"This is my wife. She has a home. I said bring her here." The hospital arranged for the necessary equip ment and contacted CNS which provided a nurse to. train the family and supervise Mrs. Richardson's care and therapy. The way was carefully prepared for Mrs. Richardson to come home, where her husband provides for her daily care, feeding her through a nasogastric tube five times a day and irrigating a catheter twice a day. Her children and grandchildren frequently pop in to talk to her and help provide the stimulation that is helping her relearn to talk and make her way on the road to recovery. For Eva Screen of East Orange, her mother's homecoming was a different matter. "They dumped my mother on my doorstep like so much garbage. It's like they just threw her away," Screen said. انه Mellow Screen is 49 and recovering from a stroke which has left her mentally disoriented. Screen said her mother was admitted to East Orange General Hospital earlier this month. In less than 'a week, Screen said, she recieved a call at work and was told her mother had been discharged and was at the daughter's apartment. According to Screen she came home to find her mother, who did not have a key to the apartment, standing in the apartment lobby. Mrs. Screen had removed all of her clothing, except for a blouse, and was wet with her own urine. Screen claimed the only thing the social service department told her, after her mother had already been sent home, was that it would be hard to find a nursing home for her. Lois Young, assistant director of nursing for CNS, said discharge planning is "going in the right direction" Xin most of the Essex County hospitals. bre The main problem is nursing home placements. There is a severe shortage in the area, and hospitals with patients who need such placements have no place to send them, she said. The state claims as many as 3,000 people are awaiting such placement at any given time, but Young said no one really has a good count or knows exactly who those people are and where they are. An East Orange General Hospital administrator said Mellow Screen's physician determined that treatment had been completed and discharged the patient. The administrator said the discharge protocol was followed and claimed Screen had been notified of the discharge, something Screen denies. He said a hospital social worker determined the mother "was alert and aware of time, place and per son" at the time of discharge. Some claim things are getting better, not worse. In July, Rosmary Cucarro, executive director of the Visiting Nurse and Health Services of Union County, testified before Sen. Bill Bradley (D-N.J.) at a Special Senate Commitee on Aging hearing. Asked if she had seen a difference in the kind of home health patients her agency was getting, she said: "Certainly. The very acutely ill, some of them don't even make it home in the ambulance, senator." Pressed for more information, she said: "We have had two patients die on the way home from the hospital in the ambulance. I am not really being very critical. I just think that everybody is very much in an economic bind... I think sometimes people are being discharged a little too early from the hospitals." Asked if that statement reflects today's situation, Cucarro said, "Things have improved. That was a year ago." But according to Dr. Howard Slobodien, president of the Medical Society of New Jersey, physicians are being pressured by hospitals to get their patients out of the hospital as soon as possible. "Yes, they're being pressured. It's 'doctor, get your patient out.' And if you say the patient still needs care, or the patient can't be treated at home, it's still 'doctor, get your patient out.'' "I can't prove it, I can't disprove it, what I hear is anecdotal, but I hear that it is creating a revolving door effect, that patients are coming out of the hospital and going right back in," Slobodien said. At present there is no easy way to track such a trend, he noted. Louis P. Scibetta, president of the New Jersey Hospital Association, admitted that hospitals are trying to reduce the length of stay. But, he said, they have been criticized for years for running up health care costs, partly because patients who could have had tests done on an outpatient basis and patients who could have been cared for at home were spending extra days in the hospital. Mr. RINALDO. I would like to ask each member of the panel, since I think that is an important point that was made, have any of you or your friends had an experience with early discharges under New Jersey's DRG system that you would like to testify to? Mr. Keiserman? Mr. KEISERMAN. No, I have no such experience. Mr. RINALDO. Anyone else? Mr. BOND. I have none. Mrs. ABRAMS. No. Mr. RINALDO. I would like to ask the panel the next question which I think is fairly important, and it deals with something we discussed earlier with Dr. Davis. Do you believe that the Health Care Financing Administration should make available the identity of those physicians which accept assignment, that is, those that accept medicare reimbursement as payment in full? Suppose we start with you, Mrs Abrams. Mrs. ABRAMS. Yes, I think we should. Mr. RINALDO. Mr. Miller. Mr. MILLER. Absolutely. We have been trying to get the doctors in Bergen County to accept assignment. And we are meeting stiff opposition from the Bergen County Medical Association. But in Monmouth County, our Monmouth County Council, a member of the New Jersey Council, made a thorough review of this. They published the names. Let us publish