July 31, 1975
Page 26258
HOME HEALTH CARE — PART XXII
(Mr. KOCH asked and was given permission to extend his remarks at this point in the RECORD and to include extraneous matter.)
Mr. KOCH. Mr. Speaker, together with 113 House cosponsors, I have introduced H.R. 4772 and H.R. 4774, the National Home Health Care Act of 1975. The bill has been given equally strong support in the Senate where it has been introduced as S. 1163 by Senators FRANK MOSS and FRANK CHURCH, respective chairmen of the Senate Subcommittee on Long Term Care and Committee on Aging, HUGH SCOTT, Senate minority leader, and Senators WiLLIAMS, DOMENICI, and TUNNEY.
To discuss the need for home health services and the public support this proposal is receiving, it is my intention to place statements in the RECORD several times a week by experts and lay persons commenting on this subject.
Today I am submitting, as the 22d part of this series, two statements: the first, a summary of an experimental program in long-term care which will be conducted in Rochester, N.Y.; the second, the opening remarks in the Senate Subcommittee on Health of the Elderly of the Special Committee on Aging's hearings on home health care and an appended proposal submitted by Mr.
Allen Lesser, director of the public affairs committee, Zionist Organization of America:
STATE OF NEW YORK, DEPARTMENT OF SOCIAL SERVICES,
Albany, N.Y.,
July 22, 1975.
Hon. EDWARD I. KOCH,
U.S. House of Representatives,
Washington, D.C.
DEAR Mr. Koch: Knowing your interest in the field of health care, I enclose for your information a summary of an experimental program in long-term care which will be conducted in Rochester, New York.
A community-based planning group freed by waivers from many constraints will select alternative modes of care and financing from a spectrum of change possibilities ranging from minimal to radical.
We feel this model program has important implications for patterns of long-term care not only in New York but in the nation.
Sincerely,
BEVERLEE A. MYERS,
Deputy Commissioner,
Division of Medical Assistance.
Enclosure.
SUMMARY
The start of an experimental project centered in Monroe County to develop new and more effective ways of providing comprehensive long-term health and social services for the elderly was announced today by Stephen Berger, Acting Commissioner of the State Department of Social Services.
One of the main purposes of this demonstration project will be to test the ability of a locally- based community group to assume responsibility for planning and organizing a system of long- term care in the county as an alternative to the present fragmented system of delivery and financing of such care.
The impetus for the project came from a meeting of key persons concerned with care for the elderly, held in Rochester over a year ago, which identified the need for greater decision-making responsibility on long-term care at the community level. The State Department of Social Services assisted the county in developing a proposal to the U.S. Department of Health, Education, and Welfare, which resulted in a first year grant of $188,700.
The need for such a project is underscored by recent studies which show that many patients in nursing homes really do not need the level of care which such facilities are designed to provide, and could be better served elsewhere.
Medicaid expenditures in New York State for care in nursing homes and health-related facilities have soared in recent years — from $254.8 million in 1970 to $662.5 million in 1974. Monroe County expenditures in 1974 for long-term care in nursing homes and health-related facilities amounted to about $25 million — more than half of total Medicaid expenditures for the county.
A community-wide planning and operating body will be established in the initial phase of the project. It will be made up of representatives of consumer groups, the Monroe County Legislature, other government agencies, the health professions, third party payment agencies such as Blue Cross-Blue Shield, and the public at large.
The community-wide body by functioning under provisions of a demonstration project will be enabled to operate in a framework freed of some of the restrictions which have characterized long-term care. It is hoped this will make it possible to overcome the problems arising out of the fragmentation of responsibility in this field.
The State Department of Social Services is the recipient of the Federal grant which is funding the project. Welfare Research, Inc., a not-for-profit research corporation affiliated with the Department, will be responsible for the grant's management.
Operations will be limited for the first year to Monroe County to determine whether the program or some of its components should be extended elsewhere. The project will seek to determine whether incentives to change the present organization of health care or methods of financing should have a beneficial effect on the availability of cost of health and social services for the aged.
