to an appropriate community or private nonprofit agency. However, we are convinced that the needs of a substantial number of these persons for home health care are not being adequately met, or are not being met at all. This may be due to a number of factors such as excessive case loads, inadequate manpower resources, maldistribution of home health agencies, excessively strict and confusing eligibility requirements, excessive administrative procedures and delays, and inadequate funding. Nevertheless, we believe that it is evident that a significant segment of the community, and particularly the senior citizen, has been denied access to a readily available, quality, lowcost source of home health care. On the other side of the coin, the same public and private nonprofit agencies, in order to reduce their case load and to more effectively utilize their resources refer many cases to us. RATES COMPARE FAVORABLY A recent study of the Lake County, Ind., Comprehensive Health Planning Council included a report of rates for home health care charged by local agencies. Despite the fact it was not at that time certified, Medical Personnel Pool was the only proprietary organization included. Its rates of $6 per hour for registered nurses, $4.80 per hour for licensed practical nurses, and $3.10 per hour for home health aides, compared favorably to the rates of the three local public nonprofit agencies, whose rates varied from $6.65 to $14.75 for a 1-hour visit by a registered nurse. Medical Personnel Pool rates in other areas of the country also compare favorably, and will result in costs savings under the medicaid program if the proposed regulations are adopted. An experimental 222 project in Connecticut titled "Triage" has been serving 3,000 elderly with a full range of home services. To quote Joan Quinn, associate director of the project: "We cannot fully utilize VNA's because of their 8-to-4 working hours. We must depend on Upjohn and Medical Personnel Pool because we can count on them round the clock, 7 days a week." Why can't or why won't voluntary agencies provide adequate services to those in need? Another example I think addresses itself to the question that Senator Moss posed to Mr. Weikel. To me, the question implied that there was an overabundance of home health agencies in Florida. Florida has just passed a licensing law, and it is holding a hearing this Thursday on proposed regulations and standards, which if adopted, will be the strictest set of home health standards in any State in the country. But a report was issued, I believe by Senator Robert Graham, on the Senate Health Care Committee in the State of Florida, in connection with the passage of the licensing law. The report is dated August 1975 and, as I recall, the title is "Utilization of Home Health Services in Florida." The Senator's report clearly indicates that one of the purposes behind adoption of the Florida licensing law was to encourage further utilization of home health services, and to expand the availability of home health services, which seems contrary to the suggestion that there is already an overabundance of home health agencies in the State. While Medical Personnel Pool has not heretofore participated as a provider under medicaid, it has had substantial experience as a provider of home health services to various State, local, and private organizations. For example, home health aide and homemaker serv ices are being provided to the Erie County, N.Y., Welfare Department in a program funded under the Older Americans Act, at rates of $3.30 per hour. Similar services are being provided to the Community Life Association, Inc., in Hartford, Conn., at rates of $3.75 per hour, and negotiations are being concluded to furnish similar services at equivalent rates to the Triage program under a medicare demonstration program funded by the bureau of health insurance. Examples of similar rates structures and costs savings exist in other Medical Personnel Pool offices throughout the country, and the same favorable comparisons can undoubtedly be found in the operation of other proprietary home health care services. "SKIMMING THE CREAM" Most discussions of the proprietary organization's role in the home health care delivery system centers around the question of cost containment, quality of service, and the suggestion that proprietary organizations are "skimming the cream" by accepting only cases that can afford to pay for services and forcing the nonprofit sector to provide free service. We believe that a careful examination of the true facts would place these questions in their proper perspective. In the first place, a careful examination of some of the executive salaries of some of the so-called private, nonprofit agencies might cause one to question whether some of these agencies are, in fact, proprietary agencies in disguise. We must also remember that there is really no such thing as free medical service. The cost of such service must have some ultimate source of support whether it be profits generated by proprietaries, tax dollars, or private or charitable donations. Of course, proprietaries do not have access to