BRONX, N. Y., May 10, 1975. Re Proposed revision of medicare routine care cost ceiling. "Section 223 of P.L. 92-603." Hon. DANIEL ROSTENKOWSKI, Chairman, Health Subcommittee, Washington, D.C. DEAR SIR: May an old lady who has been a volunteer at the Hospital for Special Surgery a teaching hospital-for over 20 years beg of you to urge that the proposed rule be modified to furnish relief to these specialty teaching hospitals, particularly those in New York State. I know what care means to these patients of all ages. Sincerely, GRACE R. DENNIS. STATEMENT OF EAST CENTRAL MINNESOTA MEDICAL SOCIETY, CARLTON R. ERICKSON, M.D. A. That the Congress of the United States and the Executive Branch recognize the basic honesty of physicians and cease attempts to control costs of medical care based on principles of implicit dishonesty of physicians. 1. That the Congress of the United States and the Executive Branch abandon the concept of pre-admission screening. B. That the Congress of the United States and the Executive Branch acknowledge and act on logistic differences of hospital size with due regard to time demands of staff physicians. 1. That alternative requirements be available for implementing P.L. 92-603 with respect to above concept. C. That the Congress of the United States and the Executive Branch develop fiscal and ethical responsibility for the impressment of physician's time necessary to implement P.L. 92-603. D. That the Congress of the United States give, and the Executive Branch acknowledge, any extension of the parameters of P.L. 92-603 so that action may be based on law, not by bureaucratic pronouncement. 1. That the Executive Branch (Dept. of H.E.W.) finance utilization review as intended by the 92nd Congress of the United States, and that 2. The Executive Branch (Dept. of H.E. W.) refrain from requiring the review of all hospital inpatients without legislative authority and or without intent of fiscal responsibility. E. That the Congress of the United States and the Executive Branch refrain from all attempts to discriminate against any and all health providers as against Constitutional implications of equality and nondiscrimination. 1. That the Congress of the United States and the Executive Branch cease from and refrain from future attempts to discriminate against health providers. (a) By attempting to authorize payment at lesser levels than current, (b) By discrimination of selection of health providers (without similar selection of civil servants, food industry, labor supply, etc.) (c) By bureaucratic fiat discriminating against health care providers by means of limiting current payments to obsolete and antiquated economic indices not current with other economic variances, not limited to, but including, taxes and all governmental salaries including those of the Congress and Executive Branches of the government of the United States. F. That the Congress of the United States and the Executive Branch cease from and refrain from further decisions regarding the health care field without reasonable input from those providers. 1. That publication in the Federal Register be acknowledged as of limited distribution and access to the very citizens it affects. 2. That other means of informing the affected citizens be developed and utilized prior to further non-legisla ed decisions especially in regard to rules and regulations. In reference to these, the following is written. I. QUALIFICATIONS This letter is written primarily as a physician to families. Our organization of six physicians are responsible for the health and welfare for approximately 28,000 persons. This means I am personal physician of over 4,600 persons, 24 hours each day. My qualifications also include serving as a staff physician at Chicago Lakes Hospital, a small community based hospital of 49 beds. In this institution I have served on all physician-member capacities. I have also had the opportunity to participate in governing boards cn large (over 400 bed) hospitals. We have served as President of the local (3 county) East Central Minnesota Medical Society, as teaching member of the Rural Physician Associate Program of the University of Minnesota and have served 3 consecutive years on the Regional (comprehensive Health Planning Central Minnesota Health Planning Council. Above all, I am a personal doctor to people. II. UTILIZATION REVIEW The issue of utilization review is not adverse to many physicians, but the approximate and distant goals have become so. Utilization review of a sort has for many years been de-facto existent. Physicians have always consulted regarding problem patients, requesting and assisting in the care of same. Tissue, record, obstetrical, medical committees have been present for many years with attempts to screen for irregularities and try to acknowledge trends in medical care. The goals of these have been first to the patients (to know adequate medical care) and to identify deficiencies (and attempt correction of same). This, however, has been as patient advocate, not as payee-advocate. Of recent origin (and partially in response to accreditation desires) hospitals and participating physicians have implemented reviews of utilization of services with comparative data. It has served purposes of identification of trends with subsequent evaluation and education attempts. More recent are the concepts of PL 92-603. Pre-admission screening has surfaced implying the physician is incapable of determining which patients need hospitalization and which do not. It is very difficult to acknowledge four-to-eight years of specialized study without being capable of making such a decision. Admission screening, to confirm that a patient is actually in need of hospitalization, has similar implications. Average stay review requirements of 50th percentile mean fully one-half of all patients by definition must be reviewed as to necessity of further hospitalization. Extended stay review requirements at the 75th percentile by definition require review of fully 25% of all hospitalized patients. Goals of these programs in PL 92-603 have uniformly been interpreted as control with only remote attempts at competence control and education value. Objections 1. The implication of basic dishonesty as evidenced by pre-admission and admission reviews cannot be accepted. 