re economical to handle the nursing and convalescent needs of such cance patients. r a broader Prior Hospitalization Requirement mits coverage Last year Congress gave HHS the direction to basicall eliminate, in whole or prid in part, the minimum three day hospitalization requirement for Medicare SNF coverage wheneve and however cost-effective. We urge aggressive implementatio of this provision. The change would provide Medicare beneficiari with greater flexibility in their long term care Coverage ar result in lowering overall costs for both the patient and th Medicare program. In light of HCFA's steadfast position that repeal in whol of the requirement would increase cost, the requirement shoul be repealed in part. Specific types of patient situations ca be identified for which the prior hospital requirement is n cost-effective nor necessary to control inappropriate utilizatio Examples of patient situations include the following: beneficiari who need skilled nursing services for a terminal illness; benef ciaries receiving Medicare home health services who devel an intensified nursing need; beneficiaries who are non-Medical nusing home residents who need further care at the more intensit skilled nursing service level; and beneficiaries who have n ended a "spell of illness" either because 60 days have not laps since their hospital or SNF care or the overly broad HHS pretation of when these inpatient services are deemed to ended. AHCA believes that the requirement can be completely elimi: even under the statute's cost-effectiveness criterion. most thorough, objective examination to date од this iss a three-year HCFA demonstration project in Oregon and Massachu and evaluation report by Abt Associates, Inc. The record likely Medicare savings would result from elimination o requirement. We know of no other public or private health which finds value in such a requirement. The current restriction is arbitrary, unnecessary and bu some. The removal of the requirement would recognize the legit needs of beneficiaries who require only skilled nursing serv There are also those who "game" the program by arranging unnecessary (and costly) hospital stays in order to become eli for Medicare SNF benefits. In addition, there are indivic receiving hospital care who would benefit as much from SNF but who are not transferred because of the paperwork (e transfer of medical records, treatment plan) and the final disincentives (e.g., no cost sharing is required after the hos deductible until the 61st day). ✓ eliminated, rion. The his issue is assachusetts record shows tion of the = health plan AHCA recommends eliminating inconsistencies in the "spel of illness" definition so that a "spell" ends when a beneficiar is neither under Medicare inpatient hospital nor SNF coverag followed by the requisite time period. In general, the Medicar program limits the duration of covered services to the perio between the beginning and ending of a "spell of illness" Unde present law, a Medicare beneficiary must remain for 60 consecutiv days out of a hospital or SNF in order to renew Medicare eligibilit for these benefits. ry and burden he legitimate ing services. rranging for become eligible e individuals from SNF care erwork (e.g• 1 I the financial er the hospital There are inconsistencies in the SNF criteria used to star and end a spell of illness. For purposes of starting a spel of illness and receiving benefits, the beneficiary must be i a facility which is licensed as an SNF, certified under Medicar as a SNF, and meets all of the program's requirements for participa tion as a SNF. However, for purposes of determining if a patien is no longer in a "skilled nursing facility", the program use an overly broad definition encompassing many facilities no certified as a SNF nor eligible to be a SNF. Under Medicare's policies, many Medicaid intermediate car facilities are classified as providing skilled nursing care only for purposes of ending a Medicare spell of illness. A a result, a beneficiary in an ICF, which is classified by Medicar as providing skilled nursing care for spell of illness pur might not receive Medicare coverage when he needs to 89 to a hospital for SNF. Coverage would not be received b the spell of illness had been deemed not to have ended. A similar HCFA policy adversely affects beneficiary co for durable medical equipment (e.g., oxygen therapy, altern pressure mattresses, and pacemaker monitors). The durable m equipment is available to beneficiaries at home or in an instit other than those meeting the broad definition of SNF. recommends the Part B durable medical equipment covera available to a beneficiary who is neither under Medicare inp hospital nor SNF coverage. Utilization of Physician Assistants and Nurse Practitioners Federally financed demonstrations have proven that phys assistants and nurse practitioners can perform cost effe and high quality services which traditionally have been pro by physicians. Physicians extenders have proven utilit monitoring care, providng routine medical services, and a priately involving the supervisory physician if major me problems develop. Congress has already recognized the value of phys: assistants and nurse practitioners to augment physician ess purposes, = to go back eived because ed. rural clinics. Long term health care facilities are also appropria settings for their utilization. iary coverage alternating urable medical institution, Medicare requires periodic physician visits of long term care patients and periodic recertification of their continued need for care. AHCA recommends that physician assistant and nurse practitioners, 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 opportuniti for new policies which would conserve program spending, improve service to beneficiaries, and enhance the provision of long term care. We hope that you will provide the charted course so Medicare nursing home benefits can finally become what beneficiaries need and think they have. JAMES E. CUNNINGHAM, PRESIDEN |