According to James Reed, Monroe County Director of Social Services, there are about 20,000 persons in the county who are potential beneficiaries of the alternatives to be developed by the program. Commissioner Reed and his department will be involved in the local effort.
The Department of Social Services has established a State Advisory Committee to provide guidance and assistance to the project, under the chairmanship of the Department's Deputy Commissioner for Medical Assistance, Beverlee A. Myers. The committee is made up of representatives of State agencies concerned with programs for the elderly.
Mr. Berger noted that Monroe County was chosen as the site for this demonstration project because it has been traditionally receptive to programs designed to bring about institutional changes in the health care field. Under a recent contract with the Rochester Health Network, for instance, the Monroe County Department of Social Services is now offering the first prepaid comprehensive health care plan in New York to persons eligible for Medicaid, he said.
BARRIERS TO HEALTH CARE FOR OLDER AMERICANS
(Hearings before the Subcommittee on Health of the Elderly of the Special Committee on Aging, U.S. Senate, July 11, 1973)
The subcommittee met, pursuant to notice, at 10 a.m., in room 1318, Dirksen Building, Hon. Edmund S. Muskie, chairman, presiding.
Present: Senators Muskie, Fong, and Stafford.
Also present: William E. Oriol, staff director; David A. Affeldt, chief counsel; Elizabeth M. Heidbreder, professional staff member; John Guy Miller, minority staff director; Robert M. M. Seto, minority counsel; Patricia Oriol, chief clerk; Gerald Strickler, printing assistant; and Yvonne McCoy, clerk.
OPENING STATEMENT BY SENATOR EDMUND S. MUSKIE, CHAIRMAN
Senator Muskie. The subcommittee will come to order.
The Subcommittee on Health of the Elderly today enters a new phase in its inquiry, "Barriers to Health Care for Older Americans."
In prior hearings — in the field, as well as in Washington, D.C. — we have dealt partly with the harsh problems facing older Americans in need of health and medical care.
We have heard overwhelming opposition to the administration's proposals to increase the cost of Medicare in the name of "cost sharing."
We have listened to older persons with firsthand experience of what it means to go without prescription drugs because of high prices, to go to hospital emergency rooms for hours of waiting because no other help is available, to know of friends and neighbors who daily become more feeble because they can't afford to use the coverage that Medicare is supposed to provide.
The subcommittee must conclude, even at this stage of our inquiry, that an intolerable number of the elderly of the United States today live in pain or in debilitating illness simply because they are priced out of the market, or they can't find the services they need.
I am speaking now not only of those older persons who are obviously ill and in need of direct treatment.
I am speaking also of those who somehow manage to get along each day — to take care of their apartments and homes, to do their shopping, to visit their friends — despite illnesses that are taking hold and that could be, with proper attention, warded off or controlled.
Why in this Nation do we insist on talking only about medical care when we should be at least as concerned about health care?
Why do we wait for the person to become incapacitated, and then insist that the institution is the place for him?
These are not hypothetical questions. They are based upon the growing realization that the United States has to put its health system in order. For those Americans in need of institutional care, there is no substitute for good institutions. But for those who can better be served outside those institutions, options should be available.
Programs endangered
The subcommittee has been told, in no uncertain terms, that those options do not exist, or that they exist only on a limited scale, and that even the limited, pioneering programs are endangered.
Home health agencies today are relegated to an almost insignificant role in Medicare. If current trends continue, their role will diminish still further. The number of home health agencies certified by Medicare dropped from 2,350 in 1970 to 2,221 in 1972, They receive less than 1 percent of reimbursements under Medicare. Reimbursement policies have been so restrictive that dollar amounts have dropped from about $80 million in 1969 to $59 million in 1972. But at the same time, the amount spent for hospitalization under Medicare has been rising.
The Federal Government should be encouraging, not handicapping, effective innovations in health care for the elderly. The figures showing declining use under Medicare suggest that in this field we are, in fact, headed in the wrong direction.
Recently, when the subcommittee took testimony in Livermore Falls, Maine, I was impressed by the earnest, grassroots efforts that were taking place in a three-county area of my home State.
There, citizens have organized themselves, with the help of the State office on aging, in what they called Project Independence. Their purpose is to provide the services needed by older persons, not only for survival, but for well-being.
