she was exhausted from his constant care since he depended entirely on her for everything-frequently getting her up at night. The physician referred the patient to our home health agency rather than suggesting institutional care. The doctor indicated Mr. Doe's restorative potential as very limited. Based on the patient's needs and physician orders, the public health nurse planned with Mrs. Doe to visit the home three times a week.

The nurse realized very quickly that Mr. Doe had not been participating in his own care. Therefore, she began to encourage him to assist in his bathing and to move toward self-help activities. With the physician's approval, the physical therapist on our staff visited in the early part of the second week of agency service. Following this evaluation, physical therapy visits were made twice a week. The nurse continued visits three times a week for the next 5 weeks. After 3 weeks of service the patient was out of bed for short periods of time and had begun to read the paper and interact with visitors.

As the patient continued to progress, Mrs. Doe's fatigue and depres sion were greatly reduced and the general tensions observed in the home during early visits had greatly diminished.

The frequency of nurse and physical therapy visits were gradually reduced as Mr. Doe became more independent. At the end of 7 months he was up, out of bed most of the time, walking with a leg brace and cane, and was about 90 percent independent in all of his activities. At the end of 9 months, the Doe family was discharged from our service. The nurse later learned that this couple had moved to California and was living independently in a small apartment near their only son. Mrs. Doe sent several cards expressing her appreciation for all the help that she and her husband received; they counted it as a miracle.

This service given in 1968 was covered by plan B of medicare-—the full cost was $785.

Today, with the present interpretation of medicare regulations by the SSA and fiscal intermediaries, Mr. Doe would not be eligible to have the cost of his care reimbursed through medicare. Present regulations prohibit payment to home health agencies for preventive health service and the care of patients with chronic illness who have a limited potential for rehabilitation. In the long run the cost to medicare or medicaid are increased substantially.

There are many elderly people who have slim prospects for total recovery, but who have the need for part-time intermittent skilled nursing observation, preventive and restorative services. Changes in the patient's physical or emotional condition may alternate between an acute and stable state, requiring observations, change in regimen, and medication. Denial of reimbursement for intermittent skilled nursing or therapeutic services to these individuals in their homes under the present regulation has, in many instances, forced their return to hospital or extended care facility at a much higher cost to the taxpayer. The regulations under medicare have grown increasingly restrictive. In addition, fiscal intermediaries do not interpret the regulations uniformly throughout the country. The present regulations restrict reimbursement to acute phases of illness and do not provide for the health services needed to prevent regression of the patient. We do not believe that this is the intent of Congress.

Therefore, we ask the Congress to state clearly in the law the intent to include coverage of home health services necessary to prevent hospitalization.

We feel that many of the medicare provisions applying to home health agencies and the care that they provide should be improved. In the long run, it costs more, not only in human misery, but in hard cold cash to institutionalize our elderly citizens rather than caring for them and providing health services at home.

We agree with the view of HIBAC-the Health Insurance Benefits Advisory Council-and others who recommend enactment of legislation which would:

Place all home health benefits under part A, with a maximum eligibility of 200 visits per year;

Remove the 3-day hospital stay requirement for home health benefits: and in addition

Provide for coinsurance for the second 100 visits per year.

Every reasonable and necessary effort should be made to improve the quality of care given to patients. We therefore recommend that:

The utilization review process be extended to include home health services;

There be a requirement for involvement of public health nursing competence in the review of claims by fiscal intermediaries and by the Social Security Administration;

The law provide for the establishment of a Home Health Advisory Committee to assist the Department of HEW in the administration of its programs that involve home health agencies; and

The home health portions of medicare, medicaid, and maternal and child health programs, be coordinated by the Department of HEW. In the interests of improving the quality of home health service, the National League for Nursing and the American Public Health Association provide for a national accreditation program of community nursing services. The criteria are more comprehensive than those required for certification in section 1861 (m) and (o) for home health agencies. We ask that section 1865 of Public Law 89-97 be amended to identify NLN-APHA as the national accreditation body for home health services.

It is the clear intent of H.R. 17550 to control costs by reducing the length of institutional care and increasing the amount of outpatient and home health services. NLN fully supports this objective.