2. The logistics involved in reviewal of fully one-half of all patients for a small-staffed hospital cannot be acceptable. (Our 6 physicians must provide the manpower for all the functions of anysize-staff hospital.) 3. The fiscal irresponsibility shown by the Dept. of H.E. W. must be corrected. Rulings now provide compensation (medicare billing) to physicians for hours provided can be accepted only if all patients are reviewed at the 50th percentile. Mr. Jay Constantine of the Senate Finance Committee, in a personal phone call to myself, assured me the intent of Congress was to fully compensate physicians for time expenditures in response to this legislation. To top it all off, the Dept. of H.E. W. wants to cut this partial pay again from 90% to 80%. I cannot interpret this in any way but as outright THEFT of the physicians. I have few material objects to sell, my only commodity for sale is my time. I cannot continue to give away further amounts of time required by governmental and quasigovernmental units to the expense of my patients, my family and myself. It is incomprehensible to consider either Congress or the Executive Branch to steal from their citizens, yet the effects of the proposals are thefts (involuntary and not legislated) demands of our time. 4. To discriminate against health providers by partial payment is difficult to understand with full payment to food-providers (food stamps, etc.), to energy providers (welfare aids to electric and gasoline industries), to manpower providers (full salary to governmental employees-welfare and medicare offices included) and full payment to intermediaries (no talk of 80% payment to Medicare passthroughs as the Blues). My Representatives: how can you continue to perpetrate the gross inequity of partial payment to health providers and not to ANY other providers to the government or its assigns? 5. Now on April 15 new regulations have been suggested which somehow explain reimbursement to health providers should be tied to (strangulated by?) obsolete economic indices. A letter to Mr. C. Weinberger requesting understandable explanation remains unanswered to date. One month was allowed for comments and then? I respectfully remind the members of this Committee that 200 years ago our government was based on principles which include equality and a representative government. This letter proposes that such principles are not found in the issues before the Committee and request consideration of the previous recommendations. Sincerely and respectfully, [Mailgram] CARLTON R. ERICKSON, M.D. Representative DAN ROSTENKOWSKI, NEW YORK, N. Y., June 11, 1975. Subcommittee on Health, House Ways and Means Committee, Feel there should and could be an extra category within SMSA group 1 for small teaching specialty hospitals with outstanding research departments whose costs per bed are therefore higher than general hospitals of comparable size. Costs of patient care cannot be fairly judged on number of beds but must be based on complexity of surgery and intensity of necessary subsequent care. Reduction of limit on hospital reimbursement from 90th to 80th percentile would cost hospital for special surgery in New York City, a recognized national leader in orthopedic surgery and rheumatic diseases well over half a million dollars in 1975. This would be destructive to present high standards. Hope you can present these views at June 12th meeting. Mr. DAN ROSTENKOWSKI, ELIZABETH C. COLE, Volunteer, Hospital for Special Surgery. COLORADO HOSPITAL ASSOCIATION, Denver, Colo., June 6, 1975. Chairman, Subcommittee on Health, Committee on Ways and Means, DEAR CHAIRMAN ROSTENKOWSKI: On behalf of the 100 member hospitals of the Colorado Hospital Association, I wish to bring to your attention and to the attention of the Subcommittee on Health and the Committee on Ways and Means our concerns on items which your Subcommittee will be considering. It is our understanding that you will be holding a public hearing on Thursday, June 12th, beginning at 10:30 a.m. It is our intent to provide you with this written report prior to that time so that it may be considered by the Subcommittee. Agenda item"tilization Review UPr oecedurs for Hospitals" is of concern to us for several reasons. Our major concern is with Utilization Review Regulation procedures as they affect small rural hospitals. As you are aware, there are many institutions throughout the nation, and especially in Colorado, where a hospital has as few as one, two, or three physicians on the medical staff. For a small number of physicians to conduct the utilization review procedures as now written is nearly impossible, and present alternatives are not flexible enough to make the procedure realistic. We therefore ask that the Committee consider amending the regulations regarding utilization review with the small rural hospital in mind. We would like to suggest one possibility. Groups could be formed of rural hospitals in close geographic proximity where physicians agree to evaluate the quality of care in all hospitals in the group. The hospitals would adopt a common data base providing the basis for review. Each hospital would monitor its own profiles, but review of those profiles would be conducted by physicians from all hospitals in the group. Such an approach would allow for several things to be accomplished: 1) development of a larger, more meaningful and comparable data base; 2) review by the physician resources of several hospitals; 3) assurance of a more objective review, in that enough physicians would be available so that no physician would be forced to review records of "the only other physician in town"; 4) encouragement to develop a division of medical education by member hospitals which could use the review as a guide in designing programs; 5) encouragement to hire a shared medical record analyst; 6) achievement of delegated