I am afraid we are going to get something else for all this money-a reduction in the quality of medical care in the United States. I do not think anyone, especially a physician whose decision must often be based on interpretations and best guesses, can work effectively with someone looking over his shoulder at every turn. If a physician can't put his finger on it, but has a feeling that his patient better stay another day in the hospital, that's good enough for me. I don't want to put that patient out on the street and be responsible for any harm that ensues if the standard length of stay just wasn't enough that time. Also, every hour spent by an attending physician filling out forms, preparing appeals and appearing before a UR panel is an hour lost to his patients. I am not aware that we have such an overbundance of doctors in this country to be able to afford such bureaucratic luxuries. The problem is especially acute in our small rural hospitals, because they do not have sufficient health manpower to staff up utilization review panels and still have enough physicians lift over to care for patients. Further, many physicians and elderly patients have written me expressing concern over the continuance of physicians seeing patients covered by UR. There are many who will choose, I fear, not to treat a public patient if they have to contend with the increase paper work, controls, and appeals of UR. No doubt there are problems in the administration of our government health programs. There are always some who will try to take advantage of the system. UR is just an ill-advised and overly expensive way to go about ferreting them out. Nothing in my bills would stop HEW from looking for patterns of possible unwarranted medical procedures and excessive lengths of stay ordered by participating physicians and institutions. Nothing would abridge the government's right to deny reimbursement in such cases, nor would my bills inhibit prosecution for fraud. If this type of enforcement needs to be increased, I would be all for it, because I do not want to see the taxpayers money wasted. I urge the subcommittee to seek remedies along thees lines, which will not cost as much, rather than continue the ill-starred utilization review fiasco. I cannot close, Mr. Chairman, without a few words about the elimination of the 8.5 percent nursing cost differential for Medicare patients. I have not yet co-sponsored the bill to overturn this arbitrary cutback, but if some reason is not brought into the picture, I well might. The way I understand it, HEW's rationale, if that is what it can be called, is based on a lack of information. This seems rather a poor way to make a decision. No studies have been done to determine if those elderly Medicare recipients who are treated as general care patients do or do not need more than the average nursing care afforded all other general care patients. It seems to me that this is something that can be easily proven one way or the other. I am somewhat appalled by HEW's feeling that such a study could not be undertaken because the hospitals could not be trusted not to load on extra nursing procedures while they were under Federal scrutiny. Even it this cynicism is valid, which I doubt, such a study could be conducted in U.S. Public Health Service hospitals. I therefore as the Subcommittee to take whatever action is necessary to continue the 8.5 per cent nursing differential until such time that HEW can prove that it is no longer required. Mr. Chairman, I congratulate you and the Subcommittee for being so responsive to the expressions of discontent over these regulations by holding these hearings, and I thank you for you consideration of my views. [The following communications were submitted for the record by the Honorable Al Ullman, Chairman, Committee on Ways and Means:] OFFICE OF THE GOVERNOR, STATE CAPITOL, Salem, Oreg., May 29, 1975. Mr. THOMAS J. UNDERRINER, Administrator, St. Vincent Hospital and Medical Center, Portland, Oreg. DEAR MR. UNDERRINER: Thank you for your letter of May 6, 1975, explaining why you object to the Department of Health, Education, and Welfare's action in terminating the 82% nursing service differential for Medicare beneficiaries. I have reviewed this regulation with the Department of Human Resources. It will have a fiscal impact on their medical programs. For instance, the Public Welfare Division estimates an additional cost of 50 cents per hospital day or some $136,000 during the 1975-77 biennium. I share your concern that elimination of the 82% differential for Medicare beneficiaries will shift this expense to non-Medicare hospitalized patients. You indicate an impact of $42,000 per year in your hospital. Based on a statewide bed capacity of some 9,800 beds, including state institutions, the impact statewide, based on your figure, would amount to just under $1,000,000 per year. Federal Register, Vol. 40, No. 65, proposing an amendment to Federal Regulation 405.430, was not available to the Department of Human Resources prior to the May 5 deadline for comment. I am taking the liberty of forwarding a copy of this letter and your May 5 letter to Oregon's Congressional delegation in the hope that they will look into this regulation and take steps as appropriate to correct any inequities. Thank you again for your letter. Sincerely, Gov. ROBERT W. STRAUB, State House, Salem, Oreg. BOB STRAUB, Governor. ST. VINCENT HOSPITAL AND MEDICAL CENTER, DEAR GOVERNOR STRAUB: As you are well aware the Department of Health, Education, and Welfare has proposed to terminate the 82% nursing service differential for aged Medicare patients as published in the Federal Register dated April 3, 1975. The Department gives the following reasons for termination of differential: (1) Since many Medicare patients are now below age 65, it is appropriate to use an average per diem for all patients. (2) The special care given aged patients now takes place in special care units, not in routine nursing. (3) The costs of these special care units are separately identified in the cost report. It is true that the disabled have been added to the Medicare Program and their