That is the outstanding study in this area done historically in this country, and I am very happy to say we did it.

As a result of that, pointing out the need for uniformity for aidelevel training, we have developed this manual* for both preservice and inservice training of the aide-level people, and we do that in all of our offices.

Where available, we use community facilities. Where we cannot get community service facilities, we rent space, and we do it continuously on an inservice basis as well as preservice.

QUALITY CONTROL BASED ON TRAINING

Quality control in home health care is based on the training of the person delivering that care, and unless we have some form of standardization of that aide-level training in this country we'll be in trouble. The need for trained aides as long back as 1971, expressed by HEW at that time, was 300,000 home health aides. That is the requirement for appropriate delivery of home health care in this country; matching the proper level of care, with the proper level of skills, so that we get the greatest amount of service for the dollars. spent. We have to train them. That is how you do it. Enforcement: We seem to forget that in title XVIII under the original Social Security Act, medicare, section 1864, there is a single State agency in all of the 50 States under contract with the Secretary of HEW this very day.

They do the surveying. They do the monitoring of the quality of care being delivered by the agency that has been permitted in the program.

If you look at section 1864 (b), it says that those State agencies may be reimbursed, or may be prepaid for doing that kind of monitoring.

That mechanism is already in place. No question at all, it is there. It will be most wasteful right now with our Government being under the kind of dollar pinch that we are in, to duplicate that kind of monitoring, that kind of quality control at the State level.

Certainly it ought to be the same agency that does it--for both medicare and medicaid-and the simple legislative change that was sent up by the administration to the Hill on July 2, would make that possible. It would open up title XVIII for proprietaries, as well as this reg opens up title XIX.

Of course, title XIX has never been closed. It has simply been misadministered on the State level since the inception of title XIX. I would urge you to push for that legislative change, and then we can truly have one State agency, and one set of standards, covering all home health agencies. That one, with Government funding, and that is already provided for in 1864 (b), is all that is needed to make sure the "schlock" operator does not get involved. He will be out of it for sure, and that is what we are all interested in. We do not want a man who does not know how to deliver care. We do not want somebody who will just take advantage of Government funding. I have been

*"Aide Training Manual," Homemakers Upjohn.

so bold as to suggest in various areas, I can only get a number of dollars out of the private pocketbook, and I should not be permitted to get more dollars out of Uncle Sam than I can get out of the private pocketbook.

We want to be very careful that we do not impose a bunch of regulations which will end up in paperwork forcing my prices up from their current level to those currently being charged by the not for profits, and I would like to give you one example of that.

Here is the case history on costs in a northwest upstate New York County. In speaking to the administrator and examining the records up there, for four home health aides in the county department of health's home health agency, they spent $52,000 a year on their salaries and benefits alone.

That administrator tells us he gets less than 50 percent of their time in the actual delivery of care to patients in that county.

If I were being generous, giving him 60 percent, that would be, after some calculations, $10.83 per hour. They are charging, however, for an aide-and this is from Assemblyman Herbert Miller's report, the study he did in the State of New York-$6.30 per hour.

That is $4.53 below their actual costs. If they file a form 1728 at the end of the year, they get that in lump sum, but look at what could happen if you applied proper business applications here.

For the same number of dollars-$52,000-if they were buying from us, including our gross profit in that marketplace where our rate for home health aides is $3.95 per hour, they could get an additional 13,000 hours of service. If all they need is 4,800 hours of service, they could save $33,040 by using our service.

Thank you for allowing me to speak to you, and I await your questions. I thank you.

Mr. HALAMANDARIS. We will now have the statements from the other three gentlemen at the table. Our next witness is Mr. Richard P. Brown, executive vice president, Unihealth Services Corp., New Orleans, La.

STATEMENT OF RICHARD P. BROWN, EXECUTIVE VICE PRESIDENT, UNIHEALTH SERVICES CORP., NEW ORLEANS, LA.

