Dr. WEIKEL. If it is, our intention would be to include every requirement on the part of the proprietary agencies that we require for nonproprietaries.

Mr. HALAMANDARIS. Do you propose promulgating new regulations which would apply specifically to for-profit home agencies, or are you saying we will go with what we have?

Dr. WEIKEL. There are new standards in our proposed regulations. In all of the regulations, the standards are spelled out, apply to nonprofit as well as the for-profit agencies.

Mr. HALAMANDARIS. I understand that. I just was asking the question, will there be any new or higher regulations that will apply specifically to for-profit home health agencies?

Dr. WEIKEL. That is a different question. I think you are getting to the potential for overexpansion of services, and one of the things that the Department has under study now is the possibility of asking for certificate-of-need legislation, which would apply specifically to the home health agency field, to prevent the overexpansion. We have been through that in the hospital sector, and we do not want to go through it with other groups.

STATES RIGHTS ISSUE

Mr. HALAMANDARIS. One last comment. On the States rights issue, your regulations seem to be saying, on one hand, "Don't worry; nothing is changing; we will not preempt the rights of the States." But on the other hand, "These regulations are absolutely necessary because the GAO and others say things must change." You describe this process as a clarification.

Dr. WEIKEL. It clearly is a change. I would not quibble with you, but it does not preempt the need; it does not preempt the State from making the decisions, because the States can make the decisions on the matter of licensing.

One of the things that concerned us is only 11 States have made that decision, and in terms of administering the medicaid program, we clearly have different agencies making the determination on the need of providers. Licensure is handled by different agencies, and in fact, many times by different committees, in the State legislature, and they do not seem to get it together all of the time.

Mr. HALAMANDARIS. Thank you, gentlemen.

Representative PEPPER. Dr. Weikel, Mr. Franklin, all of you ladies and gentlemen, thank you very much.

Dr. WEIKEL. Thank you.

Representative PEPPER. Our next panel is made up of Edward J. Wilsmann, president, Upjohn Homemakers Home and Health Care Services, Inc., Kalamazoo, Mich.; accompanied by Mr. John Smith, legislative counsel, Medical Personnel Pool of America, Inc., Fort Lauderdale, Fla.; and Richard P. Brown, executive vice president, Unihealth Services Corp., New Orleans, La.

Gentlemen, we are sorry we have to run off, but we have to meet the 5-minute rule.

You can put your whole statement in the record, and then summarize, if you will, your direct statement.

70-652-76- -6

STATEMENT OF EDWARD J. WILSMANN, PRESIDENT, UPJOHN HOMEMAKERS HOME AND HEALTH CARE SERVICES, INC., KALAMAZOO, MICH.

Mr. WILSMANN. Thank you, Mr. Chairman.

My statement has been submitted for the record for the subcommittees, and I would like the material and the prepared statement to be made a part of the record.*

Mr. HALAMANDARIS [presiding]. If there is no objection, it will be

done.

Mr. WILSMANN. I would like the subcommittee members to pay particular attention to the tables, to the maps, and the case histories. My testimony is an excellent background for the subcommittees, but now let us get down to the issues.

I am prepared to summarize the prepared statement, and that is what I propose to do now.

Speaking specifically to the issue, I would like to discuss and try to clear up some of the obvious misconceptions here today.

Second, because we are interested in case histories, I would like to give you some interesting case histories on home health care specifically-not on nursing homes, not on prepaid health plans, or anything else, but specifically on home health.

First, some ideas of what we feel are definitely needed in the standard, and I would like to talk about cost a little bit, and very definitely speak to fiscal responsibility.

A small bit of background on Upjohn Homemakers. I am Edward J. Wilsmann, president of Homemakers Home and Health Care services, a wholly owned subsidiary of the Upjohn Co., headquartered in Kalamazoo, Mich.

On a Sunday morning, 1211⁄2 years ago, I had an auto accident. My wife was killed. I was unconscious, my 7-year-old son was unconscious, and my 4-year-old daughter had a broken collar bone. My two other girls, aged 11 and 9, were unhurt, but frightened.

