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Spell of Illness" Definition

AHCA recommends eliminating inconsistencies in the spell

of illness" definition so that a "spell" ends when a beneficiary

is neither under Medicare inpatient hospital nor SNF coverage

followed by the requisite time period.

In general, the Medicare

program linits the duration of covered services to the period

between the beginning and ending of a spell of illness"


present law, a Medicare beneficiary., must remain for 60 consecutive

days out of a hospital or SNF in order to renew Medicare eligibility

for these benefits.

There are inconsistencies in the SNF criteria used to start

and end a spell of illness.

For purposes of starting a spell

of illness and receiving benefits,

the beneficiary must be in

a facility which is licensed as an SNF, certified under Medicare


a SNF, and meets all of the program's requirements for participa

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only for purposes of ending a Medicare spell of illness.

As as providing skilled nursing care for spell of illness purposes,

a result, a beneficiary in an ICF, which is classified by Medicare Congress

night not receive Medicare coverage when he needs

to go back

to a hospital for SNF.

Coverage would not be received because

the spell of illness had been deened not to have ended.

A similar HCFA policy adversely affects beneficiary coverage

por durable medical equipment (e.g., oxygen therapy, alternating

pressure mattresses, and pacemaker bonitors).

The durable medical

equipment is available to beneficiaries at home or in an institution,

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available to a beneficiary who is neither under Medicare inpatient

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monitoring care, providng routine medical services, and appro

priately involving the supervisory physician if major medical

problems develop.

has already recogized the value of physician

assistants and

nurse practitioners to augment physicians in

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titioners, acting under the supervision of a physician and within

the scope of their license, be allowed to conduct Medicare required

visits and recertifications.

Thank you for the opportunity to present our recommendations

for Medicare long term health care services.

There are opportunities

for new policies which would conserve program spending, improve

service to beneficiaries, and enhance the provision of long term

We hope that you will provide the charted course


so Medicare

nursing home benefits can finally become what beneficiaries need

and think they have.



I am Dr. Lucille A. Joel, President, New Jersey State Nurses Association,

Professor and Director of Clinical Affairs, Rutgers University, College of

Nursing, and Director, Teaching Nursing Home Project. The New Jersey State

Nurses Association appreciates the opportunity to offer testimony on
Medicare to the Select Committee on Aging.

The New Jersey State Nurses Association endorses the concepts recently

published on Medicare by Dr. Carolyne Davis, in the Federal Register: "To

focus on patient care, to emphasize outcome rather than means used to achieve those ends, (and) to promote cost containment while maintaining quality care."

(Jan. 4, 1983, Proposed Rules, p. 300)

Although quality, access and cost create equal controversy in regard to the

Medicare program, they all converge in the issue of reimbursement: Who is

reimbursable; where can services be delivered; and what is the methodological

model for reimbursement? We have become a reimbursable society. That which the

third party payer subsidizes is mainly used. From the outset, let me assure

you that I believe cost containment efforts are essential. The evolving solution
to the problem of spiraling costs may be to paradoxically wed deregulation and
competition among providers and settings and to require a more controlled approach

to institutional reimbursement.

Our testimony will focus on three major concerns which impact heavily on

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The New Jersey State Nurses Association strongly urges the federal government

to maximize the opportunity for nurses to be major providers of health care

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services to the Medicare population. For nurses to emerge as dominant health

care providers the Medicare program would have to address services reimbursed as

health-care services, not medical services, as presently permitted. Nurses are licensed to offer health care services, which must be provided for under the

Medicare program, not as medical staff to offer medical care, but as nursing

staff to offer nursing care.

The primary health care nurse traditionally prepared at the graduate level

represents a most cost-efficient and under-utilized provider professional. Primary health care nurses are exquisitely prepared to diagnose and manage minor acute illness within a joint practice model with physicians. In 1979, a HCFA funded study demonstrated that a visit by a primary health care nurse costs half as much as a visit of the same nature executed by a physician. In addition, the quality of care given by the nurse as reflected in client satisfaction and recovery was equal to or superior to physician management. 1

These nurses were also proven to be more effective in networking services,

ordered fewer costly procedures, and emphasized self-reliant behavior, counseling and health education. The competency, cost-efficiency and efficacy

of nurses is extensively documented. Direct access to primary health care

nurses and for the matter, to all nurses, has been denied the consumer because

of the absence of reimbursement. Where reimbursement is at all available, it is usually contingent on physician prescription or supervision. This

becomes absurd as we realize that nurses are licensed under their own autonomous

practice act in every state in the Union. It seems ,

at least figuratively,

restraint of trade to have one professional serve as gatekeeper to the services

of another.

It needs to be emphasized that I am not proposing to offer new

services or to extend existing services to new populations, rather I appeal

to you to seek formalization of nurses' rights to serve as a substitute for more costly provider professions. Nurses have admirably fulfilled this role

in rural health and with underserved populations such as children and aged.

In addition, we support authorizing maximum flexibility to hospitals in

granting privileges and organizing its professional staff. Granting staff privileges to health-care professionals other than those defined as physicians

is one key to containing health care cost.

We believe such initiatives will

serve to permit the substitution of nurses for more costly providers, while

at the same time not comprise in quality of care.

Volumes have been published

citing the efficiency and cost-benefit of nursing as an alternative to higher

cost care (Fagin, American Journal of Nursing, 1982, p. 56).

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