPER. There is legislation pending in the House health program for the elderly. If you want to expand that service under medicare, we would have to modify the law at the present time. Mr. FRANKLIN. Mr. Chairman, that is correct. It would require a modification.

Representative PEPPER. There is legislation pending in the House to try to modify the law so that under medicare, free hospital and posthospital home care would be provided. When I say home care, I do not mean necessarily only medical care; I mean care that would include somebody going there and fixing a meal, or cleaning up the house, or making up the individual's bed, or somebody rendering some other necessary supportive home service. If we wanted to do

that, which I believe will save money for medicare in the long run, then we have to modify the medicare law. Is that correct?

Mr. FRANKLIN. Yes, sir. There is hospital and home health coverage. under medicare, but not to the extent which you just outlined.

Dr. WEIKEL. I would like Mr. Sheinbach to comment on that. He is representing the Social Security Administration.

Mr. SHEINBACH. We have recently modified the regulations for the coverage of certain kinds of services, including homehealth services, in order to make it possible to cover more types of services than we have been covering earlier, so we are moving, even without regulations to attempt to clarify the definition.

Representative PEPPER. Under medicare?

Mr. SHEINBACH. Yes, sir.

Representative PEPPER. What are you doing by way of regulations? Mr. SHEINBACH. It is a clarification of the phrase skilled care. Representative PEPPER. What clarification are you providing? Mr. SHEINBACH. We basically are saying that the degree of supervision that has to be exercised by a registered nurse, was not as intensive as it had been defined in the earlier years of the program.

Representative PEPPER. In other words, this is going to modify the law by extensive changes in the regulations, in order to allow medicare to provide comprehensive home health services for the elderly, is that correct?

EXPANSION COVERAGE SOUGHT

Mr. FRANKLIN. Mr. Chairman, right now we are covering under medicare everything we are permitted by law. Should there be an expansion desired by the Congress, and it would have to be accomplished legislatively.

Representative PEPPER. You need legislation before you can ex

Mr. SHEINBACH. Mr. Pepper, may I add one more point? In 1968 we were concerned about areas of the country that had no home health agencies.

We identified 99 areas around the country that had a population of 50,000 or more people with no home health agency services avail

able.

Since that time, we have managed through Federal and State efforts to provide coverage to about half of those 99 areas. We are making progress all the time to eliminate these blackout areas, where people

Representative PEPPER. That is exactly what I am talking about. What can we do to eliminate the halves, the quarters, and the threequarters, and to provide comprehensive home care of the sort that is needed to the elderly people of this country? I want to know when we are going to get to the point that we will effectively do the job. Now, let us go back to medicaid. Does medicaid encompass home aide assistance?

Dr. WEIKEL. Yes, sir.

Representative PEPPER. Why can we not have a simple comprehensive home health care for the elderly in this country under medicaid?

Dr. WEIKEL. Medicaid can only cover those that are eligible for the program; that includes approximately 5 million elderly over the age of 65.

Representative PEPPER. Will you describe the categories of eligibility?

ELIGIBILITY CATEGORIES

Dr. WEIKEL. The eligibility categories for medicaid are basically the aged, the blind, the disabled, and members of families receiving aid to dependent children.

Representative PEPPER. You are talking about the people covered by SSI.

Dr. WEIKEL. The SSI individuals are covered for medicaid, that is correct, so we presently have approximately 5 million elderly over the age of 65.

Representative PEPPER. Is that all of the elderly people in this country that need comprehensive home health care services?

Dr. WEIKEL. Not all of the elderly people in this country are eligible for medicaid.

Representative PEPPER. I am not talking about who is eligible. How many need it?

Dr. WEIKEL. Unfortunately, I do not think we have a good estimate of how many really need it. We know a significant percentage of medicaid recipients should have home health care. The medicare program, which does provide the 100 visits for home health services covers 25 million recipients.

Representative PEPPER. Do we agree that the medicaid law itself is not broad enough to commit the Government, even if it provides the funds, to a comprehensive home health care program for the elderly of the country who need it?

Dr. WEIKEL. Not for all of them, no.

Representative PEPPER. What changes would be needed in the law to make it available to all those who need it?

Dr. WEIKEL. You would have to expand the eligibility categories. You would have to say that all elderly would be eligible for medicaid, and that puts you in direct conflict with medicare.

Mr. FRANKLIN. Mr. Chairman, you would have to change the definition of what is "need," who needs the care. You can certainly determine need in a number of different ways. Certainly, many, many people who need the services of medicaid do fall under what is established as the current need categories.

Medicaid spends a substantial amount of money each year providing these services to the needy. It depends on where you draw the line between "need" and "nice to have," and certainly we have to look at this with a very sharp economic eye to see what is fiscally possible to provide.

Representative PEPPER. In those eligible for SSI, is not the maximum $245 a month for a couple?

Dr. WEIKEL. Somewhere around there.