those names, and let us decide as senior citizens which doctor we will go to. The others will soon fall in line when they find out we are not patronizing them. Mr. RINALDO. You think that would be helpful and it would be one means of reducing costs? Mr. MILLER. Absolutely. Mr. RINALDO. Mr. Keiserman. Mr. KEISERMAN. I am from Monmouth County. I am one of the five persons who worked on this project, where we contacted over 1,000 doctors in Monmouth County and found 400 who replied to us that they would accept assignment. This was done through the Monmouth County Senior Citizens Council. And in conjunction with the Monmouth County Office on Aging. And we published such a book. It is available throughout Monmouth County. HCFA, in fact, sent a representative up to one of our committee members and got a copy of it to see what we had done, and Sister Simon, the director of the Monmouth County Office on Aging, made available to every office on aging in the State, our letters, our format, how we went about it, and copies of the book we developed. Unfortunately, only 400 doctors of the 1,000 replied to us that they would accept assignment. But most of them had only certain conditions under which they would accept assignment. Of the 1,000 doctors we contacted, I would say no more than 75 take assignment from all patients. The others limited it to patients in nursing homes only, patients in hospital care cases only, and other restrictions like that, which limited the amount of assignment actually that is being covered. This we did last year and we hope to update it next year. Mr. RINALDO. So you feel that the list has proven helpful? Mr. KEISERMAN. Yes. I live in a condominium where we have over 3,000 residents, and we made it available to all of our residents and people I know very well, and almost all of them have used it to very good advantage. Mr. RINALDO. Do you feel that it has reduced costs? That it helps to reduce the overall costs to the program? Mr. KEISERMAN. Whether it reduces the costs to the program, I do not know. It may make the cost to the program higher because medicare only pays assignment rates regardless of if a doctor accepts it or not. It reduces costs to the senior citizen. Mr. RINALDO. Mr. Bond, do you want to comment? Mr. BOND. I have no further comments beyond those that have been made, except to point out that in this particular community of Princeton, it is almost impossible to find any physician accepts assignment. Mr. RINALDO. Thank you. While general revenues may not be used to make up any deficits in the hospital trust fund, several advisory councils on social security as far back as 1938 and 1948, have recommended the use of general revenues for benefits under social security. It was recommended in 1965 for medicare benefits for those already retired or disabled. In 1971 it was recommended that one-third of parts A and B taken as a whole ought to be funded by general revenues. The 1975 council recommended using general revenues in medicare, and reallocating a portion of the hospital insurance tax to the retirement fund. In 1981, the National Commission on Social Security also recommended the use of general revenues in medicare and reallocating a portion of the hospital insurance tax to the retirement fund. I understand from the testimony we received earlier that the current advisory council is not going to recommend the use of general revenues. Mr. Keiserman, do you think general revenues should be used to pay part of the cost of hospital insurance? Mr. KEISERMAN. I think it would only be fair because general revenues have been using social security money in devious ways, that I consider devious ways, such as the $16 billion that has not been returned to the trust fund, which covered soldiers from World War II through to the Korean war. The fact that we get the lowest possible return on the trust fund moneys, which is actually helping subsidize general revenues and other ways. There are dozens of other little ways that general revenues have profited using the social security funds. I do not say they misused the actual funds, but they have taken advantage of issues there. You yourself, pointed out that in the last 2 years $4 billion was lost to the social security fund by the use of investments giving us lower returns. I have a newspaper article quoting you on that. So these are some of the facts. I do not see any harm from instead of abusing us, possibly helping us for once. Mr. RINALDO. Thank you. When medicare first started in 1966, general revenues and premiums were about 50/50. Why do you think now that 35 percent is too high? Mr. Keiserman. Mr. KEISERMAN. I feel it is too high based on the income of seniors. They have just delayed for 6 months the cost-of-living increase. And by the way, the delaying of it only delays it another 6 months because it is already delayed 1 year. It is based on the previous year's increases. So seniors have always been at least 1 year behind. Now they will be a year and a half behind in this cost-ofliving increase. So in a sense this actually will not help seniors in any way that way. Mr. RINALDO. Mr. Miller, are there any members of your organization who feel we can increase copayments for beneficiaries? Mr. MILLER. No. As I testified in my written statement here, I would like to go back to the previous question, if I can make a comment about that. Mr. RINALDO. Sure. Mr. MILLER. We get into a vicious cycle about taxation and who pays for it in the end. It comes down basically to the consumer. We are consumers. And