the Department your most recently certified official cost figures as they apply to the types of visits included within the scope of our program.

N.B.-The Rhode Island State Department of Health will continue as the primary resource for payment of maternal and child health nursing visits provided for patients who are eligible recipients of Medical Assistance under criteria established by the Maternal and Child Health Divison.

The following revisions pertain to other phases of the fee schedule for Visiting Nursing Services:

1. The allowable fee for each additional patient seen on the same day at the same address will remain at $3.00.

2. The maximum payment allowable for a single visit-regardless of the number of persons seen-will be increased from $9.00 to $11.00.

3.

The maximum payment allowable for a single patient visited more than once within a 24-hour period will be increased from $9.00 to $11.00.

4. Payment for nursing services provided in the Visiting Nursing Agency's office (office visit) will remain at $3.00.

It is indeed unfortunate that the current interpretation of Federal Medicare policy serves to eliminate many of those elderly and chronically ill from eligibility of payment for Visiting Nursing Services under the provision of the Federal Medicare Program (Title XVIII).

As a result of this more restrictive policy by the Federal Medicare Program, many of the Visiting Nursing Agencies had discontinued submitting those patients whose eligibility for Visiting Nursing Services was questionable under current Federal Medicare eligibilty criteria.

Please note carefully that the Department of Social and Rehabilitative Services continues to require that all Visiting Nursing Agencies submit requests for payment to Blue Cross/Blue Shield, the Fiscal Intermediary for Federal Medicare, for Visiting Nursing Services provided eligible under the provisions of Titles XVIII (A and B). This requirement continues to be necessary though the services provided may not be ultimately reimbursed by Federal Medicare under their current interpretation of eligibility for these services. It is only after this procedure is followed that the Department of Social and Rehabilitative Services is able to determine the amount of liability for payment which remains with the Rhode Island Medical Assistance Program.

You have been very cooperative in this respect-your spirit of cooperation is greatly appreciated. We have been receiving notification of Form SSA1487 HOME HEALTH AGENCY REPORT AND BILLING from the Fiscal Intermediary for Federal Medicare advising the Department of Social and Rehabilitative Services when a patient no longer qualifies for Visiting Nursing Services provided under the Federal Medicare Program. In these cases, the claims have been processed according to the Rhode Island Medical Assistance fee schedule. You are reminded that the initial receipt of Form SSA-1487 HOME HEALTH AGENCY REPORT AND BILLING by our Department is not sufficient to satisfy the total requirements beyond a period of six months. We are, therefore, asking that you resubmit each case to the Fiscal Intermediary of Medicare at the end of each six months period of service. This procedure will enable us to maintain on file a current verification that the resource of Federal Medicare has been explored and, in fact, there is no eligibility for payment for these services under the provisions of Title XVIII (A and B).

You should know that those of us responsible for the administration of the Rhode Island Medical Assistance Program are not alone in our adverse reaction to these more recently-developed restrictions as they relate to the criteria which must be fulfilled by Visiting Nursing Services in order to qualify for reimbursement under the provisions of Title XVIII(A and B). We shall continue to make every effort to seek a more reasonable and liberal interpretation of the Visiting Nursing Services provided eligible recipients of Federal Medicare for which reimbursement can be expected through Title XVIII.

I want to take this opportunity to express my sincere thanks and appreciation for the continuous spirit of cooperation manifested by all participating visiting Nursing Agencies of Rhode Island in providing high quality medical services for our eligible recipients of Medical Assistance.

P. JOSEPH PESARE, DR., P.H., M.D..
Medical Care Program Director:

CRANSTON DISTRICT NURSING ASSOCIATION FEE CARD, SUBMITTED BY
SHIRLEY A. WHITCOMB

Office Hours: From 8:00 A.M. to 4:00 P.M. daily; closed Saturdays, Sundays and Holidays. Calls for Saturdays, Sundays and Holidays must be made during regular office hours.

Charges per visit: (Effective July 1, 1970)

May be adjusted for those who cannot pay:

Nursing

Physical Therapy

It is requested that daily payment be made.