The hospital assured me that the local Homemaker-Home Health Aide service would send someone out to take care of the girls. But it was Sunday. The agency was closed. You have to have your emergency between the hours of 8 and 5 and Monday through Friday.

Out of that hurt and frustration, I resolved to start an organization that would take care of people at whatever time they needed help, whether it be Sunday or 3 o'clock on a Tuesday morning.

I would also provide whatever service they needed-from a registered nurse to a driver to take a client shopping, when they couldn't do it on their own.

Our pilot project was already operating in Joliet, Ill., when the medicare law was passed in 1965.

Now, 10 years later, we have 200 offices and are the largest single supplier of home health care in the Nation. In fact, with 52,000 employees last year, Homemakers Upjohn is bigger than all of the nonprofit certified agencies combined.

The certified agencies have less than 30,000 employees, and half of those agencies have less than three-three or fewer employees. With

*See appendix 4, item 4, p. 226.

the inclusion of Homemakers Upjohn alone, Government programs could almost triple the home health work force.

Over 500,000 people sought our services in 1974 when we delivered 17 million hours of needed services in the home. If a half million people were willing to take us on in 1974, then we figure we must be doing something right.

Why not ask our clients about the quality of service they receive? As you will recall, Congressman Heinz said, "Let us look at the track record." I invite you to look at our track record.

We delivered 17 million hours of care-paid for out of the private pocketbook. We are talking here about free choice. These very people could turn to any one of the nonprofit services, but they chose us.

There is no need to belabor the need for an expanded Governmentsupported home health program. You have already been bombarded with GAO, Comptroller General, HIBAC, AMA, and AHA reports, all detailing the current statutory and regulatory restrictions on home health benefits.

We heard the need for study this morning. We have had 10 years of experience in home health care. It has been studied. They all have studied it. We know that within the 2,248 approved certified agencies within the last year, there were only 20 that happened to be proprietary.

Dr. Weikel just reported 43. I am happy to add a number of those are mine, because we have additional State laws allowing proprietaries in, and we have been certified where it is available to us. But, within what has been delivered, until these regulations came out August 21, that care was delivered by the Queen Mary, when home health care ought to be delivered more appropriately by a tug boat. We have been paying for the Queen Mary when we should not have to.

VARYING LEVELS OF SKILL

The regulations we are talking about here today carry us down through the various levels of skill, which was Senator Moss' intention when he wrote it into the bill initially, recognizing there are various levels of skill, and when we talk about these regs being less stringent than the medicare regulations, this is not so.

What these regs do is describe-they definitely describe-the lesser levels of skill, which are appropriate, and definitely needed for proper delivery of home health care.

Some of the misconceptions we listened to this morning, when Congressman Heinz talked about Upjohn-and I would prefer to call it Homemakers Upjohn, because it was Homemakers long before it was Upjohn-underbid the VNA in his home county for home health care delivery.

There could be nothing further from the truth than that. He was not talking about home health care. He was talking about title XX. There is a big difference. Title XX has just come on the books. That is a homemaker chore service.

What is the VNA bidding on homemaker chore service for?

I am sure if you look at the VNA, they do not have home health aides to deliver home health care. Title XX is not home health.

Another point, I think, has just been clarified through your questions, Mr. Halamandaris, of Dr. Weikel, that the provider manual,

which he was not aware of because he was not here this morning, definitely covers both proprietary and not-for-profit alike. Wherever the proprietaries are allowed to serve under title XVIII, they are bound by that same provider manual.

MISCONCEPTION OF 65-PAGE EXPLANATION

This morning the whole group was here, and they are not here this afternoon, so they still have the misconception: "*** that here we have 65 pages which covers the not-for-profit and one paragraph covering the for-profits."

That is not the truth at all. We should get that stricken from the record, so everybody is clarified on that particular point.

Incidentally, the man that he had specific reference to, the fellow that violated all of the principles of proper home health care in California, had been decertified more than 3 years ago, and, yes, he is running around the country. You can find him in phone booths in all of the 50 States; wherever there are title XX contracts being let, he is in there with a bid.

He does have one in Salt Lake City, and has asked for renegotiation because he cannot service at the price he got it for.

