November 13, 1973
Page 36750
By Mr. MUSKIE (for himself and Mr. CHURCH)
S. 2690. A bill to amend title XVIII of the Social Security Act to liberalize the conditions under which post-hospital home health services may be provided under part B thereof. Referred to the Committee on Finance.
By Mr. CHURCH:
S. 2695. A bill to amend the Public Health Service Act to provide for the making of grants to assist in the establishment and initial operation of agencies which will provide home health services. Referred to the Committee on Labor and Public Welfare.
HOME HEALTH MEDICARE AMENDMENTS OF 1973
Mr. MUSKIE. Mr. President, I introduce today the Home Health Medicare Amendments of 1973, a bill to provide increased home health benefits under the medicare program.
This legislation would clarify and expand the definition of home health care medicare benefits to meet the needs of the elderly for nursing and personal care in their own homes. It would also bring under medicare the homemaking services so necessary to maintain the independence of the patient who requires continued care, but not institutionalization. And it would increase from 100 to 200 the number of home health care visits covered by medicare.
This bill is a companion to a bill introduced today by Senator CHURCH, the Home Health Services Act of 1973, which provides "startup" funds for home health agencies and funds for training home health personnel. Together, these bills would give new Federal emphasis to the critical needs of home health care.
In July, I conducted 2 days of hearings on home health care as chairman of the Subcommittee on Health of the Aging. Witnesses representing such diverse groups as the Gray Panthers and the American Medical Association endorsed home care.
Yet it was also brought out at these same hearings that home health agencies are relegated to an almost insignificant provider role under medicare – receiving less than 1 percent of medicare expenditures. In fact, payments for home care under medicare declined from $115 million in fiscal 1970 to $69 million in fiscal 1972.
In addition, a paper on the current status of home health services prepared by Brahna Trager for the committee reported a decline in the number of certified home health agencies: 2,350 in 1970 compared to 2,221 in 1972, and many of these agencies are having financial trouble.
There is general agreement as to the reason for the decline in home health services under medicare. Our witnesses agreed that it is due not to the lessening in the need for such services, but to a narrowly restrictive policy applied under the medicare program.
Thomas Tierney, Director of the Bureau of Health Insurance for the Social Security Administration, admitted that beginning in 1969 the interpretation of the language of the law has become increasingly restrictive "in application and practice." Yet he also stated that "one of the greatest breakthroughs that medicare made was that it was the first program of any size that ever really recognized a home health service as a covered benefit."
Mr. Tierney asserted that the restrictive policy toward the home health benefit was caused by congressional concern about the overall high costs of the medicare program compared to original estimates.
The result of this approach was evaluated by Dr. Andrew Jessamin, speaking for the American Hospital Association. He said that SSA policy on home health benefits has become so restrictive that few patients can qualify.
He added:
Apparently concern over opening the door too wide has kept the door so tightly shut that very little light and air could get in and few home care services could get out.
Another witness, Dr. Henry Smith, director of the Nebraska Department of Health, spoke of the "double standard" in reimbursement policy which makes it much easier to justify institutional services than to justify alternative care under medicare reimbursement procedures. He suggested that a more affirmative attitude, among other things, would be helpful.
This reimbursement double standard was affirmed by other witnesses and the experiences of many agencies. The hospital stay seems to sanctify claims while home care is subject to the most piercing and technical scrutiny.
I have received letters from agencies all over the country detailing medicare denials and delays of reimbursement and the subsequent effects on home health agencies. A feeling of terrible frustration and concern for their elderly patients is expressed again and again in these letters.
One Indiana agency wrote:
The abuses of Medicare on the home care level have been practically non-existent. The on-again off-again policies of the federal government and SSA are making orderly development of home health care services practically impossible. Board, staff and patients are confused and disgusted. Many patients go without needed care because their right to Medicare coverage of health care services has been denied them.