Health care does not stand alone as a separate, detached component of the program; it is built into almost everything that is done through Project Independence. There is a screening program to detect incipient or even acute health problems. There is a pioneering home health program which has been linked to Project Independence, with good results for all. The transportation problem is dealt with, to a large degree, by on-call buses. A health maintenance organization is also helping to solve problems caused in part by the rural nature of much of the area served.
But shifts or reversals of Federal policy could endanger the achievements of Project Independence and other similar programs.
APPENDIX 2—LETTERS FROM INDIVIDUALS AND ORGANIZATIONS
ITEM I. STATEMENT SUBMITTED BY ALLEN LESSER, WASHINGTON, D.C.
I appreciate the opportunity to submit this statement on Home Health Care for the Elderly.
As a former executive assistant to Senator Jacob K. Javits (Republican of New York), I was assigned the responsibility for the development of legislation on health care for the elderly (Medicare) for the years from 1959 to 1965, which culminated in the passage of title 18 of the Social Security Act.
My interest in the development of home health care is the result of my study of such services in Great Britain and Germany in 1962. I am deeply convinced that if Medicare costs are to be controlled and reduced, and delivery of needed services to the elderly improved, a national comprehensive system of home health care services is the way to do it.
In 1965, when Medicare became law, the average cost per patient for hospital care in New York State stood at $50 to $58 per day. At that time health economists were predicting that by 1975, the cost of hospital care would raise to $100 per day. As a matter of fact, such costs reached that high point in New York in 1970. According to the American Hospital Association, the national average for that year was $81.01, and in 1971 it climbed to $92.31. Today, it is even higher.
The accelerating rate of increase in hospital care costs has far exceeded congressional estimates made when the Medicare program was enacted. While the demand for hospital beds continues to remain high, it seems futile to hope that greater efficiency, automation, consolidation and improved management skills will somehow halt the rising spiral of costs, much less lead to substantial cost reductions.
It is important to note that current proposals for catastrophic illness insurance and national health insurance emphasize coverage for payment of costs rather than their control or reduction. As a matter of experience, there is sound reason to believe that such proposals, if enacted, would have the effect of skyrocketing costs, just as in the case of Medicare. No insurance program by itself can reduce costs; it is much more likely to result in increases by encouraging greater use of already costly facilities.
The largest single factor in the high cost of health care for the elderly is the hospital. Therefore, if the use of hospital beds can be substantially reduced without impairing necessary health care, Medicare costs could at least be stabilized. The Medicare program,however, is hospital centered. It does not have to be. Hospital and skilled nursing institutional care are not the only kinds of health care indicated for an elderly patient nor are they necessarily the best kind of health care in every case. Sharp reductions in health care costs can be effected if such institutional care were to be employed exclusively for cases of emergency or acute illness or surgery.
Emphasis on hospital health care has discouraged the development of badly needed home health care services. While home health care is authorized in the Medicare legislation, it has been used relatively little primarily because it is hospital centered and can be prescribed only after a stay in hospital. Post-hospital home health services under Medicare are limited to 175 visits after at least a 3-day stay in hospital. Where available, these services must conform to a plan prescribed by the physician in charge of the patent, and must be directly related to the patient's condition. These restrictions and lack of available services have discouraged use of this provision and encouraged the use of costlier skilled nursing home services for post-hospital care.
Home health care efforts are sporadic and limited in kind. Only rudiments of a program exist in most parts of the country, much of it on a volunteer basis, and only with state support when it involves children of a family on welfare. A major share of the health care for the elderly, however, could be taken up at far less cost by a comprehensive wide range of home and ancillary health care services such as exist in Great Britain, for example. Cost runs have demonstrated that home health care on an organized adequate scale can be provided for a fraction of the cost of hospital care, something on the order of about $15-$20 a day, depending upon the community.
