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Articles, publications, etc.:

"Determining Level of Care Being Furnished a Patient in an Extended
Care Facility," from the Mutual of Omaha Newsletter__
Health Planning Council of Central Iowa, report of, June 4, 1970, by
Miss Marilyn Russell, R.N., public health nurse for Polk County___.
Iowa Department of Social Welfare Employees' Manual:
February 28, 1967, excerpts from__





March 3, 1967, excerpt from____


"Nursing Homes-Facts and Figures," prepared by Bureau of Medical Services, State of Iowa, November 1969_.


Bureau of Health Insurance Intermediary Letter:

No. 328, issued by HEW, Social Security Administration, Baltimore,
Md., June 1968.


No. 371, issued by HEW, Social Security Administration, Baltimore,
Md., April 1969_.


Communications to:

Borchert, Richard D., director, Hospital Claims and Hospital Rela-
tions Division, Hospital Service Inc. of Iowa, Des Moines, Iowa,
from Merritt W. Jacoby, Blue Cross Association, Chicago, Ill., June
4, 1907-

Hughes, Hon. Harold E., a U.S. Senator from the State of Iowa, from:
Borchert, Richard D., director, Claims and Hospital Relations
Division, Intermediary Hospital Service Inc. of Iowa, Des
Moines, Iowa, June 10, 1970__.

Gillman, James N., commissioner, Department of Social Services,
State of Iowa, Des Moines, Iowa, May 25, 1970 (with en-

Godwin, Alden R., president, Iowa Nursing Home Association,
Des Moines, Iowa, July 8, 1970 (with enclosure).
Lackner, Francis A., executive secretray, Iowa Association of
Homes for the Aging, Cedar Rapids, Iowa, May 19, 1970.
Nelson, Earl V., executive secretary, Commission on the Aging,
State of Iowa, Grimes State Office Building, Des Moines, Iowa,
May 18, 1970 (with enclosure).

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Nursing home clients of Heckinger Accounting from Heckinger Accounting & Tax Service, Des Moines, Iowa, December 23, 1969, with enclosures__



Average number of patient-days per extended care facility, medicare program-State of Iowa___.


Average number of patient-days per month in skilled nursing homes, medicaid program-State of Iowa--


Average number of patient-days per month in extended care facilities, medicare program-State of Iowa--


Average number of patient-days for skilled nursing home, medicaid program-State of Iowa__.


Highest number of patient-days by any extended care facility medicare program-State of Iowa__


Highest number of patient-days by any skilled nursing home, medicaid program-State of Iowa..


Homes certified as extended care facilities and skilled nursing homes on specific dates-State of Iowa--


Patient days by month for extended care facilities, medicare program by month-State of Iowa--.


Patient-days by month for skilled nursing homes, medicaid program-
State of Iowa__


Percent of patient-days to the highest month, medicaid program-
State of Iowa--


Percent of patient-days to the highest month, medicare program-
State of Iowa---.


Statistics from nursing homes reflected by Heckinger Accounting &
Tax Service____


Thirty-five skilled nursing homes showing trend of patient-days in the medicaid program-State of Iowa--


Thirty-three extended care facilities showing trend of patient-days in the medicare program-State of Iowa---




MONDAY, MAY 18, 1970




Des Moines, Iowa.

The subcommittee met at 9:30 a.m., pursuant to notice, in the Valley Bank Building, Des Moines, Iowa, Senator Harold Hughes, presiding pro tempore.

Present: Senator Hughes.

Committee staff members present: Bill Hedlund, professional staff member.

Senator HUGHES. The hearing of the Special Subcommittee on Aging of the Senate Labor and Public Welfare Committee will come to order.

It is a special privilege for me to be back home to chair this hearing of the Special Subcommittee on Aging of the Senate Labor and Public Welfare Committee and I want to express my profound appreciation to the State, local, and private agencies and to a number of dedicated individuals who without benefit of much leadtime gave us their full cooperation in making arrangements for this hearing.

Senator Kennedy, who is chairman of this subcommittee, asked me to convey his regrets that he could not be here today and to express his thanks to the witnesses and others who have cooperated to make this important public service possible.

This hearing was initiated at my request as the result of urgent communications I have received in Iowa in recent months about the growing number of severe hardship cases among elderly patients in our State under the extended care category of the medicare program.

There have been drastic changes and cutbacks in the extended care program in Iowa in the past year. Why? Surely the need for this kind of care has not diminished, to this extent. According to social security records, rejections of extended care claims more than tripled in the last quarter of 1969 increasing from 2 percent during 1969 to 7.2 percent during the final quarter of last year.

Our focus is on the health and well-being of the individual patients under these programs. Matters relating to the administration of the medicare and related programs fall within the perview of other congressional committees.

