New perspectives in health care for older Americans (recommendations and policy directions of the Subcommittee on Health...

MISSING IMAGE

Material Information

Title:
New perspectives in health care for older Americans (recommendations and policy directions of the Subcommittee on Health and Long-Term Care) report together with additional and supplemental views
Physical Description:
x, 92 p. : ; 24 cm.
Language:
English
Creator:
United States -- Congress. -- House. -- Select Committee on Aging. -- Subcommittee on Health and Long-Term Care
Publisher:
U.S. Govt. Print. Off.
Place of Publication:
Washington
Publication Date:

Subjects

Subjects / Keywords:
Older people -- Medical care -- United States   ( lcsh )
Home care services -- United States   ( lcsh )
Nursing homes -- United States   ( lcsh )
Aged -- Medical care -- United States   ( lcsh )
Genre:
bibliography   ( marcgt )
federal government publication   ( marcgt )
non-fiction   ( marcgt )

Notes

Bibliography:
Includes bibliographical references.
General Note:
At head of title: Committee print.
Statement of Responsibility:
by the Subcommittee on Health and Long-Term Care of the Select Committee on Aging, House of Representatives, Ninety-fourth Congress, second session, January 1976.

Record Information

Source Institution:
University of Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
aleph - 025780737
oclc - 02237260
lccn - 76601581
Classification:
lcc - RA413.7.A4 U53 1976
ddc - 362.6/11/0973
nlm - WT 30 U537n 1976
System ID:
AA00022105:00001

Table of Contents
    Front Cover
        Page i
    Front Matter
        Page ii
        Page iii
        Page iv
    Table of Contents
        Page v
        Page vi
    Recommendations and areas for further study
        Page vii
        Page viii
    Foreword
        Page ix
        Page x
    Introduction
        Page 1
        Page 2
        Page 3
        Page 4
    Chapter 1. Proliferation and fragmentation: A national phenomenon
        Page 5
        Page 6
    Chapter 2. Home health services: A right to choose
        Page 7
        Page 8
        Page 9
        Page 10
        Page 11
        Page 12
        Page 13
        Page 14
        Page 15
        Page 16
        Page 17
        Page 18
        Page 19
        Page 20
        Page 21
        Page 22
        Page 23
        Page 24
        Page 25
    Chapter 3. Innovative alternatives to institutionalization
        Page 26
        Page 27
        Page 28
    Chapter 4. Nursing home auditing and standards: Preliminary findings
        Page 29
        Page 30
        Page 31
    Chapter 5. Important areas for further study in long-term care
        Page 32
        Page 33
        Page 34
        Page 35
        Page 36
        Page 37
        Page 38
        Page 39
        Page 40
        Page 41
        Page 42
    Summary of findings and recommendations
        Page 43
        Page 44
    Recommendations
        Page 45
        Page 46
        Page 47
        Page 48
        Page 49
        Page 50
        Page 51
        Page 52
        Page 53
        Page 54
        Page 55
        Page 56
        Page 57
        Page 58
        Page 59
        Page 60
    Appendixes
        Page 61
        Page 62
        Page 63
        Page 64
        Page 65
        Page 66
        Page 67
        Page 68
    Additional views
        Page 69
        Page 70
        Page 71
        Page 72
        Page 73
        Page 74
        Page 75
        Page 76
    Supplemental views
        Page 77
        Page 78
        Page 79
        Page 80
        Page 81
        Page 82
        Page 83
        Page 84
        Page 85
        Page 86
        Page 87
        Page 88
        Page 89
        Page 90
        Page 91
        Page 92
    Back Cover
        Page 93
        Page 94
Full Text
/


[COMMITTEE PRINT]


-ix.


NEW PERSPECTIVES


IN HI.\ALTH CARE


FOR OLDER AMERICANS


RECOMMENDATIONSS


AND POLICY DIRECTIONS


-El/~~~~~ Hi4.\ L^1 -
TOGETHER WITH ADDITION: "'"
SUPPLEMENTAL VIEWS "--,,
BY THE

SUBCOMMITTEE ON HEALTH AND
LONG-TERM [CARE
OF THE

SELECT COMMITTEE ON AGING


HOUSE


OF REPRESENTATIVES


NINETY-FOURTH CONGRESS
SECOND SESSION


JANUARY 1976



U.S. GOVERNMENT PRINTING OFFICE


WASHINGTON : 197t


For sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, D.C., 20402 Price $1.SO


OF THE
SUBCOMMITTEE ON HEALTH:
LONG-TERM CAREU) ,
/
N t
--- - -- N -
r~T' brE m


a- ~


b1


66-559


1


./ 4'/ /t V*4









SELECT COMMITTEE ON AGING
WM. J. RANDALL, Missouri, Chairman


CLAUDE PEPPER, Florida
SPARK M. MATSUNAGA, Hawaii
EDWARD R. ROYBAL, California
FRED B. ROONEY, Pennsylvania
MARIO BIAGGI, New York
WALTER FLOWERS, Alabanma
IKE F. ANDREWS, North Carolina
JOHN L. BURTON, California
EDWARD P. BEARD, Rhode Island
MICHAEL T. BLOUIN, Iowa
DON BONKER, Washington
THOMAS J. DOWNEY, New York
JAMES J. FLORIO, New Jersey
HAROLD E. FORD, Tennessee
WILLIAM J. HUGHES, New Jersey
MARILYN LLOYD, Tennessee
JIM SANTINI, Nevada
TED RISENHOOVER, Oklahoma


BOB WILSON, California
WILLIAM C. WAMPLER, Virginia
JOHN PAUL HAMMERSCHMIDT, Arkan,is
H. JOHN HEINZ III, Pennsylvania
WILLIAM S. COHEN, Maine
RONALD A. SARASIN, Connecticut
WILLIAM F. WALSH, New York
CHARLES E. GRASSLEY, Iowa
GILBERT GUDE, Maryland


ROBERT M. HORNER, Staff Director
LYLE MCCLAIN, Counsel
ALBERT H. SOLOMON, Jr., Professional Staff Assistant
MARTHA JANE MALONEY, Professional Staff Assistant
V. BERNICE KING, Financial Secretary


SUBCOMMITTEE MEMBERSHIP
(WM. J. RANDALL, Missouri, Chairman of the full committee, and BOB WILSON,
California, Ranking Minority Member, are members of all subcommittees, ex officio.)

SUBCOMMITTEE NO. 1-RETIREMENT INCOME AND EMPLOYMENT
WM. J. RANDALL, Missouri, Chairman


WALTER FLOWERS, Alabama
JOHN L. BURTON, California
MICHAEL T. BLOUIN, Iowa
DON BONKER, Washington
THOMAS J. DOWNEY, New York


WILLIAM C. WAMPLER, Virginia
CHARLES E. GRASSLEY, Iowa
GILBERT GUDE, Maryland


MICHAEL W. MURRAY, Majority Staff
NANCY E. HOBBS, Minority Staff

SUBCOMMITTEE NO. 2-HEALTH AND LONG-TERM CARE
CLAUDE PEPPER, Florida, Chairman


IKE F. ANDREWS, North Carolina
EDWARD P. BEARD, Rhode Island
JAMES J. FLORIO, New Jersey
MARILYN LLOYD, Tennessee


H. JOHN HEINZ III, Pennsylvania
WILLIAM S. COHEN, Maine


ROPErT S. WEINER, Majority Staff
ELLIOT STERN, Minority Staff

SUBCOMMITTEE No. 3-HOUSING AND CONSUMER INTERESTS
EDWARD R. ROYBAL, California, Chairman


FRED B. ROONEY, Pennsylvania
HAROLD E. FORD, Tennessee
JIM SANTINI, Nevada


JOHN PAUL HAMMERSCHMIDT, Arkansas
WILLIAM F. WALSH, New York


JOSE S. GARZA, Majority Staff
JAMES H. PETERSEN, Minority Staff
(II)







III

SUBCOMMITTEE NO. 4-FEDERAL, STATE AND COMMUNITY SERL\UL.
SPARK M. MATSU'NAGA, IHawaii, Chairman


MARIO BIAGGI, New York
WILLIAM J. HUGHES, New Jersey
TED RISENI1OOVER, Oklahoma


BOB WILSON, California
RONALD A. SARASIN, Connecticut


EDWARD F. HOWARD, Majority Staff
ROHETTA BRETSCH, Minority Staff

















CONTENTS


Foreword: Priorities of the Subcommittee on Health and Long-Term Page
Care -------------------------------------------------------- Ix
Introduction: Developing a continuum of care for the elderly------- 1----- 1
Chapter I-Proliferation and Fragmentation: A National Phenomenon-_ 5
Clihapter II-Home Health Services: A Right To Choose---------------- 7
Institutional bias----------------------------------------- 7------ 7
Office of Nursing Home Affairs Chairs HEW Inter-Agency Home
Health Task Force------------------------------------ 7---------
"Presumed Coverage" home health regulations restrict home health
benefits ------------------------------------------------------- 9
The institutional syndrome-------------------------------------- 10
Cost effectiveness of home health care----------------------------- 14
Need for home care--------------------------------------------- 23
Chapter III-Innovative Alternatives to Institutionalization------------ 26
Outpatient clinics emphasizing geriatrics-------------------------- 26
Multipurpose senior centers--------------------------------- -----27
Additional alternatives------------------------------------------ 27
Chapter IV-Nursing Home Auditing and Standards: Preliminary
Findings --------------------------------------------------------- 29
Dearth of audits----------------------------------------- ------29
Survey confidentiality------------------------------------------- 31
Chapter V-Important Areas for Further Study in Long-Term Care------ 32
Long-term care for the mentally impaired elderly------------------ 33
The life safety code, regulations, and quality of care---------------- 37
Other areas for future study-------------------------------- ----- 40
Summary of findings and recommendations---------------------------- 43
Recommendations. (See separate listinn.r following Contents.)----------- -45
Appendixes:
I. Major legislation related to health and long-term care of the el-
derly introduced in the 94th Congress---------------------- 61
II. Home help per 100,000 population in various countries---------- 63
III. Subcommittee witnesses and hearings, 1975--------------------- 64
Additional views of-
Wm. J. Randall, chairman of the Select Committee on Aging-------- 609
Representative Bob Wilson----------------------------------- 73
Representative William F. Walsh--------------------------------- 74
Supplemental views of-
Representatives Michael T. Blouin, Thomas J. Downey, and William
J. Hughes-------------------------- ---------------------- 77
Representative Don Bonker-------------------------------------- 79
Representatives H. John Heinz III, William S. Cohen, William F.
Walsh, Charles E. Grassley, John Paul Hammerschmidt, and Gilbert
Gude --------------------------------------------------------81
(v)



















Digitized by the Internet Archive
in 2013














http://archive.org/details/netivesi00unit













RECOMMENDATIONS AND AREAS FOR FURTHER STUDY
Summary of Findings and Recommendations (p. 43).

CHAPTER I-PRoLIFERATION AND FRAGMENTATION: A NATIONAL PHENOMENON
Community Long-Term Care Centers To Provide Linkage Among Health Serv-
ices (No. 1, p. 45).
A New House.,, Committee on Health (No. 2, p. 46).
A Home Health Clearinghouse within HEW (No. 3, p. 47).

CHIIAPTER II-HOME HEALTH SERVICES: A RIGHT To CHOOSE
Legislative Recommendations
Major Reorganization of HEW Health Programs for the Elderly: End Office
of Nursing Home Affairs' Coordination of Interagency Home Health Ta.-k
Force; create Assistant Secretary for Elderly Health (No. 4, p. 48).
Additional Appropriations for Home Health (No. 5, p. 49).
Extend Home Health Benefits and Eligibility Under Medicare and Medicaid to
Provide a Realistic Alternative to Institutionalization; Comprehensive Home
Health Care As Outlined Should be in any National Health Insurance Program
(No. 6, p. 49).
Legal Counsel for Sick and Disabled Beyond Current Inadequate Programs (No.
7, p. 53).
Amend Title XX, Social Services Program, to Provide Financial Incentives for
Reducing Inappropriate Institutional Care (No. 8, p. 53).
Demonstration and Pilot Programs to Determine the Effectiveness of New Kinds
of Home Health and Supportive Services (No. 9, p. 54).
Recommnendations to HEW
Publicize Availability of Home Health Benefits (No. 10, p. 55).
Informational Program on Health Maintenance for Older Americans (No. 11,
p.55).
Clear Up Confusion over Coverage Provisions (No. 12, p. 55).
Realistic, Open-minded Attitude Toward Home Health Legislation; Implement
Recommendations of 1971 White House Conference on Aging Calling for Com-
prehensive Home Health and Homemaker Services with Adequate Public
Funds (No. 13, pp. 55 and 25).

CHAPTER III--INNOVATIVE ALTERNATIVES TO INSTITUTIONALIZATION
Outpatient Clinics Specializing in Geriatrics (No. 14, p. 55).
Multipurpose Senior Centers Providing Health, Nutritional, Recreational, and
Social Services (No. 15, p. 57).
Community Care Organizations (No. 16, p. 58).
Elderly Day Health Care Centers (No. 17, p. 58).
Community "Health Fairs" (No. 18, p. 59).
Mobile and Emergency Health Units (No. 19 and No. 20, p. 59).

CHAPTER IV-NURSING HOME AUDITING AND STANDARDS
Annual Unannounced, On-site Federal Audits (No. 21, p. 59).
Prohibit Irreversible Requirement in Some Nursing Homes to Turn Over Social
Security Benefits After Entering (No. 22, p. 59).

CHAPTER V-IMPORTANT AREAS FOR FURTHIIER STUDY IN LONG-TERM CARE
Long-Term Care for the Mentally Impaired Elderly (p. 333).
The Life Safety Code for Long Term Institutional Facilities, Regulations, and
Quality of Care (p. 37).
The Escalating Cost of Medical Services for the Elderly (p. 40).
(VII)






VIII

Issues Related to the Possibility of Standardizing Medicare and Medicaid Phy-
sician House Call Fees (p. 40).
Additional Questions Related to Nursing Homes (p. 40).
HEW's Decision-making Process in Developing Long-term Care Regulations (p.
40).
The Impact of, and Possible Solutions to, Cutbacks in Medicaid Health Services
for the Elderly as a Result of Increasing State Budget Deficits (p. 41).
(Also see Introduction, Developing a Continuum of Care for the Elderly (p. 1).)











FOPEWORD


PRIORITIES" OF THE ST-BCOMMITTEE ON HEALTH
AND LONG-TERM CARE
The Subrommittee on Health and Long-Term Care c.:ii-e into exist-
ence on February 20,1975. Over the past 10 months, the subcommittee
has hear 182 witnesses during 11 days of formal and informal hear-
ings 1 in Providence. R.I., Miami. Fla., and Washington. D.C. The
subcommittee has been in contact with over 1,000 organizations and in-
dividuals with expertise in the health needs of the elderly, including
State health departments, State commissioners on aging, the chair-
men of all State House and Senate health committees. health con-
sumer organization-:, health provider- !:.nd other national and local
organization..
As a result of these efforts, the subcommittee has found two priority
areas in great need of attention:
(1) The need to correct the proliferation and fragmentation of
health programs for the elderly on a Federal level, both in the
Department of Health. Education, and Welfare, and in the Con-
gress; and on the State and local levels as well;
(2) The need to correct an emphasis on institutionalization in
Federal statutes and in the Department of Health, Education, and
Welfare, and to establish a comprehensive system of home health
and supportive services designed to permit the elderly patient,
often inappropriately institutionalized, to remain in the dignity
of his own home and community.
The report and the recommendations which follow are by no means
uncont.versial. The subcommittee ]fl.del a decision to "av w;:t has
to be said and to recommend what it believes to be right.
The subcommittee considered every recommendation. Because the
subcommittee fully understands that all will not be enacted or im-
plemented immediately, some recommendations have been proposed as
alternative to others. However, as current statutes and administrative
practice. exist, the subcommittee believes that each reonirm -indation
would be effective now and would assist the elderly citizens of this
country.
We issue this report and these recommendations on the basis of ex-
haustive hearings. Unfortunately, we have found that documentation
coming from the Department of Health, Education. and Welfare has
often been confused and lacking. Therefore, we are hopeful of obtain-
ing further substantiation and direction from the Department, from
other experts in the field, and from the public as a whole.
The subcommittee considered the quest ion of the cost of the proposed
recommendations. It concluded that the proposals to end proliferation
1 See Appendix III for list of witnesses and hearings.


(IX)







and fragmentation could reduce cost. The proposals providing home
health care to persons inappropriately institutionalized would re-
duce costs-testimony before the subcommittee indicated by as much
as $700 million nationwide (nursing homes are a $9 billion industry).
Provision of care to additional persons who would apply for home care
but who would enter nursing homes only as a last resort would cost,
but much of this cost would be saved by the fact that, in the future,
many persons will be able to avoid institutionalization or decrease the
length of stay. While some experts say there will even be an overall
saving, the evidence does tend to indicate there will be an increase in
cost because of an increase in the number of persons who will seek the
more humane benefits to be provided. During the coming year the sub-
committee will continue to conduct research into the cost and savings
implications of the recommendations.
The subcommittee believes that, even if there is to be an increase in
costs, the elderly of the nation deserve far better health care than they
are now receiving. An affluent society is obligated to undertake the re-
sponsibility to minimize the illness and suffering of its aged population.
This report represents an initial step in the efforts of this subcom-
mittee to assess the health needs of the elderly. The priorities de-
termined to date are based on the first 10 months' work, and the evalua-
tion process will be continued in these and other areas of concern.
The subcommittee intends to conduct further research into the
issues raised and to strengthen and revise the recommendations as
changing national health situations and new documentation may di-
rect. The subcommittee will continue to work toward implementation
of both the current and new recommendations as justified by the facts.
The report and the recommendations are divided into five categories:
(a) Introduction: Developing a Continuum of Care for the Elderly:
(1) Proliferation and Fragmentation: A National Phenom-
enon.
(2) o ome Health Services: A Right to Choose.
(3) Innovative Alternatives to Institutionalization.
(4) Nursing Home Auditing and Standards.
(5) Important Areas for Further Study in Long-Term Care.
The introduction sets forth a framework for the subcommittee's
provisions and future efforts, and calls for a new national policy in
long-term care for the elderly which takes into account a medical-social
model rather than one of purely acute medical services. The chapter
on "Proliferation and Fragmentation" cites some of the numerous pro-
grams, statutes, and agencies which make extraordinarily complex
the elderly patient's process of obtaining benefits.
In discussing alternatives to institutionalization, "Home Health
Services" is first because the subcommittee believes that home health
care is the primary alternative to institutionalization. The discussion
of "Innovative Alternatives" which follows is based on the premise
that the individual's living at home rather than in an institution is
socially and in many cases economically preferable. The chapter on
"Nursing Home Auditing and Standards" reflects the subcommittee's
concern that, although emphasis should be given to developing home
health care as the primary long-term care strategy, nursing homes are
still a vital part of the Nation's elderly health delivery system. The
concluding chapter, "Important Areas for Further Study," discusses
the subcommittee's specific plans for the coming year.












