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require intramuscular injections on a regular basis every second day. If this is the only skilled service required, it would not necessitate the continuing availability of skilled nurses.

N.B.-I would continue to pose the basic question pertinent to the intent of Public Law 89-97 as it applies to the utilization of Extended Care Facilities. I simply urge a more liberal approach to this important area of admission of seriously-ill patients to Extended Care Facilities.

D. PHARMACY SERVICES

1. In the development of the Public Assistance Medical Care Program in 1952; consideration was given-from the beginning-to the inclusion of all those medical services and supplies which were considered basic requirements of adequate medical care. This approach was influenced by the conviction that certain medical supplies are essential, that high quality medical care for the needy represents a sound investment of public funds to prevent chronic dependence, and that physical and social rehabilitation of Public Assistance recipients restores many to gainful employment and self-help.

2. From the inception of the Public Assistance Program in 1952, provision was made for the payment of drugs provided to Public Assistance Medical Care recipients. The Rhode Island Medical Assistance Pharmacy program was developed in 1952. This program was developed through the cooperation of the Rhode Island Advisory Committee on Pharmacy and the Advisory Committee on Social Welfare of the Rhode Island Medical Society. The Pharmacy phase of the Medical Assistance Program has always had the close support and cooperation of the pharmacists of Rhode Island.

It should be noted that 100 percent of the Rhode Island pharmacists are participating in the Rhode Island Medical Assistance Program (239 as of September, 1971).

3. The Pharmacy phase of the Rhode Island Medical Assistance Program is a liberal one which does not impose hardships on the recipients and impediments to utilization of pharmacy services.

There is considerable evidence to prove that the elderly and all recipients of Medical Assistance in Rhode Island are receiving those drugs and medical services and supplies which are necessary to maintain good health.

We Continue to be Concerned About High Quality Pharmacy Services

Since the inception of our program in 1952 and the Medical Assistance Program in 1966, we continue to maintain real concern for the provision of high quality pharmacy services for our eligible recipients. If we were to agree to provide anything but the same high quality services which are available to all other persons in the community, then we would be guilty of an unreasonable act of discrimination.

It is for this reason that we have not insisted upon utilization of the following so-called control devices:

(1) Insistence upon the prescription of generic drugs.

(2) The establishment of centralized dispensing units.

(3) Insistence that prescriptions for Medical Assistance recipients be filled through hospital clinics or pharmacies.

It is an established fact that the history of our program supports our position to the effect that every reasonable effort is made to insure the personal physician-patient-pharmacist relationship which does prevail for all other citizens who are not dependent upon a State-administered program of Medical Assistance. 4. During the fiscal year 1970-1971, over 1 million prescriptions were provided to recipients of Medical Assistance. Of these 1 million prescriptions, over 180,000 prescriptions were dispensed to Old Age Assistance recipients in Rhode Island and an estimated 350,000 prescriptions were dispensed to Medically Needy Recipients over 65 years of age.

5. The Department of Social and Rehabilitative Services has designed its pharmacy program to eliminate serious hardships which may be incurred on the part of the elderly.

Witness the fact that, in March 1965, a revised policy allowed refills for Medical Assistance recipients for drugs classified as vitamins, tranquilizers and anti-depressants. Prior to that time, Medical Assistance recipients were required to return to their physicians each month to obtain a new prescription.

Elderly recipients who obtain an original prescription from the attending physician which provides for up to a 30-days supply of medication may, in addition

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to the original prescription, be allowed three refills when indicated by the attending physician. This provides an additional 90-days supply of medication.

The Department of Social and Rehabilitative Services is currently reviewing a proposal which would provide for a 100-days supply of certain maintenance drugs thereby further eliminating inconveniences on the part of all eligible recipients of Medical Assistance.

While it is true that the pharmacy phase does not have restrictions, such as a 30-days supply of medication and prior authorization for drugs not included in the scope of our program, it should be noted that these restrictions were designed primarily to protect the Medical Assistance recipients.

CHART VII.-EXPENDITURES FOR DRUGS DISPENSED TO ELIGIBLE RECIPIENTS OF MEDICAL ASSISTANCE BY CATEGORY OF ASSISTANCE (1969-70-1970-71)

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We are concerned about the premature approval of drugs which eventually prove to be harmful drugs-responsible for adverse reactions in those who use these medications.

It is for this reason that we employ the mechanism of prior authorization as a means of employing a reasonable and desirable control as it relates to the early usage of new and clinically untried drugs which can be classified as potentially dangerous. It should also be noted that many of these new and untried drugs are extremely expensive drugs. The additional expense cannot be justified by an established certainty that the new drugs are that much more effective than the older, more well-established drugs and of equal safety.