To reduce inpatient care, further reduce hospital costs, and provide for coordinated care through early referrals to home health. agencies, we recommend that home health agencies be permitted to employ home health service coordinators whose salaries would be fully reimbursable. Such coordinators would work with the physician, patient, and family to develop appropriate posthospital plans for the care of the patient.

To decrease costs and at the same time provide needed care for people, we suggest that program efforts be directed toward increased utilization of home health agency services. During the period of July 1, 1966-December 1967, home health agency costs accounted for only 1 percent of total medicare costs.

In addition, we support the recommendations of the staff of your committee in relation to the standardization and coordination of the

administration and provision of health care services under medicare. medicaid, and maternal and child health programs, as well as the staff recommendation that the Bureau of Health Insurance be encouraged to revise procedures to avoid expensive duplication of cost finding and audit mechanisms.

Currently there is a lag in the reimbursement to home health agen cies of care rendered, as well as lack of assurance for agencies that the care provided will be reimbursed. We therefore recommend that: Procedures be instituted to facilitate the flow of cash to agencies: Procedures be developed for advance approval for home health ben efits. However, we strongly urge that the advance approval standards be sufficiently flexible to permit coverage for patients who continue to need skilled nursing, physical therapy, or speech therapy services beyond the period initially approved; and

A provider appeals mechanism be established within the law. We also suggest that home health agencies be represented on advisory groups established to review, evaluate, or coordinate community health services.

You may remember that at the beginning of our testimony I told you of Mr. Doe. We have several other equally critical situations in which patients today would not have their services reimbursed under the medicare program. I do not want to take up this committee's valuable time recounting them.

We are most grateful to this committee for giving us an opportunity to present our views and to share with you our concerns for the patients in our care. Thank you, and we are certainly willing to answer any questions you may have.

Senator ANDERSON. Thank you very much for your appearance here today.

Reverend Eggers.

STATEMENT OF REV. WILLIAM T. EGGERS, PRESIDENT, AMERICAN ASSOCIATION OF HOMES FOR THE AGING; ACCOMPANIED BY FRANK G. ZELENKA, ASSOCIATE DIRECTOR; REV. CHARLES J. FAHEY, DIRECTOR OF CATHOLIC CHARITIES, DIOCESE OF SYRACUSE; BERTRAM B. MOSS, M.D., CLINICAL DIRECTOR, DIVISION OF GERONTOLOGY, CHICAGO MEDICAL SCHOOL

Reverend EGGERS. Mr. Chairman, I am Rev. William Eggers administrator of the Home for Aged Lutherans, a 265-bed facility. participating in medicare and medicaid, in Wauwatosa, Wis.

I appear here today as president of the American Association of Homes for the Aging, an organization of nonprofit facilities for the aging, the greatest number of which are church related.

Accompanying me is Rev. Charles J. Fahey, a member of the AAHA board of directors, chairman of the AAHA interfaith group director of Catholic charities, Diocese of Syracuse; Dr. Bertram B. Moss, clinical director, Division of Gerontology, Chicago Medical School. Also accompanying me is Frank G. Zelenka, associate director of the American Association of Homes for the Aging. Reverend Fahey, Dr. Moss, and Mr. Zelenka are here to help us respond to any questions that you might have. We have filed with the committee

longer statement and are currently filing a brief summary and, with your permission, we will file some additional material in the future concerning our position on various points of H.R. 17550.

Senator ANDERSON. The staff will review that.

Reverend EGGERS. All right, thank you.

We have three points to make in an informal way before you this afternoon, and I would like to call on Dr. Bertram B. Moss, the clinical director of the Division of Gerontology of the Chicago Medical School as well as the medical administrator of the Parkview Home and the Jewish Home for the Aging. Dr. Moss, therefore, not only teaches but practices daily with older people. Dr. Moss. Senator ANDERSON. Just bear in mind the time limit.

Reverend EGGERS. Yes.

Dr. Moss. Mr. Chairman, from a medical viewpoint, we anticipate difficulty with the 90-day cutoff projected in H.R. 17550, section 225 (a). We have to consider the multiplicity of illnesses that do exist in almost all elderly persons, and we also must consider the fact that there are many individual physical deficits in practically all older

persons.