NEW PERSPECTIVES IN HEALTH CARE FOR
OLDER AMERICANS

(Recommendations and Policy Directions of the
Subcommittee on Health and Long-Term Care)

INTRODUCTION
DEVELOPING A CONTINUUM OF CARE FOR THE ELDERLY
The Subcommittee on Health and Long-Term Care of the House
Select Committee on Aging has begun a comprehensive series of in-
vestigations on the organization and delivery of a continuum of care
to the elderly.
The subcommittee is seeking to redress the lack of public and Con-
gressional attention .given to planning and implementing key pro-
grams that will benefit the elderly and the current unilateral focus
on curative programs in existing health legislation. Dr. Stanley Brody
of the University of Pennsylvania has said:
While the aged have need for acute medical care, their major requirement
is in the continuum of services for the chronically disabled that will enable them
to function optimally. Any health system which continues to be limited to a
disease orientation will not meet the increasing needs of the aging community.
Medical services must take their place as a part-and only part-of the con-
tinuum of health care.'
The medical model meets the acute, episodic needs of the patient.
The objectives for acute care are to help the patient through the
acute crisis as speedily as possible. In the process of treating acute
illness, all the other needs of the patient become secondary. Success is
measured in improvement or recovery terms. The health-social serv-
ices model places greater emphasis on secondary needs. Instead of a
disease orientation, health-social services place emphasis upon the
patient's potential to function in the social, professional, and family
spheres of his family. Success is measured in terms of actual level of
functioning compared to potential level rather than a set textbook
utilization review procedure.
A prime objective of this subcommittee in view of the findings of
its past investigations is to further explore present and proposed
policies of the Federal Government toward providing health-social
services and to recommend a series of actions which must be taken by
the Congress and the Executive Branch to insure that policies which
are initiated under the justification of meeting the health needs of
older Americans do in fact meet these needs. This concentration on
health-social services does not imply a denigration of acute medical
delivery to older Americans; rather it will determine the need for
1 Stanley Brody: "Comprehensive Health Care For The Age'd: An Analysi!," The
Gerontologist, Winter, 1973.
(1)








the elevation of health-social services care professions to equality,
visibility and recognition comparable to that of the medical model.
Elderly persons are not a homogeneous group, but many of them re-
quire community or institutional health and social services to stay
alive, active and productive. Of particular need in the delivery of
services to the elderly is an approach which coordinates such services
as homemaking, transportation, counseling, group activities, aide
services, and ambulatory monitoring of chronic illness with institu-
tional and residential forms of medical and social care.
Essential to the understanding of recommendations that the sub-
committee will be setting forth later and those proposed in this report
is the recognition that there is an urgent need to reconstruct our
health care financing system to match services to patient placement in
a specific institution or organization. Congress must know which serv-
ices are needed now, for which persons, and at what cost in order to
enact legislation. Of major importance in developing rational legis-
lation is finding a means to coordinate existing community resources
with newly-developed Federal and Federal-State programs.
Developing new programs in isolation has proven to be an inefficient
way to allocate resources. The Congress must learn to spend dollars on
projects that will alleviate some of the consequences of growing old
and will permit older Americans to actively contribute as part of
their community.
At the root of present practice are two limiting factors which cause
an institutional bias in the health care system and retard the provi-
sion of needed care to a sizable patient population.
First, both government and carriers of health insurance accept as
given a tightly defined medical model as the premise for defining bene-
fits and payments. It is this carefully defined clinical-treatment sys-
tm that sets in motion the machinery to justify admission, treatment
modalities, utilization, lengths of stay, and monitoring the quality and
quantity of care. While this medical model meets the acute, episodic
instif'- ional needs of the patient it overlooks the patient's potential
to function in the social and family spheres of his life at home. The
objective of this care is only to help the patient through the acute
crisis as quickly as possible. Success is measured in recovery terms.
The services, facilities, and resources needed to attain a recovery are
usually finite.
The medical model has severe limitations which hamper its appli-
cation in designing benefits for chronic illness, geriatrics and long-
term care services. The complexity of multiple-diagnoses and chronic
illness conditions, combined with social, emotional, economic and other
fragilities common to many chronically ill persons, limit the applica-
tion to a tightly defined clinical-treatment system.
Second, it is the norm under present practice to describe the scope
of and eligibility for health care services in terms of levels. The levels
of care needed by the users and the level of service provided by classes
of providers not only have complicated and limited the provision of
patient care, but have also created an administratively cumbersome
mechanism for monitoring the quality and quantity of services.
This develops an artificial classification of both patient and pro-
viders. Superimposed upon patient need is a rigidly defined benefit
structure complete with limitations upon lengths of stay and eligi-







ability for placement. Providers are grouped according to an array of
rather complex, lengthy and unwieldy regulations. This erroneously
implies that most users have the same needs which require the same
sets of services and that all providers in a class are alike and have the
same capacity to furnish the same sets of services.
Working in tandem, 1l1e medical model as the premise for entry
into and exit from the liealth care reimbur'seiient proglani. and the
artificially defined levels of care as the basis for payment and place-
ment, contribute to the following problems:
(1) Delayed entiv .into the health system throi idi limitations
that prevent early detection and treatment;
(2) Lack of incentives for optimum u.-e of health ref'.:dmrces and
cost-efficient use of home health services;
(3) Incieased dependency upon in-.titutionalization for ii-
viduals whose needs are for maintenance and rehialiilitation
rather than "cure";
(4) Continuum of minimal standards for providers which in
turn discourages the provision of individualized care.
(5) Over-emphasis of quantitative factors such as size of physi-
cal facility rather than quantitative results that can be measured
through periodic use of a patient functional assessment evaluation
instrument; and
(6) Neglect of the needs of a sizable patient population whoQ-e
requirement for care does not conform to the artificial structure
of the reimbursement systems.
Commitment of additional funds to programs based on these exist-
ing approaches may only increase confusion, lack of coordination, and
poor service for the elderly.
The most direct route to developing a sound legislative approach
is to go beyond examination of separate categorical programs in isola-
tion from their effects on each other on the elderly. What is most criti-
cally needed as we face the prospects of a national health system and
examine the efficiency and effectiveness of our existing health and
welfare programs, is a systematic investigation of each major influ-
ence on the quantity and quality of care services delivered to the
elderly.
The subcommittee in its future investigations will gather testimony
and data that will make interdependent relationships explicit between
such factors as financing of health care, provider trainin,r, and insti-
tutional resources and will assess their respective contributions to
producing sufficient and good care. From these, studies, realistic projec-
tions of cost, cost-effectiveness, and benefits of the current and pro-
posed recommendations set. forth in the report (especially Recom-
mendation No. 1) will be derived, and the relationship between
medical-social programs of special interest to the elderly and those
of general interest to all citizens can be assessed.
Consistent with its above stated objectives, the subcommittee will
orient its investigations towards community-based programs which
develop increased local initiative, unfettered by conflicting Federal-
State jurisdiction and regulations.
The subcommittee will seek ways to allow older Americans them-
selves to participate more fully in their community and receive more







care per dollar spent. Concomitant with this focus will be analysis
of long-term care options that have potential for delivering a full
spectrum of care services for the elderly and contain provisions which
perinit public accountability.
The subcommittee will also examine and seek remedies to an un-
fortunate and degrading social phenomenon that has been brought
on by current legislative policy; namely, the requirement that the
ehl!rly be driven into a state of legal and actual poverty in order
to gi11 the benefits from public health and long-term care programs.
The subcommittee will propose a relationship between long-term
care programs and national health insurance and recommend a design
for an optimum be];litlce of social and medical services for the elderly.
Tie' project in effect has begun with this report, which summarizes
current long-term care options for the elderly, and recommends what
mi'ht be done under present legislative and fiscal conditions to pro-
vide a continuum of care to the elderly.
The subcommittee will continue to work on this report by analyzing,
in greater detail, service programs which have the potential to be
prototypes for larger efforts in the field.












CHAPTER I


PROLIFERATION AND FRAGMENTATION: A NATIONAL PHENOMENON
D)urintr tie lhiearings of the subcommittee, "prolifer;ttion'" an(
"fragmnentation" have been two of the most commonly us.,d terms to
describe the plethora of Federal laws and programs for elderly health
and the multitude of (ragenlcies and organizations that administer them.
Consider the followinL "r:
In the Department of Health, Education, and Welfare, the Assist-
ant Secretary for Health coordinates the National Institutes for
Health, the Health Services Administration, the Health Res:ource.'s
Administration, the Center for Disease Control, the Alcohol, )rug
Abuse, and Mental Health Administration, and the Food and Drug
Administration. The Area Offices on Aging (under the Commissioner
on Aging) administer home health aids and homemaker services under
the Older Americans Act. The Social and Rehabilitation Service
coordinates the Medical Services Administration, which adminiii.s(te,'s
medicaid, and SRS also coordinates the Rehabilitation Services
Administration and other programs.
Social Security Administration's Bureau of Health Insurance ad-
ministrates medicare. Special assistants to the Secretary are appointed
to fill desired ad hoc elderly health needs. The Office of Nursing
Home Afflairs theoretically coordinates Depart nerital long-term care
programs but has no real line authority (see next chapter).
This partial listing barely touches the surface of the complexity of
HEW's elderly health organization.
One witness told the subcommittee that "it would take a Philadel-
phia lawyer to lead a person through the layers of red-tape to find
the right service at the right time."
Nowhere is fragmentation and proliferation more evident than in
the delivery of home health services.
Programs which provide medical or supportive services for the
elderly in their homes include medicare (title XVIII of the Social
Security Act), medicaid (title XIX), the new Social Services Pro-
gram (title XX), the Public Health Service Act Amendments (new
home health grants), State and community grant programs for the
elderly (title III of the Older Americans Act), nutrition programs
for the elderly (title VII), the Senior Companion Program and Rie-
tired Senior Volunteer Program (RSVP) both under title II of the
Domestic Volunteer Service Act, and Older American Community
Service Employment Program, Senior Opportunities and Services
under the Community Services Act, and others.
1 See Rifu-z E. Miles, Jr., "The Dp.nrtniont nf Health, .uilucation, and Welfnro."
Praop-,r. New York. 1974. pp. 73-77. 133; and Claire Townsent, "Old Age: The Last
S r,,r__'-atin," Grossman, New York, 1971, pp. 218-219.
(5)








Dr. Arthur S. Flemming, U.S. Commissioner on Aging, testified
before the subcommittee on November 19:
Although a wide range of in-home and community based services are avail-
able to maintain older persons in their homes, most of these services are frag-
mented, fit1ai!-ed under different Federal programs with differing eligibility re-
quirements, income levels, and sometimes conflicting regulations.
For medicaid and title XX social services, the State and local wel-
fare offices or the social services department are responsible.
For SSI, the disabled individual must contact the Social Security
District Office, and have his case periodically reviewed.
For medicare, identification cards are provided by the Social
Security Administration.
Older Americans Act services under titles III and VII are provided
by a variety of public and private non-profit organizations generally
at the community level.
Individuals needing a range of services frequently complain about
the physical dexterity and transportation costs required to travel
from agency to agency-the agencies being dispersed over wide areas.
There is proliferation in Congress too. Health jurisdiction is dis-
tributed among at least three committees in the House of Representa-
tives-Interstate and Foreign Commerce, Ways and Means, and Edu-
cation and Labor-with resulting fragmentation and a lack of ration-
ality in health planning. Home health and nursing home benefits
under medicare for example, are considered by the Ways and Means
Committee, home health and nursing home benefits under medicaid
are considered by the Interstate and Foreign Commerce Committee,
and homemaker services under the Older Americans Act are under
the jurisdiction of the Committee on Education and Labor.
From the standpoint of oversight, one of the subcommittee's prime
goals for the coming year is the establishment of a simplified or
streamlined administrative vehicle through which all programs and
funds for the maintenance of the mental and physical health of older
Americans would be funneled in a rational and cost-effective manner
to the target population they were designed to reach. Such a vehicle
would cut administrative costs and allow the money saved to be
applied to expanded services and direct patient health care.












CHAPTER II


HOME HEALTH SERVICES: A RIGHT TO CHOOSE
"The poorest man in his cottage may bid defiance to all the
forces of the crown. It may be frail. The roof may leak, the
rains may enter, the storm may enter-but the King of
England cannot enter-all his force dare not cross the thresh-
old of the ruined tenement."-Wlia mt Pitt (speech before
the House of Lords, England, 1766).
It is a tragedy of our times that we as a Nation should find our-
selves in the position of thinking of home health care for the elderly
as an alternative to institutionalization. Somehow, it shocks the con-
science and goes against the grain to deal with the subject in that con-
text. It orday stands to reason that in the natural order of things it
should be jwt the ree'erse. Institutionalization should be an alterna-
tive to hamne health care.
While there will always be highly disabled patients who require 'ulnil-
time institutionalization in nursing homes, persons capable of remain-
ing in their own homes should have the right to choose.

INsTUONAL BIAS
It is the intent of this report to examine the national emphasis on
institutionalization, a concept that has evolved both from compromises
made in statutes (the acute-care basis of medicare and medicaid in
1965) and the tangled bureaucratic web of HEW, where it has taken
shape in the Office of Nursing Home Affairs and elsewhere.
At times HEW officials wax eloquently on "viable alternatives to
premature institutionalization." They are not consistent in this. For
example, the Department testified:
It has only been in the past two decades that home health services have been
recognized as a promising approach which may help resolve the complex prob-
lems hamipering the efficient tand effective delivery of health care in the United
States-.'
Yet what is the Department of HEW doing about the bias in favor
of institutionalization ?

OFFICE OF NURSING HoME AFFAms CIIAIRS HEW
INTERAGENCY HO ME HEALTH TASK FORCE
HEW testified:
In January of this year the Secretary reaffirmed the Public Health Service
as the lead agency for coordinating and monitoring the implementation of the
Department's short-term (emphasis added) home health care imiprovrnf nt
efforts. This responsibility has been assigned to the Oflice of Nursing Home
Affairs.
1 Peter Franklin testifying before the Subcommittee on Health and Long-Termni Care.
August 7, 1975, transcript p. 614.


(7)


66-559-76---2








Imagine-to the Office of Nursing Home Affairs. The Office of
Nursing Homie Affairs is the lead agency for home health.
HEW continued:
The Office of Nursing Home Affairs chairs an Inter-Agency Task Force on
home health services. This Task Force includes representatives from the Social
Security Administration, the Social and Rehabilitation Service, the Adminis-
tration on Aging and the Office of the Secretary2
On its face there is something wrong with the structural setup of
the task force on home health.
Mr. Franklin further stated:
The other experiment I would like to cite, Mr. Chairman, is an experi-
ment being carried out here in Florida, specifically in Tampa, to develop and
implement a new health care delivery system for the patient needing long-term
care. The purpose of the experiment is two-fold: first, to develop through the
collaboration of nursing homes, medical care facilities and services, health
and social service agencies and programs, a realistic community plan which will
e.tiale nursing homes to utilize community resources in order to meet the needs
of in-patients or to plan for a patient's return to community living * 3
Dr. Faye G. Abdellah, Assistant Surgeon General and Director,
HEW Office of Nursing Home Affairs, shed further light on the sub-
ject under questioning by Chairman Pepper:
Our Office of Nursing Home Affairs is limited to the policy coordination of
these services. That is, our responsibility would be working with all of the
agencies concerned with home health services and to give some overall oversight
direction to the implementation.'
HEW's Long Term Care Facility Improvement Study 5 points out
further that "to avoid duplication", ONHA "coordinates efforts
throughout the Department" in "research and development and data
collection * through contracts and grants" concerning "assess-
ment of alternatives to institutional care".
The subcommittee questions the propriety of placing home health
services under the jurisdiction of the Office of Nursing Home Affairs.
The nursing home industry and the home health industry are, at least
theoretically, competing for the same market.
In addition, while the Office of Nursing Home Affairs has been
given the task of coordinating the long-term care service programs
of the Department, the subcommittee is concerned as to whether an
instrument of the Public Health Service can in fact coordinate the
functions of the two primary reimbursement programs (medicare and
medicaid). Medicare and medicaid are under the functional control
of two distinct organizational units within the Department, the So-
cial Security Administration's Bureau of Health Insurance and the
Social and Rehabilitation Service's Medical Services Administration,
which are not subject to the primary control of the Assistant Secre-
tary for Health who oversees the Public Health Service. ONHA is
neither a line function nor does it have authority over the Bureau
of Health Insurance (medicare) nor over the Medical Services Ad-
ministration (medicaid).
2 Peter Franklin testifying before the subcommittee on August 7, 1975, transcript p. 614.
3 Peter Franklin testifying before the subcommittee, August 7, 1975, Miami, Fla.
4 Testimony, subcommittee hearings, Miami, Fla., Aucust 5-8, 1975.
5 Public Health Service, Office of Nursing Home Affairs, Department of HEW, "Long-
Term Care Facility Improvement Study," Introductory Report 1975, p. 2. Also see "Fed-
eral Register," Nov. 26, 1975, p. 55145.







Tihe subcommittee commends the Secretary for establishing an
;(d hoc interagency task force to better coordinate policy, particularly
in the writing of recommendations. However, even aside from the
seelning titular conflict of interest, the structural situation forces the
subcommittee to conclude that ONHA cannot be an effective mecha-
ism either to stem abuses in institutional long-term care or to develop
(quality home health care.
The power to force compliance with ONIHA decisions has never
existdl except to the extent that ONHA can persuade BHI or MSA.
to follow its recommendations. ONHIA, because of its stiiictural situia-
tion, is extremely limited in its authority to en force any decision which
it i re,,ardless of whether they are nursing home decisions or
home, althi decisions.

"PiKESuMi:i> Cov0ERAGE"' IH1OME ItEALTIT REGULATIONS RESTRICT IHOME
HEALTII BENEFITS
Medicare regulations proposed during 1975 by the Department of
Health, Education and Welfare would discriminate against home
health, in the view of the subcommittee. A brief sumilmary of the issues
follows::
"Presumed coverage" for home health under medicare, published
in the July 9 Federal Register,6 would create a fixed formula for post-
hospital and post-extended care facility home health services, specify-
ing the allowable number and length of visits under certain patient
conditions.
BACKGROUND
The 1972 Social Security Amendments (P. L. 92-603) included a
provision (Section 228) for advance approval of post-hospital ex-
tended care and home health services under medicare. This provision
authorized the Secretary to establish, by diagnosis, periods during
which a post-hospital patient would be presumed to be eligible for
home health services. The Secretary was directed to take into account
"the severity of condition", the "degree of incapacity," and the mini-
mum period of home confinement generally needed for such conditions.
The Committee reports 7 cited "retroactive denial" as the main
reason for this section of the legislation. "Retroactive denial" is the
process whereby the intermediary-the third party, usually an insur-
ance company making the payment-refuses to reimburse care after
the patient receives it, on the ground that the care was not covered
under the law (which was ambiguous on the subject).
However, the committee report also stated that the legislation would
provide a dual advantage over the present system of coverage determi-
nation by:
(1) Encouraging prompt transfer through assurance that the
admission or start of care will be reimbursed, and
(2) Identifying in advance the point at which further assess-
ment should be made, on an individual care basis, of continuing
*6Federal Regi.ter, July 9, 1975, Proposed Rules for Presumed Level of Carp( (Soetion
22_ of P.L. 92-63)
'House Report 92-231, May 26, 1971 ; see also Senate Report 92-1230, Sept. 26, 1972,
and Conference Report 92-1605, Oct. 14, 1972.







need for extended or home health care. Where request for cover-
age beyond the initial presumed period, accompanied by appro-
priate supporting evidence, is submitted for timely advance
consideration, it is expected that a decision to terminate extended
care or home health coverage would ordinarily be effected on a
prospective basis. For those conditions for which specific pre-
sumed periods cannot be established, current procedures for de-
termining coverage would continue to apply.
The effective date was January 1, 1973.
Another provision, Section 213, effective October 31, 1972, is re-
ferred to as the "Waiver of Liability" provision. This section per-
mitted both the individual and provider to qualify for waiver, i.e.:
"nor be held responsible for repayment of incorrect amounts" where
it can be determined that they are without fault.
This was effective October 31, 1972.

FINDINGS
The subcommittee believes that home health agencies today do not
need "presumed level" to provide relief on retroactive denials because
the regulations implementing "waiver" of liability and adjustments
by fiscal intermediaries have virtually eliminated the retroactive de-
nials and have improved provider intermediary communications on
"Covered Care."
A comparison of covered post-hospital home health services with
the "Presumed Level" indicates that the regulations, intentionally or
unintentionally, will reduce coverage of post-hospital home health
services. This is clearly in conflict with the legislative intent of this
provision.
The subcommittee received letters and comments on the regulations
from home health providers, consumer organizations, and others. Spe-
cific problems cited which the regulations would cause include:
Fiscal intermediaries will restrict covered visits to those listed;
preclude daily visits; fail to include provision for home health aide,
occupational therapy and social services visits; fail to identify and
state the relationship between coverage and the minimum presumed
levels; one hour time limit; additional paperwork caused by addi-
tional certifications; do not consider that teaching is based on intelli-
gence, patient receptivity, supervision and environment; require
additional recertification procedures; inadequately list procedures; do
not provide for changing conditions (emergency, etc.) ; do not use a
statistical basis for visits; mandate extra paperwork because 90%
would require extension requests; do not provide for more visits at
first, initially to be tapered off; will be used by intermediaries to
determine eligibility for part "B" patients; provide no allowance for
more acute patients; do not provide consideration for an initial evalua-
tion visit; fail to take into account changing of conditions; and do
not consider individual needs or physician orders.

THE INSTITUTIONAL SYNDROME
An "institutional syndrome" has been discussed by many experts,
and is believed to develop so rapidly after institutionalization in
skilled nursing facilities that-







* certain dependencies develop that are not nornimal. People becomtiie de-
".L.ndelLt on an institution for services that perhaps if they had reiaine]. -aty,
in their own home that they could have conitiuued to perform for llicisilves.8
Yet the s:ibeoi-'mittee finds that current law discrinina!es in favor
of institutional ,are even when it may be inappropriate and more
expensive. For example, t]he current nm..lic-.re ,vision of 100) post-
hospital nursing home days (and more when recertified) colp.r,.s
with an allowance of 100 far less expensive home h! alth "visits" ; there
is a 3-day hospitalization requirement before receivin medicare
part A home health benefits, thereby often preventing needed home
health care which can assist in stopping the necessity of a hospital
stay; medicare provisions cover prescription drugs and diagLniostic
screellning in nursing homes and hospitals but not as part of home
health: and. of course, room, board, and maintenance and custodial
services are covered in institutions but not at home. In addition,
testimony before the subcommittee has demonstrated conclusively
that the health of the elderly is based not only on physical but social
aid psychological factors as well, and that registered nurses, certified
social workers, ,-idance counselors, home b',alth aides, and other
lhealthl professionals, who often play the key role in patient care.
should have a major part in decision making. The medicare and
medicaid restriction of "home health" to care Mrescribed and super-
vised by doctors greatly limits the development and use of effective
home health services.
Over the last decade, the nursing homes have gotten a lion's share
of Federal dollars and home health services only an extremely small
portion. 1974 fil--ires indic-:te that under medicare part A (hospital
insri:iLe) home health bills for the elderly repre-ont about 10
percent of all billings, or $78 million of the $7.3 billion expenditures
for part A. Under parit B (supplementary medical insurance) home
health bills are about 1 percent of all bills, or $35 million of the 4
billion of supplementary medical insurance expenditures.9
Under medicaid there is no breakout for home health services pro-
vided excliswi.cly to older persons, but the expenditure for 1974 home
health services for all age bra ck&,s was $31 million-al-out .3 percent
of the iO0.1 billion medicaid expenditures. With a national elderly
population of 21 to 22 million out of over 10 million people over 21
in thte United States. it is cleir that less than 1 per,'-.It of medicaid
home health funds are for the elderly. Moreover, medicare benefits
replace many medicaid services for many needy and indigent per-
sons over 65. Finally, of the $31 million, $19 million was spent in two
states-Massachusetts and New York State-s16 million for New York
State alone.10
The followin-gr charts are Government figures on home health reim-
bursements together with other health cost reimbursements:
SPeter Franklin. Sppeial Assistant to Secretary of IhEW, ti-ifyin 1 r.-fore the sub-
co:nimittee. July 12, 1975, Providence. R.I.
Hiairin, trin-ner'pt, "Comprthensiv-e Home Health Services," Novembfr 19, 197>.
10 Ibid.