$10.50 12.25

ITEM 8. LETTER FROM ALEX M. BURGESS, JR., M.D., CHIEF, DIVISION OF PLANNING AND STANDARDS, IN RESPONSE TO SPECIFIC QUESTIONS RAISED BY SENATOR PELL

February 16, 1972.

1. How can the State and Federal governments cooperate most effectively to provide health care for senior citizens?

Since basically, the State and Federal governmental aims tend to be identical, there should logically be no problem. However, the nationwide focus of the federal programs leads to the establishment of objectives, procedures, and even standards which do not reflect the variability of the individual states' needs and objectives. As I have mentioned before, the smoothly functioning system set up under the "Hill-Burton" legislation provides a worthwhile model. Here, the Federal establishment furnishes certain over-all guidelines and regulations, and the state develops its own detailed plan, within the latitude that national policies provide. My plea, then, is for systems which do not impose "all purpose" plans and procedures on state agencies to the extent of impairing their ability to approach local problems, which may be unique to the particular area. Our developing new systems will need to take account of this problem with particular care if the citizens, young or old, is to get maximal health benefits.

2. What are the major deficiencies in Medicare and Medicaid that should be eliminated in an ideal plan of health care for the elderly in the future?

The major deficiency, overriding all others in my opinion, is the existence of these parallel and basically similarly motivated programs side by side. In fact, the existence of programs aimed at limited aspects of the problem of health care will guarantee problems. If some further federal program or programs comes to sit beside these two, even more outrageous duplication and unnecessary administrative expense will result. I see, in some of the pending legislation, a real risk that this could happen.

The infusion of money and new programs will not solve the health care program, and may compound the factors producing ineffective care. What is needed, in short, is not more and better Medicare and Medicaid programs, aimed at the elderly but some constructive approach to the entire system, for persons of all ages.

3. Is the replacement of the current multiplicity of health care systems by a single system the best approach to pursue in planning for the future?

The multiplicity of different bills now before the Congress, in itself, guarantees that further "boiling down" must take place before a single alternative can be selected. I feel, however, that the need for a single over-all approach is an urgent one.

We have too many other fiscal and administrative problems, to continue to tolerate those that are based on duplicative parallel systems of payment and quality control. The cost in terms of extra administrative personnel alone in the State and Federal establishments and in the business side of the health care providers' establishment is undoubtedly high, and would be unnecessary if a single system of payment, record-keeping, and quality standards implementation were in force.

Appendix 3

ADDITIONAL MATERIAL SUBMITTED BY WITNESSES

ITEM 1. LETTER TO SENATOR PELL FROM VERONICA MURRAY, PROVIDENCE, R.I.*

DEAR SENATOR PELL: I was allowed a short time to speak at the end of the meeting, but was not allowed enough time to finish what I had to say, as you were tired, and I also was tired, as I was at that meeting from 10 a.m. until it finished; however, I will finish now, Senator Pell.

We, the elderly, know best what we need.

We, the elderly, are sick and tired of surveys and studies of aging. That money that is spent for surveys, etc. should be in our pension checks instead.

1. Higher Social Security pensions for those in the lower bracket. If the poverty level is considered to be $3,300 a year, why are we receiving such low pensions? Why are we not receiving what we should be receiving?

2. Housing for the elderly-Many of us are unable to get into public housing, as there is a long list waiting to get in, and when you are called for an interview, a single person is only allowed an efficiency apartment, which consists of one large room (very small kitchenette and bath). At least we should be allowed two large rooms and bath.

3. Transportation for the elderly should be improved.

4. Last but not least, a good medical bill covering such as foot doctors, dentists, eye doctors, eyeglasses, and chiropractors. I believe if these things were met, many problems would be solved, and less money would be required. Let's forget about sending men to the moon to bring back rocks; also let's forget foreign aid until our people are taken care of.

The elderly are sick and tired of money being spent on Studies and surveys on Aging. We feel we know what we need and it certainly is not surveys and studies, it is higher Social Security Payments for those in the lower Pension bracket. Those receiving the higher Social Security payments benefit by the small raises in Social Security but those in the lower bracket don't as the raises are too small and should be corrected at once. Many are forced onto the Welfare rolls that are very much against charity and they should not be classed as Welfare People as they worked all their lives for small wages and long hours only to find when they no longer could work they seem to be penalized for becoming old.