the source of private or charitable dollars, and, in fact, contribute to the tax dollars which are used to support the nonprofit agencies; and since they do contribute to these tax dollars, and since they have demonstrated their ability to provide quality home health care at low cost, we believe that proprietary organizations should have access to medicare and medicaid funding mechanisms. Adoption of the proposed regulations would give State medicaid. agencies access to a substantially greater supply of home health service personnel, yet under conditions and standards regulating utilization and quality of care. It is important to note that the proposed regulations authorizing certification of proprietary agencies under medicaid will not directly increase medicaid program costs, since these regulations do not create or broaden existing services or require expenditure of additional funds. They merely enlarge the source from which home health services can be obtained, and eliminate unfair discriminatory conditions presently imposed on proprietary providers. In fact, we submit that adoption of the proposed regulations may in fact result in a reduction in medicaid program costs, or at least result in a reduction in unit costs for equivalent levels of service. Most importantly, let me tell you about how we assure patients and payers of superior service. Patients are accepted by medical per sonnel pool upon receipt of a written plan of treatment by the attending physician and with the understanding that the patient's medical, nursing, and social needs can be met. When services are terminated, the patient is notified of the date of termination and the reason for termination, which are documented in the patient's record. A plan is developed or a referral made if continuing care is needed. Services are not terminated unless the attending physician and the director of nursing mutually concur. The plan of treatment is reviewed by the attending physician and the professional staff of medical personnel pool as needed, but at least every 60 days. The plan of treatment includes, but is not limited to: diagnosis, mental status, type of service and equipment needed, frequency of visits needed, prognosis, rehabilitation potential, limitations, activities permitted, diet, medications, treatments, discharge or referral institutions date, and signature of physician. CARE PLAN DEVELOPED Each patient has a care plan developed by all members of the health team. The plan includes, but is not limited to: patient or family problems, assessment of patient, goals-long and short term -specific needs of patient, date, and signature of health team members who developed the plan. The plan of care is reviewed and revised as needed, but at least every 30 days. Progress notes to the physician are written and sent to the physician as often as necessary, but at least every 60 days. A clinical record is maintained and regularly updated for each client. The clinical record includes the client order, the plan of treatment, the plan of care, progress notes to the physician, clinical notes, client evaluation, and termination summary. Here, I might add, we maintain clinical records for even the cases requiring lower levels of care, below the home health care level. The following is an analysis of the specialized nursing skills of medical personnel pool RN's and LP/VN's. In addition, there is an analysis of the number of unlicensed personnel we employ and how many are hospital qualified, based on training and work experience. These figures represent the personnel employed by a typical medical personnel pool office. Registered professional nurse: presently employed, 75; number of baccalaureates, 25; average years of nursing experience, 7.3. Specialized nursing skills: med.-surg., 70; peds, 14; ob, 13; ortho., 10; EENT, 5; urol., 15; neuro., 5; team L, 15; burns, 1; OR, 5 ER, 2; RR, 3; ICU, 8; CCU, 8; psych. 6; kid. dial., 2; Geri., 12; rehab., 3. Licensed practical-vocational nurse: presently employed, 45; average years of experience, 5.9. Specialized nursing skills: med-surg., 39; peds, 6; OB, 5; ortho., 5; EENT, 3; urol, 7; charge, 12; ER, 1; ICU, 7; CCU 7; psych., 5; geri., 16; burns, 1; rehab., 2. Nurses aides, nursing assistants, home health aides: presently employed, 112; average years of experience, 5.3; acute care hospital qualified, 62. Home health aides are hired only if they have at least 1 year of experience. We also provide inservice training to increase or update the skills of all our health personnel. As a professional nursing service, we strive to maintain the highest standards and optimum quality concerning our selection process of all employees. Medical personnel pool welcomes the opportunity to answer any and all questions concerning the makeup of our nursing staff. Included with our written testimony are copies of all the forms previously mentioned; copies of medical personnel pool job descriptions, an outline of the nurse aide inservice training curriculum, an employee performance evaluation form, and other information pertinent to our management policies. FORMULATING A DELIVERY SYSTEM In formulating