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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 limits the duration of covered services to the period between the beginning and ending of a "spell of illness" Under 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 as a SNF, and meets all of the program's requirements for participation as a SNF. However, for purposes of determining if a patient is no longer in a "skilled nursing facility", the program uses an overly broad definition encompassing many facilities not certified as a SNF nor eligible to be a SNF.

Under Medicare's policies, many Medicaid intermediate care facilities are classified as providing skilled nursing care, only for purposes of ending a Medicare spell of illness. As a result, a beneficiary in an ICF, which is classified by Medicare

as providing skilled nursing care for spell of illness purposes, might 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 deemed not to have ended.

A similar ECFA policy adversely affects beneficiary coverage for durable medical equipment (e.g., oxygen therapy, alternating pressure mattresses, and pacemaker monitors). The durable medical equipment is available to beneficiaries at home or in an institution, other than those meeting the broad definition of SNF. AHCA recommends the Part B durable medical equipment coverage be available to a beneficiary who is neither under Medicare inpatient hospital nor SNP coverage.

Utilization of Physician Assistants and Nurse Practitioners

Federally financed demonstrations have proven that physician assistants and nurse practitioners ca can perform cost effective and high quality services which traditionally have been provided by physicians. Physicians extenders have proven utility for monitoring care, providng routine medical services, and appropriately involving the supervisory physician if major medical problems develop.

Congress has already recognized 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

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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

services to the Medicare population. For nurses 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

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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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