The restrictive policy of medicare administrators also puts an unfair burden on concerned agencies who feel obligated to provide care even though the patient cannot afford it. As one administrator, a nun, succinctly put it:
Do we refuse to give these patients the care they need, or do we give them the care without third-party reimbursement?
When care is given without third-party reimbursement, agencies may be faced with a financial crisis. Then agencies are faced with the cruel choice of either not taking care of the elderly poor or becoming poor themselves.
This is an intolerable situation unworthy of a nation which professes to have a system of medical care for the elderly.
Therefore, it is imperative that the medicare law be amended to provide a home care benefit that truly meets the needs of the aged and provides a real alternative to institutional care. The Congress must reaffirm its intention that home care be a viable medicare benefit.
Mr. President, the legislation which I am introducing today would make the following changes in current law: First, delete the restriction that only "skilled" nursing care or physical or speech therapy may be reimbursed as home health services under medicare, and the requirement that home health treatment be related to the condition which required previous hospitalization; second, include full homemaker services in medicare coverage; and third, increase from 100 to 200 the number of home health services covered by medicare. Each of these changes remedies a barrier to the effectiveness of home health services which has been identified by witnesses testifying in hearings we have held.
The "skilled" nursing-physical-or-speech-therapy requirement has been one of the main barriers to the provision of needed home care to the elderly since it has in effect limited the home care benefit primarily to those who are acutely ill and need rehabilitation. It does not cover, and thus bars from medicare coverage, a wide range of situations when the patient's condition has stabilized or when the patient requires something less than the level of "skilled" nursing care as defined by the Social Security Administration. All nursing care performed by a nurse is skilled, but the term has come to have a very narrow meaning.
As an example of what is not covered, SSA cites the following in its intermediary letter No. 395, which defines skilled nursing care:
A stroke patient whose condition is stabilized and has no more potential for rehabilitation may require help in getting in and out of bed, getting meals and meeting other activities of daily living. A nurse would visit this patient to evaluate his personal care needs and, subsequently, to assure that the home health aide is performing necessary duties and that the patient's social and personal care needs continue to be met.
Such a situation, I repeat, is not covered. And one of the managers of a home health agency commented on this type of denial as follows:
In receiving Medicare denials, I have often wondered just how much rehabilitation can be done for an 88 year old person who has perhaps had a stroke or some other debilitating disability and is being cared for by a spouse of equal age. It would almost seem that the provisions of Medicare could more appropriately be applied to a 21 year old, where rehabilitation potential is naturally higher and health problems for long-term chronic disease disability ate very low. Medicare, however, is specifically for our senior citizens. Therefore, it ought to be realistic about the health care needs and problems of geriatrics. Under the present restrictions it certainly is not fulfilling that realistic need.
In order to meet that very common and even desperate need, this bill would make a patient eligible when he needs, on an intermittent basis, nursing care or any other home health services listed in the law. These other home health services include: Physical, occupational or speech therapy; medical social services; medical supplies or the use of medical appliances; and part-time or intermittent services of a home health aide. The need for nursing care or other necessary services would make the patient eligible if directed by the doctor. Thus, a patient could need only the services of a home health aide for bathing, dressing, et cetera and would qualify if the service was approved by a doctor and carried out under appropriate supervision.
The bill also deletes the requirement that the home health care treatment must be related to the condition which required hospitalization. This requirement has resulted in the denial of many home health care claims because the condition requiring home treatment is different from the one which was originally diagnosed as a cause of hospitalization. As one witness testified:
Frequently we get patients with four to five or more diagnoses, and if hospitalized for one of these diagnoses and then sent home to home care, we should be treating the reason for hospitalization in order to have Medicare coverage. This condition perhaps was resolved in the hospital, but the other chronic problems appear now to be more disabling. This should be covered under Medicare but usually is not.
By deleting this requirement, this bill makes no change in the requirement that home health services are only covered if they follow a medicare-covered hospitalization.
My bill would also expand medicare coverage of the important service of homemakers.