Mr. BROWN. Honored chairmen and distinguished members of the subcommittees, my name is Richard Brown, and I greatly appreciate your allowing me these few minutes to speak to you.

By way of background, I am executive vice president of Unihealth Services Corp., whose business is to provide consultation to health facilities across the country. We primarily serve 24 home health agencies in 12 different States and the District of Columbia with management and professional consultation, accounting, and data processing services. These home health agencies provided 375,000 visits to 25,000 patients in the last year. I am also associate adjunct professor in the graduate program in hospital administration of the School of Public Health and Tropical Medicine at Tulane University. I have come here to give testimony with reference to proposed rules published in the Federal Register, volume 40, No. 163, Thursday,

August 21, 1975, 45 CFR part 249. As I understand these proposed rules, they are meant to expand the availability of home health services to categorically eligible title XIX recipients.

STATE MUST PROVIDE SKILLED NURSING

To the extent that these rules do this without altering the present orderly framework for the provision of home health services under the standards set forth by the conditions of participation for home health agencies they would be welcome. Unfortunately, however, the only good part of these rules is the part that clarifies the fact that the State must provide for at least skilled nursing, home health aide services, and supplies and equipment. If you want to make this extension of services effective, there needs to be added to the rules the minimum quantity of services to be made available to the recipients, that the State must pay at least cost as defined under title XVIII and that States must purchase the services in addition to providing them through State agencies. Further, physical, speech, and occupational therapy as well as medical social services and nutritional guidance should be considered essential parts of home care and should be included as home health services required in the State plan.

Presently, many States maintain artificial barriers to the provision of home health care to title XIX recipients and avoid meeting the requirement to provide skilled nursing visits by offering to pay less than cost to providers.

The preamble to the regulations states in general the requirements that providers meet statutory requirements and particularly that the requirements to provide a second service to nursing service limit participation and deters creation of new agencies.

It is not very difficult to develop a second service and I shudder to think that the Secretary would be willing to purchase home health services from such unsophisticated providers who could not complete such a simple task or who could not otherwise substantially comply with the current title XVIII conditions of participation for home health agencies.

Further, the rules would strike down the requirement that the provider be tax exempt in the absence of licensing laws in the State. Over the years, I have come to learn that the requirements of the Internal Revenue Service to obtain and keep a 501 exemption are very much in consonance with the titles XVIII and XIX concepts of dealing at cost.

The Government has had a tremendous impact on the health care delivery system in the United States as a handler of 50 percent of the money that flows through the system and as a rulemaker. In this role, it has developed conceptual models through the conditions of participation for various types of providers. Through this influence, the adoption of these rules would invite the creation of a new set of providers of home care that would meet lower standards for service for title XIX recipients than those for title XVIII recipients. The lowering of standards, the provision of second-class home health services to medicaid recipients, and the purposeful fragmentation of the system of providing home health services, which all would be the result of the adoption of the bulk of these regulations, cannot

possibly be acceptable for the purpose of the Secretary or anyone here assembled.

In summary, we are in favor of section 249.10 of these proposed regulations but feel that this should be expanded to include physical, speech, and occupational therapy as well as medical, social service, and nutritional guidance. Further, the States should be required to purchase an adequate and specified quantity of home health services for title XIX recipients at not less than cost. The remainder of the proposed regulations should be deleted.

We appreciate the opportunity of testifying. Our staff at Unihealth is available and would appreciate the opportunity of responding to any revision or new regulations concerning these issues.

Mr. HALAMANDARIS. Our next witness is Mr. John B. Smith, legislative counsel, medical personnel, Personnel Pool of America, Inc., Fort Lauderdale, Fla.

STATEMENT OF JOHN B. SMITH, LEGISLATIVE COUNSEL, MEDICAL PERSONNEL, PERSONNEL POOL OF AMERICA, INC., FORT LAUDERDALE, FLA.

Mr. SMITH. Thank you, Mr. Chairman.