12



[Reprinted from "Social Security Bulletin," July 1975]



















In X
C3 O._ .. 4. a4 oc-" r -7( .-''i'Z o t- w'.c<'ov" -~u S S jI
2 ~ 2
^ :a A**^u' .s -, -
h -5
_~~0 _______________________________________________3 _



3 --------------,7---


) -: _ C, -1 _ __t- r_ 00 -1 0-



I =3 -
_.<.S3-- ^ ^^^ ^ -^ -- 8 *-ug

_g---------------- ----*.gq^ |

fcI -a o-' 4s.o =;N-M *'"..I --. I-c-'.0 >^ S

-s v _i -^ -il

0 0 -
--C U 2 ,^ ^S^-- a 2 -


I v
-- a:3. y o 3;



"D 1' C 1 C C)C

jt |- C -r In



-'C) o^ _ _'IV_ I ^4 _




C4C'
-5:1 ------- -------------------------------^3"*" a







-4 2 C4 g CD 1
c^| --- ---- 4Z j--------- ---- ----i. 3 -


-<.-< t? 0" QRU-<.^ .4.C^ ^ ~~-r" ^ crl<^ i^ -a ^








C112
71 C4C14 'A '44 1
-C_ -- 71 C C3
45 ^ ---------- a---1 l









I _m__"n _P_____ ___00C'2C'4.D t_
*' 14 .. 3 -> ^ '0 w 'r C. C l i
0 ^Sas~ ~ ^ 4222 c.A a s*c 4aa









G 7 -*2 2 .


v : CnC,42 ~ ~ ~ ~ I
C. r; 3 ~ \ ---- -----------------------------
".- *ic"-riC."- M.'ir'OT i-d^.-^o c' r. '' '
0 . 5 S 4^^-';) "S"-?^S^ 'S *.*s

j i 6 5c~a -Tt30 twcr -o S - ..^ ^
O'0 *< 0 ^^ ^ ^d ^ ^ ^-rt 5 w-9.3

^~0 CIS_______________________g S .
^~~I P.-I, r------------------- 41, .








13


[Reprinted from "Social Security Bulletin," July 1975]










0 114 r
-. It TJ-'" .- ^ 'c '- 0 *' -'



L.<- -. c u.- =S ,.;; aS
I2'-v



M to11


-~~~ g ??SS K' 0<&S .-^ -^
-W C1 W C C4







S ^ *.= |-*:
U. tdr. as ^= ' :~



a$ W 0 -: -- *4

;S S fc. O r00 r- C,--.o> ccC,-r~ V-i C,4. -I*-- C<'. 3*-





0 0 r C'4
t-- g .- -M 0 0s- C)




o 0 g- a^ ^ ^ g c.. Ijs o ^ c^ ~

I| .1. 0 il^i3-,.
-Z-


I_.. ______ -_ J -_ | !i |

00
-* I ^C -- 0-c^ -'s..r0t' *0 *N < | I-= L...<- y'- *S
O j 3 I -' = -4 0C -



_______ot I l-.. I'Ja ^^--
to CI 2



C O -r r, -0o o I- MC-----



., CCf - | SCI'" *1 1'^
*^~~~C Z t4. S-^ '' S ^ s




'- --J.z -..c -~- *-'I : *Qo- Ifs fc "-.


r^ - '^ ^ ^ S tj^
q,- ..> Ut r' Inn M m
0 oc C-11 --M 1 -71




4W C


I , I S -* ,;-i- ^ ..C & = -. CA -
r: --- -


5 3 C s-- 3 R 2 -!z
c 0 4 *
t-IC, C _



L4 C-) 7, =.
0 0 '.-

K.2 ~ ~ C C" o C13^ JI l-3
Q *- r:;" -*^^ -^ '- te10s3
- < wo~ >^ J' "^ o a -' 06-
^V w ::: ?S i |-^53 |
oo 0 w^ ^ ? ^ s |,^5|^
I-& eS S ^ 2Sfc 5 s;_.,3-:;34-
'.'3~~~t to "S =SS^ S -J -=^ SJ
00 o ^^- Ea G 8 S G ^So" io^- .& T.~~~~~~~~: I- U00^. ^. Sl iS^'-^
.4< Cn 7 r;4 ,S S rS ^ ~ ^ -s ^f
/-'.-- fc~~~~o~f' inM as 0^. 43_3 c^ s :33
-.r ~~~~~~-I, In4 "-4 0-4, )-1,;j;.9 ." .5






14

The chrlinology of the development of thle home health industry
follows a very similar pattern to the development of nursing homes-a
rapidly burgeoning indu.-itr. While the subcommittee wholeheartedly
supports and encourages the development of home health care, the
Congress must mandate care of a quality nature to avoid the same mis-
takes of the nursing home industry.
Within 9 months, between September 1965, when the funds became
available, and July 1, 1966, when the benefits became effective, "home
health services improved as never before". 11 The number of programs
increased, as did the range of services offered. By October 21, 1966,
1.256 agencies had been certified under P.L. 89-97, The Social Se-
curity Amendments of 1965, and others were operating as local out-
posts of State agencies or were potentially certifiable in their own
right.
Are they growing financially ?
Millions
Fiscal year 1972, medicare reimbursement---------------------------- $59
Fiscal year 1973, medicare reimbursement---------------------------- 75
Fisetl year 1974, medicare reimbursement---------------------------- 110
Despite such growth, home health receives a miniscule portion of
national health expenditures. Preliminary figures for 1975 of the
Social Security Administration cited by the Committee for National
He: ith Insurance show the following estimated breakdown of $118.5
billion spent in Fiscal Year '75 for medical costs (Private-$68,552;
Public--49,948) :
1975 neical cxprnscs in United States'
Billions
Health services and supplies----------------------------------- $111. 250
Physician services.------------------------------------------- 22.100
Dentist -------------------------------------------------------- 7. 500
Other professional services--------------------------------------- 2.180
Drugs and drug sundries---------------------------------------- 10.600
Eyeg lass and appliances---------------------------------------- 2.300
Nur.,'ng home care------------------------------------------------ 9. 000
Expensres for prepayment and administration----------------------- 4. 593
Governmeent public health activities-------------------------------- 3.457
Other health services-------------------------------------------- 3. 000
Research and medical facilities construction------------------------ 7.250
Social Security Administration, USrDHE:W, Staff Paper No. 1, 1975, provided to
subcommittee by Committee for National Health Insurance.
Conspicuous by its absence is a figure for home health care esti-
mated to be well under $400 million.12
Yet, P.L. 89-97 and P.L. 90-248, the Social Security Amendments
of 1965 and 1967, require State medicaid plans to provide home health
services, and P.L. 89-97 also states that home health services must be
reimbursed under medicare.

COST EFFECTIVEXNSS OF HOME HEALTH CARE

The issue of the comparative costs of home health care and other
alternatives to i stitutionali]ation arose throughout the subcommit-
tee's investigations.
1 P'eter 'rinklin t-.tifvii,_: before the Subcmnmittpt on November 19, 1975.
12 The National Association of Home Health Agencies, December 1974, estimated
national home health medical expenditures at $315 million.








A report by the Department of Health, Edi-ation. a!nd Welfare
argues that-
* to proceed with the development of a national policy, to recommend the
reallocation of large sums of public funds, and to encourage or stipulate a major
increase in resources and activity, is a risky venture in the absence of more
definitive verification (of the economics of home health).'3
The subcommittee agrees that cost comparisons Lave often boen of
limited empirical value. However, most of the n.,-;itive cot compar-
isons have attempted to equate the uz of home health services. to the
acute medical model rather than to adjust f'ir tl he efiY.tivenez. of
preventive and maintenance zi--e'ts of home health. In nac;,,-:.r,-,l-
sis of home health costs, three observations become apparent:
(a) The role of preventive medicine (which are currently
largely negated by current requirement for prior hcpitalization
to be eligible for medicare home health) indicates favorablle long
term costing;
(b) Expansion of home health care will pro',i.bly briMr an in-
crease in public health costs but throughr an expand,* service
population, not through a per-patient health cost: and
(c) Narrow economic costing molelz: often nezlect to evaluate
the favorable social and health co.-ts a-soci.t,1. with retention in
the community.
As Dr. Philip Weiler argues in The Gerontologist:
At the present time there cannot be ratirinil [cst-efft.tive] analysis of the
geriatric health-care system as long as it remains imbedded in a system which
is essentially only acute-care oriented. In order to develop the proper objectives
a long-term care orientation is needed . .
Although it seem< obvious we have been late in realizing the acute-cet:re mood.-l
cannot fit the problems of long-term care. Long-term care requires that the social
needs of the patient be given primary importance and the medical needs s-:.c-ondary
importance. Medical needs must be structured into a matrix of other needZ and
not vice versa. Success cannot be measured in "cure" terms, but in the level of
functioning of the patient in relation to a broad spectrum of parameters (e.g.,
physical, medical, social parameters, activities of daily living, mental health.
and family life). Effect should be measured in terms of the patient's functioning.
with his actual level of functioning compared to the potential level for each
parameter. The long-term care model is not locked in on diagnosis. It is more
important to know the effects on the way the patent functions.
Especially since the advent of Medicare and the subsequent demand on health-
,are services for the elderly, it has become evident that the planning for such
services based on the acute-care model is totally cost-ineffective. The objec-
tives of such services have either been vague (i.e., nursing care. custodial care),
or inappropriate (i.e., cure), or entirely lacking. Using the acute-care ninde].
health services lave been prividod for the elderly a- if the-p were thoir domi-
nant need (at time this may be the cawe beeauit? the elderly n-l ill. but Sor'( have rb.hronic prrolems, which is the primary problem).
The health zerviees that have been delivered are uzuily in etti ti- which ."ll
for a suspension of all other needs of the elderly. The results. therefore, have
been less than encouraging."
The Minneapolis Age & Opportunity Center (MAO). a very inno-
vative multinurpnse outp-itient center for the elderly in Mfinneapolis,
offered convincing testimony on the cost-effectiveness and the hurnan-

"s April'r-d Manrnement Sciences "Interim Repnrt." Contract nHEfW-OS-74-_ P .Jnn. .
1975, Vr.1. 1, cited in Marie Callendrar nnd1 Jir-" La Vor. "Home Hpatb' C,- PDc -
ment: Prnbom--. and Pot-rntial" In Dicability L,:.-n Term ':ire St''lv. DF'.v, April 1975.
p. 53.
"Dr. Philip Weiler. '"Cost Effectlve Anvlys:" A Qfonndrv for Geri'tric Ha'"t C.re
.:ytpm--." Thp Geront1.,'.L, rt. October 1974. T',. 414 .n-, 415.






16


effectiveness of home health and supportive care. MAO, a non-profit
organization working with a "consortium" of Federal, State, local and
private "partners," provides an alternative health and health-social
system for people who do not require 24-hour care.
Daphne Krause, Executive Director of MAO, testified before the
subcommittee on July 8, 1975. Mrs. Krause stated that, during any
period, MAO is providing "medi-supportive" services to 8,000 people,
voluntary action programs to 29,000 people and clinical services to
3,800 people. "We have over 5,000 people waiting to get our services,"
Mrs. Krause explained, "and we do not know if those are the only
people who need them." 15
Senator Hubert Humphrey of Minnesota, a guest of the subcommit-
tee during the hearings on MAO, pointed out the effectiveness of MAO
and the mechanism of a consortium of partners: "It really is * *
one of the curses of our modern society, whether we have international
problems or domestic problems, we say . write a check, rather than
try to figure out how we can put human resources to work * *" 16
Among the supportive services MAO offers are:
1. Home delivered meals
2. Employment service
3. Home care services
4. Handyman services
5. Transportation services
6. Legal services
7. Counseling services
8. Information and referral services
9. Special health services
10. Facilitation of health services
11. Decentralized miniclinic services
In support of her thesis of the cost-effectiveness of home health
care, Mrs. Krause presented a number of case studies to the
subcommittee7
The subcommittee believes that the evidence, presented in charts to
the committee, does demonstrate the cost-effectiveness of MAO's
approach. While the subcommittee would caution that the savings
indicated may not be universally applicable and that it cannot be ab-
solutely ascertained that the individuals assisted by MAO would other-
wise have been institutionalized on a full-time basis, the evidence indi-
cates a great potential for cost savings under certain conditions.
The charts17 follow:
15 Testimony before subcommittee, "Innovative Alternatives to Institutionalization,"
July 8, 1975, p. 6.
"I Ibid, p. 82.
17 Hearing on "Innovative Alternatives to Institutionalization," July 8, 1975, p. 32, et seq.




17


COST EFFECTIVENESS OF MAO HOMECARE A


VERSUS INSTITUTIONALIZATION


OST IF CL(NT M'A TITUTIONALIZEDOVEk


3 NW


Z42 7E


pFtR OL)


RA3C COST OF WI NOME AT 450/ -3 5
MINUS I[ENTS INCOME 18//1mo. fOR 3 MOS.
CLIENT WOUIV' lB ALLOWS 125/, FO, [^A N5bS
COST TO TITLE


CO57
/,1 55000

- 355.00
$ 996.00


COST OF MAO. SVICES OVCR A 3 MO Pk Ib1


HAYM.AMN
HOMECARE
COUNSELING
TRUiK RTATIN


I
5
Z3
3(50 SE ECBANSN tM OL
TOTAL


S27.75
I1.10
230.00
10.50
2 279,55


N.. THE LIFT WA ON L' WWThOUT&4". lZ MF P R Ab LIVED oNIgL,
ThEN Sk C0A E WOULD, tI4AV A TO K ARAWNW .)
COST EFFECTIVENESS


TO


TI-TLE OF INSTITUTIONALIZATt'
FOR 3 MONTHS


MIMUS COST OF MA.O SERVICES FOR 3 Mt05.
TOTAL SAVING TO TITLE IY


996.00
279.355
$ 716.65


T [EREFORF,"TITLEFX COULD PAY FOR ALL 4. A.O.


SERkVICES, AM STILL SAVE TiE TAYPAYER


7/6.65


OVER A 3 MONTH PERIOD


AS MAO


bib


w %,


COST






COST EFFECTIVENESS OF MAO WMGWR PLAN


VERSU AOSTALIZATION


`446E


MSIC COST IF CIENI WAS H HOSPiTAL 1711FOR. 11 MS


AVERAGE BASIC COST OF 9OPTALIZATiON FYR


LESS bEDUCTILE AV8R@ 8Y
SEN OR CtIZZi CLIN1


14 DAYS


AF8OIT-WigTWIMSI/M A 0.


LESS CO-4INSANMC ZOF PhIAME/ W#(9 AROTT-
MOkIW E/M 4 (L(W(( R^^
5'nce M Me% D h a ot
hfatp y,. r77 ...dl
COST Savedo
COST OF MAO. S[MCES FO (WE MONTH


2, 1/84.00

Z 090.00

18.00

t 1867Z.00


SERVICES
T SPOKTATIOR(
COUMSFLLU\
DIETARY CON5)LT


(diakt+c)


z MCAfS/DAV, 7DAYS/W% 6AS
(coor PAibi/.US/oAY)


4 10.50
6.80


27.6Z
OTAL 53.'-2.


COST EFFETIVENUS


CO,-S 0 iADiFCAM F-R
1A(fUS COST oF M Ao


TOTAL


/4 DAY bIOSPI7AIwATON
SEkVICES F6K I WWTH


5V/S TO MEDICE


$1,


672.0O


53.42
1 l8.5O


T-IXl E MENCAKE COD PAY


MAO


SVkICES
'R 'I67


AW STILL S4LE
s 4SI4. h/b.


-OK ALL
THE







COST EFFECTIVENESS O "MA0. HOME CARE PLAN
VERSUS CTT-6ALRIZATIOM 4 .

COSF iLW -I1A ttHIl[m IVTWlIOUAL1 / ) 5VMONT85


AV[AG[ AIC CUT Of N HSiWJMr
CARF AT *540/MONfH -FO 59 MOS
LSS ClIET'NS I(OM[ f //ZI/W)
HE WOULD HiAVE &f11N AIOWELb "25/MO


C~r7 7;'r Z


COST5
'031,860.o0

S7, 139.00
"4f 721.O00


COST 01f


MAO 1SIV0/QS


31S) MON'T45s


SRVICf
HOME !)UiV[JRD MIS
HOME CARE
CHORE
TRANSPORTATION
COUNSELING
VOLUNTEER


-KVK\WR O- SRVI.S
2 MALS/AY, 7 > ,'r
AAcE. 34S bAYS
( 514i1a REULALY' BY FAMILY
I .. .9 .


101
97


TOTAL


C015r-
S817.80
o 3.99
3.99
3,.40


281. 75
* 1.45900


COST FFFCTIVEIESS
COST TO TITLE XIX OF INSTIT(TIOMLIZATiON
FOR 59 MONTHS
MIN US C05T5 OF MAO SWVICE(S-59 MOS.
TOTAL SAV/INS TO TITLE IE


S24,7Z 1. 00
-,45 1.93
35z.66.07


ThERFO R[,"111Ei[ OULD PY FOR All MAA. SERVICES, Atb
STILL SAVE THE TAYPAYER'23,266.07 O A 59 MONTH
PERIOD AS MA.O. DID).




20


COST EFFECTIVENESS OF MAO. HOMECARE PLAN
VEkSUS INSTITUTIONALIZATION '42 -
COST IF CLITS IS m!T( TONA UOVEK 22 MGNT


rSI COT OF llrS w Ht E w4hf&4 :
FOR A0K 0 -22 MOJf0S
FOR k. 0-20 MOWNT1S
TOTAL
MINUE C[IEFTS INCOME OF /86/, CLIENTS
WOL AVE 0I AVL TO KEEP R 4 FOK ?g-iNAI
COST TO TITLE


COST OF AO SEtVICES (iR


22


COST
Co05 r
19.900.oo00
9,.XOO
9IB,90.00

a -4,092.00
414,808 .00
MOWTUtS


HOE RVIC V b MEALS
[IOW DFLI[DE M[ALS


COUNSELING
VOLN T[Ek


SRV/lCs


Z rmazis/faay, 7d.ys/we^K
fr btt+ M% t Mr. 0
IZO
17Z
TOTAL


3, 295.00
310.00
86.00
" ,J,691.00


COST EFFETVENESS
COST TO TITLE XX OF INSTITUT!ONALIZAT(ON
FOR ZO 22 MOS. FOR MR4MmS 0.
MINUS COST OF MA SERVICES
TOTAL SAViN& TO TITLZi


'14,808.00
-3,691.00
11,17.00


T4EREFOP,'"TITLEIH COULb PAY FOR ALL MAO VMICES
STILL 5AVE TIHE TAYPAV'II, IIiW OVKR ZW5. At M-AO. bDID.









The following additional studies presented to the sinbcommittoe fur-
ther demonstrate the cost-effectiveness of lhoimc health care.18

REPORTED SAVINGS ON HOSPITAL COSTS TiROLUGH IIoME CARE*

SELECTED STUDIES
This paper summarizes data on savings in hospital costs resulting from early
discharge to home health care as reported in selected studies in New York State
and elsewhere. Various other reports now available could have been included,
but the number has been restricted in the interests of brevity.
Studies selected represent programs at three levels-statewide, met ripolitan
area, a single community hospital.
Figures are given below which summarize savings in hospital days and hospital
costs reported in these studies. Later tables give source references and addi-
tional breakdown data.
REPORTED HOME CARE SAVINGS

Hospital days
saved per Net savings
Study report patient per patient1

Visiting nursing service, Denver, 1971 -------------------------------.------- --. 15.6 $1,170
Blue Cross, Philadelphia, 1963-71....-----------------..---....--------.---------------. 12.9 330
St. Luke's Hospital, Denver, 1970...--------------------....------.........--..........--------------- 14.0 850
Blue Cross, Connecticut, 1970-72- ------------------------.---- --------------.. 21.6 2,175
Patients in traction, Rochester, 1973----.....------..------------------------------- 49.8 4, 590
Blue Cross, Michigan, 1961-70.--------------------------------------------- 14.7 562

1 Figures are net savings-costs of home care deducted from estimated savings in hospital costs.

A number of comments are in order with reference to the above figures:
First, reported hospital days saved in the Philadelphia, Connecticut, Denver
VNA, and Michigan studies are based on estimates made by attending physicians.
Figures in 4 of the 5 studies fall within a relatively narrow range of 12.9 to 15.6
days saved. Such a result involving hundreds of physicians and thousands of
patients in so many parts of the country strongly supports the validity of the
data even though an element of subjective judgment is involved. (See Table V
for explanatory comments on the higher Connecticut figures).
Second, data in the St. Luke's and McGill University reports are ba-ed on
carefully designed control studies. Savings reported are based on objective data
comparing selected groups receiving hospital care only, and groups receiving
hospital plus home health services.
Third, the substantial reductions in hospital stays reported in the hemophiliac
and traction case studies add an important dimension to the cst effectiveness
potential of home care. The number of such patients in the population, of course,
is relatively small. However, in view of the very high dollar savin,.-, there is
strong indication that earlier discharge to home care for these and other -leLial
disability groups-post-surgical, pediatric, coronary, pulmonary, to litLie a few-
could add up to an impressive cost reduction.
Fourth, taken together these studies present a strong weight of evidi.cle that
home care can make significant savings in hospital days. Admittedly, there are
limitations in the studies. But it would seemni imprudent to iiore the evidence
of these reports while awaiting some more comprehensive re-.a.'ich 'il',ject for
which there is presently no visible sponsor or source of fundizn..
Meanwhile, the explosion in health costs continues. C('areful clinical studie-
consistently report unnecessary hospital and nursing home u-e. a l1ortion of which
could be reduced by home care. Over 42 percent of Medicaid expi.tiitur,.- in tli.
state in 1970 were for hospital care. and more than 24 percent for nursing home
care. Only a fraction goes for low-cost care in the home.
The cost situation and the data in this report strongly suggest the timneline-s
for action on home care.

