August 1, 1973
Page 27167
HOME HEALTH CARE AND OLDER AMERICANS
Mr. MUSKIE. Mr. President, the Subcommittee on Health of the Elderly, Senate Special Committee on Aging, of which I am Chairman, has continued its study of "Barriers to Health Care for Older Americans" by holding hearings on July 11th and 12th on home health care.
These hearings not only demonstrated the value of expanding home health services, but pointed out the need to change existing law to eliminate administrative problems encountered by home health agencies.
These points were first made to the subcommittee last May in testimony from Mr. Richard Hooper, executive director of the Androscoggin Home Health Services in Maine. While Mr. Hooper described his agency's many positive achievements of providing good quality services to the aged, he explained many problems in the day-to-day operation of his agency. Not the least of these problems are those caused by congressional or administration policies which severely restrict home health care under the Medicare program. The hearings in July, devoted almost entirely to home health care, amply demonstrated that Mr. Hooper's problems are far from unique.
The witnesses at our hearings all agreed on the tremendous value of home health care. Dr. Charles Weller, representing the American Medical Association, testified that home health care can improve convalescence. There is no better place than his own home to treat the patient who needs continued care, but does not require the facilities of a hospital. It makes sense financially and psychologically because it costs less and because patients respond best to their home environment. Home health services not only cost less than comparable service in a hospital, but from a community-wide perspective, these services can lessen the pressure to build expensive institutional facilities. For instance, the subcommittee received information that in Rochester, N.Y., home health care has been covered by Blue Cross for the last 12 years, and as a result there has been no need to build additional hospital beds. And one of our witnesses, Dr. Henry Smith, director of the Nebraska department of health, felt that using Federal funds to expand home health services would not require additional spending, but merely a redistribution of the funds available.
With little dispute about the value of home health care, most of our witnesses devoted their testimony to describing the problems encountered by home health care agencies. For instance, on the first day of our hearings representatives from operating agencies and from national organizations detailed how home health agencies are relegated to an almost insignificant role under medicare. This is not because their services are not needed, but because restrictive reimbursement policies have limited payments for home services to less than 1 percent of Medicare expenditures.
Hadley Hall, executive director of the San Francisco Home Health Services predicted that agencies will be forced to reduce services or go out of business if the present reimbursement policies by the Social Security Administration are continued. He said that those who receive services from his agency have an average age of nearly 75, that three-fourths live alone, and that the remainder usually live with someone equally old and often just as feeble. Unless we provide more basic help in the home, he said, "we will need to build more unnecessary and expensive institutions just to warehouse our elderly who need care."
Mrs. Janet Starr, executive director of the Coalition for Home Health Services in New York State, said that medicare does not cover patients whose conditions are stabilized. Thus, a stroke victim whose condition has stabilized is not eligible for services although clearly in need of such services. Many of these elderly people are being forced into institutional care earlier than necessary because of the lack of supportive home services. Mrs. Starr saw a valid role for medicare to fill in providing occasional nursing and home health aide service to make it possible for a person to remain at home and relatively independent.
One of the primary barriers to the expansion of these services under medicare as the law now stands, and as it is interpreted, is the "skilled" nursing services requirement. This requirement provides that unless a patient needs skilled nursing services, or speech or physical therapy, medicare will not provide coverage. The effect of this requirement is that only a person with an acute condition can receive in-home services under medicare – and patients with stabilized or chronic conditions will be denied home health care coverage.
Dr. Andrew Jessamin, speaking for the American Hospital Association, pointed out that the administration of home health benefits has therefore become so restrictive that few patients can qualify. "Apparently," he stated, "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."
Mrs. Maxine Thomas testified even more forcefully on this point on behalf of the National League of Nursing, as follows:
With the enactment of medicare legislation the designation, "skilled" was unfortunately attached to nursing as a reimbursable service provided by home health agencies. The practice of nursing is an art, a science, and a skill as is the practice of medicine, physical therapy or occupational therapy. Fortunately, these later disciplines escaped the "skilled" label and medicare regulations do not refer to skilled medical care, skilled physical therapy, skilled social worker, etc.
This inexpedient labelling of "skilled" nursing has become a major barrier to the delivery of care to the aged as incongruous efforts towards definition and interpretation ensued.
Greatly needed care has been withheld; patients, families, nurses and SSA/BHI personnel have suffered immeasurable pain, frustration, expense and wasted effort at horrendous cost without return to taxpayers.
Thus, after the first day of hearings, the testimony we had received was technical, but its message was brutally simple – what should be an important segment of our national health system has been badly crippled by a combination of negative attitudes and shortsighted, sometimes contradictory, Federal policies.
On the second day, we heard from a panel of witnesses who are concerned about the older person as a low-priority patient in our system of medical care. This panel included: Ms. Margaret Kuhn, leader of the Gray Panthers; Dr. Herbert Shulman, chairman of the National Task Force on Aging, Medical Committee for Human Rights; and Sharon Curtin, R.N., author of "Nobody Ever Died of Old Age."
Ms. Kuhn asserted:
America is the best place in the world to be if you have a rare kidney disease, but you might just as well be in Guatemala when you have arthritis, if you have hypertension, or if you have any other prevalent chronic ailment that the elderly are predisposed to.
The lack of adequate care for other than acute illnesses was also emphasized by the other two witnesses. Sharon Curtin described the built-in inhumanity of a fancy and sanitized nursing home that costs $1,000 a month but only provided depersonalized care that was physically and mentally debilitating. Dr. Shulman stated that medical care for the aged is out of the "mainstream" of American medicine.
On the second day of our hearings the subcommittee also heard from Dr. Charles Edwards, Assistant Secretary of Health in the Department of Health, Education and Welfare. Dr. Edwards made a valuable contribution to the hearing record. But his testimony also demonstrated that the administration could make additional efforts to promote home health care.
Since the need is so enormous, what can be done to improve the delivery of home health services? A twofold approach is, I believe, needed as far as Federal programs are concerned.
First, I urge the administration to reexamine the positive role of in-home services as a provider of health care to the elderly. This should include a critical examination of the administration of reimbursement policies toward home services under the medicare and medicaid programs.
Assistant Secretary of Health Edwards endorsed home health services in his statement before the committee as one of the "good parts" in our present medical care system. I urge him to exert leadership in moving health care to the elderly in their own homes.
Second, it is clear from extensive testimony received at our hearings that the medicare law needs to be clarified and expanded. After the experience of some 7 years under medicare, during which time home health care has actually declined, I think that a reexamination of the law is overdue.
Home health care can serve not only to hold down health costs, but also to provide a better way to take care of the chronically ill older person. I hope that the Congress, and the administration, will make a commitment to the expansion of this vital service.