status from the PSRO for a group of hospitals where individually that might not be possible. None of these six points would happen, in our opinion, if the review were based in the local medical society (which could be nonexistent in rural areas). It also would seem unnecessary to obtain the approval of the Secretary for such an arrangement, which it now appears would be required. Agenda item "Determination of the 82% Nursing Differential for Medicare Patients" is a highly controversial issue. We have contracted other Committee members and our own congressional delegation from Colorado to bring our dilemma to their attention. Recent studies in six states have indicated that the aged required up to 20 percent more nursing care than the non-aged patient. If the 82% nursing differential is to be eliminated, hospitals will transfer the cost of this care of the Medicare over age 65 patient to other non-Medicare patients in the hospital. The Department of HEW presently maintains that there is a great number of Medicare patients who are under age 65, therefore reducing the critical care cost element. It is our contention that the number of people who are under 65 and insured by the Medicare Program is insignificant and further that they are not considered in the 8%% differential. Therefore, this argument to eliminate the 82% nursing differential is not valid. The Department of HEW also maintains that because of the intensive care and coronary care units existing in hospitals, any critical care patient under Medicare will be cared for in those situations. This explanation is not valid either. The 82% nursing differential is utilized only in the routine care of the aged. If this elimination of the 82% is permitted, hospitals will suffer a severe financial loss or will be forced to shift the burden of that cost to non-Medicare patients. In our opinion, the elimination of the differential violates the Medicare Law which requires full reimbursement for reasonable cost. We urge you to continue the 82% nursing salary differential for Medicare patients. Agenda item "Limits on Hospital In-patient General Routine Service Costs", Section 223 of P.L. 92–603, is our third item of concern. In the past, this has been computed at the 90th percentile limit plus 10% of the median and is proposed to be reduced to the 80th percentile plus 10% of the median. This requires that a hospital having routine, in-patient costs which exceed the cost limitation ceiling will be asked to provide further justification. We do not oppose the review of a hospital falling out of the existing norm; however, we are concerned about the method by which the review will be made. A review should have strict guidelines to insure that hospitals are given every consideration in respect to factors which may contribute to the cause for review. We would urge the continuation of the present Section 223 of P.L. 92-603 unless guidelines for review are published and are sufficient to provide a hospital the opportunity to justify the reasons for moving outside of the norm. We trust the Subcommittee will give their serious consideration to these views and concerns. Sincerely, 54-804 0-75 -25 ARVID B. BREKKE, CORONA COMMUNITY HOSPITAL, Hon. DAN ROSTENKOWSKI, DEAR SIR: This letter is written to protest the proposal published in the “Federal Register" revising the Schedule of Limits on Hospital Inpatient General Routine Service Costs in the Medicare Program. Our protest is based on two distinct points: 1. It is completely discriminatory in that the 1975-76 rates for neighboring Los Angeles County-where we obtain the majority of our supplies and with whom we compete in salary scales-remain pretty much the same or are actually increased $134 to $170, while our area rates decrease anywhere from 15 to 20% ($114 to $86, $134 to $87). Our salary costs have increased a minimum of 15% and one item alone under non-salary costs has increased 100%, i.e. malpractice insurance. 2. Because our fiscal year costs equal or exceed those of the 1975-76 proposed limits, the Administration will be in the position of knowingly and deliberately under-reimbursing us. Of necessity we will be forced to re-coup such losses from other third party programs as well as from all other patients. This is completely contrary to Section 2102.1, "The objective is that under the methods of determining costs, the costs with respect to individuals covered by the program will not be borne by others not so covered." Thank you for your consideration of this problem. STANLEY M. GRUBE, Administrator. U.S. SENATE, Hon. DAN ROSTENKOWSKI, House Ways and Means Subcommittee on Health, Washington, D.C. June 9, 1975. DEAR MR. CHAIRMAN: Recently Sister Mary Lawrence Hallagan, an administrator of Mercy Hospital in Cedar Rapids, Iowa, whom I have known and respected for a number of years, communicated her concern regarding federal regulations related to the Medicare program which affect various aspects of hospital administration policies. She advised me that your Subcommittee will be holding a public hearing on June 12, 1975, on issues related to her concerns. Enclosed is a statement and related documents submitted by Sister Mary Lawrence on behalf of the Mercy Hospital Board of Trustees of Cedar Rapids. I would greatly appreciate it if you would bring Sister Mary Lawrence's comments to the attention of the Subcommittee and have the statement included in the official record of the hearings. I hope the Subcommittee will give every appropriate consideration to this statement as it formulates recommendations or reports legislation in this area. Warmest personal regards. Enclosure. Hon. JOHN C. CULVER, Washington, D.C. 20510 DEAR SENATOR CULVER: We are enclosing with this letter statements of concern as expressed by the Board of Trustees as they relate to the vital issues to be discussed at the June 12 hearing of the Sub-Committee on Health of the Ways and Means Committee. We are seeking your support and assistance in bringing these concerns to the Committee. Sincerely, Sister MARY LAWRENCE HALLAGAN, R.S.M., Chief Executive Officer, |