a delivery system for home health care services to the aged, we would urge the subcommittees to carefully consider and adopt standards for quality care. Insist that all home health agencies meet the same certification criteria. Congress and the Federal agencies certainly have a legitimate need to focus on standards. affecting the utilization of services. Most of the medicare conditions of participation are directed toward utilization rather than toward the quality of care. In our opinion, quality of care and concern for the patient has been secondary to proper utilization. We urge the subcommittees, in considering these regulations, to agree that they go a long way toward developing realistic and adequate safeguards for the protection of the patient and the quality of care rendered. In closing, let me thank the Senator and members of the subcommittees and their staffs for the opportunity to express our views. Let me just add, Senator, an indication of the skilled levels, of some of our people. We have done a survey of the typical office, and this office employs 75 professional nurses, 25 of them had baccalaureate degrees, and the average have 7.3 years in nursing experience. Home health aides and nursing aides, 112-averaging 5.3 years of experience. I think this demonstrates our organization, and undoubtedly the other organizations similar to ours, are interested in quality and standards. We are not solely concerned with moving in-taking business away, if you will, from the voluntary agencies. We are interested in becoming a supplemental source of home health aide services, and we are vitally interested in the continued need to develop and strengthen standards for quality care. Representative PEPPER [resuming chair]. Thank you very much. Let me ask these questions, and either one, if you wish, may answer them. I noticed in Mr. Brown's statement, he says, "if you want to make your service effective, there should at least be added the minimum quantity of services to be made available to the recipient and, that the State must pay, at least, costs as defined under title XVIII, and that States purchase service, and so forth." Now, do you submit a bid when you want to render service for an authority that has provided money from public sources? Mr. BROWN. Mr. Pepper, when I was referring to costs, I was referring to costs as defined under title XVIII, which is defined in the cost report, and what is happening is, that for a skilled nursing service, generally, in Florida, the costs from title XVIII certified agency will run maybe $25 a visit. The States Representative PEPPER. Now, do you submit to a public authority, any item of your costs? COST REPORT FILED Mr. BROWN. Yes, there is a cost report that is filed, and it is filed and audited by the fiscal intermediary. Representative PEPPER. Do you mean like a contract for doing business with the Government-you might have to explain to the Government every item of cost? Mr. BROWN. Yes, sir. Representative PEPPER. In the contract? Mr. BROWN. Yes, sir, and then you say these are the costs that I have got to incur, and then you say I want to make a certain price for my services, so give me a reasonable profit. Representative PEPPER. Do you specify what that profit is to be? Mr. BROWN. We are talking-in the medicare program, there is no allowance for profit. You deal with costs. Representative PEPPER. But you are a profit organization. Mr. BROWN. No, we provide consultation for 24 nonprofit organizations, and 1 for-profit organization. Representative PEPPER. You are talking about consultation? Mr. BROWN. I am talking about the agencies that provide the services, so far; nonprofit in 23 instances, and for-profit in 1. Representative PEPPER. But is not Upjohn a profitable pharmaceutical company? Mr. BROWN. Excuse me, Mr. Pepper. It has sort of been a matter of happenstance that we got put on the same panel, because I think, out of all due respect for Upjohn and Medical Personnel Pool, and I feel there is a lot of validity to what they have to say, and not only do we work closely with them, but I am not involved with the for-profit sector. Representative PEPPER. You are a nonprofit corporation? Representative PEPPER. Mr. Wilsmann, in how many States do you do business? Mr. WILSMANN. I believe it is 37 out of the 50—with 200 offices. Representative PEPPER. Now, I have information here from the staff that in only about seven States do you receive medicare and medicaid contract money. Mr. WILSMANN. Up until this particular session of the State legislations, there were only nine States in which we were permitted to be certified for medicare, and, therefore, certified for title XIX. Just recently, a couple of States-one is Florida, it is not done yet, because they have not gotten their regulations in place-but Florida passed a licensure law this year, allowing the for-profits to participate under both titles XVIII and XIX. Representative PEPPER. Do you agree with Mr. Weikel, under this new proposed regulation, you are still subject to the structure of being licensed by the State, and having to meet State criteria before you can operate? |