of our aims is being recognized and accepted. A high salaried professional in the nursing home cannot compete with the private administrator who unstintingly dedicates himself to providing around-the-clock bed comfort.

Our association has done much to strengthen and implement State licensing in Maine and strongly advocates stringent enforcement of the laws, rules, and regulations for the purpose of raising standards of care. However, enforce ment of licensing should be accomplished in an atmosphere of cooperation as opposed to an atmosphere of Government mandate.

In conclusion, we submit that the payment of realistic rates for the State aid and general relief patient will gear the nursing home economy to a level where the problem of private patient care will be self-solving. Respectfully submitted.

KENNETH D. ROBINSON, President.

Mr. CONNELLY. Realistically, this State and Nation must look to proprietary nursing homes as the main avenue, now and in the future, for the nursing home care of the elderly infirm. Charitably supported homes could not possibly expand enough to do the job. Government institutions would be impractical and costly. Now what does that mean? It means that each proprietary nursing home has a responsibility not alone to itself, but to the general public, and to society as a whole. The Federation of Nursing Homes also has a large responsibility.

I want to make it clearly understood that when I speak of nursing homes as counsel for proprietary nursing homes, I am not trying to insist that every nursing home in the Commonwealth is perfect, or even that they are doing as good a job as they could under the circumstances. But I do insist, and I think reasonable men will agree, that by and large the nursing homes in Massachusetts are doing an excellent job and their quality of performance is to be applauded. This, may I say, is due in no small measure to the leadership and understanding provided by many departments of State government. We are indeed fortunate in this respect.

Now, though we believe this, and though we insist that the public good will be served by such proprietors receiving a decent return for their investment and services, in our estimation the important thing is that the operation of the proprietary nursing home is akin to a profession and must have as its primary motivation the performance of the service. As we look at it only those people who have this motivation for service should be the proprietors of nursing homes. We have and we will support all laws and all regulations directed toward the maintenance of this concept.

Now, Mr. Chairman, before turning to some of the realities involved in this field I should like to try and answer a question, although I know it has been answered before here today, which the newspapers and the radio have said is in the minds of this committee. The question is, Why does Massachusetts have 14,544 nonacceptable beds?

The fact of the matter is that a Federal agency had been granted money by Congress to distribute throughout the States for the purpose of constructing hospitals and nursing homes. One of the conditions was that need for such nursing homes must be established. Therefore a questionnaire was drawn up. One of the questions in that questionnaire was, "How many beds are in homes that are constructed entirely of fire-resistant materials?"

Well, our State literally answered that question. We sent to Washington the simple fact that 14,544 beds were not in homes constructed entirely of fire-resistant materials and only 405 were in such homes.

The fact is that the literal answer required this State to exclude all beds in every frame nursing home in the Commonwealth. It excluded all of the beds in every brick nursing home in the Commonwealth that had a wooden floor or wooden steps. All of those nursing homes are regulated rigidly by the State Department of Public Safety, by local city and town departments of safety, by building departments, by fire departments. Many of these homes have sprinkler systems and every manner of fire protection.

Now I should like to turn to some of the realities and I would like to skip over them very, very quickly.

(1) Though great progress has been made in the nursing home care of the elderly infirm, much remains to be done.

(2) About 60 percent of patients in our State are public aided and the percentage is rising and will continue to rise. One of the reasons is the enactment here in this State of the medical aid to the aged law which broadens the area of participation of people in public funds for nursing home care.

(3) Standards of care and safety cannot rise much above what the public-aided rate can provide. Now let's be realistic. Whatever talk we may have about standards of nursing homes, the simple fact is that now and in the future such standards cannot be any better than what the public aided rate will allow.

(4) States must establish systems whereby standard setting is matched by cost studies so that patients can get the care that is being purchased and the home can have income to give the care.

(5) All of us struggle to move forward toward a greater acceptance of our responsibilities toward the elderly. But most of the time we are not entirely sure of where we want to go or of how we are going to get there or of how much it will cost or of whether it is practical. All of us want to do everything that we can to improve the standard of care but how many times do we know what we are talking about? Do we know what the standard of achievement is that we want to find?