Could those people in Congress live on the small Pensions many are forced to live on? Why don't they try and then they would find out how long before their health would break down. Now is the time for a change, not 1972-73. Now. Also Senator Pell the Pension Age should be lowered to at least 58 years of age and the ones that were forced to take their Pensions at 62 years of age, through no fault of their own (just that their health broke down) should be given the amount they lost by taking their pension at 62 instead of 65 years of age. Why must the elderly Poor have to suffer so Senator Pell? Many doctors have become wealthy on the elderly and they know how the elderly are suffering but I don't see them speaking out. Let's wake up Senator Pell and do something about these conditions.

* See testimony p. 292.

(363)

ITEM 2. LETTER TO SENATOR PELL FROM MILDRED A. DEAN

PROVIDENCE, R.I.*

DEAR SENATOR PELL: I understood that there was only 7 minutes for each one so I cut short one of the things that is surely needed. The program for entertainment for the institutionalized elderly at Hospitals. The R. I. Association of Senior Citizens and Senior Citizens Clubs Inc. has devoted much time to this program as the Doctors at the Medical Center has often commended the lift it gives to the patients. I have carried on with little help this past year and this program as well as Grand Parents day of Rhode Island will also go out of existence. I have been very proud of these programs and am very discouraged to see them pass on. Thanks for all your help.

Sincerely,

*See testimony p. 245.

MILDRED A. DEAN.

Appendix 4

LETTERS FROM INDIVIDUALS AND ORGANIZATIONS ITEM 1. LETTER TO SENATOR PELL FROM DORIS E. JOHNSON, LIBRARIAN, PROVIDENCE, R.I.

September 28, 1971.

DEAR SENATOR PELL: I am so sorry that I could not be present at the conference that you held recently in Providence regarding the problems of senior citizens. I am writing this to call to your attention an injustice (inequity is a better word) regarding social security payments. Knowing your deep interest in helping the elderly, I feel sure that you will be interested in my point of view. At first glance, you may not agree with me, but if you will bear with me a little, I believe you will see some merit in my arguments.

When a working person retires, he is entitled to social security payments from which money is deducted if more money is earned-$1800 a year may be earned without deductions, I believe. However, if the person retiring happens to have income from investments, real estate or other holdings, he may collect his full social security without any deduction being made. In other words, the working man who could not manage to save or make other investments and who feels -obliged to go on working to supplement social security payments is penalized, while the more fortunate person may actually be wealthy and not even need the social security.

I am not contending that the more fortunate man should lose his social security payments, or even have them reduced. What I believe is that when a worker has paid income taxes through the years, he should be entitled to his social security as a right, regardless of whether he goes on working or not. If this were true beginning at age 65, there would not be too many who could collect, and go on working because many firms require their employees to retire at that age. However, if a man were well enough and lucky enough to be able to work, I think he should be allowed to do so without any deductions being made. Most people at age 65 only want to work part-time, but the limitations on what they can earn keep them in a low financial bracket and count against them in accepting special work that they alone may be qualified to do well.

In these days of heavy unemployment, some people would say right away that if the older people go on working, they would not make way for younger men to fill their jobs. My belief is that there would only be a small group able and willing to work, and probably not for more than a couple of years. But this would give them a chance to save something more for retirement and make up for some of the time when they couldn't save because of high taxes and high cost of living. Here, in brief, are the advantages of letting older citizens have their full social security with no strings attached :

1. They would, of course, pay income taxes on their earnings plus social security payments.

2. The clerical work involved in keeping track of their exact earnings and the ratio to their social security would be eliminated.

3. They would not be competing for poorly paid jobs because they could work at their own specialty at a higher rate and might not need more than a few hours a week to supplement their income.

4. Those who are now employed full-time and are not compelled to retire could work less and collect social security. In other words, they would not feel forced to go on working full-time because they could not live on their social security payments alone.

5. The difference in cost to the Government would not be great for those who are working part-time and getting social security. Some social security is being paid them anyway. The difference would also be offset by less clerical work in keeping track of their accounts.