Homemaker services are not now listed in the law as one of the services which may be provided by a home health agency, and the services of the home health aide are narrowly defined in terms of personal care. As a result, aged persons who live alone may be forced to remain in a hospital longer than necessary for the lack of a few simple supportive services such as cleaning or shopping. They may be forced from their own homes and communities into an institution earlier than necessary.
The testimony which I received pointed out again and again the great need for homemaking services by medicare patients. And the report to the committee by Brahna Trager stated:
The assumption [by Medicare] that others in the home are available to provide the essential supportive services of daily living is not generally applicable to the age of living arrangements of the insured group. It is far more likely that the patient who lives alone or with an elderly spouse will be able to achieve his 'personal care' services independently, than that he will be able to maintain a decent environment and get the laundry in.
Since homemaking services are so often essential to the continued independence of the ailing elderly, my amendment would include the part-time or intermittent services of a homemaker in the list of services that may be provided by a home health agency.
Finally, the Home Health Medicare Amendments I introduce today would increase the number of home health visits covered by medicare from 100 to 200. The limitation on visits to 100 under both parts A and B is a hardship to persons requiring extended home care visits. Relatively few medicare recipients need more than 100 home health visits. But those who do should not be cut off from necessary home health services, and possibly forced back into the hospital. Establishing a limit of 200 visits would grant coverage to almost all qualifying home health patients.
Mr. President, medicare is now very much oriented to post-hospital acute-illness care, and is not meeting the needs of many of our elderly. These Home Health Medicare Amendments would make medicare more responsive to the need for home care for patients with chronic and stabilized conditions.
These liberalizations are not costly in terms of the medicare program as a whole. And in the long run it is possible that they may save money by substituting home care for more expensive institutional care.
In fiscal year 1975, for instance, it is estimated that my amendments would raise home care expenditures under medicare from approximately $100 million to between $275 and $300 million. This would be about 2 percent of the total projected medicare benefit expenditures.
These actuarial estimates do not take into account any savings that could be made by the shortening of a hospital stay and the avoidance of hospitalization and nursing home admittance. And these savings could be substantial. The General Accounting Office, for example, has stated that 25 percent of the patient population are treated in facilities which are excessive to their needs.
Home care can normally be provided at a fraction of the cost of inpatient care. The exact ratio is dependent upon the level of care provided. There are no definitive national cost figures. Under the medicare hospital insurance program, however, the amount reimbursed per claim in 1972 was $844 for inpatient hospital care, $398 for skilled nursing facilities and $91 for home health care or roughly 9 to 1 and 4 to 1. These figures give only a very rough idea of cost ratios, for medicare does not necessarily cover total costs, particularly in the case of home care.
Other estimates from the National Association of Home Health Agencies state that home care is 31/2 times less expensive per case than hospitalization and four to five times less expensive per day than skilled nursing home care.
Home health services not only cost less than institutional services, but from a communitywide perspective these services can lessen the pressure to build expensive new facilities. And it is from the community perspective that we must view home care – not from the narrow perspective of the cost analyst who may see the home care benefit "cost more" because of this legislation.
Dr. Charles Edwards, Assistant Secretary of Health, stated at the subcommittee hearings that in order to contain the costs of health care we must "encourage the service that will push health care away from the institution and closer to home."
I see an expanded home care benefit as a cost effective and humanitarian device that will help take care of the people in the way that they want to be taken care of and at the least possible cost. It is time to quit paying lip service to home care and make it a viable supplement and alternative to institutional health care for older Americans under medicare.
Mr. President, on behalf of the distinguished chairman of the Committee on Aging, FRANK CHURCH, and myself, I ask unanimous consent that the text of the bills we introduce be printed in the RECORD following his remarks.
The PRESIDING OFFICER. Without objection, it is so ordered.
(See exhibit 1.)
STIMULATING HOME HEALTH CARE
Mr. CHURCH. Mr. President, I introduce for appropriate reference legislation (S. 2695) to stimulate the expansion of home health agencies and services.