It is fine to talk in generalities but you have to ask yourself some very practical questions. When we talk about rehabilitation of patients in nursing homes are we thinking about recreational therapy, or occupational therapy, or physical therapy? Or are we thinking about plain tender care that spurs on people to enjoy their faculties to their fullest extent?

Now when we have this desire for achievement do we know what it would cost? If we do, are we willing to incur this cost? Is provision for giving such a service included in the rate?

(6) Now the next reality is the taxpayer. Very understandably the taxpayer wants everybody to have everything but he does not want to pay any more for it, and that is a very understandable reaction. The taxpayer is certainly entitled to be assured that the goals we set are not beyond his capacity to pay.

(7) The next reality is this: Though those who operate nursing homes are not in any sense singularly gifted as compared with others, nevertheless because of their preoccupation for many years with the elderly infirm, there are probably more people among them who know more about the total picture of nursing home care than in any other group in our society. I am now talking about those who operate the

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proprietary nursing homes as well as those who operate the charitable homes.

These are a few of the realities. What do they add up to? In my own mind the first is that there is a lot of working together that needs to be done on the part of the governmental agencies and the interested parties who have a responsibility and have a knowledgeable interest. The second general conclusion is that the primary level of working together is the State level.

Now I am going to skip through this. I am going to say that the working together on the Massachusetts level has been been exceptional and that is primarily due to the unusual qualifications of the people in the Massachusetts Department of Public Health, the Massachusetts Department of Public Welfare, the division of hospital costs and finances, and others.

I am going to skip on to one example of working together. Recently in Congress there was enacted, last year in fact, the Kerr-Mills bill. With the passage of the Kerr-Mills bill the Massachusetts Commissioner of Public Welfare, with great foresight and expedition, introduced a medical care for the aged bill in the Massachusetts Legislature to implement congressional action. Now in addition to opening up the areas of coverage not previously existing, the commissioner's bill shifted all nursing home patients and other patients over to the medical aid to the aged category and it brought in about $12 million more in Federal money to reduce cost burdens on the State, cities, and towns.

Now such legislation has its problems, both in language and in the detailed application to specific circumstances, and in many other ways. The Massachusetts Commissioner of Public Welfare brought together a representative of the Massachusetts Federation of Nursing Homes, a representative of the Massachusetts Taxpayers Association, and a representative of the Senior Citizens of Massachusetts, Mr. Charles C. O'Donnell. This group cooperated with one another, they differed with one another in detail but they were united in objectives. They worked together with a subcommittee of the legislature on the legislation, they journeyed to Washington together to iron out problems with the Federal agencies, they considered the problems of all other groups with respect to details on which the subcommittee was bound to advise the legislature, and ultimately the law was enacted last year. This State was among the first, if not the first, to implement the Kerr-Mills bill.

This is an example of working together that is taking place here in Massachusetts between the nursing homes and the various departments of government, and it is the reason why Massachusetts stands today near the top in the Nation in the standard of care for patients in nursing homes.

Under the Kerr-Mills bill as implemented by the Massachusetts medical aid to the aged bill, all low-income elderly over 65, in Massachusetts, have assurance that their medical needs will be met without exhausting their capital, their equity in their homes, or their income. When we mention the Kerr-Mills bill we can't avoid some mention about the King-Anderson bill of last year in the Federal Congress insofar as it relates to the area of nursing home care. So far as it relates to this area of nursing homes and nursing home care, the Massachusetts Federation of Nursing Homes does not like it. We

don't like it because (a) it is unrealistc and is of little help to those needing nursing home care and (b) it is vague, cumbersome, and pregnant with a multitude of practical problems for nursing homes. Let us see how far it would help elderly people needing nursing home care. Remember that the average age of persons in nursing homes in Massachusetts is 81 or 82. Remember that they do not come into nursing homes unless they have physical disabilities, and the combination of age, disabilities, and family circumstances generally make it pretty farfetched that many can return to home or family.

As we read the King-Anderson bill the maximum number of days of nursing home care covered would be 180 days in a benefit period. The number of days would be less where the person spent time in a hospital. The benefit period, during which this limitation of compensable days of care would apply, would begin with the first day in a hospital or nursing home and last for the rest of that person's life unless for some period of 90 days such person was not confined to either a nursing home or a hospital.