every time you raise the taxes on the corporation or on the workers, they are going to get their money back. They are going to pass on those costs. When they pass on those costs, we have to pay them. And we keep going down, which might be termed inflation, but the basic cause is, is taxing the product and taxing the workers. That does not help the senior citizens in any way. As I said, I think the senior citizens that are affiliated with our Council feel that the problem does not exist as a result of income. The problem exists because of not containing the cost to hospitals or the exorbitant fees of the doctors. Mr. RINALDO. Well, how about inflation? Mr. Keiserman in his statement seemed to indicate that the Federal Government and not the medicare beneficiary ought to absorb all the impact of health care inflation. Is that putting it correctly? Mr. KEISERMAN. No, I did not say that. We are paying an increase in our cost insurance monthly. The deductible has gone up. The coinsurance on hospitalization has gone up. So actually I dispute that statement by you, Congressman, respectfully, of course. Mr. RINALDO. How do you think we should pay for increased costs? How do you think we should handle it? Do you think any of the costs should be passed on to the medicare beneficiary? Mr. KEISERMAN. I think the only organization that is capable of making medical care cost effective, efficient, at a reasonable cost, is the Federal Government. It cannot be done on a local basis. And by just raising rates constantly to meet cost increases without looking toward making this whole program more efficient, and rendering better health care, is just ridiculous. It is just a dog chasing its tail going in a circle. And that is exactly what is happening. Mr. RINALDO. Well, do you think we can make it more efficient, render better health care, not increase the cost to any beneficiary, and still handle a projected shortfall of up to $400 billion by 1995? Mr. KEISERMAN. I do not know if we could actually address that big a deficit, but I do know we can make a big dent in it. I have made a number of recommendations. Home health care service, for example, would reduce hospitalization tremendously at a much lower cost. This hospice program that Congress passed to take effect next November, why they delayed it a year and a half, I do not know. It will keep terminal cases out of hospitals, in homes, and reduce the cost to members. We have no schools of gerontological medicine really worth talking about. I attended a seminar where it was admitted right here in Rutgers they still did not have a chair for that. That is being instituted now, according to Dr. Bergen, who is president there. Now, this is true throughout the country. Seniors react differently to different prognosis, different medication. If they would study better the care that seniors need and the reaction of seniors to medicine, perhaps they could cut costs tremendously. There is so much that can be done that must be done on a national basis, instead of just raising the costs to seniors constantly. Mr. RINALDO. Let us assume all of that is done. Every proposal that the Commission, the Council, Members of Congress can think of to reduce costs are put into effect, and it is still not enough, do you still object to any cost-sharing increases? Mr. KEISERMAN. No, sir. Not at all. But I would like to see some innovative ways tried, which is all that is happening now and you see it from the budget proposals by the administration, that all they are doing is raising the share to seniors and that is it. They are not doing anything to actually cut the costs. Mr. RINALDO. Mr. Miller, is your organization-what would you say are the most important priorities that your organization has come up with, if any, to improve medicare? Mr. MILLER. Why do you not make a contract with the doctor and not with the senior citizens? Why do you not set a schedule of rates? Make it a voluntary program. Any doctor who wants to join this plan, he knows in advance what he is going to get for certain treatments. And if you did that, you can control the doctor. Right now, he keeps on increasing his rates and that adds to the cost for the senior citizen. How much more can we stand? We are on fixed income. Every dollar you add to us reduces us for something else. We must make sacrifices. Mr. RINALDO. Thank you. Mr. Smith. Mr. SMITH. Thank you, Mr. Chairman. First of all, we have heard some very strong objections from the panel to hospital copayments to some strong objections to raising the part B medicare premium to 35 percent, and also I think, among all of you perhaps, support for including general revenue moneys, as part of the mix in the equation for financing medicare. I do have a few questions, and I think, Mr. Chairman, you covered most of them, but I will ask my remaining questions. Mr. Miller, you spoke of inclusion of comprehensive eligibility for reimbursement to home care, and we were just having a discussion on that. Could you elaborate on that? Exactly what kind of services do you see the proposal taking. Mr. Miller, and then Mr. Keiserman, because you were also sharing on that. Mr. MILLER. And the question is? Mr. SMITH. The question is: Specifically, what kinds of home health care services, if you could itemize some of those services, could you share that with us? Mr. MILLER. Well, we feel many doctors are required to make a determination or a diagnosis of a condition, the first thing is they want to get all the best equipment that is available to them, and |