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Health Care Settings

While strides have been made in support of alternative health-care settings for the Medicare population, we have not gone far enough in providing other than costly institutional care. Provisions are necessary to expand the

use of community health services and home care as alternatives to long-term

or acute care institutions.

Careful monitoring is needed to assure that

these options fill the gap as legitimate substitutions and do not create new

or expanded benefits. A bill recently introduced by Senators Inouye and

Packwood seeks to authorize the establishment of Community Nursing Centers under

Medicare and Medicaid. The proposal builds upon the historically demonstrated

capacity and concern of community based nursing organizations, such as

visiting nurse agencies and departments of health. Services would be offered

on an inclusive per capita fee basis to well children, to those in need of

home care, as presently authorized under Medicare, and to individuals, who

without the services of Community Nursing Centers would require institutional placement. Through such a commitment the Community Nursing Center unifies existing

services and promises to impact costly admission and retention of patients

in hospitals or nursing homes. Assurances to safeguard against both under

utilization and over-utilization of services would mitigate against any income

maximizing techniques.

Health Care Reimbursement

Finally, are our recommendations for a reimbursement system that truly

addresses quality care outcomes while containing costs.

We strongly oppose increasing Medicare user's co-payment as we believe

that budgets should not be balanced on the backs of those least able to bear

the costs.

The prospective payment system, currently under discussion by HCFA, is

a logical mechanism to contain cost.

Further, a case-mix reimbursement system

is a useful model to implement prospective payment. However, NJSNA is

fearful that implementation of a case-mix model without addressing nursing

intensity resource use on a patient-specific basis will jeopardize patient care,

since adequate nursing resources may not be allocated. A result of seven years of funding, the methodology on Relative Intensity Measures of nursing care (RIMS) developed in New Jersey with HCFA funding, provides a workable allocation

statistic.

The DRG model as conceived by Medicare includes no sensitivity to the

intensity of nursing resource use on a patient-specific basis. It will never

achieve the control it desires without this patient-specific measure of nursing.

Thrity-five percent of a hospital's budget is concentrated in the department of nursing; 55% of the manpower budget exclusive of hospital based physician cost is devoted to nursing service personne1.3 Nursing reports a yeoman's share of hospital finance, and while it is costed out on a per diem basis and quite

arbitrarily patient-to-patient, maximum budget control is impossible. The relative intensity measure methodology (RIMs) is the only allocation statistic

of its kind and is currently pending incorporation into rate setting for 1984.

In summary, the New Jersey State Nurses Association supports a Medicare program that gets quality care to the ageú and selected populations. We believe

that nursing can offer excellent cost-efficient resources as health-care

providers in settings where nursing is reimbursed to the fullest, without con

straints of health care gatekeepers.

We believe that the prospective payment system holds promise for cost

containment, while offering quality care, but are adamant that nursing intensity

resource-use must be addressed as a separate cost unit.

References

1. Joseph Romm, et al. Survey and Evaluation of the Physician Extender Reimbursement Experiment: Productivity and Cost, Washington, D.C.: Health Care Financing Administration,

1979. 2. Virginia Cleland, "Perspectives for Nursing: 01d Dreams, New Visions", Perspectives for Nursing: A symposium, Hyattsville, Md; US Deparment of Health and Human Services, Health Services Administration, Bureau of Health Division, Division of Nursing, August 1980.

3. Russell Caterinicchio and Pearl Morrison, "Case-Mix Reimbursement", The New Jersey Nurse, Sep/Oct 1980.

22-020 0-83--13

PREPARED STATEMENT OF DORIS FULLERTON, PRESIDENT, PRACTICE INSIGHT, INC., AND

PRESIDENT, HERE TO HELP, INC.

Congressman Rinaldo and Members of the Advisory Council,
I am Doris Fullerton, President of Practice Insight, Inc.,
a management consulting firm serving physicians and den-
tists and President of HERE TO HELP, INC., a medical claim
service which assists individuals, attorneys, estates and
small businesses to obtain the maximum reimbursement un-
der their policies. I have been the Administrator for
multi-physician medical groups for over fourteen years.
I have taught courses and seminars in Medical Office Man-
agement for physicians and their office personnel.

Over the years I have witnessed numerous insurance reimbursement problems for health claims. I will address only the problems of the elderly at this time.

Many of our Medicare clients are covered by additional health insurance policies but are not aware of the benefits or limitations of each policy or what should be claimed from which carrier.

Some of our clients have so many health problems that they
simply cannot sort out or deal with the maze of forms and
bills. Many are procrastinators who readily pay their
bills but become confused when it comes to forms. They
do file their claims on top of the refrigerator or in
a desk drawer. Others simply cannot remember what has
been filed, reinbursed or paid. Very few Medicare bene-
ficiaries have the insight or perseverance to investigate
or challenge unwarranted Medicare denials.

Our clients come to us because their claims are so complex that they cannot reasonably expect their physicians or huspital business office personnel to assist them further. They

cannot deal with the red-tape, the "lost claims", the low reimbursements, the appeal process and the general confusion. Many have multiple insurance policies.

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I feel that much of the confusion Medicare beneficiaries have could be avoided if they were able to have their questions answered knowledgably by personnel in their physician's offices who have a keen understanding of the Social Security system and Medicare as well as working knowledge of supplemental insurance plans. I have personally spoken to numerous physician's office personnel who do not understand Assignment of Benefits, do not know current deductible amounts for Part A or the definition of a Benefit Period. These people care very deeply, as I and my staff do, about our senior citizens whose lives they touch each day. Their contact is inore frequent and intimate than a visit to a distant SSA office. I encourage physicians to take responsibility for providing continuing education for their professional receptionists and other staff members.

I propose that the Social Security Administration conduct seminars and workshops specifically for medical office personnel regarding updates and revisions in Medicare and other SSA programs.

Medicare was designed to meet the health care needs of the individual, Has it done that?

Better utilization of Home Health Care Services would provide a substantial savings to the Medicare program and help to preserve the dignity of the recipient. The services of

skilled nurses, approved as providers, could show a substantial savings through Community Nursing Centers as proposed by Senators l'ackwood and Inouye in a bill recently introduced.

Legislation signed into law by President Reagan extending Medicare coverage to Hospice care as of Novenber 1, 1983 will not only save the Federal Government hundreds of millions of dollars in health care costs but allow beneficiaries a compassionate alternative to hospital care.

The psychological needs of the patient and his family will now be dealt with in a humanitarian and cost-effective way.

I do not believe the Medicare benefits are structured
properly. How can a person relying on Social Security
benefits in 1984, $4,860.00, as his/her only source of in-
come be expected to survive even one average hospital stay
with the Administration's proposed Medicare changes? The
out-of-pocket expenses for an average hospital stay would
amount to more than one-quarter of the total income for
the year.

How can we let this happen to the people who have worked and suffered and fought wars to keep us free?

The fiscal 1984 budget is really just shifting costs to the elderly and disabled. If the deductibles continue to increase as well as the co-insurance amounts and the premiums they will be forced to enroll in the Medicaid program. We cannot honestly expect them to do otherwise if they are to urvive.

One of our clients, Mary Husted, an 82 year old childless widow underwent cancer surgery in August of 1981. She re

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