Thus when we think of the benefits which would come from such a law, so far as nursing home services are concerned, we come up with these realistic facts:

(1) Such a law would not benefit a very high percentage of elderly people at all because they would not have contributed under the system.

(2) Even for those who would be under the system, 90 to 95 percent of them would be entitled to only up to a maximum of 180 days of nursing home care during their lives.

Thus the nursing care help they would receive from such a law would be minor and they would still have to look for their main source of assistance to State programs implementing the Kerr-Mills bill or otherwise.

Now I am not going to detail the degree to which Federal agency control or domination of the nursing homes under such a bill would be extended. In the main it covers the field of what is a skilled nursing home, excluded services, medical policies of such homes, general conditions which the Secretary "may find necessary," usage of a nursing home facility utilization plan, conditions and limitations attached to becoming an eligible provider of nursing home services, determination of costs of services, execution of contracts, and innumerable other relationships.

Now we insist that for the good of the people who need nursing home care, there should not be more than one system covering them. If they are included under the King-Anderson bill, or any similar bill, it will merely mean that most will get only 180 days of coverage and the remainder will have to be picked up by another system. It is better they have one system rather than two.

Now I would like to conclude with these observations.

A democratic society can meet its problems only through cooperative action on the part of its members. Here it is cooperative action by nursing homes and their organizations with others in and out of government. By encouraging and aiding such cooperation we strengthen democracy as well as follow the most practical course to a speedy attainment of the highest objectives. Massachusetts offers many examples of the fruits of this cooperative spirit.

The area for strong cooperative action is the State. Trying to mastermind and regulate from the national level can be disasterous

in this field. Strong Federal interest and aid to the States in evolving this cooperative approach is greatly to be desired.

All authority over standards of care ought to be centered in one State department; namely, the department of public health. All authority with respect to safety should be coordinated in one State department. Standards of care desired should be genuinely studied and fair costs determined.

Cooperation and united action in common objectives at the State level should give the guidance to local community cooperative action. We deal here with a human problem, and the solution to human problems ultimately comes down to the relationship of the nursing home staff, and its administration, with patients. The closer we get to seeing the picture through their eyes; namely, the eyes of the patient and the eyes of the people who have got to give the care to the patient, then the quicker we will accomplish some great things.

Thank you, Senator.

Senator SMITH. Thank you very much, Mr. Connelly, for this testimony. Let me say that I realize that the Massachusetts Federation of Nursing Homes has a great responsibility, we all realize that. I feel that they are trying to meet these responsibilities at the present time, but I think there is a great deal more that we can do in the future and a great deal more that must be done.

Mr. CONNELLY. I agree with you, Senator.

Senator SMITH. Would you state again how many homes are members of your federation?

Mr. CONNELLY. There are 300 nursing homes who are members of the Massachusetts Federation.

Senator SMITH. What proportion of the 21,000 beds?

Mr. CONNELLY. As far as beds are concerned, in the vicinity of 50 to 55 percent of the beds in the Commonwealth, but in terms of number of nursing homes it would be a ratio of 300 to about 700.

Senator SMITH. In other words, these are generally the larger nursing homes?

Mr. CONNELLY. No, they are not generally the larger nursing homes. A greater percentage of the larger nursing homes are members, but most of our members are small homes. The average number of beds in a home is 30 and I suppose the average number of beds in the Federation homes are about 30 to 32.

Senator SMITH. Mr. Connelly, you mentioned decent return. What is a decent return on a nursing home investment? Are there any figures on that?

Mr. CONNELLY. I have not seen any figures. We have never attempted to set it down categorically because in our present experience of 3 or 4 years in the setting of the rate by the division of hospital costs and finances the method of setting such rate has never gotten down to such a percentage detail. I think we have to start from this concept, that the cost of money today, for instance under an insured Federalwhat is it, the Federal home mortgage?

Senator SMITH. FHA.

Mr. CONNELLY. Even under FHA, where repayment is guaranteed by the Federal Government, you must pay 51⁄2 to 6 percent interest. Therefore a return to nursing home proprietors for all of the risks they take in the operation of the nursing home, obviously that has got to be well in excess of any 52 or 6 percent. I am not so sure that most