I am interested in obtaining the answers to a very few simple and basic questions: Are elderly citizens of Iowa who are qualified for extended care under the law receiving the amount and quality of care which was intended under the legislation setting up medicare and related programs?

If not, why not?


Are there gaps in the law that overlook certain categories of elderly patients who desperately need help?

Have rules which are administered by the intermediates, the insurance companies, who actually administer medicare for the Social Security Administration become so tight that they exclude and deny patients in dire need? Or are the cutbacks in extended care simply an inevitable result of cutbacks in funds ordered by the Federal Government?

I frankly do not know the answers to these questions at the present time. As a Senator concerned with the well-being of the thousands of elderly people of Iowa, I intend to find out. I believe the people of Iowa are entitled to know.

It would appear that elderly patients who once qualified or would have qualified for extended care are now being turned down. Others who are taken in under the program are given only a fraction of the treatment that such patients had been given formerly.

As of January 1, 1967, we had 97 certified extended care facilities in Iowa, a total of 4,942 beds. As of now, we have 77 extended care facilities with 3,198 beds. At first glance it would appear that the central difficulty is not in a shortage of facilities that presently exist or could be provided for extended care patients.

The main difficulty appears to be in the inability or unwillingness of the Federal Government acting through its intermediaries to provide necessary funds to defray patient costs of this vitally important program to the extent this was being done a year ago. If so, this brings us face to face with the question of priorities and Government spending. Is your Government building supersonic transports and financing moon flights at the expense of providing adequate care for the elderly poor and sick?

We hear a great deal these days about the reassessment of our national priorities. If care of our elderly sick is not one of our most compelling national priorities, then I can only say that we are not the civilized and compassionate society we purport to be.

I am sure this viewpoint is shared by the others participating in this hearing today. I hope this hearing will also bring to public attention one category of elderly patients who were not being adequately provided for even under the optimal operations of our medicare and medicaid programs.

I refer to those who are the victims of long-term illness who have exhausted all of their funds and are no longer eligible for hospitalization or extended care medicare. These elderly patients need more than old-age assistance for the care that regular custodial or nursing homes can provide.

I am convinced there are a great many of our elderly in this category and there is no adequate operating health care program whatever that specifically covers their needs.

It is imperative in my opinion that our society do something to meet this pitiful need even if it entails cutting back on other less critical areas of Government spending.

The Biblical admonition "Honor thy father and thy mother" applies to a society as well as an individual. Our first witness this morning is Mr. James Gillman, Commissioner of the Department of Social Services.

Mr. Gillman, you may proceed with your statement as you desire.

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Mr. GILLMAN. I will be relatively brief this morning, Senator. The material that I have developed is limited itself primarily to medicare but does tie in somewhat with the medicaid programs also because they are now invariably related and of necessity must be put together. It appears to me that one of our major problems is the identification of the extended care and what it really means.

Unfortunately, most people took extended care to mean, when the extended medicaid and medicare programs were being developed, long-term care.

This was not the intent, as I understand it, of the law, as the Congress passed it. It was misleading to many elderly people.

Senator HUGHES. What do you understand the intent of the law to mean?

Excuse my interruption. It would be easier if I interrupted you, if you don't mind, as we go along.

Mr. GILLMAN. Extended care, as I understand it, according to the law and the way the Health, Education, and Welfare has interpreted it, is to mean an extension of care from the hospital. In other words, restorative, rehabilitative, care which will follow a period of hospitalization designed to be of relatively short term.

Senator HUGHES. What makes you believe that it is designed to be a relatively short term in the case of emergency?

Mr. GILLMAN. I think that the reason it is short term is because of the time limitations that were placed on it by the Congress.

Senator HUGHES. What is the limitation?

Mr. GILLMAN. 120 days. That is pretty short term. When we talk about long-term illnesses we talk in terms of 5, 10, 15 years and many times longer than that. I think generally people assume that extended care was going to be this long-term care rather than the very short term that it is."

Senator HUGHES. Have you received any directives from the Federal Government to your department indicating to you what they consider extended care to be and the approximations of what it should be? Mr. GILLMAN. Yes.

Senator HUGHES. Or any of the intermediaries?

Mr. GILLMAN. Yes. I think it is pretty well laid out in the guidelines as to what is expected from extended care and particularly in terms of the length of care that is involved. I think it is unfortunate that the extended tends to mean long term to most people when in fact according to the guidelines that have been issued from HEW and to the carriers

Senator HUGHES. Who determines how long the care is to be for? Does the personal physician of the patient determine that or does the intermediary determine that?

Mr. GILLMAN. I believe that the primary length of time is determined by the Congress as to how long they will be involved in it. Senator HUGHES. 120 days.

Mr. GILLMAN. Right.

Senator HUGHES. Who determines whether it will be 7 days or 60 days?

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