18 Th, information was collated and supplied to tlh P ui)eCrn-mi tt hby Filward G. LIlnpy,
Dirpertor of Health Service.f, State Comirnmintie- Aid Association. New York.
*Preppred ,v I.:dwnrd G. Lindsey, Director of Iealth Serviix-. State Communities Aid
Associ:it!in, New York, New York.






22


ADDITIONAL DATA ON STUDIES
Tables I through VII which follow present additional data on the home care
studies cited on page 1. In some instances for convenience, figures have rounded
to the nearest dollar.
Denver Early Discharge Program
Table I below summarizes data reported by the Denver Visiting Nurse Service
on the 1971 Early Discharge Program. The study involves 620 patients referred
to home care by 10 voluntary hospitals.

TABLE I.-Denver early discharge program-Hospital days saved,1 1971
Hospital days saved per patient2----------------------------------- 15. 6
Hospital savings per patient2------ ---------- -------. $1,472
Home care cost per patient2------------- ----------- --_-- ..$302
Net savings---------------------------------------------------- $1,172
1 "Report of Early Discharge Program," Visiting Nurse Association, Denver, Colorado,
1972.
2 Based on average hospital per diem of $95.
An additional 768 patients were referred to home care, but not designated as
"early discharge." Data on these patients is not included in Table II.
Philadelphia Blue Cross Study
Table III below summarizes data on hospital days saved as reported in a home
care study by Blue Cross of Greater Philadelphia. The study covered a ten (10)
year period-1961-70, and provides figures on 3,940 patients discharged to home
care by four (4) hospitals during that time.

TABLE III.-Hospital days saved-Philadelphia Blue Cross088,1 1961-70
Hospital days saved per patient------------------------------------12.9
Hospital savings per patient---------------------------------------- $634
Home care cost per patient---------------------------------------- $304
Net savings per patient------------------------------------------- 2 $330
1 "Coordinated Home Care: An Effective Alternative," Blue Cross of Greater Phila-
delphia, February 1972.
2 A net savings of $473 per patient was later reported for the year ending June 30, 1970.

Estimated hospital days saved on 3,940 cases totaled 50,800 days valued at
$2,495,267. Net savings after deducting costs of home health services and related
administrative costs were estimated at $1,298,381.
St. Luke's Hospital Study, Denver
Table IV below summarizes data on hospital days saved as reported in a con-
trolled study by J. W. White at St. Luke's Hospital, Denver, Colorado in 1970.
The study involved one sample of 100 patients referred by the Hospital Nurse
Coordinator's Office to home care, and a second sample of 100 patients selected
on admission until "the same number of cases for each diagnostic category was
reached" as in the home care sample.

TABLE IV.-STUDY OF HOSPITAL DAYS SAVED THROUGH REFERRAL TO HOME CARE 1-ST. LUKE'S
HOSPITAL, 1969

Hospital Hospital Home care
days cost2 cost Total cost

Hospital group---------------------------------- 2,554 $196,504 ------ $196, 504
Home care group....--------------------------------- 1,155 88,935 $22,534 111,469
Net savings---------------....................--......-----------------------.---.--------------..- 85,035

1 "A Comparison of Referred and Nonreferred Cases to Home Nursing Care," unpublished masters thesis, J. W. White,
M.A. Hospital Administration, 1970.
2 Average per diem (St. Luke's, 1969), $77.







H,,pital days saed avera.-d 14.0 day; per laiti',nt. II',,pital cois savy,1
averaged $1.076 lKr patient. Homnv health -crvi..-s averai-ed :1i;.4 d;iy- per i:itieut.
Net sa.ivings were $,.5() per patient, a cot redurt.tin of over 43 T .ci''crii.
A General Accounting Office analysis of 20 studies by expert s com-
paring the cost of home health care with the cost of institutional serv-
ices developed the following conclusion:
Of the 20 studios. 19 prestenttd data which sulpp)orted the ,rilposition tii;it horne
health rare can lie less expenIsive iunider some cir.'.Iiii.td.Ces thiani alteri::tive
iistituti ma] care."
Tire iwdi,',lu" o ri ght to c1'oo.,e should be ,,, (1 'd.

NEED FOR HIOMrE CARE

The subcommittee has examined various surveys which attempt to
assess the extent of need for home health services. The subcommittee
has concluded that there are from 2.0 to 3 million noninstitutionalized
aged persons who are bedfast, homebound, or have difficulty in getting
outdoors without help.
The National Council of Senior Citi;eii.ens estimates that 1 out of
6 older Americans who are not in institutions are in need of direct
health and social services if they are to be able to remain in their own
homes and communities.20
Preliminary estimates by the National Association of Home Health
Agencies indicate that home health agencies are serving less than 15
percent, of the projected national need.21
U-in, statistics from a one month survey in eastern Massachusetts,
a Brandeis University study stated, "'The total volume of delivered
home health aides and home help reached only 2.5 percent of the per-
sons estimated to be in serious need . ."22
Particularly poignant is the fact that 54 percent of the Nation's
counties have no medicare-certified home health agencies.23
144OO, to 400,000 Nutrsinq Home Patients Shoud Be Freed:
There are over 1 million elderly persons in long-term care institu-
tions today. Many of them have been placed there because there were
no alternatives available to them.
A January 1975 study contracted by HEW cited figures indicating
that between 144,000 and 260,000 people, or between 14 to 25 percent
of the approximately 1,000,000 elderly persons in skilled and inter-
mediate nursing homes, may be "unnecessarily maintained in an in-
stitutional environment." 2*
A 1972 GAO report reveals that:
There is a consensus among health care authorities that about 25 percent of
the patient population are treated in facilities which are excessive to their inecds.
19 General Accounting Office, letter to Representative Edward I. Koch, September 17,
1975.
: RudYrlph Danstedt, testifying before the subcommittee. November 19, 1975.
2aDonald Trautman, National Association of Home Health Agencies, testifying before
the subcommittee, June 16, 1:l75.
HEWV statistics. April 1975, supplied by Library of ConLrez.
2 Evaluation of Pprsnnil Care Or.-r, i7,atlonn and Other In-Home Alterntives to Nurs.
in, Home Care for the Elderly and Lona-Term Disabii. Interim Report No. 3: A-,-.s-
ment c.f the Foa-llility of Condu( tin?- a Pr,-prctive Study of Clients Served by Alternatives
to Institutional Cnro: Vonlumn 1. JTnri'rv 3, 1975" (P1rnr',r d by ApplifI! .Mani,-1menr
Sciences Office nf the As.sistant Secretary for Plainninr and :vn'liittion. Drt. of IIHEW,
pursuant to Contract No. HEW-0O-74-294), placed into the Congressional Record by
Representative Edward I. Kochi, April 14, 1975, p. Ii27:2'.





24


The report continues:
The health care system is oriented primnarily toward treatment of the acute
phlas;is of illic'..,s and does not offer a complete spectrum of health care by pro-
viding available alternatives to acute care, financing for the alternatives, and
educating physicians and patients in ace- itin." alternatives.
Home care can be viewed as meritorious by itself in that it provides the most
appropriate care to the patient which best fits his n.-e.is. Patients on home care
also pay a good deal less than the rate they would have to pay in a general
hospital, and there is a growing s:ontiment among medical economist; that a
well-conceived home care program could make uIziiieressary the construction of
a substantial number of new general hospital beds.2'
Other reports indicate that at least in some areas of the country,
the.-e figures may even be conservative. The Levinson Gerontological
Policy Institute of Brandeis University, in testimony before the sub-
committee, spoke of-
* the high proportion of persons forced into nursing homes because no
alternative home care provision is available, even though they do not require
institutional care for medical reasons.
Dr. Robert Morris, testifying on behalf of the Institute, said that
"the percentage of such unnecessary institutionalization . depend-
ing on the area of the country studied", ranges from 10 percent to as
high as 40 percent.26
While discussing home health legislation during the subcommittee's
November 19, 1975, hearing on "Comprehensive Home Health Care,"
HEW said, "We find very little, if any, evidence of that (patients
using up allowable medicare home health visits) occurring." HEW
also stated, "We are opposed to such (expansion of home health) leg-
islation because there is inadequate justification." HEW testified that
"additional experiments" are needed to "provide a sound basis for any
proposed changes." Yet, on September 17, 1975, the Social Security
Administration, within HEW, had provided information to GAO
demonstrating that 1,965, or 1.4 percent, of medicare part B home
health recipients used up the allowable benefits in 1974 and about 2
percent, or 3,000 people, exhausted their part A home health benefits.
Such patients then have no covered alternatives but expensive hos-
pital or nursing home care.
The subcommittee supports the Department's attempts to gather
data. We ask that HEW promptly report on the results of its ongoing
experiments concerning the effectiveness of homemaker services as a
means to delay or prevent institutionalization under Section 222 of
Public Law 92-603. That project period ended January 27, 1976.
fHowerver, th.e subcommittee sees the call for additional ..,crbnents
as a delaying tactic. The subcommittee has conducted months of hear-
ings and gathered voluminous data demonstrating the cost-effective-
ness and care advantages of home health. We already have the experi-
ences and the data to back up the need for legislation. We are sorry
the Department does not.
The subcommittee believes that the time for relying on new experi-
ments had ended, and the time for meaningful legislative reform to
make home health care a reality is now.
25 Study of Health Facilities Construction Cost," Goneral Accounting Office, November
20. 1972, p. 10.
26 Dr. Robert Morris. Director, Levinson Gerontological Policy Institute, Brandeis
University, testimony before the subcommittee, June 16, 1975.







Thie recommendations of the 1971 White House Conlference on Ag-
in._, which this committee is mandated by law to over.-L,, vTre .; fol-
lows reurding home health:
Sm.imary of Home lA ('th, Riommcnd"t'i,... 1,'1 IK', I O'.', Co-
fc, i (' e on A ,;i,,
The five major recommenlldations set forth ,>. l go.ab for a conl-
preLhensive. effective program of horiomcair aiml ,home health .,.. i'vics.
Brierfi they aLc -ti4,tr.>I a follows: (1) -,ll .rvi. ,tus l t e, qarc(
lai fit i (r 0 any clerJ,.y J( ,,tfh amd' welfare,.: Pl.,o i '* .'Il.n? l/"( / w i F' -
(7al.y. Int a.ld'.twn ,oi v
mv.sf b,- broadly defl',,, with flexible eligibility eonditio.-, widely
available, and well publicized; (2) such services must have adequate
public funds and 1e available free, or on a sliding scale of 1 '*... to Ilie
recipient or through third party payments; (3) all a i i (,ci t providiJ(1
such :services must meet nationally established standards; (4) other
related in-home services must be available to coordinate with ho it.-
maker and home health aide services; and (5) homemaker and home
health aide services must be available as supportive, protective, and
preventive services on a flexible basis as needed whether on a continu-
ing supportive basis or for only a temporary period of time.
The subcommittee believes that it is past time to implement these
recommendations of the White House Conferctce on Aging.












CHAPTER III


INNOVATIVE ALTERNATIVES TO INSTITUTIONALIZATION
A review of both the testimony before the subcommittee and the
literature on the health care needs of aged Americans demonstrates
that many of the Nation's elderly are confined in institutional settings
simply because alternative living arrangements for more appropriate
support and care are not available. At the same time, it is recognized
that the elderly utilize health care services more intensively than other
age group categories. The care which many elderly individuals re-
quire to allow them to return to their homes and to maintain their in-
dependence includes expanded home health and homemaker services,
as discussed earlier. However, the subcommittee has found that for
many elderly individuals, outpatient health services available on a
periodic or regular basis-in conjunction with needed home health
services---would be a more appropriate alternative.

OUTPATIENT CLINICS EMPHASIZING GERIATRICS
The subcommittee believes that outpatient health services provided
in outpatient c!iinics emphasizing care of the elderly but not exclusively
for elderly persons should be provided. Services should include a com-
bination of primary medical (preventive, interventionary, and refer-
ral) ; dental, ophthalmic; otologic; podiatric; rehabilitation; mental
health; and health education services.
Testimony has been presented to the subcommittee demonstrating
thlit while outpatient clinics for the elderly are not unique, they are by
no means common. Clinics specializing in elderly care exist in such
cities, as San Diego and Minneapolis.1 Still other health center serv-
ices for the elderly are provided by home health agencies in apartment
buildings and housing units for the elderly or in area schools or
churches. It has been found that such services have served to reduce
total health care costs by reducing tenant visits to physicians and
clinics; by reducing transportation problems and costs; by providing
referral information for community resources; and by preventing hos-
pitalization with early recognition of health problems that can be
treated at home.
Sutch care is less costly than full-time hospital care, nursing home
care, and( often even home health care, because the center delivers a
wlio,, range of services by a variety of providers. In addition, such
centers assist in the important principle of keeping the patient in the
community.
A Department of HEW study, "Health Service Use, National
Trends and Variations, 1953-1971," (No. 73-3004, October 1972)
'See "Innovative Alternatives to Institutionalization," hearing before the Subcom-
miittee on Health and Long-Term Care, July 8, 1975.
(26)








found that, ii 1970, for 16 percent of thoe persons 65 mld over, a
clinic served as a rc',ilar source of care. Another 11 p< .t of indi-
vidu/w8 605 a..d o:,' rr''wrc found to haIe no i'wueitr shou,',r of c ure
av ailable.
MULTIPURPOSE SENIOR CENxTEILS
Another alternative which the subcommittee believes should be en-
couraged, midultiu'lrpose srvior center's, has been found to serve a very
valuable community service for health services, nutrition prograliS,
and referral services. They are also a means of bringing elderly per-
sons together in a social setting to relieve the pain of loneliness suf-
fered by so many.
The subcommittee has found that senior centers which provide
coml prehcnd ae s;rr1' ces-helalth, nutrition, r creation, and social pro-
grams-can provide a meaningful life for many elderly persons who
would otherwise be institutionalized.
A 1974 survey conducted by the National Institute of Senior Centers
(NISC) found 4,870 senior centers and clubs with regular activities
for older persons. Of the 4,706 for which service data were available,
1.967 provided less than the three basic services (set forth by NISC)
of education, recreation, and information, and referral or counseling;
255 provided these three basic services; 1,471 others provided these
services plus community volunteer activities for older persons; and
another 1,003 provided all these services plus health services. Of the
total 4,870, only 1,474 provided health services and 1,476 provided
nutrition services.2
According to another recent survey, 18 percent of persons aged 65
and over (approximately 3.7 million people) had attended a senior
center in the past year or so. However, almost as many (17 percent)
said they would like to attend a senior center but didn't. Of these,
over one million said they "didn't attend because there were no known
facilities where they were." This number, which could be interpreted
as needing a senior center, would increase if persons aged 55 to 64
were added.3
ADDITIONAL ALTERNATIVES
The subcommittee heard testimony concerning a variety of addi-
tional alternatives to institutional care and believes the following
should be encouraged.
Conmmnunity care orgacu.-:afions, providing a package of home health
pn"-1 related services including Meals on Wheels, hob,,',ker, home
maintenance, snow shoveling if necessary, lawn mowing and other
gardening; and medical and health related service including phy:si-
cal therapy, visiting nurses, guidance and counseling, social workers
if needed, and physicians.
Elderly day health care centers, where health professionals perform
identical or similar services to those ,y participants in A.-:'illed nursnz
facilities and intermediate care facilities, especially for per-mons in
tho-e facilitit :- as a i,'liptional step toward ,iull recovery .,:i a retlurnl
to their homes in the community.
2 Data provided by T.i!,rir y of Cron' resz.
3 "The Myth and Reality of A-in,-i in AT ,rir'-" by L ,uis HTarris ".rN.l A -i-tes for
t,,c National .',iinjl on A ... ._, ;:,;. 1.,t-I''-.







The subcommittee further believes that nursing homes and ICF's
should be encouraged to provide alternative day modes (with adequate
standards against abuse) so that the elderly individual can see the
entire continuum of care available to him in the same location so as
not to become unnecessarily accustomed to remaining in the institution,
and so that a possible transfer back home will be accomplished by
continuing health care with which the patient feels comfortable.
Geriatric mobile health units, providing regular medical services
for persons over 60, which would travel to various locations on a
regular basis.
Expansion of mobile and stationary emergency health units special-
izing in the emergency health needs of the elderly.
Annual "Health Fairs" in communities, to provide free medical
checkups, appropriate referrals, and printed information relating to
health education. One such fair in Coral Gables, Fla., found an indi-
vidual with brain damage who had to be rushed to a hospital emer-
gency room.













CHAPTER IV
NURSING HOME AUDITING AND STANDARDS: PRELIMINARY
FINDINGS
The subcommittee recognizes the need for adjustments in long-term
care regulations, standards, and review procedures which would en-
lhance their appropriateness, efficiency, effectiveness, and compatibility.
However, the subcommittee has gathered data and testimony which
points to glaring deficiencies in enforcement of existing regulations or
implement ationof sound procedures for auditing.

DEARTw OF AuDrrs

At a hearing of the subcommittee in Providence, R.I., on July 12,
1975, "Auditing of Nursing Homes and Alternatives to Institutionali-
zation." HEW revealed that since the inception of Medicaid there
was a dearth of audits of nursing homes not only in Rhode Island but
across the Nation. During the period from 1966 to 1975 20 States did
not conduct a single audit of a medicaid eligible long-term care facility
(see exhibits I and II). In addition, many of the audits listed in the
table took place only after a nursing homnscandal was revealed, as in
the case of New York State or Rhode Island where 20 of the 27 total
audits performed since 1967 had been done in the previous 6 months
before, the hearing on July 12, 1975. As of December 1975 there were
11.785 facilities eligible to receive medicaid long-term care funds.'
These statistics point to the urgent need to develop a rational scheme
of financial auditing; one that would permit the States, the Federal
Government. and the public to monitor the use of Federal and State
funds, as appropriate, under current statutes and regulations, or if
necessary under new statutes or regulations.
EXHIBIT I
Number of mnedicaiid facilitic.q audit',l by State organizations *
Alabama ---------------------- 55 Ilaw;ii -----------------------_ A
Alaska------------------------ 0 Idaho ------------------------ 3
Arizona -----------------()------ Illinois ----------------------- 3
Arkansas --------------------- 0 Indiana ----------------------- 0
California --------------------- 0 Iowa ------------------------- 0
Colorado --------------------- 1 Kansas ----------------------- 36
Connecticut ------------------- 0 Kentucky --------------------- 94
Delaware --------------------- 24 Louisiana --------------------- 206
District of Columbia------------ 0 Maine ------------------------ 75
Florida ----------------------- 0 M.Naryl.anl _--------------------- 43
Georgia ------------------------ 0 Ma< .:lit ---------;----;
1 Does not r articipate In the medilc.iid prozr;im.
:A-Inf ration not available.
Si,.v. Enactm-n1t of r1,,,rirtqi.. 'ii-t taken from testimony of HEW ]':r"'.'_ s' .om-
mittee hearin:. J '.12. 19.75. (Provti'..e).

1 Source : O f ce .'-f Nir:',,, Home AffzirT, Jan. 14. !9T75.


(29)







30


EXiIBIT I-Continued


Michigan --------
Minnesota -----------
Mississippi ---------
Missouri ----------
Montana -----------
Nebraska ----------
Nevada---------------------
New Hampshire--------
New Jersey ---------
New Mexico----------------
New York ------------
North Carolina-------
North Dakota---------
Ohio----------------
Oklahoma ----------


1370
51
0
350
1
0
16
25
316
36
222
87
0
4
0


Oregon --------------
Pennsylvania --------
Rhode Island---------
South Carolina-------
South Dakota ---------
Tennessee --------
Texas ------------
Utah ------------
Vermont ----------
Virginia -----------
Washington ----------
West Virginia--------
Wisconsin ---- -------
Wyoming ----- ------
Puerto Rico ----------


EXHIBIT II

HEW Audit Agency audit reports issued by State since 1967


Alabama ---------
Alaska -------------
Arizona ----------
Arkansas ---------
California ---------
Colorado ----------
Connecticut --------
Delaware ------------
District of Columbia------
Florida -----------
Georgia -----------
Hawaii ----------
Idaho ----------
Illinois -----------
Indiana -----------
Iowa ----------
Kansas ------- ---
Kentucky --------
Louisiana ---------
Maine--------
Mai ryland ------
Mias4achusetts --------
Mic-ligan --------
Minnesota ------ --
Mis.ci^-'ippi
M issouri __ _ __ _


4
2
(1)
2
11
7
5
2
2
4
3
3
3
9
4
2
3
3
1
4
5
S
4
5
3
4


Montana------------
Nebraska --- --------
Nevada ------ ------
New Hampshire----------
New Jersey----------
New Mexico -----------
New York----------
North Carolina-------
North Dakota--------
Ohio ------------
Oklahoma ----------
Oregon -------------
Pennsylvania --------
Rhode Island--------
South Carolina--------
South Dakota-------------
Tennessee --------
Texas ----------
Utah --------------
Vermont -- -------
Virginia ---------
Washington ---------
West Virginia---------
Wisconsin --------
Wyoming ---------
Puerto Rico---------


1 Does not participate in the medicaid program.

Some preliminary dTta Ind testimony has been gathered by the sub-
conmmittee on ithe cost and benefits of unannou,,'ed on-site auditing of
"nd care ,,*facilities. The
Federally funded skilled nmusingx. and in ermed.iate care facilties. The
testimony firom i ede:-il and State officials on the estin:te' cost of
seicil anitill, Ias varied widely. The i department. of Ialth. Educa-
In .t.e T o -1t c -h. Ednea-
tion. an.] Welfare est(imated tie, ave'a."e cosot of auIditing a skilled
nursin", facility at $3.7O per facility if all facilities were surveyed,"
Vv'hile P 'I'an( oiI:,(ais have Cstifated the cost at about ,'f00')
per V c-'i'- and predicted that such auditk "would have surfac-d h -

2 St.t ment Iforp the subcommittee of Peter Franklin, Sp,' *-. Assistant to NII:W
Secretary, July 12, 1975.


57
319
27
38
0
60
375
0
0
170
0
0
487
0
0







d(rel- of tl1 ;islIa 1Is of dollars that woutild hav-e becn iowe Ato lie State.'*3
A n''e of enforcement procedure: such a's periodic ti-,;l nudit- )y
CPAs or sostemiS Of graded1 peiialtis for infractions, sliotild e coil-
sideredl. The subcommittee not<- t-hat 11.R. 733 (s Appendix I)
would requi e the Secretary of IHEW\ to conduct an animal 'audlit of
hospitals, mnursingo- homes, and other iizstitittional faciliti-, participa)t-
ino- in medicaid, and annual audits of medicare 1)providers of service.
The sub'o,1oimittee las concluded based on the record befon', it, thIat
it is not a que-4 ion of whether nursing homes -liould be audited, but
rather by what means, how frequently, and by whom. Beyond the
specific, recommendation concerning on-site auditing contained in tii--
report, the subcommittee recognli::e- the need for further develop nent
of regulations and auditing procedures wlIich are eff.etive, fair, and
appropriate to the goal of producing the best available care for each
Federal dollar spent.