E. DENTAL SERVICES

1. Federal Medicare does not make provision for payment of dental services for those aged individuals entitled to Federal Medicare supplementary medical insurance benefits. In addition to this, the conditions for Federal participation in our title XIX Medical Assistance Programs does not require the State to include provision for payment of dental services. Rhode Island, has always considered dental care a very important facet of total medical care and, therefore, voluntarily included payment for dental services within the scope of our Medical Care Program since 1952.

The Rhode Island State Department of Social and Rehabilitative Services expended in excess of $1,000,000 for dental services provided for all categories of assistance entitled to Medical Assistance benefits under the provisions of title XIX during the fiscal year 1970-1971. Of this expenditure, in excess of $300,000 was expended for dental services provided eligible recipients 65 years of age and over.

2. The Rhode Island Medical Assistance Program does make provision for payment of dental services for Medically Needy Only Recipients as well as Money Payment Recipients. There is a uniform scope of dental benefits for all eligible recipients of the Rhode Island Medical Assistance Program.

3. With the implementation of the Kerr-Mills Program in October 1964, the dental phase of the Medical Assistance for the Aging Program did provide for a limited scope of benefits for eligible recipients classified as Medically Needy Only. However, with the implementation of the Rhode Island Medical Assistance Program in 1966, the dental phase was expanded to include the full scope of dental

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services which previously had been provided only to Money Payment Recipients. This expansion of scope of services was particularly beneficial to those persons65 years of age and over-since it included provision for payment of partial and full dentures.

4. On October 1, 1967, an upward revision of the Dental Fee Schedule was implemented with the concurrence and acceptance of the Rhode Island State Dental Society. The practicing dentists participating in our program have expressed an overall satisfaction with this fee schedule which has resulted in a more extensive participating in the program by the practicing dentists.

We are convinced that high quality dental care is available to all our eligible recipients of Medical Assistance; that these services are being utilized by our eligible caseload. We take pride in the fact that these services are provided for these recipients by the private dentist of their own choice.

CHART VIII.-DENTAL EXPENDITURES FOR OAA AND MA RECIPIENTS TOGETHER WITH THE TOTAL DENTAL EXPENDITURES FOR ALL CATEGORIES OF ASSISTANCE

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1. Payment for visiting nursing services has always been included within the scope of our Medical Assistance Program. We have always looked upon the services of visiting nurses as essential services required for:

(a) the provision for medical care on a continued basis;
(b) prevention of any unnecessary hospitalization;

(c) facilitate the early discharge of patients from expensive hospital facilities.

(d) returning these hospitalized patients to their families and community at the earliest time possible in keeping with good quality of medical care. We consider these services as essential for the intelligent administration of the Medicare Program.

In planning for the implementation of the Medicaid Program, the State Agency looked upon the provision of Title XVIII (A) and (B) for the payment of socalled home health services provided by visiting nurses. We considered these as essential for the intelligent administration of the Medicare Program and, more specifically, the hospital phase of the Medicare Program. We have always felt that if expensive hospital facilities are to be utilized only for those patients requiring these services, the early return of the patient from the hospital to the community would be predicated upon the provision of adequate home health services.

2. Our State planning for the cost of Visiting Nursing Services was predicated upon the fact that these services would, for the greater part, be paid for through the Federal Medicare Program. However, an apparent re-definition of standards and Federal Medicare policy, in 1969, has created a very real and serious problem for the Visiting Nursing Associations who are providing home visits to the elderly and to the State Agency which is responsible for 23.4 percent of the population 65 years of age and over in Rhode Island.

It appears that, since 1969, a substantial number of our eligible recipients whom we considered eligible for home health services under the provisions of

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Title XVIII (A) and (B) no longer qualify for these skilled nursing services. The situation becomes all the more difficult to comprehend when we can obtain no satisfactory or logical answer to our queries as to why this restrictive policy. N.B.-We object very strongly to this new policy by Federal Medicare. If these essential nursing services cannot be provided at home, then we may rest assured that they will be provided through unnecessary extended hospital stays or through unnecessary admissions to Extended Care Facilities, Skilled Nursing Homes or Intermediate Care Facilities.

3. Title XIX has chosen not to eliminate the elderly and chronically ill from eligibility of payment for visiting nursing services. Title XIX chose to make payment to Home Health Agencies for essential proper skilled nursing ordered by a physician. No restrictions were required in terms of the patient being chronically ill or requiring long-term health care.

The resultant of this more reasonable Title XIX policy is, of course, calculated to an increased expenditure of Title XIX funds for visiting nursing services. For the fiscal year 1970-1971, we had anticipated a visiting nursing agency expenditure of $157,274; our actual expenditure was $185,964.00.