There have been abuses in the social services, but I would like somebody to quote the abuses in home health. We have 10 years of it. Don't be talking about title XX and nursing homes. Let us talk to the issue. It is home health.

We need expanded service. In those 2,000-plus agencies; they have less than 4,600 home health aides in their entirety.

We have something in excess of 32,000 home health aides. You cannot deliver proper home health care without home health aides.

Part A of medicare mandates against the use of that tugboat, We just heard about-through the questions and answers of Mr. Halamandaris and Mr. Scheinbach of SSA-whose fault is it, Congress or SSA? Who is going to get it clarified?

We have it clarified now in the new regs for title XIX, and we, for the first time, are permitted to deliver home health care, matching the level of care, and the level of skill, and paying for that appropriate level of skill, and, of course, I agree completely with Dr. Weikel, that the new regs do not preempt State rights.

All this does is, if the State does not choose to go to the licensure route, they may include the proprietary. If they choose to exclude the proprietaries, they do that via State licensure. There is no preemption of State rights within that particular set of regulations. And one more time, the standards are not lower, the standards regulate lower skills, and everybody has misinterpreted that as being inappropriately lower standards.

We heard the question about oversupply of home health agencies. Mr. Pepper asked about the situation in Florida. Within my testimony-my prepared testimony-you will find that Florida has a greater need for home health agencies than any other State.

For every home health agency in the State of Florida, there are 31,000 medicare enrollees. The average across the country is 9.941, and the lowest, where we need the fewest home health agencies added to what we already have, happens to be in New Hampshire, where that figure is 2,198.

HOME HEALTH IN FLORIDA INADEQUATE

It is definite that additional home health in Florida is very, very necessary; 31,000 enrollees per agency under what they have now is inadequate coverage.

Now, a few case histories. Here is a good one, Salt Lake City, a letter we received from the executive director, Maxine Thomas, of Salt Lake Community Nursing Services, March 27, 1975:

There are increasing incidences where visiting nursing services and home health services from your agency are being coordinated in the home, and thus is proving to be beneficial to patient, family and other concerns with patient welfare.

We are working together and are supplementing each other in the very appropriate and effective manner.

That was an unsolicited letter received from Maxine of Salt Lake City.

Here is one from Elizabeth, N.J. Visiting Nurse Service has been under pressure from the public, because of its 8 to 5 hours.

They contracted for nurse service with Homemakers Upjohn to provide 24-hour, 7-days-a-week coverage, and the Elizabeth, N.J. Visiting Nurse Service is now turning over 50 cases a week to our agency there.

Now, let us take a look at one that everybody has been talking about-New York. We are talking about the Nassau County, N.Y., Department of Social Service, and it states:

Since the certified home health agencies in this county do not have the capacity for providing the required amount of home health care services, we welcome the opportunity to utilize small visiting nurse associations, and proprietary agencies who can meet prescribed standards.

This county has to rely on purchaser services from the proprietary home health agencies in large measure.

Here is another one, in Connecticut; this is not a licensure State, yet they have issued us a title XIX provider number and pay us 100 percent with State funds, rather than getting Federal matching funds, because they could not get the service anywhere else.

Now, let us talk about what ought to be in the standards. Certainly, the standards have to be high. I do not want the "schlock" operator in anymore than you do. If you set the standards high to begin with, we will keep them out. We should not allow them to participate 6 or 7 years, and then decertify them.

Let us make sure he can meet the standards when he comes into the ball game, not only 6 or 7 years down the road.

Certainly the stuff we have heard on nursing homes would indicate standards must be elevated.

Now, let us talk about standards of quality care. I am positive one of the reasons for the low quality of care in nursing homes today is because of some nursing homes having utilized inappropriately trained nurse aides and orderlies.

Appropriately, then, in home health care, untrained home health aides have no place in our business. If they are not trained properly, let's get them that training.

But, there is absolutely no uniformity in the training of home health aides, and this study we did right here in Washington, D.C., points it out very, very vividly.

"Health Aide Education and Utilization: A Task Identification Study," T. J. Gilligan and V. C. Sherman: Homemakers Home & Health Care Services, Inc.