SURVEY CONFIDENTIALITY
Many Government surveys such as the Office of Nursin Home Af-
fairs' 1975 Facility Improvement Survey, and many of the State fiscal
audits of nmursinf homes are confidential, inisuring the anonymity of
the institution being surveyed. The ONHA's survey stressed:
(a) The reqearchi nature of the survey; (b) the a.suranee that the surveyy
was in no wvay related to certification surveys for participation in the Milicare/
Medicaid prc-:oram ; and (e) the assurance that all data were contfidlenitial.
While the subcommittee believes that confidentiality may serve tlhe
purposes of insuring. wider cooperation and receipt of more accurate
information, ro-triction of access to the names of institutions or nurs-
ing home owners may not in many cases serve the interes-ts of the public.
The subcommittee believes that the testimony offered points to the
need for full public disclosure of major violators. Such disclosure may
encourage action that will result in correction of deficiencies and im-
provements of life safety conditions for re idents. Accordingly, the
subcommittee will investigate disclosure procedures which allow for
greater public accountability within the bounds set by the Privacy
Act of 1974 and accompanying regulations which insure individual
anonvmity% and confidentiality.
3-lHon. Philip W. Noel, Governor of tle St.tte of Rhode T-L.ll, July 12, 1975, te>timiony
before the subcomminittee.












CHAPTER V


IMPORTANT AREAS FOR FURTHER STUDY IN LONG-TERM CARE
Throughout the subcommittee's investigation and taking of testi-
mony on alternatives to institutionalization, persistent themes emerged
which require this subcommittee's commitment to further study. Al-
though often phrased in terms of alternatives to institutionalization,
witnesses and experts who served as resources to the committee seem
to have implicit in their testimony a question: How would we design
a long-term care system to serve our elderly citizens' needs if we could
start over again? New initiatives in long-term care, whether experi-
mental in nature or a reflection of tried and proven techniques, are
thought to be hampered by the existing categorical nature of programs,
inconsistencies in regulations, current staffing patterns, or the like.
The message to Congress is clear. To effectively promote and stinm-
ulate positive efforts in this area, Congress must understand the
decision-making process in the individual assessment and treatment
of elderly persons. Indeed, in certain areas to be outlined below, Con-
gress must not only know how the decision-making process affects the
elderly, but also how it affects other non-elderly persons who receive
treatment for chronic impairment.
Much of the recent legislation enacted by Congress is predicated on
the assumption that increased availability of services will lead to in-
creased access and utilization of services. But the subcommittee has
found that more service is not necessarily better service, especially if
the potential recipient is not given opportunity to use services, under-
stand what services he may receive, or is not defined as "eligible."
There is also an assumption that increased access to services will
lead to better health and the improved welfare of the elderly. Our in-
vestigations have shown that the formula for delivery of quality care
to the elderly are more complex than te-e. simple equations would
indicate.
Te-timony given to the subcommittee by diverse groups indicates
the. need for evaluating the appropriate emphasis to be Qiven to two
distinct models of care within tle contini.uum of geriatric health care:
(1) the medical model, alnd (2) thle health-soial s. rviccs model. Should
the press ,nt iledically oriented medicaid and medicare programs be
continued, or do we need alternate long-term care programs which
integrate the social and medical components of care tlhrouo'] their
programs and regulations? WJhat balance between institutinal and
nlon-institutional services would best meet the needs of the elderly?
Those are major questions which the sbco1ltte.e h.as be'imn to ad-
dres-, and it will continue to direct its efforts toward them in the next
eATr.
Issues which will be examined by the subcommittee in this f:':me-
work include the following:
(32)






33


Lo ".G- II[ (.M CA.\I FIt TIIE .H MENTALLY I.[l'.\ 1;;:i EL)DELI.Y
The Supreme Court's landnImark in Doiald.-on vs. O'Connmor, L,'ard-
ing the rights of individuals who are involuntarily coiiimitted to a
(mental) institution. The Supreme Court found the ,ca- rais..1 a
single, relatively i ilope. 1but nonethele-s important question concern in
every mans constitutional right to liberty. The jury had found that
Donald,-oil wa-; neither daiingrous to bi-eilf nor daiigerous to other-Z.
and also found that, if mentally ill, Donaldson had not received treat-
mrent.
The Court lield a State cannot constitutionally confine without more
a non-danoerous individual who is capable of surviving safely in
freedom by himself or with the help of willing and responsible family
members or friends. Since the jury found upon ample evidence, that
O'Connor, as fn agent of the State, knowiiigly did so confine Donald-
son, it properly concluded that O'Connor violated Donaldsoins con-
stitutional right to freedom.
Mr. Justice Stewart's opinion further states:
May the State confine the mentally ill merely to ensure them a liviiig stand-
ard superior to that they enjoy in the private community? That the State hais
a proper interest in providing care and assistance to the unfortunate ^res
without s-aying. But the mere presence of mental illness does not disqualify
a person from preferring his home to the comforts of an institution. Moreover,
while the State may arguably confine a person to save him from harm, in-
.arceration is rarely if ever a necessary condition for raising the living stand-
ards of those capable of surviving safely in freedom, on their own or with the
help of family or friends.
In effect, the Supreme Court in its decision emphasized the indi-
vidual right to treatment or release of persons in such institutions.
Testimony in a September 28, 1975, hearing on Mental Health and
the Elderly by the Senate Special Committee on Aging also pointed
to the fact that more often decisions were being made regarding
deinstitutionalization on the basis of cost than on the basis of the
individual rights or trieatnienit availability where geriatric, or mental
patients were concerned. Mental hospitals and nursing homes through-
out the country are now faced with critical decisions which directly
affect the life and health of thousands of patients.
There is no question that older people in institutions differ from :a
g,,rmral population of older people. The institutionalized are in an
advanced old age (average age of 82 compared to 72 in the general
eldrdely population of institutionalized and non-institutionalized per-
sons combinedl). They have a high incidence of both phbyical and
m,'ntal impairment which hampers their ability to care for themselv,'z.,
I,1 inde',r ndent and be active. Studies by Elaine Brody v indi..ite that
on til. averpg o, elderly persons in long-term care institutions a'
.addled with four, major disabilities.2 Between 50 and 80 percent of
older individuals in institutions have some degree of mental impa;,-
mont.
1 Elalne Brn'--y: "T' he De1ion MibMnz Pr.rr.-: in Tnrvi0'iii'l .\I.armert." TTvit#]
t.inr. National Couincil (,f Social Workors nConferpnep. M.iv 10. 1975.
2 .-\mnE Th,- most frequ4 ntly encountered problems heart di ,.*i ,, chronic brain di(i ;' ',
n.rtPrinc:1ePrn ziq and hvPyrtrrpni,--in. '*,-n,9p of the 1-wiiloskeleta l 'vyste trol. .:.-
tur.-', (ia.,.;s, and deafness.





34


Althoughl mental impairment varies widely in its etiology and form
of expression, all forms whether diagnosed as "mental illness" or
'"senility" have some potential for making individuals dysfunctional.
However, we also know that with proper treatment and individual
understanding, the effects of such impairment can be lessened for
all populations-including the elderly.
Data and estimates show that there is a disproportionately high
number of elderly in mental hospitals: the total population over 65
in mental hospitals range from 28 to 40 percent although the elderly
compromise only about 10 percent of the total population. And while
there are only about five percent of the total population in all forms
of institutions at any one point in time, almost 1 in 4 elderly persons
will be institutionalized at some point in their later years.
The prospects are not bright for meeting the immediate and long
range mental health needs of the elderly without major initiatives at
all levels of government and individual communities. Nathan Slote in
the HIandbook of Co',mmu nity Psychiatry and Community Mental
Health, 1974, asserts that should present trends of mental health serv-
ice continue through 1980. 80 percent of the elderly in need of mental
health services will never receive them. On the other hand it is clear
that many elderly persons are in mental hospitals not because of severe
mental impairment, but because there is no other place for them to go.
At present institutional care facilities provide 85 percent of the mental
health care received by the elderly. The impact of the Donaldson deci-
sion may well be to release additional elderly persons from the cus-
todial facilities such as mental institutions and nursing homes without
there being sufficient resources in the community for their mental
health or general care and human needs.
The President's Task Force on Aging in 1970 expressed its concern
regarding the use of State mental hospitals as custodial facilities for
the elderly who are not in need of active psychiatric care because alter-
native living arrangements and psychological support do not exist.
The problem for Congress and the American people as well as for
those who are currently providing mental care for the elderly is to
develop means whereby the constitutional rights to liberty of the
elderly will not be infringed, and their individual needs for protec-
tion and care will be met.
For some years the Nation's efforts in this direction have been
focused on a consensus: individuals should be confined against their
will only to the extent that no other alternatives are available. To put
it in a more positive way, State intervention in an individual's life
regardless of that person's age or condition must be rigorously limited
under strict and definable conditions.
Peter M. Horstman. an expert in the legal aspects of protective serv-
ices for the elderly defined these conditions as the following:
(1) The individual has been declared mentally incompetent to
determine the advisability of seeking or refusing treatment;
(2) Less r,'trictive alternatives than total institutionalization
have bepn fully explored;
(3) The individual is unable to live safely in freedom either by
himself or with the assistance of willing responsible family mem-
l'ers or friends:
(4) The individual is untreatfable; and
(5) Institutionalization is in the individual's best interests.






35


Mir. Horstman says that these conditions must be simultaneously
present before we impoe. protective, custodial, or institutional re-
straints on the elderly. (Missouri Law Review, Spring 1975, pp. 215-
278)
The' stbeomm/ttee believes that intrusive ..t(ysudy must be made of the
relationship between the total mental health and protective services
available to the elderly and comim ui;fy or social support wih ich may be
aialable either oit.qide mental instt iutions and nursing wme., or in
such institutions. Legislation in this area should stimulate the provi-
sion of assi-tance to the mentally impaired elderly, and should not
impose rest saints on the ability of the elderly to live in their community
unless no other alternatives are possible.
Before study and investigation is completed the subcommittee does
not wish to make specific recommendations. However, we feel the fol-
lowing kinds of investigations may yield important results:
(1) The subcommittee will give strong emphasis in the future hear'-
ings on individual treatment programs for persons in nursing homes
and mental institutions. This implies the development of programs in
institutions which will treat severely impaired physically and men-
tally elderly individuals as human beings. Where the individual has
no "alternatives" to institutionalization, he should have some "alter-
natives" within the institution. Other countries, particularly those in
Scandinavia, have set specific nursing home policies and goals which
have as their prime goal the treatment of persons in such institutions
so as to maximize their individual rights and allow them needed health
and social support. Persons institutionalized in these countries are not
called "patients" but residents. The goal of treatment is to develop a
person's maximum capacity for self care, but where this has definite
limits, in any case, to take into account the patient's interest and life-
style in his treatment plan.
(2) The subcommittee will study the decision-making process in the
assessment, placement, and treatment of individuals. It will examine
treatment plans and assessment procedures which go beyond the defini-
tion of a person's physical, mental, or medical state. There have been
successful attempts to assess the individual human and social needs
dictated by a person's past lifestyle and future goals. For example, the
Philadelphia Geriatric Center uses such assessment in planning a treat-
ment program for elderly residents of its facility.3 The subcommittee
believes that an understanding of these essential priorities in care of
the elderly, will lead to the enactment of legislation and promulgation
of regulations that stimulate rather than inhibit local community
respon:-s to these needs.
(3) The subcommittee will study the patterns of admission and
re-admission of elderly patients to mental institutions.4 There will be
special attention given to the role of adequate treatment plan in trans-
fer of elderly persons to nursing homes, other long-term care institu-
tions. or the community. The General Accounting Office is currently
studying the role of differing regulatory requirements and former
residents of mental hospitals. The subcommittee has discussed the study
with GAO, will make use of the findings of that study, and will go
beyond it to examine other regulations of programs which affect dis-
3 See various reDorts and studies of the Philadelphia Geriatric Center by Tlaine Brody,
L. Gottesman, M. P. Lawton, et al., 190S-1974.
State legislation such as the Lateran-Petra-Short Act in California. reinilating patient
placement and admission are being considered as possible methods.





36


charge and transfer for the elderly (1. Titles VI and VII of the Older
Amnericans Act; 2. Title XX of the Social Security Act; 3. Title
XVIII-M-edic re; 4. Title XIX-Medicaid). In particular the sub-
committee will examine the interrelationship between the regulatory
provisions of SSI and medicaid as well as the interrelationship between
the so called levels of care provided under definitions of Skilled
Nursing (SNF) and Intermediate Care Facilities (ICFs). These
reculatiTons will be examined and assessment will be made of how they
may be better defined or changed to permit adequate monitoring and
evaluation of discharge, planning, referral, transfer, and follow-up.
(4) The subcommittee believes there is an urgent need to study both
the inappropriate placement of elderly persons in mental hospitals
and inappropriate placement of persons who are severely mentally
impaired together in institutions with persons who are faced with
more general problems of old age. What institutional facilities offer
appropriate environmental supports and treatment for both the men-
tally impaired and non-impaired elderly? While there have been no
national studies of this problem it has been estimated the majority of
persons in mental institutions over age 65 are inappropriately placed
and treated.5 In 26 states old age is used as a statutory recognized
cause in the definition of mental incompetency.6 Peter Horstman in
testimony before the subcommittee on June 16, 1975, reported a study
undertaken by the National Senior Citizens Law Center in October
and November of 1974 on guardianship and conservatorship filings in
Los Angeles County General District Superior Court. The study
showed that of 1,010 cases examined, in 84.2 percent of the cases the
only persons present at an incompetency hearing were the judge, the
petitioner, and the petitioner's attorney. Physicians were present to
testify only about 0.1 percent of the time. The proposed ward himself
petitioned to have a guardian in only 12.2 percent of the cases studied
and for elderly persons this percentage was even less (7.8 percent). 80.1
percent of the proposed wards were over the age of 60 and only 4.4
percent of the petitioners were denied or dismissed for reasons other
than death or disappearance of the proposed ward. In 2.9 percent of
the cases where the proposed ward was represented by counsel, the
dismissal rate was 34.6 percent.
These data imply that large numbers of elderly in mental hospitals
are there because of the inequalities in the commitment procedure
itself rather than because of individual needs.
Nursing homes have become a major source for the placement of
aged state mental hospital patients. Are these homes appropriate
placements for this type of patient? The subcommittee doubts that
there has been adequate determination whether individuals released
from mental institutions and placed either in the community or in
nursing homes receive services which alleviate or change their condi-
tion appreciably. The subcommittee will examine (1) institutionaliza-
tion of elderly persons who do not require institutionalization; and
(2) placement of persons diagnosed as having any one of the several
forms of severe mental impairment in institutions and congregate
5 Alexander G. and Lewin T., "The Aged and The Need For Surrogate Management,"
Syracuse University Press, 1973, Chapter 3.
6 See "National Association for Mental Health, Inc., Position Statement on Fncilitivs
and Services for the Geriatric Mental Patient," December 4, 1971.






37

care facilities with other perlsonll- who have no severe fan<'tioii:il or
organic disability ie-.
(5) h'lre is amn urgent nedcl to study tie -p1''-ial for.II of ii,,n1itil ill-
ness that be.e-t elderly i.opulations. It',:ilts. of :-i-dis ft.'m the Iuke
Univv-rsitv Center for Thie Study of Aging, the University of Michi-
ga n Centers fori Human Developiment and Geronotology,. and other
research sourc(-s funded by the National In.titute of Mental Health,
indicate that while one should expect a gradlual i.-ening of abilitie-
with age. many of the probli ms of aqng e..dt from psychologr.,-
U1,d p,,(./.xOlogWal distr,.,.X which is p1ct ,dtab-. One of tlhe major
factors which cause the elderly to turn away from society (and society
from the elderly) has to do with the reality of death, the lo-s of friends
,,lad immediate dav-tn-day contacts. Such loss further incre"-cs the
social isolation that the physical infirmities of old age brings. The
Biome(trics Branch of the National Center of Health estimates that
there are 236 new cases per 100,000 in persons from 35 to 54. A ma-
jority of thee cases involve severe depression and other forms of in-
volutional disorders. Clearly psychopatholorgy in general and depres-
sion in particular rise sharply with age. Suicide reaches its zenith both
in elderly white males and females at this time.
It may well be that the use of public mental hospitals and nursing
homes to care for the elderly with depressive syndromes may only
further exacerbate their problems. There is 'great potential in this
area for the subcommittee to study alternatives to such placement,
such as the development of community-based congregate placement
that could sharply reduce the incidents of depression in elderly popu-
lations which may lead to such institutionalization.
(6) The subcommittee will study means to reduce tlhe isolation of
persons who are in mental institutions and to the development of con-
sumner and provider community based visitation terms which will lead
to greater community presence in institutions and greater opportunity
for elderly persons to move into the community when they are able.
The subcommittee recognizes that there are no simple answers to the
questions of deinstitutionalization of the elderly. Indeed, some studies 7
have shown that under some conditions state hospitals are a better
place for the elderly than are nursing homes. The subcommittee be-
liev-e the key to looking at this problem involves a new awareness
on the part of Government of a sense of the person-currently missing
in our legislation and regulations. Accordingly, the subcommittee's
efforts will be directed at formulating recommendations for legisla-
tive and programmatic action which give privacy to the individual
need for treatment and humane ways of case management and
placement.

Tim. LIFE SAFETY CODE, REGULATIONS, AAND QUALITY OF CARE
In the aftermath of recent findings on nursing home fires and un-
safe conditions in long-term care facilities,8 strict life safety code
Nothably Epstein, 1973.
8 .PP GAO Reprt. "Many Medicare and Mediraid Nursinz Homes Do Not Need Federal
Fire .arety Requirements." Mar. IS, 1975; and Supporting Paper No. 5, "Continual
Chrmonilep of Nursinc Home Fire-," committee print from the 94th Congressional Session,
AiieuZt 1975, part of "Nurqing Home Care in the United States: Failure in Public Policy,"
Senate Special Committee on Aging.








requirements and regulations were imposed on skilled nursing facili-
ties and other institutions caring for the elderly and disabled. There
has been widespread failure to comply with the requirements of that
code and failure to enforce provisions of Federal regulations which
would result in withholding of funds to institutions who do not meet
the life safety codes.9 This state of affairs is further complicated by
changing codes of the National Fire Protection Ass.ociation. The As-
sociatioin, which is currently responsible for setting the requirements
of the code, has at least 3 operative or soon to be used versions of the
codes it chooses. The 21st version of the code was drafted in 1967, and
the 23rd in 1973. The code is currently undergoing revision and will
be published as the 24th edition in early 1976.
Legislation (H.R. 10317) which would update the life safety code
requirements for skilled nursing facilities by requiring that the cur-
rent 1973 version be complied with has been passed as part of H.R.
10284. The Medicare Amendments of 1975 are now Public Law 94-
187. This act stipulates that facilities currently qualified under the
1967 or State codes approved by the Secretary will not lose their cer-
tification due to changes in requirements specified by the 1973 edition
of the code.
The subcommittee intends to study whether the pending 1976 ver-
sion of the code is more appropriate to long-term ca re needs. However,
it i. more than the differing specifications of such variations in Federal
and State approved codes that give State enforcement agencies and
individual care institutions problems. A major problem for State
licensing inspectors has been that there is a, shortage of beds available,
for example, to medicaid recipients. A strict application of the provi-
sions of life safety and other facility standards would result in closure
of a large number of homes, thereby creating an even greater shortage
of care facilities for the elderly. Closing institutions in the absence of
adequate provisions for care of its residents may well do more harm
than good. This in turn can lead to an unfortunate tendency not to
enforce standards or to create an internal set of standards which may
not be reviewable. (These legal and ethical problems of this situation
are discussed more fully in Elias Cohen, "Long Term Care: A Chal-
lenge to Concerted Legal Techniques," unpublished manuscript,
September 1973.)
The Life Safety Code requirements in their present form are ori-
ented toward large institutions. This means that hospitals and large
nursing homes are more capable of complying with the kind of insti-
tutional standards set by the National Fire Protection Association
than are smaller residential and congregate care facilities. There is no
question that all homes and institutions, regardless of size, should be
made safe for residents. However, by adopting and enforcing stand-
ards which tend to eliminate smaller and more intimate care settings,
govern :-,nt may be working directly at cross purposes with its inten-
tionii to dein< itutionalize whenever possible or place the elderly in suit-
able group living arrangements.
There are problems for the states in trying to conform with the most
recent editions (1967,. 1973 and 1976 (pending)) for the code. The
SThe Long Term Care Facility Improvement Study (July 1975, p. 13) of the Office
of Nursing Home Affairs reports that only 6.1 percent of institutions surveyed met all
life safety code requirements.







