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sentative Skiffington on the utilities to try to reduce what we are paying on the phone and electricity. We haven't had any answer from him, yet, so I was hoping that could be worked out. Also, in regards to the seniors on their pension, it would also be a big help in reducing and helping out towards the other expenses they have to meet with. So you know that would be a big help if it can be worked out.

Thank you.

Senator PELL. On the Federal level we are working on some bills*— I have cosponsored three-which would reduce transportation costs on those means of transportation on which some of the funding is Federal. Those would be airline or federally regulated railroads; but, when you come to taxicabs I am afraid the Federal Government is not going to do this. Perhaps Representative Skiffington would like to reply.

Mr. SKIFFINGTON. Senator, and people here today, I did introduce a bill to reduce fares on buses, and utilities, and the bill is still in the committee of the House of Representatives and like everything else this morning, when you get down to the real cold hard facts the answer is money. As the gentleman said here that's the problem-getting the money to finance these programs. As you all know we have a financial crisis in the State of Rhode Island which is not any different than any other State and not any different from the Federal Government and we are always trying to do our best for senior citizens and anyone else that needs help.

Senator PELL. Anyone else in the audience that would like to say something at this time?


Mrs. HERVE. I was listening today, unfortunately it is all one side and I appreciate what you have been doing for all of these places. I am still a taxpayer at 75 and every year they jack the taxes instead of giving us a reduction-you know-especially at my age. I am not the only one. I have never been on relief, never had a nickel for relief nor asked for it, but why should we be taxed, you know, at full price? They raise the tax every year, and they jump up the evaluation besides. Another thing about the State tax, you know, this week-or last Saturday—I got a bill and I went down for my State tax. I have a few dollars in the bank. I explained to the woman down there in the office in Woonsocket and asked if I had to pay that. She said, “Well, I don't know, you fill it in and we will let you know about it." Now, Saturday I got a bill for it plus 25 percent-which they will never get from me, because I already filed it. If they want the rest of the money they will get it. I won't be penalized, no. I don't care who hears it, anybody from the State House I don't care.

We got 10 percent for the Medicare, that is only the Medicare of 10 percent for the old age and the very same day they raised our fee for the Medicare, is that right? After that I pay a Blue Cross-and I bet a lot of these people pay Blue Cross besides. It used to be $11 for 3 months and now I get a bill for $21. That is what we got for the 10 percent more.

*See appendix 2, p. 202.

Thank you.

Senator PELL. Thank you very much. I am afraid that you confirmed the fact that there are two things sure in life, death and taxes. Our last witness; would you identify yourself?


Mrs. BEAUDOIN. I am Mrs. Harriet Beaudoin. I got a raise in my pension and they give us Old Age Assistance of $7. In Massachusetts they are getting $10, how is that? They raised our pension and Old Age Assistance to give us $7 in Old Age Assistance; but, in Massachusetts they are getting $10. How is it they are getting $10 and we are being cut to $7?

Senator PELL. These are differences in the State regulations, and I am not familiar with them myself. I would think that Mrs. Slater might be able to help us. Well, she has left. Doctor Mulvey? Dr. MULVEY. The State regulations.

Senator PELL. This is a Federal hearing and I am afraid that we can't help you in this at all.

Mrs. BEAUDOIN. Thank you very much.

Senator PELL. I want to thank each of you, as we bring this meeting to a close. Now, you have seen these blue sheets of paper and if any of you have any suggestions or ideas write them out on the piece of paper and mail them to me.* I think this was an interesting and instructive meeting. We had witnesses from one community, Woonsocket, talking about the problems as they affect the group-one group of people and that is the elderly. The record will provide many insights to Congress as they consider changes that need to be made.

Today we have also heard some new suggestions on amendments to H.R. 1. These suggestions indicate that Medicare should be expanded and not contracted. There should be less restrictions on nursing home care, greater use of home care services, and there should be more nursing homes throughout the country. Moreover, it seems that the hearing has shown that Washington will do better to do more listening and less issuing of regulations.

The subcommittee is in recess, subject to the call of the Chair. (Whereupon, at 12:30 p.m., the subcommittee was recessed, to reconvene at the call of the Chair.)

*See appendix 3, p. 219.


