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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
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,
available to a beneficiary who is neither under Medicare inpatient
monitoring care, providng routine medical services, and appro
priately involving the supervisory physician if major medical
has already recogized the value of physician
nurse practitioners to augment physicians in
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
nursing home benefits can finally become what beneficiaries need
and think they have.
JAMES E. CUNNINGHAM, PRESIDENT
PREPARED STATEMENT OF LUCILLE A. JOEL, Ed.D., F.A.A.N.
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
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 institutional reimbursement.
Our testimony will focus on three major concerns which impact heavily on
The New Jersey State Nurses Association strongly urges the federal government
to maximize the opportunity for nurses to be major providers of health care
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
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).