Under State and local administration, a home health care program can become an effective and economic way to treat chronic disease and long-term disability. As outlined below, the program I advocate can be used satisfactorily not only for post-hospital care but also when illness strikes and hospital beds are not immediately available, and the ailing person can be taken care of temporarily in his home. Furthermore, the psychological advantages of home health care offer a distinct benefit and should not be overlooked by the physician. Gerontologists are agreed that aging patients almost without exception would be greatly relieved if they knew that they did not have to go to a hospital for care and could remain in their own familiar surroundings while undergoing treatment.
To establish a national comprehensive program of home health care, legislation amending title 18 of the Social Security Act will be necessary to authorize such services without a prior stay in hospital and on the prescription of an attending physician. There should be no limitation on the number of days such services can be provided. Legislation will also be necessary to amend the Public Health Service Act to provide for Federal-State sharing in financing these services. With the Federal Government setting standards and providing overall national coordination, home and ancillary health care services can be set up as the responsibility of state and local health authorities. They should be as readily available as police or fire prevention services, or as current ambulance services. Abuses should not occur if the following organization of services is established and made available:
(1) A health supervisor. This is usually a woman who is trained to assess the health care needs of the household as a whole, and particularly the health care needs of infirm old people who are living alone. Her basic concern should be to provide for preventive care, but in all instances she should be the one responsible to the physician for the execution of his orders and the one to negotiate with the physician for any other services she believes are required.
(2) Home nurse. This is a professionally trained practical nurse capable of caring for the sick and coping with the complications arising from social breakdown and mental confusion. Where possible she would enlist and instruct relatives to care for their elderly sick. In cases of acute illness, her services might be employed — day or night — under the direct guidance of the physician in charge until a hospital bed becomes available. (In rural or sparsely populated areas, the functions of the health supervisor and the home nurse may be combined in the same person.)
(3) Technicians and therapists. Ancillary services of all kinds should be available to the physician on prescription through the centrally administered service.
(4) Social worker. This person may be called in to help where problems arise concerning the accommodation, care and family adjustment of those who become tubercular, disabled, chronically ill, or otherwise handicapped.
(5) Home helpers. These persons are primarily concerned with domestic duties such as washing, cooking, cleaning, and purchase of food. For elderly men living alone, male home helpers may be indicated.
(6) Hospital equipment. Wheel chairs, walking aids, hospital beds, sanitary equipment, appliances, etc., should be made available for temporary loan in the home.
(7) Meals-on-Wheels. This service should be available in order to provide housebound patients with at least one hot meal a day.
(8) Supplementary services. Voluntary groups and organizations should be encouraged and assisted. Working in coordination with local health authorities and in some cases partially subsidized by them, church, fraternal, local industry, senior citizens and golden age volunteers could provide a wide range of specialized services including shopping, visiting and socializing, repairing, reading aloud, holiday and outing programs, organized entertainments, transportation library services, staffing for day centers, and special housing for the elderly. There are no limits to the quality and number of services that a properly motivated community can provide on a volunteer basis.
Physicians could be alerted to the availability of ancillary services as they are organized ,and encouraged to make maximum use of them in order to enable the elderly to remain independent and in their homes as long as possible. Increased emphasis and professional quality of home health care services could reverse the present tendency to refer aging persons to hospitals and other institutions simply because there is no other way to take care of them.
We have hardly begun to tap the community resources, voluntary as well as professional, out of which ancillary and home health care services can be developed and supplemented. There would also be side benefits of such a program through opportunities for greater employment of low- income groups. The kind of home health care services suggested in this statement would require the training and employment of large numbers of paraprofessional workers and thus help reduce unemployment.
To a large extent the costs of a comprehensive home health care program can be met out of savings effected in the reduced use of hospital services. Extension of the program to cover Medicaid and some veterans' health services could result in further substantial savings.
A comprehensive, fully staffed and adequately funded program in each state would take home health care services out of their present piecemeal and limited existence, help control and reduce Medicare and Medicaid costs, reduce unemployment, and make a vital contribution to the health and morale of the infirm poor and elderly in urban and rural communities. As the number of men and women over 65 years of age continues to rise — it is expected to total 25 million in 1980 — we shall have to make use of all our community resources and services in order to keep the cost of delivering health and medical care viable and within a manageable range. Home and ancillary health care services outside of the hospital point the way in which this can be done.
Respectfully submitted.