Appendix 1



The Rhode Island Home Health Agencies wish to take this opportunity to share with you some of our concerns over the plight of the patients over age 65 who were led to believe that Medicare would solve most of their health problems and who now find out-of-hospital service to be severely limited. Rhode Island is fortunate in that there is complete coverage of all areas of the State by Home Health Services.

When the Federal Medicare legislation was being drafted, the Visiting Nurse Services, certified under Medicare as Home Health agencies, were considered an important resource in keeping costs down because, according to experts, health maintenance care and prevention at home would be considerably less expensive care than care in a hospital or extended care facility. Yet the conditions for participation which govern reimbursement set up a barrier to the use of home health services, limiting what might become an important health resource. Since the patient must be certified as needing skilled nursing care on an intermittent basis or physical or speech therapy in order to qualify for home health benefits under Parts A and B, the definition of skilled nursing care and the interpretation thereof becomes a most important matter for Home Health Agencies providing services to Medicare patients.

In August 1969 the U.S. Department of Health, Education and Welfare's Social Security Administration's Bureau of Health Insurance issued Intermediary Letter No. 395 on the subject of "Skilled Nursing Care Provided as a Home Health Benefit". This letter contained a definition of skilled nursing care which became a matter of grave concern to Home Health Agencies.

It appeared that the Home Health Agencies and Federal Medicare Intermediaries had not interpreted the definition of skilled nursing care uniformly throughout the country,

In an effort to assist Rhode Island Home Health Agencies in determining acceptable levels of care, a subject in which Social Security has shown much concern, the Rhode Island Blue Cross, Federal Medicare Intermediary, prepared a brochure entitled "Level of Care Guidelines" in early October 1969.

As the definition's interpretation still was not uniform among the Rhode Island Home Health Agencies, it was felt that the Rhode Island State Nurses' Association's official definition of Professional Nursing should replace the present Medicare Program's definition of skilled nursing care.

The Rhode Island State Nurses' Association's official definition is as follows: "Professional Nursing is a health service to individuals and Groups, which is based on principles derived from the biological, physical, and social sciences. It utilizes the skills in observation, communication, and interpersonal relationships. It contributes to the maintenance and promotion of health, and to the provision of physical and emotional care, comfort, and support to the people with a variety of health needs, by: health teaching, and supervision of patients and families; teaching, supervising, directing, and participating with all members of the nursing team in identifying patients' nursing needs, developing and implementing appropriate nursing plans; collaborating with other health professionals in providing comprehensive

health care; making critical independent judgements about patients and their care; and increasing and disseminating the body of nursing knowledge which enhances health care."

The present requirement that the home health reimbursement must follow a hospital stay of at least three days under "Part A" makes admission to home health care dependent on institutionalization. This is self-defeating in a system which hopes to encourage alternatives to institutional care.

The least expensive part of the Medicare Program which affects Home Health Agencies (Part B) has been the first to be restricted. Present regulations allow reimbursement for acute phases of illness, yet the major health problem of our aging population is not related primarily to acute illness, but rather to chronic illness. Current regulations do not provide payment for home health services needed to prevent regression of the chronically ill patient who has limited potential for rehabilitation, thus making the patient a potential candidate for hospitalization.

In the second annual report from the Secretary of Health, Education and Welfare on operation of the Medicare Program, the utilization data is of interest. In-patient admissions to long and short-term hospitals amount to an annual average of 291 admissions for every 1,000 persons covered under the Program. Twenty percent represented second or subsequent admissions. Admissions to home health services averaged 13 per 1,000 persons covered with payments averaging $69.00 per recorded claim under hospital insurance and $42.00 under medical insurance. Besides reasons of simple decency for assuring nursing care and comfort to those in need, valid practical economics support our mission. Unfortunately, insufficient attention is paid to the savings to the public that could accrue from expansion of Home Health Agency services.

Home Health Agencies have demonstrated their ability to move forward, initiate new home health practices and to cooperate with and assist satellite health care units, social action agencies and group practices. In order to substantiate savings to the public we are including a portion of a study on utilization of Home Health Services in Rhode Island. This Study was conducted by Dr. Helen Cleary of the New England Tri-State Regional Medical Program and submitted for publication in May 1971.

"Reference was made to information on costs for those patients who, in the agency's judgment, could not be maintained in their homes without nursing service. The obvious questions related to this point are: What does it cost to maintain these patients in their homes and what would it cost if they were patients in a nursing home, boarding home or extended care facility. In order to answer these questions, information on the patient's expenses in addition to medical care, as well as their financial resources, would have to be available. A different kind of study than this would be needed to gather these data.