subcommittee will explore this qi-.sttion particularly witil thi view
toward propo)siniLS legislation which will *r4it swilri r'iita a-
cilities for the aging and ability to comply with life -:taety v ,liiirc-
ments.
True "life safety" requirements involve more tLan fire 'proht i'lii or
structural changes in a building. It may be that excc-sive eniphasi- on
development of regulations centered on one area of life s:ifetyvN, scU s
fire safety, can lead to de-emphlasis on development or comll;n,,ir- with
regulatory alraln,,ement-, which may stimulate mci.---. ,tality of
direct care given to the elderly. Under conditions where 1'k-,trces
(both human and financial) are severely limited, the stat.-, bec01m1
1r,'-ed with ain unacceptablle either/or situation cit ,(r one :ust limit
dollars available for meeting life a,, fety provisions sI.!, as ts, which
will maximize the quality of individual treatment or a produce or
acceptable congenial environment, or limit enforv;.:ent or life 'ety
fire safety codes.
Certain provisions of the fire safety code are drafted so as to 1A
inappropriate or senseless in certain situations. For example, tile Phil-
a;delphia Geriatrics Center built a large, opeit flexible room for its
mentally impaired elderly residents. This room was designed on tlhe
basis of the latest findings concerning how to arrange a living environ-
inent to meet the special needs of the mentally impaired elderly. In
order to conform with the letter of the code, the desiLrners of that room
were required to have corridors at least 8 feet wide. Since there were no
corridors in this section of the building and since to build walls creat-
ing corridors would have destroyed the concept of that living environ-
ment, the inspectors and the administrators of the Philadelphia Geri-
atrics Center finally agreed upon a plan whereby an 8 foot strip of
different, colored linoleum floor tile was laid down to represent "the
corridor."
This anecdote illustrates the weakness in the life safety code with
regard to its applicability to the diverse institutions which provide
various levels and types of care. The current blanket application of
life safety codes on all types of facilities, including those that pro-
vide skilled nursing care, intermediate nursing care. and ambulatory
care. has the potential for further confusing the issues of placement
and treatment of the elderly with those of providing a safe and appro-
priate place where the elderly can be treated.
The subcommittee will invvAstigate current regulatorv pi'actic,-
which may over-emphasize compliance of a physical plant to stand-
ards or codes which are not fully appropriate to them. Its scoper of
inquiry will thus go beyond examination of life safety code, facility
accre(litation standards to examination of basic priorities for en-
forcement of existing regulations, and development or streamlining of
regulations and procedures that would reduce the bureaucratic bur-
dens on institutions and improve the quality of individual care.
The subcommittee will also explore ,ieu, ways to provide legislative'
authorization for imposing a u.'irranty of habitability on 1long-term
eAire fac'ldas as an alternate to exelusive relcncc o (1od(rs Lichi
empcha.s ze fi'e safety primarily. The subconmittee will caam ne regu-
lator!/ ch0liires-i nccded that w ill c'mbruee eu technqwcs, fow pro /,du
clear legi.slatiae intent on regulations, guidance to the judiciary, and






40


power to administrative agencies to achieve goals of legislative bodies
as they promulgate life safety cnd quality of care regulations.
In the time when there are limited dollars available both for con-
struction of more modern and adequate facilities for the institutional
care of the elderly and/or development of increased resources for
individualized treatment, difficult choices will have to be made. The
subcommittee will attempt to investigate means which would permit
us to put more dollars toward the maximization of the quality of indi-
vidual care without sacrificing in measurable degree specific safety re-
quirements which bear on physical structures. Clearly there is a need
to determine how dollars and resources can best be allocated to permit
people to live a safe and active life in institutions as well as outside of
them.
OTHER AREAS FOR FUTURE STUDY
During the coming year, the subcommittee intends to investigate
several additional areas of concern in the field of the health and long-
term care of the elderly:
1. Investigation of the reasons for, and possible solutions to, the
escalating cost of medical services to the elderly. Evidence concerning
unregulated construction of hospital and other health facilities will be
gathered and its impact on cost evaluated. Consideration of the use
of vacant hospital space for outpatient services for the elderly, includ-
ing preventive care, will be evaluated. Inappropriate patient place-
ment in various modes of care and the high cost of personal assistance
equipment such as hearing aids are other lines of investigation that will
also be included.
2. Issues related to the possibility of standardizing medicare and
medicaid physician house call fees. Testimony before the subcommittee
revealed increasing difficulty in encouraging doctors to make house
calls. Where public health programs have varying fees, doctors are
less likely to be enthusiastic about making a house call to persons
under the lower fee, and this fact has made the situation worse. In
New York City, for example, medicaid house calls reimburse $28,
while medicare reimburses $11 to $14.
3. Additional questions relating to nursing homes: control and man-
agement of personal finances of patients, the need for standard cate-
gorization of Federally funded long-term care facilities, the quality of
long-term care provided in the United States, the feasibility of Federal
assistance in the development of home health outreach programs by
non-profit and public nursing homes, and other means of improving
long-term care for the elderly.
4. Oversight of Regulations:
A joint report with the Senate Subcommittee on Long-Term Care
will be filed shortly on a unique joint Senate-House oversight hearing
on October 28, 1975, on recent HEW regulations. The regulations
would allow Federal reimbursement for the first time of unlicensed
proprietary home health care.
In the interim, it is clear that new decision-making processes in
long-term care regulations must be developed. The subcommittee in-
-tends to investigate HEWTV's decision-making process in developing
long-term care regulations, including the restrictive impact of HEW






41

regulations on providers of medical crM. ,Id red tape iJrurr'd by
individuals seeking care.
5. The impact of, and po-sible solutions to, cutbacks i state mrdic-
aid health .s'Cservces for the elderly. The Medical Services Ad( inis-
tration of HEW informed the subcommittee that over 20 States have
announced service cutbacks because of increasing State budget deficits.
At. the conclusion of these investigations, the subcommittee will
i ake additional and possibly revised, specific recommendations both
to Federal agencies and the Congress.















SUMLJIARY OF FINDINGS AND 'RECOIMMENDATIONS

In its investigation, the subcommittee found extreme proliferation
and fragmentation in both HEW and the Congre.:s concerning the <1e-
livery of health services to the elderly, to the detr-ment of the )at ient
who requires a continuum of c(aire. The subcommittee further found
institutional bias both in the Departmtent of IIhEW and under current
health benefits statutes, which is largely responsible for the current
inappropriate and unnecessarily costly placement of hundreds of
thouisa nds of the nation's nursing home patients.
The recommendations include both incremental and long-range pro-
posals. They focus on the very serious uvnmt need for home health
services for approximately two million chronically ill elderly: the
need to reduce inappropriate institutionalizition of elderly patients
with cost-effective alternatives; the need to develop better methods of
assessing long-term care patients; and the need for better methods
of referral to the proper level and type of care. While recognizing
that there is more to long-term care than nursing homes and home
health care, these components are major, and this first report of the
subcommittee focuses principally on them.
Recog,_nizing the lack of priority for home health care for the elderly
in the Federal health dollar-approxinmately 1 percent of medicare
and medicaid-the recommendations not only suggest extension of cur-
rent home health benefits under existing and additional programs, but
propose innovative alternatives to institutitonalization: outpatient clin-
icws specializing in geriatrics, multipurpose senior centers including
health and nuti'itional facilities: elderly day health care centers: com-
munity care organizations; mobile health units; and other approaches
utilizing a "consortium of partners." where Federal, State, local,
and voluntary agencies cooperate in maximizing patient care. The
subcommittee has recommended a system of community long-term
care centers to coordinate the provision of health services for older
Amiericans in order to provide linkage in the current fragmented de-
livery system.
The subcommittee believe. the present acute-medical orientation of
the Nation's health policy, largely based upon compromises in the
19.) medicare and medicaid statute, should be c'an e'l. A preventive
and medical-social model needs to be developed to avoid later costly
curative care and to allow the elderly to be productive in the
cor pmnitv.
The subcommilt,0 :.:"ks ,-r,,ter adm i.-r.ation and congr-'e-onal
rttelntion to health maintenance )pro'-:.i .is and reccfi i'dnds .:' ar'nil i
.halth f;.;r in communities, medical' and iidi :aid r.!: endmiCnt pro-
vIi:, anna:il physical checkups. for persons over 60, and other health
I: mintenan, ,and health educa'.ini p,,ro ':1;:.
1i he subcommittee has suggesteol m re. of i-ictin, ederly patients
to know wh:.4 t bncfits are available to them. The establlishnmeit, of a


(-I-)





44


home health clearinghouse is recommended to disseminate and collect
information on existing Federal, 'State, local, and voluntary home
health benefits and programs.
The subcommittee has also suggested major reorganization of HEW
health programs, including the creation of an Assistant Secretary for
Elderly Health, and the removal of the chairmanship of the Inter-
agency Home Health Task Force from the Office of Nursing Affairs
due to the structural conflict of interest.
The subcommittee considers of major importance the creation of a
new House Committee on Health, nec('-tated by the impact of the
split-jurisdictional problems in current national health insurance and
other health legislation between Ways and Means, Interstate and
Foreign Commerce. Education and Labor. and other committees.
While the subcommittee is aware of the political difficulties of such a
proposal adjusting jurisdictions, it felt that unity and rationality in
health planning are paramount and that a single united committee,
with initial membership drawn from the current committees with
health expertise, is a sensible solution to the current jurisdictional
dispute over national health insurance. As an interim solution, the
subcommittee has strongly urged the Committee on Ways and Means
and the Committee on Interstate and Foreign Commerce to hold joint
rather than separate hearings on that subject.
The subcommittee found a "dearth of audits" of nursing homes-20
States have not audited a single medicaid nursing home since 1967-
and found that hundreds of thousands of dollars had been inappro-
priately spent in those that had been audited. The subcommittee has
recommended Federally supervised, unannounced, on-site audits of
nursing homes receiving Federal funds under medicare and medicaid.
In addition, the subcommittee states its intention to investigate the
reasons that 93.9 percent, according to HEW, of the nation's nursing
homes do not comply with the Federal Life Safety requirements-is
the fault in the Code, the homes, or both? The subcommittee also
plans to investigate institutionalization of the mentally impaired
elderly and to study other important issues in long-term care of the
elderly.
Alternatives within the recommendations regarding home health
care and innovative alternatives to institutionalization are offered to
furnish each of the legislative committees and subcommittees with
jurisdiction over the particular matter the fullest possible range of
le'isiative options to accomplish the goals cited in the report.
The subcommittee hopes that the Congress, the Department of
IHealth, Education, and Welfare, and other appropriate agencies will
consider the recommendations in determining future directions in
health care for older Americans. The proposals are intended to open
hone(St and thoughtful debate on questions of public policy. It is hoped
that tlhe recommendations will lead to alte,':tion of the fermented
approach of the past, which has kept hundreds of thou:iiids of older
Americans inappropriately institutionalized and has denied to still
others adequate health care.












RECOMMENDATIONS


[Both incremental and long range policy changes are recom-
mended below. While the subcommittee believes that, the creation of
community long-terni care centers (Recommendation No. 1) is of vital
importance in providing a continuum of care for the elderly, it recog-
nizes that the Congress must thoroughly analyze the financing wid
administrative ramifications of this proposal before enactment of this
process, which will be time consuming. Therefore, interim recoil-
mendations are also offered that would be implemented immediately
as part of the existing health care framework.
[The subcommittee has made specific recommendations below to
end the proliferation and fragmentation of Federal health programs.
both by congressional and statutory consolidation. However, because
recommendations such as the proposed new, united Committee on
Health are not yet enacted, and because health statutes are accord-
ingly not consolidated, the subcommittee has also offered recommenda-
tions which recognize the current situation.
[As stated earlier, alternatives within the recommendations re-
garding home health care and innovative alternatives to institutional-
ization are offered in order to furnish each of the legi-lative
communittees and subcommittees with jurisdiction over the particular
matter the fullest possible range of legislative options to accomplish
the goals cited in the report. The subcommittee is hopeful that the
chances of enactment of these important goals will thereby 1,t
enhanced.]

I. PROLIFEP.RATION AND FRAGMENTATION: A NATIONAL PHEXNOMEXON
(1) Legislation such as ILH.R. 1354 (See Appendix I) the Medicare
Long-Term Care Act (also H.R. 2268, H.R. 10008. and S. 2157)
should be enacted to create a sy- .ev mf of Iommunty lo ,,,-t i, I".
,',rl, < to coorrdutae t1he prr, sion of health rces for older Amerl-
c'-,,.s suffering from chronic illness or disability. Services would in-
chide home health services, homemaker services, nutrition ervic..
long-term institutional care service,. day care and foster home s.rv-
ice-. -,iid a community mniental liealt,, (center for outpatient rervicr-.
4 1L
Th-., servi-e would ]ie made a;,. able through ]i(,,iimumlitv loi-
te' ,:-;'are center- which would coordiiate and dii-':it t .e loni-terin
care s.*rvices. Such 0 11ters would be p)ii ,ed and de(veloio ol ndeer the
..is of the Sta Il health and social welfare functions, allowjinu "ate
o;iiriility for Feder:il gr:i'its.
T'he 1ong-ti r,,. care c, r','/,. would proNiue local .,,,Z7" '.'.'.o/ fro-
Si the ot,'rt',.., fragm. hIfcli delic' Y/ system .l d, would provide
geater fle.xibilitv in a.:i:;ii:i pei.ns to L c -tt-.
(45)





46


The subcommittee bel'ev, that the elderly must have the right to
hgh. quality care in the setting of their choice, subject to utilization
review and appropriate standards and guidelines. Under this legis-
lation, the long-term care center team, working closely with the
patient, would be able to provide the patient this choice.
The center would evaluate and certify older Americans' needs for
services through a team composed of individuals with the skills neces-
,ary for such evaluation and certification. The care prescribed would
be based on the maintenance of an individual in an independent living
arrangement if reasonable, given the individual's state of health and
other circumstances. Hospitals, skilled nursing facilities, or home
health agencies would be considered to have a transfer agreement with
a community long-term center when such transfer is deemed medically
appropriate by the attending physician. Interchange of medical and
other information necessary or useful in the care and treatment of
individuals transferred between such hospitals and other facilities is
provided for in determining whether patients can be adequately
treated outside a hospital or skilled nursing facility.
The legislation would also provide that a community long-term
care center shall not certify the need for inpatient institutional serv-
ices for an individual unless a determination has been made that the
needs of such individual cannot be met through the provision of the
services covered under the bill's alternative benefits to institutionaliza-
tion or other community resources available to such individual.
Legislation should also authorize grants to colleges, universities,
public agencies, and nonprofit private entities to develop models for
more flexible patient assessment in public health policy, with special
emphasis on means to avoid placement in inappropriate levels and
modes of care.
(2) A newo House Committee on Health with exclusive jurisdiction
over medicare, medicaid, national health insurance, health aspects of
the Older Americans Act, and health care legislation in general.
In its hearings on health services for Older Americans, the subcom-
mittee found a majority of needed health legislation to have overlap-
ping jurisdiction in the Congress. Most major national health insur-
ance, home health, nursing home reform and other health proposals
were divided between the Ways and 3Means Committee and Interstate
and Foreign Commerce Committee because of the jurisdictional divi-
sion between medicare, medicaid, and other health programs. The
House Parliamentarian's office has termed such health bills referrals
"a nightmare."
The subcommittee agrees with the report of the Select Committee
on Committees of March 21, 1974, which states:
Consolidation of the jurisdiction now divided between these two Committees
(Ways and Means and TInter-rate and Foreign Commerce) would bring greater
rationality to the question of supply and demand in health care needs.
In addition, a Select Committee on Committees' staff report of
September 12., 1973, pointed out, "M"edicare and Medicaid have not
been closely coordinated with programs such as health personnel
. 1; i;imi .
Also, the Older AmericO': Act provides health services to many
elderly citizens who would be covered under various national health
]in1srhck lls.








Both the Ways and Jcean.s Committee and the Ij tcr-.oi'f and For-
e;gn Comme'rce Commiittce 'e ac iv'unty conduct!U, hearings on ni-
tion/l health insurancee. We find the provision of adequate health care
of paiamount importance to the Americ.ii people. As an interim
Illeasure W.cc hope and (1rerovincmd strongly that these two co tteS
join forces on this s.su). Thle current division and duplil p 0 ion i.:- .:-P e-
cially unfortunate for the elderly citizen in need of lhaltIi ca:re. While
we (en1courai"e the committees to unite in these.( current inve-ti-,;Lt ions,
we believe that the only way to guarantee future rational health plan-
nq is to create one committee irith cl-,usive jused /;-!tion.
Becau.?e of the expertise developed by membe.rs of the subcomni;/'i e
*;th c-ur.,e/t jurisdiction over health questions we recoi)mmend that
Initial m7nemb ship i;n the new comm ;Ittee be drawn from these subcoi-
mittee.s of the follo-.,tng committees. in the following proportion: .'
from the Committee on Inte.rstate and Foreign Commerce (Subcoim-
mittee on Health and the Environment), six from the Committee on
lVays and MJfean. (Subcommittee on Health), and three from the
Committee on Education and Labor (Subcommittee on Select
Education).
(3) Legislation to create a eompreher.sioe Home Health Clearbng-
hous.e within the Department of Health, Education, andm Welfare to
gather and d;sLseminate information concerning the various public
and private agencies jwrovediig home health care and correlative err-
ice. to the elderly.
Throughout the subcommittee's hearing, the message rang over and
over that with the extreme proliferation of programs, the elderly need,
a place where they can obtain information on the health programs
available to them.
The proposed clearinghouse would serve this function. The national
clearinghouse, will collect information on Federal. State, local., and
private services and would assist in information referral to orgtiniza-
tions, agencies, and patients by providing input to local community
locations.
The Home Health Clearinghouse will establish a computer network
feeding into the 1.200 branch and district social s,.uritv offices that
are alrI-Idy equipped with a two-way "turn around" computer system
for cash benefits evaluations; and as many as possible of the follow-
ing locations, convenient for senior citizens: the total of 4,500 social
security district offices, branch offices, and reuln-iarlv scheduled ;ervi.'.
lIn nations ; the 487 area agencies on ngin; the over ,,000 local welfare
office-.: the 4,000 s.:-!or centers (1,00 n ceive JFederal funds), and
ot her public or voluntary agencies. The Social Securit, Administra-
tin's established computer .v-y.-temn for various belx,.-fit program is
iVIII,,- :'Iv.. considered the "world's larget record keeping opert ion."'
While the'e will be human error in an undertaking of this extent the
..''. i .-** would be worth the predictable error Ia tio.
The immedimte infor'iatio, availability could be minval,':ible 'for tle
potential h- ilth service recipient who is now sh-ittled froti, oi',e to
o0(ce, never cetail he Il.%- obtained :;ii alIov. ; I)l relief.
Tlit jcom-puter net xork -would both p ote.t the beneficiary's privacy
and yield virt.Kullv instantaneous criteria to the cseworer. Thie infor-
nmation (but ,,'. out the .-, ,,h ,t-s wi-,,,e) would be -i'I into the
computer sy tenm so P3to proLtect Y{e; o i i. Zie rcp v J






48


shortly be pro ,';led a prbitout of the exact Federal, State, and local
outpatient and home. health benefits he or she qualifies for, a list of
whom to contact to obtain them and if possible a list of voluntary
agency benefits and contacts for his or her particular situation as well.
The clearinghouse would also be given the responsibility of prepar-
ing an easy-to-read manual, entitled "Federal Home Health Services
for Older Americans." The manual should describe the available Fed-
eral home health, clinical, and other outpatient benefits under medi-
care, medicaid, the Older Americans Act and other programs; the
eli goibility criteria; the overlap among programs; and offices one should
contact for additional information or to confirm eligibility for the
various programs.
The manual could be modeled after the excellent one published in
May 1975 on title XX. "Social Services '75-Program Options and
Public Participation Under Title XX of the Social Services Act: A
Citizen's Handbook."
The clearinghouse should be established immediately, so as to begin
determining the correlation between the various programs, to publish
the manual as soon as possible, and to establish initial computer out-
lets. The legislation should provide that HEW investigate the cost
of the computer network aspect to determine the feasibility of full
dissemination and report the findings to the Congress within 1 year.
In creating the clearinghouse, HEW should take into account the
current clearinghouse function of the Area Offices on Aging, as well
as the informational systems of the Social Security Administration,
and HEW may place the Home Health Clearinghouse in either of
these organizations or elsewhere in the Department. In addition,
HEW should be required to upgrade its present computer systems
(such as those of SSA), to insure they are first used to their full
capacity for the new Home Health Clearinghouse (but without im-
pairing their other functions) when establishing the new networks.