Each aged person has a specific ability to recuperate in reference to time, and this ability to recuperate is entirely unpredictable. It is unpredictable at the time of each illness and it gets more unpredictable as an individual has more and more illnesses and deficits within his body.

The entire situation of recuperation in the elderly is slow at its very best but it gets slower and slower as persons become more and more ill. There are many complications that do occur when elderly people are recuperating from an illness or during their period of rehabilitation, and these happen often, and they are quite unpredictable.

What may be considered a minor complication for younger people as they recuperate from illness is often very grave among the elderly and this prolongs the time of their recuperation.

A specific limitation of time needed for the elderly to recover or to recuperate is impossible to prognosticate from a medical viewpoint and I think it would be impossible to state a definite number of days with a cut-off period.

Therefore, each elderly person should be allowed ample time to recover or to recuperate and not have an unnecessary length of time. By the same token, this can be accomplished with proper utilization review and medical audit mechanisms which already exist in law as well as those provided for in H.R. 17550. I believe that these should be continued.

The Social Security Act should continue to require in-house utilization review for purposes of in-house self-improvement in education as well as for consideration and recommendations concerning the needed benefits for the particular individual patient in question, and these cannot be determined specifically by law.

Thank you, Mr. Chairman, for allowing me to testify here today. Reverend EGGERS. Dr. Moss was talking to 225 (a), 90-day reduction of benefits in Federal participation which our association feels. is inadvisable.

I would like to ask Rev. Charles Fahey, a member of the board of directors of the American Association of Homes for the Aging, chairman of our interfaith group, director of Catholic Charities of the

Diocese of Syracuse, and chairman of the Commission on Aging of the National Conference of Catholic Charities to discuss a second point briefly.

Reverend FAHEY. I would like to address myself to 225 (b).

It is the position of all of those organizations which took so long to enunciate that this is a most unfortunate provision in the law based upon the false premise that the definition of intermediate care could mean a significant differential in regard to the cost of the provision of

care.

There are many instances in which a person who would be located in an intermediate care facility so designated would actually require more services than a person in a skilled nursing home.

It is the position of our associations that the actual services rendered should be the basis of reimbursement rather than any presumptive services rendered. It would be most unfortunate if that which was unfactual became the basis for reimbursement and, as such became frozen into law.

We believe the concept of reasonable cost as is now prevalent in hospital care should be the kind of basis for reimbursement in terms of care whether in an intermediate care facility or in a skilled nursing home facility; that any other type of arrangement would be most unfortunate, and it becomes particularly unfortunate when it is frozen into law.

Reverend EGGERS. So our association, Mr. Chairman, feels that 225 (b) with the provision that there must be by law a cost differential between skilled nursing care and intermediate care would be a very unfortunate thing to make law because

Senator ANDERSON. Our staff will check that very carefully.
Reverend EGGERS. All right, thank you.

Our third point relates to a matter that is not a part of H.R. 17550 but which we would strongly suggest to you that you consider making a part of the law, namely, that a task force be created under the aegis of this committee and of the Committee on Ways and Means; that the charge to this task force should be that it should examine the health care programs for the aging, not including the hospital programs, that are presently provided by the Social Security Act, with a view of trying to create a single program of care short of hospital acute care, and for which reimbursement would be provided on an individual patient basis according to reasonable costs. A second charge to that task force would be to try to see if it would not be possible and feasible and best for the interests of the aging and the country and the taxpayer to have facilities with a patient mix in them rather than to have the split that we now have between intermediate and skilled care and ECF and so on, which we feel has been done to a large extent, for reimbursement purposes.

We would propose that this task force be composed not of representatives of providers of care, nonprofit homes, or for-profit facilities but of geriatricians, geriatric nurses, gerontologists, medical economists, and consumer representatives, provided that the consumer representatives do have experience in programs for the aging and have no personal financial interest in those programs.

We feel that the fragmentation of care, which has resulted from the many programs that now exist, is based on some assumptions that

are erroneous.