"The data we do have include: the cost to the agency to maintain these patients in their homes for the first nine months of 1970, and the per diem rates allowed by Medicare and the Welfare Department for nursing-boarding homes and extended care facilities. If we apply the percentage of patients in our study sample eligible for these two sources of payment to the 2313 patients, and do some arithmetic, interesting figures result. This process assumes that all Medicare and Welfare patients could not be maintained in their homes without nursing services. This is not a vaid assumption. It is, however, valid to assume that few people required to live in a nursing home or similar facility can afford to pay their own way over time. At some point, public monies must be available to support them, whereas many may be able to support themselves at home.

"We suggest, therefore, that the following calculations are useful as a very rough comparison of the cost of nursing service in the home as against maintaining a patient in a facility outside his home. These figures do not include medical care costs in addition to nursing service in the home, or board, room and nursing care outside the home.

"1. The total cost to the nursing agencies to serve the 2313 patients for the first nine months of 1970 was $660,464.47, or, assuming all patients received equal care, $285.54 per patient.

"2. The primary source of payment for 42 per cent of the patients in the study sample was Medicare. If this percentage is applied to the 2313, 971 were Medicare patients. Carrying this assumption one step further: 971× $285.54=$277,259.34, or the cost to agencies for Medicare patients for nine months.

"3. The range of per diem rates allowed by Medicare for nursing homes or an extended care facility is $11-37; median cost, $22. Therefore, the cost to maintain 971 patients in these facilities for one month would range from $320,430 to $1,077,810; the median, $640,860.

"4. The primary source of payment for 22 per cent of the patients in the study sample was Welfare (19 per cent) or Medicaid (3 per cent). If this perecntage is applied to the 2313 patients 509 were the responsibility of Welfare or Medicaid. The cost to the agencies for these patients would be: 509×$285.54 or $145,339.96 for nine months.

"5. Than range of per diem rates allowed for boarding and nursing homes by the Welfare Department is $7.50-$13.75; median, $10.21, Therefore, the cost to maintain these 509 patients in a nursing home or similar facility for one month would range from $114,525 to $209,962.50; median $155,906.70.

"It should be noted that calculations for supporting a patient outside of his home are for one month, and the nursing agency figures are for nine months. Despite the inequities in these figures which we have noted above, it is clearly obvious that patients cannot be supported less expensively outside the home than in their homes."

The Home Health Agencies of Rhode Island wish to make the following recommendations:

-That the Congress state clearly in the law the intent to include coverage of home health services necessary to prevent hospitalization.

-Place all home health benefits under Part A with a maximum eligibility of 200 visits per year.

-Remove the three day hospital stay requirement for home health benefits and the requirement that services rendered be related to the condition for which patient was hospitalized.

-Provide for co-insurance for the second 100 visits per year.

-Remove the $50 deductible restriction.

-Provide direct reimbursement for medical supplies to the provider or 100% reimbursement to the Home Health Agency.

-Provide for reimbursement on an actual cost basis to the providers of services rendered to patients receiving custodial care who are not entitled to services under the Medicare Program.

-Adoption of the Rhode Island State Nurses' Association's official definition of Professional Nursing as the Medicare Program's definition of skilled nursing care.

It is our sincere belief that our elderly citizens who are able to be maintained at home are entitled to quality care in their own homes, with the dignity and family comfort they deserve, and to postpone hospital or nursing home placement as long as possible.

We wish to thank this Committee for the opportunity to share our views and concerns for the elderly patients under our care.

Statistical information

No. of visits made to patients age 65 years and over..
Percent of total visits made by our staff 65 years and over----

No. of visits made to Medicare patients___.
Percent of visits made to Medicare patients--
No. of "disease control" visits made by staff.

(12 mths)
7, 666

1971** (4 mths)

2, 474

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No. of such visits made to people age 65 years and over--
Percent of such visits made to people age 65 years and over..
No. of such visits made to Medicare patients----
Percent of such visits made to Medicare patients.

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7, 666 69.3% 6, 602 59.7%

2, 328 72.0%

7, 666 -6, 602

1, 064

Visits NOT covered by Medicare (13.9%)

Approximately 275 Medicare patients served during 1970.

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