II. HOME HEALTH SERVICES: A RIGHT TO CHOOSE
A. LEGISLATIVE RECOMMENDATIONS
(4) Major reorganization within HEW to correct the structurally-
based institutional bias of the Office of Nursinq Home Affairs' coordi-
nation of the Interagency Home Health Task Force.
The subcommittee recommends that the Department create, directly
under the Secretary, an Assistant Secretary for Elderly Health, to be
the focal point for the coordination of Departmental policy for the
health of the elderly, and to have ultimate "line," authority and re-
sponsibility (except for the Secretary) over all health and health-
social matters for persons over 60 under medicare, medicaid, the
Public Health Service Act, and other relevant statutes, regulations,
and Departmental policy directives.
The new Assistant Secretary for Elderly Health will coordinate in-
teragency task forces on long-term care, both in the home health area
and in institutional care. The Office of Nursing Home Affairs' coordi-
nation of the current Interagency Task Force on Home Health should
immediately be terminated.
The Assistant Secretary for Elderly Health would also have re-
sponsibility for health financing and reimbursement for persons over
60. Other Departmental officials (excepting the Secretary) working on







other health areas would obtain the Assistant Secretary for Elderly
Health's approval for policy regarding health financing and reim-
bursement of the elderly.
The subcommittee recognizes that there are differences in current
programs that would be brought together under the proposed Assist-
ant Secretary-particularly between purely acute medical services and
health-social services under the Social Security Act. However the sub-
committee is convinced by the depth of the testimony before it that the
current fragmentation must be ended both among the purely medical
programs and between medical and health-social programs. Imple-
minentation of the recommendation would be a step toward developing
continuity in programs that can maintain the elderly as healthy and
productive citizens in the community.
(5) Additional appropriations for grants and loans for nonprofit
and public home health agencies and for the training of professional
and paraprofessional home health personnel.
The House-passed Supplemental Appropriations bill, H.R. 10647,
appropriated $3 million of the $10 million authorized under Public
Law 94-63, amendments to the Public Health Services Act.
The subcommittee recommends that the home health grants pro-
gram under Public Law 94-63 be appropriated to the full amount, and
be extended beyond its current 1-year period. The subcommittee rec-
ommends an increase in this program in fiscal year 1976, with a grant
and loan program administered by HEW providing $10 million in
grants and $10 million in loans for expansion of services by existing
agencies; and $20 million in grants and $20 million in loans for the
development of agencies in underserved counties and counties not
served at all by certified agencies. The subcommittee believes that the
projected $60 million total would be extremely cost effective in view of
the $118 billion spent on health care in the United States in 1975 in-
cluding $9 billion on nursing homes and over $41 billion on hospital
care.
The program should include grants to colleges and universities to
train or retrain guidance counselors, social workers, registered nurses,
and other geriatric specialists in the home health needs of the elderly,
and for the inclusion of gerontology in existing programs in counselor
education, nurse training, and social work programs. The scope of the
training should emphasize maintaining the elderly individual in the
home and community environment and should transcend purely medi-
cal areas by emphasizing the related sociological, psychological, and
supportive needs of the individual.
Furthermore, the Department of HEW should immediately develop
procedures for use of the home health funds appropriated under
Public Law 94-63.
(6) Legislation should be enacted to expand home health benrfif.
qpder Medicare and Medicald, prordidq eligibility to more people ;r
nerd of health services and allowing additional .qrr,?ces as necr.ar?! to
provide a tr-ue comprehensive alternative to often inappropriate and
co ftly full-time institutionalization.
The subcommittee recommends legislation to accomplish the
following:
Add a full rnnge of homema 'r and otlrr cor;,, 'e7a .'rrh';es to
medicare's current coverage of doctor and nurseo visits. Specifically








provided would be assistance in household tasks, shopping, walking,
transportation to and from doctors' offices and senior centers, personal
and vocational guidance, and such other services as deemed necessary
by the Secretary of HEW to maintain an individual outside an in-
stitution. Also, provide medical supplies (including prescription
drugs and biologicals), the use of medical appliances, and other sick-
room supplies which would have been provided if the individuals were
receiving institutional care.
Removal of the confusing and restrictive "skilled" nursing require-
ment for obtaining home health benefits. Use of this term, which the
doctor and intermediary (generally the insurance company) often dis-
agree on after the doctor prescribes and the patient receives services,
has largely been responsible for retroactive denial of reimbursement
to the patient. (See GAO Report, "Home Health Care Benefits Under
Medicare and Medicaid, July 9, 1974.") Furthermore, services which
are not "skilled" are often critical to keeping a patient outside a full-
time institution.
Require States to include the full-range of medical and supportive
home health services in order to qualify for Federal medicaid funds.
Permit State medicaid programs to cover payment of rent or mort-
gage, repairs, and property taxes for elderly or disabled persons who
would otherwise require nursing home care. While initial implemen-
tation of this program may be difficult in some cases, the fact that it is
optional, together with the incentive of matching funds, will encour-
age those States which are able to do so to develop a broader alterna-
tive to institutionalization. It should be noted that all living costs are
covered in hospitals and nursing homes.
Require disclosure for all medicare and medicaid nursing homes and
home health agencies, of any persons with ownership interest in the
home or agency, or in the land or building housing the home or
agency. Also, require disclosure by nursing home or home health
agency owners or operators of any interest in businesses provid-
ing goods or service to nursing homes or home health agencies.
Provide for any additional funding needed, if any, from the general
treasury rather than impose on the patients themselves any higher
premium, deductibles, coinsurance, and payroll tax.
The subcommittee notes that H.R. 10422 (See Appendix I) now
pending in the Congress, achieves most of the above goals, which the
subcommittee finds are needed to avoid inappropriate institutionaliza-
tion. However, while there are sections of HT.R. 10422 relating to the
number of allowable home health visits, delivery of home health bv
hospitals, and utilization of prudent buyer methods by home health
agencies and nursing homes, the subcommittee recommends the fol-
lowing new legislation to clarify and improve those sections and new
legislation to cover additional needed areas:
The 100 home health visit limits of both medicare part B (,7hich re-
quires no hospitalization) and part A (post-ho.p; tziation) should be
removed. The two parts should be combined, with no hospi;tali^ation
req/;re d for either.
Current law requires medicaid nursing homes to utilize co4t-related
prudent buyer methods of purchase, so as to reflect rePonable costs.
The subcommittee recommends expansion of this requirement, to pro-
vide uniformity among other long-term care providers, so that med-







icaid and medicare home health agencies and nursing homr.n should all
be rcqurcd to if'W;.-e co.t-'rfted methods of puro'hluxf'. In addition, the
Secretary ofo HEW should be giren, the power to cut off unreasonable
funds if he finds noncomplian ce. (See later recommendations covering
nursing home auditing.)
While HI.R. 10422 provides for patient referral to the appropriate
level of care, the bill only specifies home health services. Recognizing
that many high disability patients do require full-time institutional
'are and that in such cases home health may be more expensive, the
legislation states that Federal payment for home health services will
not exceed reimbursement that would have been made for skilled
nursing facility care; the individual can pay the difference himself or
enter an institution if home care exceeds skilled nursing care.
The subcommittee believes that it would be unfair to the patient to
cut off funds and possibly force entry into a nursing home if home care
costs exceedl projected nursing home costs. Such cost estimates in
adlvan.-e would be difil'ilt at best. A cutoff of funds later would create
worse "retroactive denial" situations than those even caused by the
current reliance on the criteria of "skilled" care, with problems not
only in reimbursement but in the transfer to nursing homes of patients
that had been led to believe they could remain in their own homes. The
legislation would be improved by providing for prospective reassess-
ment of the need for home health care vis-a-vis institutional care,
by the threc-meniiber panel already provided for in the legislation,
after any month in which reimbursement for the patient's care exceeds
the cost of skilled nursing facility care.
The subcommittee believes, however, that patients should be pro-
cded a continuum of ca(rc, without the threat of a cutoff of funds for
)particular services at a specific point.
While the Government should not pay for inappropriate care, a
stated or implied obligation to the patient should not be cancelled
later.
The subcommittee, therefore, finds that H.R. 1354 (and similar
legislation), which provides that community long-term care centers
wovld coordinate the provisions of a wide range of services, is more
effective in this important area of allowing a continuum of care. (See
Recommendation No. 1.)
Mandate reimbursement for home health services under medicaid by
pcrsons who are eligible for medicaid intermediate care nursing homes
in those States which permit medicaid reimbursement for intermediate
care. Testimony before the subcommittee demonstrated that the sad
irony of this omission is that "those are the people who are most likely
to benefit by it, because those are the ones who do not need 24-hour
nursing home services, and who are largely able to get along on their
own. 1
Medicare and medicaid should be amended to allow reimbursement
for periodic chore se vices for individuals who would otherwise re-
quire full-time institutional care.
The subcommittee believes that provision of home chore services
in instances where the patient would otherwise be in a hospital or
nursing home would be cost effective and far better for the patient.
SHerb Semmel, Center for Law and Social Policy, testimony before the subcommittee,
June 16, 1975.







Specific services would be determined in regulations of the Secretairy
and could include light household repairs, laundry, shopping, advance
meal preparation where the individual would only have to "put it on
(or off) the stove," help in personal grooming and similar assistance.
To make certain abuse would not occur, PSRO's or other appro-
priate utilization review mechanisms sliould be mandated.
Medicare andi medicaid should be amended to provide mecian ismns
for preventive health e,(,e to i.sui e maximnim health maintenance.
The subcommittee heard numerous expert witnesses point to the effec-
tiveness of early detection of disease in the prevention of later costly,
long-term illness and di,-;abilities.
The subcommittee recommends that at a minimum, the following
services must be provided:
A yearly a /,-l physical checkup for persons over 60 who are eligi-
ble for medicaid, and for all persons eligible for medicare (over 65),
so that developing disabilities might be detected early; diagnostic
services, under regulations of the Secretary, including laboratory
work and radiology; and health screening.
Medicare and medicaid should be amended to include, as a home
health service, nutritional counselbg provided by or under the super-
vision of a registered dietician. While hospital and nursing home
patients receive such care, the subcommittee believes that nutritional
counseling is equally needed for home health patients to assist in
long-term health maintenance. Such legislation for medicare has been
introduced in the Senate (S. 2547).
Amendments to medicare and medicaid to permit from 1 to 3 hours
per week of professional guidance and counseling for the elderly sick
and disabled who are living alone at home; (and an amendment to the
Older Americans Act to establish community-based programs pro-
viding from 1 to 3 hours per week of professional guidance and coun-
seling for the families of the elderly sick and. disabled, with emphasis
on the families of individuals who are entering, residing in or leaving
skilled or intermediate nursing homes.)
Amendments to medicare to mandate provision of hearing aids,
podiatry, dental care including dentures and the extraction of infected
teeth, glasses, and other sight aids. The subcommittee considers these
services, which are not provided presently except by option of some
States under medicaid, as necessary for functional living. The sub-
committee also recommends that hearing and sight examinations be
covered for medicare recipients.
In view of the skyrocketing cost of hospital care (the average cost
per bed per day is now over $128, according to the American Hospital
Association), and because of the advantages to the patient of a skilled
team approach, hospitals should be encouraged to develop outreach
programs in the community by allowing reimbursement to accredited
hospitals for health and supported services deliv'ecd to the home of
medicare and medicaid patients, particularly for post-hospital care.
Despite the obvious care advantages of continuity of care from hos-
pital to home, home health services are now reimbursed only when
services are performed by medicare and medicaid home health agen-
cies. Testimony from hospitals has emphasized the need to avoid the
red tape of home health certification for accredited hospitals which
can assist patients at home with qualified health providers.





53


The nwdi'careo profl';sion that home health care must be pro,'(;d, d
"under the sup-r;st''ont of a physician" should be allied, ,I to be "by
the appropriate health, professional, und, ryulations of the
Secretary."
Quality could be assured by legislation rcqoir."ng prof< ("-o/al stad-
ard(r., cii, (PSROs\) for long-t, r.m (''.,rc, also by the approlK-;I'fe
health professional under regulations of the Secrettary. PSRO's should
always include a physician, but should also include, as appropriate, a
nurse, a social worker, a guidance counselor, and/or other expert.
lde0 cu.,',eIt law, PSiO's ,iri," r(qui'ed for hospital .b.,,ces 1ut not
for long-termn care, and PSRO's are specifically limited to doctors.
with "advice" from other health profe:.-ionals. In addition, the leMis-
lation should direct HEW to promulgate regulations providing that
PSRO's review not only the cost, but the quality of care received by
patients.
In any national health insurance program., comprehensive home
health care as outlined in all the above recommendations should be
included. If medicare, medicaid, the Older Americans Act, or other
home health programs mentioned are replaced by a national health
plan, the specific legislative references will not apply, but the provi-
sions cited should be included.

(B) ADDITIONAL RECOMMENDED LEGISLATION
(7) An amendment to the Legal Services Corporation Act to pro-
vide legal counsel for the elderly sick and disabled who have reason-
able cause to appeal HEW decisions against the patient's receiving
benefits under established programs in medicare (middle and low in-
come persons only), medicaid, or title XX of the Social Services Act
for home health and other programs for avoiding institutional care.
While legal counsel for the elderly is now possible under the Older
Americans Act, it is not guaranteed for persons who may require it.
The American Bar Association's Committee on Legal Problems of the
Aging has testified, "Without such representation all such proceedings
are suspect and perhaps fundamentally defective."2 Under the pro-
posed legislation, all persons who believe they have been treated un-
fairly regarding eligibility for institutional alternative programs
listed above will have the right at least to a determination of "reason-
able cause," and if "reasonable cause" is agreed to, counsel will be
provided.
(8) Legislation amending title XX of the Social Security Act, the
new social services program under a 75 percent-25 percent Federal-
state matching arrangement, to provide further financial incentives to
n.aximize No. 4 of the program's five objectives: "to prevent and re-
duce inappropriate institutional care as much as possible by making
home and community services available."
Information provided by the Department of HEW indicates that,
of the 51 states and the District of Columbia, 40 are not utilizing the
full entitlement even though authorized by Congress.
The committee recommends that States which have used up their
allocation may submit plans for an additional 10 percent restricted to
2 Testimony before subcommittee, Ed Krill, Vice President, American Bar Association
Committee on Legal Problems of the Aging, June 16, 1975.







use toward goal No. 4, if they have the ability to provide matching
funds to implement those plans. The funds will come from unutilized
funds of the previous year in other States.
Such funds must be additional to the State plan, which already
must include at least one service under goal No. 4.
The subcommittee believes that such a financial incentive will pro-
vide further encouragement for States to develop plans to utilize their
full allocation as authorized by Congress, and that such a financial
seed incentive will encourage the development of badly needed appro-
priate alternatives to institutionalization, alternatives which can cost
the government less in the long run and which are far better for the
patient.
(9) A series of demonstration and pilot projects to determine the
effectiveness of various home health and supportive services:
A demonstration project under which current nursing home resi-
dents ('rd their families would be provided the funds to finance the
patient's care at home. The goal of the project would be to determine
the economic, medical, psychological, and sociological feasiblity of
transfer of nursing home patients back to their own homes where both
the patient and the family so desire but have been prevented for rea-
sons of finances and/or burdensome patient care. The experiment
should provide regular monitoring by a registered nurse or other
appropriate health professional. The experiment should also attempt
to determine what percentage of nursing home patients could effec-
tively lire at home, and what types and percentages of patients would
benefit economically and qualitatively from transfer back to the home
setting compared to care in the nursing home.
Programs to encourage older persons to make periodic visits to
other elderly persons who are chronically ill and living alone. The
subcommittee believes that such a program would have significant
psychological impact on the lonely, ill elderly. In addition, such a
program could provide employment for elderly retired persons. While
this program and the following one are already possible under some
Federal programs, such as ACTION, testimony before the subcom-
mittee demonstrated a need for expanding such programs.
A demonstration project to determine the feasibility of personal and
maintenance assistance of elderly individuals in their own homes by
"a neighborhood family," where the care would be provided by two
or more individuals related to each other and whom the elderly per-
sons would consider geographically and sociologically in his or her
neighborhood.
Experimental programs in five communities selected by the Secre-
tary of HEW to provide disabled persons over 65 taxable "long-term
care vouchers," to be spent on any of an approved list of health goods
and services. The goal of the experiment is to determine the impact
on the health and well-being of elderly patients in an unrestricted
market, under freedom of choice by the patient, and with a diminish-
ing of the oversight role of the government on the actual choices of
care by the patient.
Pilot programs under the Older Americans Act to provide home
services to the terminally ill of low income so that patients can die in
the dignity of their own homes, rather than in institutions, if at all
possible.








(C) Ri.;(O'[rvI'NI)\TIONS T(t iII'
(10) A major effort by HIEW to publir.e the ,7,aaUlity of home
health benefits through a radio, television, and(l pre public service
announcement campaign. Patients. (doctor-. and other liealth providers
should be informed of potential patient benefit.
In addition, regulations should I e promulgrated ri.quiring similar
outreach programs by states to medicaid participants.
(11) An HEW informational program on health maiate,,nrce for
older Americaos?. The pamphlet could be distributed to churhee., com-
munity programs, businesses., and, upon request, directly to f;inmilios.
Suggestions should be made concerning guidance in nutrition, exer-
cise, proper care of the body, a positive mental outlook, the need for
physical checkups, and other appropriate activities.
(12) HIEW should follow through on the July 9, 1974, GAO re-
port3 to tIe onre- stating that there I "con fus.on by i i Cd(-
,t;es ,and- ly )1',ye F~iar',. of 0 / e cot, ,'/le ,, ,i Ks';o'.'" GAO .;I led for
"more effective and uniform interpretation of existing. instructions to
intermediaries and home health agencies regarding the various cov-
erage requirements for home health services."
Such confusion and inaction was found to be largely responsible for
the low rate of use of available home health services.
(13) Clearer channels of information between top officials of ITEW
and Departmental Staff, and a realis ;e, opcn-,'inded attitude by
HEW toward home health legislation, especially those provisions
which would implement the recomamehdf;on.s of the 1971 White
fTou." Co f i'. onf vg iig (S"o1p. )

III. INNOVATIVE ALTERNATIVE iS TO INSTri'T TI ONALIZATION
(A) OUTPATIENTr CLINICS SPECIALIZING IN CARE OF THE ELDERLY
(14) The subcommittee recommends comprehensive legislation uti-
lizing a variety of Federal statutory and program options to abolishs h
and expand outpatient c-hdcs specializring i but not nece.qs.i'ily ex-
clusive y for geriatrics.
Legislation is needed to amend the Public Heaclth Servic'- Act (S,'*'-
tion 314 (d), Comprehensive Public IHealth Services, and P.L. 93-641,
the National Health Planning and Resources development Act. prlo-
viding 7l-B IHto.,, Iu ds}) to target a ),,,,''.,.;, ;) ,1- of /i#/o/ :,d-
(Itional over 3 y, 'rs (.'9O million is nov, provided, but for other p r-
poses with no empba.is on geriatric need.) for the 7'od zton. on-
struction, and conversion of miedic-al fact' fo ot ,,'It t U 1...
specializing in rr,: for the eld, .y. The subcomminittee hi:.iev. that
.150 million for sti'h construction and c;.nversioni while I.ot :dequate
to establish an entire natioiwl network of clinir- will nevertliele.-s begin
to meet the need and will encourage -tate and local ver" i -n to take
similar steps. Such clinics would provide a combination of primary
medical (preventive. intervcntioiary and referral); denti:tl; opt.;c
(vision); speech; otologic (bearing) ; podiatric (foot) ; rell;bilitation;
mental health; and health education service-. Preventive .rvi,'- ."12
as physical checkups and minor medical service- would be provided to
SGAO Report, "Home Health Care Ben,!fits Under Medicare aind Medhiald." July 9, 1974.
66,-.7,9--76---5


55






56


attempted to prevent the later necessity for many elderly persons to be
hospitalized or institutionalized.
Fifty pfr)cen t of the funds would be provided to clinics operated by
hospitals and 50 percent to freestanding clinics.
The goal of this program is "one-stop" health service for the elderly,
where they can obtain all their health care needs.
Such outpatient clinics which may also be termed "Home Health
Care Centers," should be located in places easily accessible and familiar
to the elderly-churches, union halls, settlement houses, community
rooms in elderly housing units, senior centers, etc. The goal is to es-
tablish the programs in locations that are "visible, accessible, comfort-
able, and comforting." 4
Legislation directing that the Secretary of HEW give priority in
project grants for Comm ,n Public Health Services Act (recently extended by Public Law 94-63),
to applicants who propose to establish outpatient c7in cs with special-
ization in elderly care in areas determined to be of medical under-
service.
States should be required to include freestanding clinic services under
medicaid. This is currently optional.
Legislation amending the Public Health Services Act Amendments,
Public Law 94-63, to target a minimum of 5 per(cInt of title I (Health
Revenue Sharing) funds received over the next 5 years for the estab-
lishment and operation of outpatient clinics specializing in the care
of the elderly in underserved areas, 50 percent of such funds for clinics
Associated with hospitals and 50 percent for freestanding clinics.
Legislation a mevd!ng Title XI of the National Housing Act, pro-
viding mortgage insurance for the purpose of constructing medical
group practice facilities, to require the Secretary to give special em-
phasis to mortgage insurance for outpatient clbnics specializing in
elderly care.
Legislation providing medicare reimbursement for services provided
by certified outpatient rehabilitation centers regardless of their con-
nection wivth a hospital. The subcommittee notes that S. 2506, pending
in the Senate, would accomplish this end. Curcirntly, hospitals can be
reimburs:.e', for all servicess included in part B of medicare, but out-
patient rehabilitation centers that arc not part of a hospital-even if
eetified as providing equal care standards-can be reimbursed only
for physical and speech therapy.
An amendment to medicare is needed to give the Secretariy of HEW
power to ,f;mnburse deductible and coinsurance fees to hospitals pro-
viding inpatient services for patients referred by (and, at the time,
under the care of) nonprofit, comprehensive outpatient centers who
do not require such fees. The Secretary may expend such funds if, in
his determination, the transfer arrangement between the outpatient
center and the hospital is saving Federal money that would have been
spent on more expensive long-term institutionalization.
The goal of this proginn,, is to allow nonprofit comprehensive out-
p)atient centers like the Minneapolis Age and Opportunity Center
(MAO) to have successful working arrangements with hospitals when
inpatient care becomes a necessity. MAO works with a "consortium of
4 Rose Dobrof, Lzis:lative Representative, National Association of Social Workers, sub-
committee hearing, November 19, 1975.