These bills are part of a twofold legislative package being introduced by the distinguished chairman of the Subcommittee on Health of the Elderly of the Committee on Aging, Senator EDMUND MUSKIE, and myself as chairman of the committee. This legislation would open up the home health care benefit for the elderly under the medicare program and at the same time expand the services available from home care agencies.
We are just beginning to realize that there are many illnesses that can be better treated at home if they do not really require the specialized and very expensive services of a hospital. Often an older person can be happier at home in familiar surroundings than in an institution and it will be far less expensive.
Institutional costs have continued to soar upward dramatically and they constitute the great bulk of costs under the medicare program. I think it is about time to reverse this trend and enlarge the home care aspect of the program.
Home care is nowhere more needed than in rural areas where institutional facilities are sparse and there are large proportions of elderly people. I recently chaired a field hearing at Coeur d'Alene, Idaho, as part of the "Barriers to Health Care for Older Americans" series and a witness testified that the home health agency was the only link between the patient and distant physician.
This was in an area without public transportation and an elderly population with limited incomes.
Many rural areas, however, have no home health agencies or agencies that can provide only limited service. About half of the agencies certified under the medicare program offer nursing plus one other service, usually physical therapy. These agencies cannot provide the range of professional and supportive services which will encourage physicians to utilize and depend upon home care.
Now no mechanism exists for agencies to expand or for new ones to be established in communities without such services. Home health agencies do not have sufficient funds to finance the expansion of services since their fees for services performed barely cover operating costs.
One agency wrote the committee of being asked to expand into two neighboring counties without any home care services. It was hesitant to do so, because of the possibility of incurring increased costs which surpass income.
Mr. President, because of the need to expand home care agencies, particularly in rural areas, my bill would provide funds for public and nonprofit agencies in areas without such agencies. It would also authorize funds to expand services in existing agencies.
In addition, the proposed legislation would provide grants to public and nonprofit private agencies and institutions for training programs for home health personnel. Professional and paraprofessional personnel would be trained to staff expanding agency services.
Under the companion legislation which Senator MUSKIE and I have also introduced, homemaker and home health aid services would be made more available under medicare.
Therefore it is anticipated that many more aides will be required. Now we have only about one homemaker-home health aide for every 7,000 population and the aides are clustered primarily in urban areas of the eastern seaboard. Just how inadequate this supply of aides is can be judged by the fact that the White House Conference on Aging recommended a ratio of one homemaker- home health aide per 100 older persons.
Mr. President, this legislation would make it possible for home health agencies to begin to expand their services and to reverse a downward trend caused in part by a too narrow interpretation of the medicare home care benefit. Other legislation which I have cosponsored would liberalize this benefit and allow coverage for desperately needed home services. The bill I am introducing now would insure that comprehensive home care services are available not just in a few urban areas, but to all of the elderly wherever they may be.
Mr. President, I urge early adoption of this legislation and ask unanimous consent that the bills be printed in the RECORD at this point.
EXHIBIT 1
S. 2690
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That (a) section 1814 (a) (2) (D) of the Social Security Act is amended to read as follows:
"(D) in the case of post-hospital home health services, such services are or were required because the individual is or was confined to his home (except when receiving items and services referred to in section 1861 (m) (7)) and needed nursing care on an intermittent basis or any of the other items or services referred to in section 1861 (m); and a plan for furnishing such services to such individual has been established and is periodically reviewed by a physician; or".
(b) Section 1835(a) (2) (A) of such Act is amended to read as follows:
"(A) in the case of home health services, such services are or were required because the individual is or was confined to his home (except when receiving items and services referred to in section 1861(m) (7)) and needed nursing care on an intermittent basis or any of the other items or services referred to in section 1861(m); and a plan for furnishing such services to such individual has been established and is periodically reviewed by a physician;".
(c) The amendments made by subsections (a) and (b) shall be effective only with respect to services provided in calendar months after the calendar month which follows the month in which this Act is enacted.