I am John B. Smith, corporate attorney for the Medical Personnel Pool division, Personnel Pool of America, Inc., headquarters in Fort Lauderdale, Fla. Medical Personnel Pool is a division of Personnel Pool of America, Inc., a national temporary help service whose origins date back to 1946.

In 1966, we became aware of the needs of the community for private duty nursing services, and of the needs of institutions for nursing personnel to supplement their full-time staff. Since its organization in 1966, Medical Personnel Pool has grown into a national nursing service, presently having 94 offices throughout the country. In utilizing its parent company's prior history as a supplier of temporary help services, Medical Personnel Pool has extensively developed and augmented a scarce labor resource, thereby employing more people with critical skills and significantly expanding the availability of nursing and home health care services in the community.

In this regard, it is interesting to note that a significant percentage of our work force, particularly employees in the categories of nursing assistant, home health aide, and companion, are senior citizens. We are highly pleased with the quality of care and service rendered by our older employees since they seem better oriented to the needs and problems of our older clients and in many cases find it easier to establish the degree of trust and confidence so essential to the rendering of a professional service.

Medical Personnel Pool provides registered nurses, licensed practical nurses, and nurses aides directly to hospitals, nursing homes, and other institutions to supplement the permanent staff of these institutions. With the rapid expansion, and, in some cases, overexpansion, of health care institutions, and with growing concern over utilization and cost containment, more and more institutions are adopting staffing patterns directly related to bed census. By utilizing the services of Medical Personnel Pool when census patterns fluctuate, health care institutions can reduce total employment costs while at the same time

continue to provide adequate quality nursing care for patients. As a result, cost savings or at least cost containment is achieved, thereby ultimately benefiting the health care consumer or the fiscal intermediaries under various Federal funding programs.

In addition to its role of providing supplemental staffing to institutions, Medical Personnel Pool provides private duty nurses, home health aides, and other health care personnel in all skill categories to individuals in their homes and while hospitalized. Medical Personnel Pool works closely with physicians, hospital nursing and social service departments, various governmental and community agencies, and other referral sources. This aspect of Medical Personnel Pool's service is constituted and operated in much the same manner as a home health agency acting as a provider under existing medicare or medicaid programs, and Medical Personnel Pool's standards and methods of operation conform in every respect to existing standards of participation under medicare and to the proposed standards for agencies qualified to provide home health services under medicaid.

RENDERS 10 MILLION HOURS OF CARE

In 1974, Medical Personnel Pool employed nearly 30,000 nursing and health care personnel and rendered approximately 10 million hours of patient care. With offices in over 94 cities throughout the country, Medical Personnel Pool could become an effective additional source of quality home health services, if the proposed regulations are adopted.

The Older Americans Act does not include the same limitations on the eligibility of proprietary organizations to become providers that are found in existing medicare and medicaid regulations. As a result, Medical Personnel Pool has demonstrated, through contracts with a number of State and private voluntary agencies in various parts of the country, that it can effectively provide nursing services and home health aide services to the elderly, under the Older Americans Act. For example, Medical Personnel Pool for several years has been a primary provider of home health services under the Triage project and the community life association personnel care program in the Hartford, Conn., area. We believe that our participation as a service provider in this program has significantly increased the availability of quality home health care services at the lowest possible cost to the elderly residents of the Hartford, Conn., area. We are also actively involved as a provider in programs in the Rochester, N.Y., area.

Erie County, N.Y., has proposed a 75-percent expansion in Older Americans Act programs for elderly citizens of Erie County, N.Y. Medical Personnel Pool has been the provider of home health care services under this program and increased funding is being sought for the home aide program together with additional funding for escort and transportation services and other home support services. We believe this is further evidence of the possibility of increased utilization of proprietary organizations such as Medical Personnel Pool. Almost daily we receive calls from prospective clients who lack sufficient resources to afford home health care, and whom we are unable to serve due to present limitations on provider eligibility and funding. In some cases, we are able to successfully refer these persons