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better management practices on the part of hospitals, increased communication between physicians and hospital administrators,

more accurate data, and a heightened awareness of the costs associated with providing patient care

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despite the myriad

of problems that have accompanied the system's implementation. Over time, we can expect that improvements in the areas noted will reduce hospital costs and hence expenditures on the part consumers of hospital care.

REFERENCES

of

1. In an effort to develop an allocation statistic which is more sensitive to the amount of nursing resources actually consumed, the New Jersey Department of Health has recently completed an analysis of the number of nursing minutes required by patients in each major diagnostic category. The use of the new statistic in the DRG program is currently under consideration by the State's Health Care Administration Board.

2. The members of the evaluation team were drawn from Coopers and Lybrand, the National Health Care Management Center of the University of Pennsylvania, Agnew Peckham and Associates, Inc., and Yale University's Center for Health Studies.

3. Dunham, A.B. and Morone, J.A. "A Political History of DRG Rate Regulation in New Jersey". In DRG Evaluation Volume IV : Political Evolution and Organizational Impact. Princeton, N.J.: The Health Research and Educational Trust of New Jersey, 1983.

4. Ibid. p. 180.

SUGGESTED READING

Grimaldi, P.L. and Micheletti, J.A.Diagnosis
Related Groups : A Practitioner's Guide.

Pluribus Press, 1982.

Chicago, Ill:

May, J.J. (ed.) Diagnosis Related Groups. Topics in Health
Care Financing, Vol. 8, No. 4.

(Summer 1982).

New Jersey Hospital Reimbursement Under S-446: Elements and Effects 1981. Princeton, N.J.: New Jersey Hospital Association, 1981.

Perspectives on Diagnosis Related Groups. Cleveland, OH: The Greater Cleveland Hospital Association, November 7, 1980.

Wasserman, J. DRG Evaluation Volume I : Introduction and Overview. Princton, N.J.: The Health Research and Educational Trust of New Jersey, 1982.

Mr. RINALDO. Mrs. Abrams.

STATEMENT OF ESTHER ABRAMS

Mrs. ABRAMS. I have been a resident of Princeton for 38 years, and I have also traveled to Trenton for many activities, so I am very happy to see both our Congressmen on the Select Committee on Aging.

I am proud and appreciative of the opportunity to testify here today as a representative of the Older Women's League. Ours is the first national organization to focus exclusively on the concerns of older women. Our members are working for changes in public policy that will reduce the inequities older women face today.

By far, one of the greatest problems older women share is obtaining access to affordable health care. On the whole, women in the United States experience aging very differently than men do. The most important of these differences are found in longevity, marital status, and income.

Women make up 60 percent of the population age 65 and over, and by the age of 75 there are twice as many women as men. Thus, because of the age differences in longevity, women outnumber men 2 to 1 in the older age categories, where health care costs and use are highest.

Then, too, there are very large differences in the proportions of men and of women over age 65 who are living with a spouse. Forty percent of women age 65 to 74 are widowed, while this is true of only 8 percent of men in that age group.

For those age 75 and over, 70 percent of the men, but only 22 percent of the women are still married. This is partly due to longevity, but also due to the fact that men generally marry younger

women.

In 1981, of the approximately 7.5 million elderly living alone, 6 million or 80 percent were women. Of the elderly poor, 75 percent are women. At any adult age, there are very large differences between the incomes of men and women, but for those age 65 and over, the differences become dramatic and appalling.

For men over the age of 65, the median total money income in 1981 was $8,173; for women $4,757. In that same year the official poverty level for a person living alone was only about $300 less than the median income for all women over the age of 65.

Although women are 60 percent of the elderly, they comprise 75 percent of the officially poor of these elderly.

There are some differences in the types of health problems men and women face in their later years. Older men have higher rates of fatal diseases, such as heart disease and cancer. Older women tend to suffer more from long-term chronic diseases, such as arthritis, diabetes, visual impairment, and osteoporosis. Thus men 65 and over have more surgery and more days of hospital care, women have a longer average length of stay reflecting the differing martial status. A larger portion of older women than men are transferred from hospitals to other facilities for continued care. And, finally, women comprise 70 percent of the residents in nursing homes. All three related, no doubt, to the large percentage of older women who live alone.

Thus, since women are so likely to end up living alone and often in near poverty, and since they must from an early age stretch a smaller income over a longer life span, their great concern about being able to afford health care during a time of ever-increasing costs is very understandable.

Even though the elderly are happy to have medicare, this by no means pays for all their health care. Thus, lack of coverage and growing out-of-pocket expenditures are a major problem for the aged poor, the majority of whom are women.

First, medicare requires that beneficiaries share cost through deductibles and copayments. Second, patients must make up the difference when physicians charge more than what the Government deems reasonable charges. And, finally, many health needs are not covered by medicare, and most significantly by women. These are things like at home prescriptions, hearing aids, dental and eye care, and long-term custodial care.

Older women, on average, now spend one-third of their median annual income on health care.

Inflation of medical costs has greatly exceeded general inflation over the past 10 years. Combined with budget cuts during the past 3 fiscal years, the result has been a heavier financial burden for older persons, and rising prices and increased cost sharing for health care.