ages are below 65. It is not true that “many” medicare patients are below age 65. At St. Vincent Hospital and Medical Center, Portland, for calendar year 1974 the below 65 medicare patients accounted for no more than 7% of the total medicare patient days of 44,412. Nationally, there are about 21.4 million aged medicare beneficiaries and less than 1.8 million disabled medicare beneficiaries. Also, you should know that from a reimbursement standpoint, the extension of the program to disabled persons did not change the "intensity" of care provided to the over 65 patients. The new medicare cost reports, specifically schedule 2781 (7-74) "Routine Service Reimbursement" does not allow the nursing differential on disabled days. It appears the Social Security Administration intends to do what Congress expressly forbid them to do and that is the shifting of medicare costs to non-medicare patients. Further, regulation Section 405.430, which established the 8%% nursing differential, provided for periodic redetermination of the differential by stating, "further studies will be conducted periodically: 1) to determine the amount of an inpatient routine salary cost differential for the aged that is appropriate in the future, 2) to ascertain what variations in differentials should be established for such classes of providers as may be found appropriate and, 3) to obtain other pertinent data including data on nursing care costs for maternity, pediatric, geriatric, and general medical and surgical patients." To the best of our knowledge no such studies have been accomplished. As to the existence of special care units and the assumption that special care given aged patients now takes place in these units is also not correct. St. Vincent Hospital and Medical Center has had special care units in existence for well over five years and the medicare census in these special care units has not increased by virtue of their existence, rather by the fact that advances in medical technology have prolonged life and these sicker patients must be treated in special care units and not on routine nursing floors. It is true that the medicare cost reimbursement formula separately identifies the costs of special care units. We strongly argue that the Social Security Administration has not presented evidence of import to substantiate its claim. We further claim that the nursing differential is now paid only where it is required, that is, to reimburse us for the disproportionately large amounts of routine nursing care required by aged medicare beneficiaries. The elimination of the 82% differential will result in a shifting of over $42,000 per year to nonmedicare patients in our hospital. With the already inevitable existing increase in the cost of hospitalization we do not believe an additional increase subsidy of the aged patient would be well received by non-medicare constituents. Sincerely, THOMAS J. UNDERRINER, Administrator. ST. ANTHONY HOSPITAL, Pendleton, Oreg., April 30, 1975. Congressman MICHAEL G. THORNE, Salem, Oreg. DEAR MR. THORNE: On behalf of St. Anthony Hospital, and the patients we serve, I urge you to direct the Social Security Administration to withdraw its proposal to terminate the Nursing Salary Cost Differential for aged Medicare patients. It is unfair for other 3rd party payors and especially the private pay individuals to absorb the termination of the 8%% Nursing Cost Differential. With all respect to you in the government field, us dealing directly with patient care realize that an aged individual requires more individualized nursing care on a routine basis. Are you suggesting with this withdrawal of the 82% Nursing Cost Differential, that we put these patients requiring this routine care into our Intensive and Cardiac Care Departments where they would receive specialized care at a much higher cost to the Medicare program, just so the agred would receive the needed care and we would be reimbursed for losing the 82% Routine Nursing Care Differential? Please give us who work directly with these patients the consideration for determining that these aged people do need the additional routine care that we give them. With all respect Mr. Thorne, I ask you to direct the Social Security Administration to withdraw its proposal to terminate the Nursing Cost Differential for aged Medicare patients. (40 Federal Register 14934, April 3, 1975.) Sincerely, Sister ANNE L. MCNAMARA, Administrator. [The following two letters were forwarded for the record by Congressman Omar Burleson:] MASON MEMORIAL HOSPITAL, INC., Mason, Tex., June 5, 1975. Hon. OMAR BURLESON, Washington, D.C. HONORABLE OMAR BURLESON: Our little hospital and the community it serves are desperately in need of your help. Mason Memorial Hospital has only 18 beds, but we have two doctors and somehow manage to scrape by even though our entire county has a population of only 4,000. However, we fear a new revised regulation of Utilization Review ordered by the Department of Health, Education and welfare, to become effective July 1, 1975, will almost certainly put us out of business. We are sure you know about this regulation, which is well-intentioned as it hopes to eliminate the abuses to which Medicare and Medicaid are subjected, but it will be impossible for a little hospital such as ours to comply. We use the term impossible and unfortunately that is the correct term. A hospital no lorger than ours simply cannot supply the staffing for the Committees of Regiew as the regulation requires. Also, there is an abundance of clerical information demanded which neither the hospital nor the doctor can possibly furnish except at excessive cost and time, and with our small patient load, we are unable to defray the excessive cost. We know of no abuses in our hospital this regulation seeks to eliminate. However, we face the possibility of closing our doors unless new regulations can be passed which will offer some relief to small hospitals such as ours. Please, any help will be appreciated, as we simply do not know what to do. MASON MEMORIAL HOSPITAL BOARD OF DIRectors; WAYNE HOFMANN, Vice President. DOROTHY LEMBURG. CHILDRESS CLINIC & HOSPITAL, Hon. OMAR BURLESON, DEAR MR. BURLESON: This is a copy of a memorandum we received from the Texas Hospital Association today. It is my understanding that IIEW is attempting to figure our cost on the basis of the average cost throughout a certain area and may even penalize a hospital that would be above the 80th percentile limit. This may be a little bit unfair to a hospital in a small town such as the hospital that I own since we run almost 80% Medicare. Mills County has probably the oldest population in the state of Texas. Most of our patients have to be hand fed, turned every two hours, and changed frequently due to incontinent bowels and urine. The amount of time allocated for nursing care of an older person may run as high as two or three times as much as for a younger individual. I understand that the 8.5% excessive allocation for Medicare patients has already been deleted and it appears that the private hospital is soon to be foregotten. The 1.5% profit allowed for private hospitals also has been deleted. I built this hospital about 16 years ago with my life's savings. For a while, we were one of the largest taxpayers in the county. We have not received one cent from county, state, or federal government for any type of subsidies and with all the money I have invested we still are unable to have any decent return. I am sure that it is a matter of time before all small, privately owned hospitals are squeezed out by new government regulations, however, I would appreciate what you can do to keep us open as long as possible. Sincerely yours, M. A. CHILDRESS, M.D. CONGRESS OF THE UNITED STATES, Hon. DAN ROSTENKOWSKI, Chairman, Subcommittee on Health, Ways and Means Committee, Washington, D.C. DEAR MR. CHAIRMAN: Enclosed is a copy of a letter from the President of the Board of Trustees of the Akron City Hospital regarding the Administration's proposal to discontinue the 82 percent nursing service cost differential under Medicare. I would appreciate having his letter included in the record of your hearings on this subject. Thank you. Sincerely, Enclosure. JOHN F. SEIBERLING, M.C. Hon. JOHN SEIBERLING, Longworth House Office Building, Washington, D.C. AKRON CITY HOSPITAL, Akron, Ohio, June 3, 1975. DEAR JOHN: I wanted to write you and tell you of my concern about Medicare changing the rules as of July 1 to disallow the 82% increased labor cost for Medicare patients. I am sure you can understand that the elderly require more care than younger patients, such as taking them to the bathroom, etc. I realize that Social Security is currently underfunded, but I can't see other patients subsidizing this additional cost. I understand that Representative Mark W. Hannaford introduced H.R. 7000, a bill which provides for a differential of at least 8%. To give you a feel of the importance of this to Akron City Hospital, the 82% differential amounts to $70,000 per year. Best regards. Sincerely yours, Hon. DAN ROSTENKOWSKI, HARRY B. WARNER, President, Board of Trustees. AMERICAN ACADEMY OF FAMILY PHYSICIAN, Chairman, Subcommittee on Health, Committee on Ways and Means, Washington, DEAR CONGRESSMAN ROSTENKOWSKI: As chairman of the Board of Directors of the nation's largest medical specialty association, I would like to call your attention to the plight of the small hospital. Because of your interest in increasing the availability of medical care in currently underserved urban and rural areas, I believe that you will be concerned with a situation which threatens the continued existence of hospitals providing patient care in these areas. Most small hospitals are run with a minimum of administrative staff and without the availability of computers or large records departments. It, therefore, will be difficult, if not impossible, to meet the requirements of the new Utilization Review Plan Regulations published in the Federal Register, Vol. 39, No. 231, Part II. Under these regulations the administrative staffs of small hospitals would have to be increased beyond the hospitals' means to finance such expansion. Another consideration is the tremendous demand the regulations place on the medical staff. Large amounts of time would be devoted to implementing review procedures which could otherwise be devoted to providing patient care. Section 405.1035(e)(3) of the regulations provides that the utilization review function may not be performed by "any person who is financially interested in any hospital or by any person who is professionally involved in the care of the patient being reviewed." In many rural areas, every physician in the community either will be involved in the care of the patient or will have an interest in the hospital. Thus, the regulations would require these hospitals to perform utilization review while the same regulations make it impossible for them to do so. That the rural hospital may find itself unable to survive financially, if current trends continue, is a matter of special concern to us because the family physician is more likely to enter rural practice than any other medical specialist. While the potential demise of the rural hospital is of great importance to the rural physicians currently participating who are dependent upon the hospitals to serve their patient population, more serious is the impact on the future medical needs of our rural communities which already suffer physician shortages. It is futile to attempt to encourage more physicians to practice in rural areas while at the same time burdens are created which threaten the survival of their hospitals. The American Academy of Family Physicians has appointed a subcommittee of concerned physicians to study this problem in depth and we will be happy to notify you of the results of this study and our recommendations when they are completed. We ask that your subcommittee recognize and give consideration to the problems being faced by the small hospital when considering applicable health care legislation. As an example of the concern expressed by some of our 37,000 members, I have enclosed a letter from one of themi, Dr. Philip Cleveland, Omak, Washington. Sincerely, HERB L. HUFFINGTON, M.D Enclosure. |