SEC. 2. (a) (1) Section 1812 (a) (3) of the Social Security Act is amended by striking out "100 visits" and inserting in lieu thereof "200 visits".
(2) The first sentence of section 1812(d) of such Act is amended by striking out "100 visits" and inserting in lieu thereof "200 visits".
(b) (1) Section (a) (2) (A) of such Act is amended by striking out "100 visits" and inserting in lieu thereof "200 visits".
(2) The first sentence of section 1834 (a) of such Act is amended by striking out "100 visits" and inserting in lieu thereof "200 visits".
(c) the amendments made by subsection (a) shall be applicable in the case of home health services provided under part A of title XVIII of the Social Security Act on visits which occur in one-year periods (described in section 1861(n)) of such Act which begin, in the case of any individual, after the date of enactment of this Act. The amendments made by subsection (b) shall be applicable in the case of home health services provided under part B of such title XVIII in calendar years which begin after the date of enactment of this Act.
SEC. 3. (a) Section 1861(m) (4) of the Social Security Act is amended to read as follows
"(4) part-time or intermittent services of a home health aid and of a homemaker,".
(b) The amendment made by subsection (a) shall be applicable only in the case of services furnished in calendar months after the calendar month which follows the calendar month in which this Act is enacted.
S. 2695
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That this Act may be cited as the "Home Health Services Act of 1973".
SEC. 2. Title VI of the Public Health Service Act (42 U.S.C. 201) is amended by redesignating Part D as Part E and inserting after Part C the following new Part:
"PART D – Establishment and operation of home health agencies
"SEC. 635. (a) For the purpose of assisting in the establishment and initial operation of public and nonprofit private agencies (as defined in section 1861(o) of the Social Security Act) which will provide home health services (as defined in section 1861 (m) of the Social Security Act) in areas in which such services are not otherwise available, the Secretary may in accordance with the provisions of this section, make grants to meet the initial costs of establishing and operating such agencies and expanding the services available in existing agencies, and to meet the costs of compensating professional and paraprofessional personnel during the initial operation of such agencies or the expansion of services in existing agencies.
"(b) No part of any grant made under this section shall be used for the construction of facilities, and no recipient of an initial grant under this section shall be eligible for further assistance under this section.
"(c) In making grants under this section, the Secretary shall consider the relative needs of the several States for home health services and preference shall be given to areas in which a high percentage of the population proposed to be served is composed of individuals who are elderly, medically indigent, or both.
"(d) Applications for assistance under this section shall be in such form and contain such information as the Secretary shall prescribe by regulation.
"(e) Payment of grants under this section may be made in advance or by way of reimbursement, or in installments as the Secretary may determine.
"(f) There are authorized to be appropriated to carry out the purposes of this section such sums as may be necessary. Funds appropriated under this subsection for any fiscal year shall remain available until expended.".
SEC. 3. (a) Part D of title VII of the Public Health Service Act (42 U.S.C. 201) is amended by inserting after section 767 the following new section:
"GRANTS FOR TRAINING OF PERSONNEL TO PROVIDE HOME HEALTH SERVICES
"SEC. 767A. (a) From the funds appropriated to carry out this section, the Secretary is authorized to make grants to public and nonprofit private agencies and institutions to assist them in initiating, developing, and maintaining programs for the training of professional and paraprofessional personnel to provide home health services (as defined in section 1861(m) of the Social Security Act).
"(b) Applications for grants under this section shall be in such form and contain such information as the Secretary shall by regulations prescribe.
"(c) Payment of grants under this section may be made in advance or by way of reimbursement, or in installments as the Secretary shall determine.
"(d) There are authorized to be appropriated to carry out the purposes of this section such sums as may be necessary. Funds appropriated under this section shall remain available until expended.".
(b) The caption for Part D of title VII of such Act is amended by adding at the end thereof:
"AND TRAINING OF PERSONNEL TO PROVIDE HOME HEALTH SERVICES"."