Proposals in the administration's fiscal year 1984 budget, many rejected by Congress last year, would further increase the cost of health care services for most older persons. The changes will hit hard at older women particularly, since they have a higher incidence of chronic diseases than men, but also less income than men to pay for the care they need.

The administration has proposed cuts of over $1.8 billion in medicare for fiscal year 1984. Almost all of these cuts will mean increased costs to medicare patients. Under the guise of catastrophic coverage, the administration proposes requiring medicare patients to pay part of the cost of hospital stays from the 2d to the 60th day of care, in addition to the existing 1st day deductible of $350.

Current copayments now required after 60 days in the hospital would be dropped. It may seem like a good idea to insure older persons against financial devastation from a long hospital stay, but the proposal is actually a gift horse for the elderly. The average length of stay in the hospital is only 11 days. Even for women age 85 and over, the average length of stay in 1978 was only 12 days. Only about 2 percent of medicare beneficiaries would benefit from this proposal.

The administration's rationale for this proposal is to discourage beneficiaries from overutilization of services. Not only is there no evidence of this abuse by the elderly, but conveniently ignored is the fact that doctors, not patients, order hospitalization.

The Reagan administration has also included in the budget several other proposals which would result in increased cost sharing, delayed eligibility, all of which will make less accessible adequate health care for older women.

The health care system, including medicare, is based on an acute medical model with cure rather than care as its central focus. To

the extent that older women need care for their prevalent chronic illnesses, they are not well served by the existing system.

The budget cuts proposed in fiscal year 1984 will not change this focus, and will only exascerbate the problems older women face in gaining access to affordable health care.

Mr. RINALDO. Thank you very much.

Mr. Keiserman, you brought up the article on early discharges under New Jersey's DRG system that was in yesterday's Star Ledger?

Mr. KEISERMAN. Yes, sir.

Mr. RINALDO. I would like to request unanimous consent that that article be included in full in the record.

Mr. KEISERMAN. I would appreciate that, Congressman.

Mr. RINALDO. So ordered. It will be in the record.

[The material submitted by Mr. Keiserman follows:]

Nurse group accuses hospitals of forcing patients to go home

By JOAN WHITLOW

New Jersey hospitals are under fi. nancial pressures to move patients out as soon as possible and some claim many patients are being sent home too

soon.

The New Jersey Home Health Agency Assembly, an organization of home nursing agencies, said members are complaining that too many patients are being sent home before they are ready and one result has been an increase in relapses and readmissions to the hospitals.

The agency has asked its members to provide hard data on its contentions.

One major home nursing agency has collected such information. According to Nancy Sweeney Stanhope of the MCOSS Nursing Service of Red Bank (formerly the Monmouth County Organization of Social Services), her nurses went to visit one patient the same day the person was discharged from the hospital.

"That patient had an intestinal blockage that had not been picked up in the hospital. We walked in, saw what it was and sent that patient right back to the hospital," she said.

"The utilization review committee (which monitors length of stay in a hospital) came marching through with their clipboards one day. One man got an hour's notice that he was being discharged. He was a stroke patient and a newly diagnosed diabetic," she said.

As the man was leaving the hospital, someone realized he had never been taught how to give himself insulin injections-as he would have to do each day at home.

According to Stanhope, "They ended up showing him insulin injection techniques in the hospital elevator as he was leaving."

She said a cancer patient was discharged from a hospital after being

given a special catheter, a tube which extends from the site of the tumor through the skin so that cancer-killing drugs can be injected directly into the tumor.

It is a form of treatment which can be done at home, Stanhope said, but the patient was sent home without being told what to do to keep the tube open. Nor was any referral made to a home care agency to prove the needed care after discharge.

"We just happened to find out about that patient," she said.

She said part of the problem is that New Jersey's system for paying hospitals, diagnosis by related groups or DRG, financially rewards hospitals if a patient's stay falls within certain limits and financially punishes hospitals when the patient runs over the average.

.

"With the shortened length of stay, people are starting to fall through the cracks," she said.

She said that in the case of the cancer patient, the discharge was not handled properly because "the doctor never filled out the right form, the hospital social worker did not fill out the form, my coordinator at the hospital did not fill out the form.

"We all missed, and that makes me wonder if he didn't come out of the hospital too quickly."

Stanhope said she did not want to name the hospitals involved because "it is nobody's fault; it is a combination of all our faults."

Agencies like hers say they are seeing sicker patients than ever before, patients who are coming home from the hospital on respirators, patients who need intravenous feedings, patients coming home much sooner after surgery than in years past with wounds that need a kind of care home nurses never used to provide..

The agencies say that it is appropriate to get patients out of the hospital as soon as possible, and new technology does make it possible to care for more complicated problems in the home, but only if the patient and family are properly prepared.

Discharge planning and home care also worked for the Richardson family of Irvington.

Lucille Richardson is a stroke patient. Her husband, Joseph, said that when it was time for her to leave Irvington General Hospital, "The doctor gave me two choices: He said she could go to a nursing home or she could come here to her home.

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