FEDERAL MEDICARE CRITERIA FOR ELIGIBILITY FOR VISITING NURSING SERVICES UNDER THE PROVISIONS OF TITLE XVII(A) AND (B)

In order to qualify for home health benefits under Parts A and B, the following must exist:

1. Federal Medicare provides payment for home health benefits following hospitalization of at least three days consecutive duration. (For Part A Only)

2. A doctor determines that home health care is needed and sets up a home health plan within 14 days after discharge from the hospital or a participating extended care facility. (For Part A only)

3. The home health care is intended for further treatment of a condition for which services were received as a bed patient in the hospital or extended care facility. (For Part A Only)

4. The beneficiary must be homebound.

5. The services received must fulfill the criteria of intermittent skilled nursing services.

a. Skilled nursing services include two components:

(1) The rendition of direct skilled nursing services, such as the changing of in-dwelling catheters, and the application of dressings involving prescription medications and aseptic conditions.

(2) Skilled nursing observation and evaluation such as may be required in those cases where symptoms are quite likely to occur which will indicate the need to revise the patient's treatment regimen.

Reaction. These criteria are quite broad. As a physician, I fail to comprehend or accept the very rigid-unilateral determinations that are made in denying benefits to specific cases.

EXAMPLES OF CASES IN WHICH FEDERAL MEDICARE HAS DENIED PAYMENT FOR VISITING NURSING SERVICES

1. 86 year old woman-diagnosis of chronic brain syndrome

Service provided-enema.

2. 77 year old woman-diagnosis of diabetic neuropathy Service provided-insulin.

3. 82 year old woman-diagnosis of ASHD with pacemaker Service provided-checking vital signs.

4. 85 year old woman-diagnosis CVA-left paralysis

Service provided-physical therapy.

5. 93 year old woman-diagnosis fractured ankle Service provided-general care and instruction.

6. 82 year old woman-diagnosis of Entropion/trichiosis

Service provided-remove ingrown eyelashes.

7. 82 year old woman-diagnosis of vascular ulcer left ankle, fracture right humerus

Service provided-physical therapy and dressing.

8. 89 year old woman-diagnosis of chronic brain syndrome, decubiti on back Service provided-injection and general care.

9. 88 year old woman-diagnosis of mild congestive heart failure

Service provided-Thiomerin injection.

G. AMBULANCE SERVICES

1. Ambulance services is one of the benefits provided under Part B of Federal Medicare. We call your attention to the fact that 100 percent of our Old Age Assistance caseload are entitled to benefits under Part B of Federal Medicare as the State Agency purchases this coverage for its eligible Money Payment Recipients 65 years of age and over, and that 94% of the Medically Needy Only are also entitled to Part B benefits. This means that the State Agency recognizes and assumes responsibility for payment of ambulance services provided persons 65 years of age and over:

(a) when there is a deductible to be met.

(b) when there is a co-insurance factor to be met.

2. A major problem confronting the State Agency and our elderly citizens relates to the failure on the part of the Federal Medicare Program to assume responsibility for certain ambulance services which are truly required. However, Federal Medicare maintains that certain ambulance services fall beyond the scope of their program.

VI. The rise in Federal medicare premiums, deductibles and co-insurance factors A. As of April 1, 1968, the State Agency entered into a buy-in arrangement with the Federal Government to purchase Federal Medicare SMI benefits for all Old Age Assistance recipients.

Our latest estimates indicate that approximately 94% of our Medically Needy Only Recipients 65 years of age and over have voluntarily purchased coverage through Part B of Federal Medicare. We consider this a very significant indication that the vast majority of persons are eager to maintain their dignity in making every effort, even at personal sacrifice, to preserve their independence as it applies to payment for their medical services despite the fact that Federal Medicare has made it increasingly costly for them to continue to qualify for these benefits.

I consider this one of the most serious injustices of the Federal Medicare Program.

When Federal Medicare was implemented on July 1, 1966, the monthly premium for the benefits under Part B was $3.00 per month. The premium has gradually increased up to the present assessment of $5.60 per month-an increase of 86%.

In addition, the deductible for hospital payments increased from $40 in 1966 to $60 in 1971, an increase of 50%.

The co-insurance for hospitalization has increased from $10 per day to $15 per day after the 60th day of in-patient hospitalization, an increase of 50%. For those who are eligible for the State Medicaid Program, the State has assumed responsibility for the payment of the increased deductible and coinsurance segments. However, I am thinking, at this point, about the persons who are not eligible for the State Medicaid Program and who must assume personal responsibility for these payments.

N.B.-Why has the Federal Agency permitted the creation of this hardship for approximately 80,000 elderly persons in Rhode Island?

I am aware of the arguments presented by the Federal Agency to the effect that the Federal Medicare Program represents an insurance program and, therefore, must maintain financial solvency. I fail to comprehend the wisdom of the Federal Legislators who have permitted these increases to be assumed by the beneficiaries of the Federal Medicare Program.

Certainly, if there is one area in which the Federal Government could be of very definite assistance to these elderly persons, it would be in this area of assuming responsibility for increases in monthly premiums, deductibles and the co-insurance factors that have been levied against this group.

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