57


partners" (see. Home Health section of report), provides a Comp're-
liensive continuum of care onl a sliding -cale l'e -'. :.il1e, and free inll
some case.s. Tihe co't is a frZaction of that of r.-p:n1ite care facilit*e-. and
the combined services often prevent iilnec(--ary ir-stitutiow.l,/z.,tion in
hospitals and nursing home- or retard such il-( itutioiilli,.:;tioin.
Legislation conmmnciorating the Mimiiieapoli- m\i' iud Opl',,rtinity
Center as an excellent p, ftotype for other witp:.tient .-(10or 1 (1int ,rs.
and appropriating $500,000 to thle Center for a d,',nstration proje.-t
of collating relevant information on its method of or) ration and dis-
semninating thesl, materialsto State HIealth Co iS'.-ione.-. Stat,. 'Com-
inissioners on Aging, and other intere-ted p::-tih~ acro-- tlh c ,intry.
Medicare and medicaid should ie ,uiended to r: ,'iii,,,, thl e cost of
tran.Sporttt';on for the disabled. and for those over 60. to aid /I t',' ouwt-
patien t ch';c;s.
Legislation authorizing $10,000,0' for demonstration projects in-
creasing the out r',eh calabilitie. of e:,isting nonprofit outpatient
clinics specializing in care of the elderly by the derc o, me;tif of Vl:1tcd
mh!-clh'ebs located in nearby cities and countKi -.
Providers of free sp ce for non-profit outpatient clinics sp-,,,Ializing
in geriatrics should be granted a tax d(,"wtu ,i equal to .0 per". -t of
the fair market rent.

(1 ) III I( -; SK I"IO ( CENE *'i'i -
(15) The subcommittee recorii.ends th-t tl,., ,tablishment and
operation of wultjpjUrpo" '., ;.or cent-:,,, pro(idbng b,,..C .N* ,u.,'i' /. ist-
ance in health, in'r,/,frl guidance, creation, nd so.'al e(d,' ~'~ors
should be enc'oq';.rged by a varety of F,->d1'l st-at7fory and pro gr,',
options.
Authorization of a specific .'lm. a minimum of '100 million the f/st
yeai, in grants, mortgaare insurance, and loan guar:i-iz.. uder title
of the Older Amceri'cans A-et for the acquisition, alter::tion. rcio'.:ition,
initial staffing and operation of multi-purpose .-,. nior centers with a re-
quiiremnent that they include health z.nid nutrition i rvices as "ill as
recreational and social facilities. The legislation has previously b,'en
"such sums as nece scary As no funds have everI '- n appropr:'ted for
this program; the subcommittee believes that a specific authorization
would be an important first step.
The subcommittee recommend-, that 0 of the funds b
authorized for the c,.n action of such centers and ;0 /" r, ;i' f,-,r their
operations.
In addition, the subcommniittee recoi: inends the at ?ual apprqr';.,o,
of $100 million under Title V for multipury.o:'e senior rc.nters as le-
fined above.
As a financial incentive, title I. Section 105. of the Ho .;,y afnd Con-
munity D: clopment Act should .b anl'di,-d to ,,o'i:de a 10 p) ,'-crnt
bomn.y to add to those funds which comimutnimq plan to 7c,, for 7 ti-
purpo-., s,-nor rcntr. The bonus will apply only if the center iInclude
health and nutritional service., as well a recreational and so.--ial. A
HUD survey of 200 communities l:as shown t:at only 17 ,re planning
to use a portion of their funds for senior centers.
An amendment is needed to Section 231 of the Ntonal Jo nflf
Act, mortgage insurance for construction of elderly or handi.c:ippol







living units, to allow mortgage insurance for elderly day facilities as
well in order to provide financial incentives for multipurpose senior
centers (with health, nutrition, recreational, and social facilities).
An amendment to title XX of the Social Security Act, the social
services amendments, to provide additional incentives for the establish-
ment and operation of multipurpose senior centers, including health,
nutrition, social, an(i recreational :-.:vices, by pe,)-,nitting a 10-percent
bonus in matching funds for senior center programs if the State plan
includes the funding of senior centers. An HEW survey of the pro-
posed State plans indicates that 22 States planned to fund recreation
centers in 1975, and the subcommittee believes that additional incen-
tives would encourage the inclusion of health and nutrition facilities.
Providers of free space for nonprofit and public senior centers pro-
viding health, recreational, nutritional, and social facilities should be
granted a tax deduction equal to 50 percent of the fair market rent or
property tax on the actual space used.

(C) COMMUNITY CARE ORGANIZATIONS
(16) Legislation authorizing $15 million in demonstration grants
under the Public Health Services Act to increase the number of non-
profit Community Care Organizations as alternatives to institutionali-
zation, and to provide for the development of related satellite projects
in additional sites. Community Care Organizations shall be defined
as a health and health-related organization serving a minimum of 50
percent of clients over 65 and providing a package of home care serv-
ices including Meals on Wheels, homemaker, home maintenance, snow
shoveling if necessary, lawn mowing and other gardening; and medi-
cal and health-related services, including physical therapy, visiting
nurses, guidance and counseling, social workers as needed and
physicians.
(D) ELDERLY DAY HEALTH CARE CENTERS
(17) The subcomn.iittee recommends legislation assisting in the
further development of non-profit and public elderly day health care
centers, where health professionals perform identical or similar serv-
ices to those by participants in skilled nursing homes and intermediate
care facilities, under reIulations of the Secretary of HIEW5 gov-
erning quality and scope. Such programs should emphasize interim
treatment for persons who have been institutionalized, so as to en-
courage leaving the institution, full recovery, and a return home.
Medicare and medicaid should be amended to authorize reimburse-
ment for health and supportive services for the elderly received in
elderly day care centers as described above. The Secretary should issue
regulations of definition within 3 months of enactment of this
legislation.
The statutory requirement for "minimum but continuous care"
under the HUD Section 232 of NHA Mortgage Insurance Program
for Nursing Homes and Intermediate Care Facilities should be re-
pealed for ccrtificd day health care services. Currently, the SNF or
ICF is allowed to have a day care center, but it can only use 10 percent
allowed for "commercial space" for that purpose.
5 See F'deral Register, Jan. 9, 1976, p. 1603, for new regulations governing day care
contracts.





59


(E) HEALTH FAIRS
(18) Legislation authorizing grants to communities, under the
Health Revenue Sharing Act, for an annual "Health Fair" for persons
over 60 years old. Free medical checkups, including diagnostic screen-
ing, and appropriate referral, would be offered, and printed informa-
tion relating to health education would be disseminated.
(F) MOBILE AND EMERGENCY HEALTH UNITS FOR THE ELDERLY
(19) Legislation authorizing grants for geriatric mobile health
units, a doctor's office in a motor vehicle (generally a van), providing
regular medical services for persons over 60. Services would include
diagnosis, lab work, treatment, medication, follow-up, and referrals.
The units would travel to various parts of the county on a regular
basis and would provide advance notice of location.
(20) Legislation amending the Emergency Medical Services Act,
Public Law 93-154, to target funds for the research, establishment,
and expansion of facilities and personnel in emergency centers, both
mobile and stationary, specializing in the emergency health needs of
the elderly, and emphasizing coverage of areas in which large con-
centrations of persons over 60 reside. Twenty percent, or $14,000,000
of the $70,000,000 authorized for 1976 should be earmarked for this
purpose.
IV. NURSING HOME AUDITING AND STANDARDS
(21) The subcommittee recommends to the Committee on Ways
and Means and the Committee on Interstate and Foreign Commerce,
immediate legislative hearings on legislation including H.R. 8733, to
require annual, unannounced, on-site Federal audits of medicare and
medicaid nursing homes. The subcommittee further recommends that,
if faulty or questionable finances are found in any medicare or medi-
caid nursing home, HEW shall be authorized to audit the facility
as many times during the year as necessary until the situation is
corrected.
The subcommittee believes that such unannounced Federal audits
should be begun immediately on at least a spot random basis, and
recommends to HEW that the Department immediately develop a
cost analysis of possible annual audits of all federally subsidized
nursing homes for presentation to the Congress.
(22) An amendment to the Social Security Act providing that no
nursing home shall be permitted to require any patient to turn over
social security benefits if the patient pror,;des 30 days advance notice
that he intends to leave the nursing home. For those homes which re-
ceive Federal funds, this limitation shall be a requirement for the
receipt of such funds.
















APPENDIXES

APPENDIX I

MAJOR LEGISLATION IN HEALTH AND LONG-TERM CARE OF TIHE ELDERLY
INTRODUCED IN THE 94TH CONGRESS


94TH CONGREllS
1ST SESSION


H.I R. 1354


I4mi CONRE;INs
Isr I* .ssu'


H. R. 8733


A BILL
To amend title XVIII of the Social Se,'iritv
Act to provide long-term care services as a
part of the supplementary medical insur-
ance program,. to encourage the creation of
community long-term care centers to assist
in providing such services, and for other
purposes.

By Mr. Pr'i,'R

JANUARY 14,1975
Referred to the Committees on Ways and Means and
Interstate and and Foreign Commerce


94TIr CONi;IlI:SS
1ST SESSION


H. R. 10827


A BILL


A BILL
To amend title XIX of the Social Security Act
to) require the Secretary of Health. Educa-
tion. and Welfare to conduct an annual
auditt of each hli,,ital, niir-inL1 home,. and
other institutional facility partlicil,:itil in
thlie medicaid program and each State or
loIIl ;i .,lii di-tiilt fii'_ medicaid funds.
;and to amend title XVIII of such Act to
ri1ii ire annual audits of providers of serv-
ius1 under the medicare program.

By Mr. BEARD of Rhode Island, Mr. PEPPER,
M['. C(N'YRnS. Mr. FISHi, Mrs. CHISHOLM.
Mr. YO M. YOS, HARINXGTOX, Mr. HEINZ.
and Mr. MACDOXNALD of Massachusetts

JULY 18,1975
Referred jointly to the Committees on Ways and Meuans
and Interstate and Foreign Commerce


To amend the Community Mental Health Cen-
ters Act to require States which receive
assistance under that Act to estalblish and
maiidtain mniental haltw h advocacy services
for persons inxo!minariXymyu-
By Mr. FiLOI o tionalized

N\'vI:.'IBmH 19, 3'175
Referred to the Committee on Interstate and ForvLgn
Commerce


94-rit C(ING;R -SS
1ST SESSIOX


S. 2506


A BILL
To amend title XVIII of the Social Security
Act to provide for the furnishing of out-
patient rehabilitation services.

By Mr. RBICOFF, Mr. BAYH, Mr. CANNON, Mr.
HARTKE, Mr'. HUMPHREY, Mr. Io- M, Mr.
J.JACKSON,. Mr. JANvITS. Mr. McGovi nx, Mr.
MC-INTnYE, Mr. MANSFIELD, Mr. MONDALE,
Mr. PASTORF., Mr. PEm., Mr. PEncr, Mr.
RANDOLPH, Mr. STAFFORD, and Mr. WEICKER

OCTroBE 9 (legislative day, SEPTEMBER 11), 1975
Read twice and referred to the Committee on Finance
(61)


94,rn C( .',.S
.1ST >. s-,l-i\


H. R. 10422


A BILL
To amend part B of title XVIII of the Social Security
Act to broaden the coverage of home health serv-
ices under the supplementary medical insurance
program and remove the 100-visit limitation pres-
ently applicable thereto, and to eliminate the re-
quiirtment that an individual need skilled nursing
care in order to qualify for such services, to amend
part A of such title to liber.ilize the coverage of
post-hospital home health services thereunder, to
amend title XIX of such Act to require the inclu-
sion ,,f home health services in a State's medicaid
program and to permit piiym1-1 nts of housing costs
under such a lr,."ram for elderly persons who
would otherwise require [mrsing home care, to
require contributions by adult children toward
their parents' nui-Iiig and home health care ex-
penses under the medicaid program, to provide
expanded Federal funding for congregate housing
for the d]i'iplncril and the elderly, and for other
purposes.

By Mr. KocH and Mr. MOAKLEY

OCTOBER 29,1975
Referred jointly to the Committees on Ways and Means
and Interstate and Furvien Commerce








62


94TIH CONGRESS
1ST SESSION


H. R. 1939


C


H. R. 6494


A BILL
To amend the Social S(ecurlty Act to extend i-tiitttib ont to
health care benetits on the basis of atge under the Federal
medical Insur-ance program (medicare) to al! persons vho
are citizens or residents of the Unite(.d States aged c;, or
more ; to add additional categories of iwtnitils uoi.-r th"'
program (including health rnaitilntntice and preventive
services, dental services, outpatlt-ient druts, ey3gias.es,
hearing aids, and proth etic d-vlc-.) for all p#.r ons
entitled (whether on the busls tif age or )snblil|ti k) to
the benefits cf the program ; to -.tendl the (lduratioin of
benefits under the program where ;: .v limnitd ; to lilul-
nate the premiums now requlr.-d unhlr the supil; nointary
medical insurance t'nefits part of th medicitre pir-raln
and minerge that part with tht' hh.iiltal insiratuce part;
to eliinintte all deductible;: ; to ellnuinate <.j iayueu.ts for
low-income persons under the prograin, and l to provide,
for others, copayin-nts for certain (rvl( ,-. or litm but
only up to a varl:tble income-reluatd otti f-;.okft ex-
Iense lmllit catastrophicc expt-itse limit) ; to providel for
prospective review and approvi.l if the rat-s of clharges
of hospitals and other itstrlttiuti.i undcr the program.
and for prospective establishment (on a ncgotettit d iasti
when feasible) of fee schedule:; for phyi-%,, ltms tedl other
practitioners; to revise the coverag.- of thie tax previslons
for financing the medicare prograin and is rs-:isr the
Government contribution to the program ; ant for theirr
purposes.

By MIr.- M NIATSU .UA

JetAN tARY *ys3, 1975
Referred to the Couiwiittee on Ways and Mcitns


A BILL

To amenwliti tli "'ocil 'cuiilty Act, to improve
Ili( it'tvv c\ ([ c'rtl- itication lproctess, rate-
s(tii,,- ail l i-tcal audit lethlo(ds, and gelln-
eeal l '-gitatliof i of lnlusili. ]ltli'S and inter-
ii'ti ilt-i' cdirt lf;,it i tit ids ii r the niedicaid
l'wro nm, anld to provide fixr ',r.l,'.. i"y"
,'ll, ,.'i.-al. a;nl scial a- -'-liiioint Of l 'i'.-
tcll c talc', ii l t-.i l ii dintlr Ibotli tli lledicare
a11d lilcdliruid pri)z('r1':il ..

:/liy[ M r. Kncit I :IMI r. Ill.

APRIL 29, 1975
It-i4rrmid ito th ('o-ntiitt'es on Wa.iys and Means and
Iiitq' tr;'. il d l,'(!'iorei;;l ConinuicrCe


91r CT uNGRESS
1ST Sirm ioN


vTH CONGRESS T w 92
1ST SESSION 1.I


A BILL

To amend the I'ublit Health Service Act to >pro,tide fo)r
the making of grAnt., to assist in tle ,-,strablish-
ment and initial ot('ration of a',ecios ad expsand-
ing the services available in exi.-Iiiur aoencie:;
which will providt- home health lx'rvices, and to
provide grants to public and priv tve :iencies to
train professional and paraprofessioniial personnel
to provide home health servicess.

By Mr. FRASERa, Mr. STEr.I.MA', Mr. BA(.J)'s, Mr.
BADIU.O, Mr. (CARa, Mrs. (CoLLrNS of Illinois, MN-.
DOWNEY, Mr. EDWARDS of Ca'ifornia, Mr. EiiH-iL!,
Mr. GILMAN, Mr. HARtINGTON, Mr. IHAWKINS, Mr.
HICKS, Ms. HOLTZMAN, MIr. MAocIR1, MI. MiN-IINTA,
Mr. I>RESSLEn, Mr. lio.ito. Mr. IloynAi., Mr. STiAIIK,
Mr. STOKES, and Mr. VAN:;'I,:R V:N

MABciX 5, 1q75
Referred to the Committete on Initertate :tandm I'.)r-.ii
Comuierc*,


S. 2470


A BILL


a non(]d (lie Social Security Act by adding
itt'reto a new title XN.X1 ,hicbh will provide
if,,iraince a :thiin-t hite costs of catastrophic
I In ..' y i :.' .:: *** __ iii] ii'.I iji i u~a!iana
witl h;i F ((i]"ied-;7(ic, al as-isthwce plan for
lo\,-i ii ,,,)ItI(,. aiilnd by 'yllidrd'in a new
lit ic XV l'rtti wvhi1lh will .i,'Lni age and
ft'ihii ate lie avN:ilability, thrilulih private
iii)-!it':tic.o' ,-a irii'-. of l basic health insurance
at ,:ir-htai;'] lt'ol-iiium charges, and for
other puI rp)o-(es.

I')Y Mr. I Mr;. Mr. .lu(-cOFFr, Mr. CANNON, Mr.
lA\si2:x. Mr. M II.JIN S, Mr. INOUyE, .-Mr.
S\NSFILI). AMr. 5MONTOYA ,Mr'. PERCY, Mr.
!lt ('S i r. Mr. WlLI\ r L. ScoTr, MAr.
TI \i.r\;L,. Mr. WEIKl.m. and Mr. YOUNG

( i ()J:tir I 3 (legislative day, SEPTEMBER 11), 1975
l,:itl \ ijte ,lid referred to the Committee on Finance















APPENDIX II

The following (.hart gives ratios of home help per 100,000 populatit n iL v-ari(i,
count rieC as reported in May, 1973:'

RATIO OF HOME HELP PER IC0,000 POPULATION IN SELECTED COUNTRIES, AS REPORTED IN M.AY '973

Total Ratio per
population Number of 100,600
Name of country (in millions) home help I population

Sweden----------------------------------------------------- 7,968 65,700 825
Norway.----------.------------------------------------------ 3,851 22,231 577
Netherlands...-----------.---------------------------------- 12,878 52,130 405
Great Bitain........-------------------------.....---..-- -----------. 48,988 67,439 1
Finland -- -------------------------------------------------- 4, 638 4,556 97
Belgium-....------- ------------------.-------------------- 9,531 4,018 42
Switzerland-.-------- -------------------------------- ---------, 150 2, 060 33
Canada-----------.---------------------------------------- 21,377 5,000 23
West Germany--..-..-.-------------------------.------------- 58,653 11,203 19
United States-----------. -------------------------------- 203, 166 30,000 15
France-...------------------------------------------------- 49,756 7,144 14
Israel.....--- ---------------------- ------------------------ 2,879 273 9
Austria....------------------------------------------------- 7,373 355 5
Australia-------.-. --------------------- -------------------- 12,296 30 0.2
Italy ------------------------------------------------------ 53,708 50 0.1
Japan 2 .......................................................... --------------------------107,372 9,220 9

i International Federation on Aging (sic). "Home help" includes homemaker and supportive services provided by Fed-
eral, local, and private agencies.
The International Federation on Aging is an international organization comprised of organizations representing the el-
derly. The U.S. representatives to the Federation are the American Association of Retired Persons and the National Retired
Teachers Association.
2 Japanese figures supplied by Mr. Miiio Mori.
Source: International Council on Homehelp Services.

(63)


C .'- ,.5' --7 6---6














APPENDIX III


WITNFSSF.S BEFORE THE HOUSE SUBCOMMITTEE ON HEALTH AND LONG-TERM CARE,
MAY 5,1975 THROUGH NOVEMBER 19,1975

Inform al Hea rng-May 5,1975-Washington, D.C.
Beaumont, Constance-Public Policy Director of AAHA
Br i cI iield, Cyril-Legal Counsel, American Association of Retired Persons
Boyle, Mr.-Legislative Director, IBW, Representing Harold Tate
Clarke, Elsie B.-Senior Program Planner, Division of Services for the Aged
for the District of Columbia
Cruikshank, Nelson-National Council of Senior Citizens
Dicl-:,rson, Dr. Jack-Vice President, Kirschner Associates, Inc.
Griesel, Elma-Project Coordinator, Gray Panthers
Hess, Arthur-Deputy Commissioner of Social Security, Department of HEW
O'Brien, James-Department of Older and Retired Worker.- of the U.S. Steel
Workers
Oriol, William-Staff Director, Se&n-te Special Committee on Aging
Park, Judy-Legislhtive Assist:- nt, NARFE
0i il;, D, oi el-Director of Public Policy of the NOCOA
Raviv, Sheila-National Council on Aging
Smedley, Larry-Associate Director, The Dept. of Social Security for the AFL/
CIO
Sullivan, James-Special Assistant to the Executive Director, AARP
Tarr, Clarence-Vice President, NARFE
Weiner, Robert-Legislative Assistant to Hon. Edward Koch, M.C.
Informal Hearing-Discussion of Problems of the Aged--Mfay 19, 1975-Wash-
ington, D.C.
Barker, Cozette-American Occupa tin a I Therapy Ass',ciation
Batten, George-Director, West Essex Nursing Services, Inc., West Caldwell,
NJ
Cornish, Larry-Deputy Director of Legal and Legislative Affairs, American
Speech and Hearing Association
Dreisner, Richard-Attorney, American Academy of Physical Medicine & Re-
habilitation; National Easter Seal Society
Fosdick, James-Kappa Systems, Inc.
Galkin, Dr. Jean D.-Director, Instructive Visiting Nurse Association
Goodf.1, Vincent-Director, Division of Services and Programs for the Aging,
Prince Georg, -. County, Maryland
Leimer, Sandra-Americ.n n Oc.ul:pational Therapy Association
Solon, Dr. Jerry-Program Planning Officer, National Institute on Aging, NIH
Thompson, Ms. Frances-Nursing Home Coordinator for Prince Georges County
Health Department
Verville, Richard-Attorney, American Academy of Physical Medicine & Re-
hi;iiilitation; National Easter Seal Society
Viklund, Birger-Labor Attache, Royal Swedish Embassy, Washington, D.C.
Warner, Braxton-Field Services Coordinator, Nat. Assoc. of Social Workers:
NCOA
Hcair'ig-"Home Health Care Services-Alternatives to Institutionali'ation"-
June 16, 1975-Washington, D.C.
Dunlop, Dr. Burton; and Dr. William Pollak-Research analysts, Urban Insti-
tute, Washington, DC
Horstman, Peter-National Senior Citizens Law Center, Los An-,les, CA
Koch, Hon. Edward I.-Rep. in Congress from the State of New York
Krill, Edward J.-V.P., American Bar Association Committee on the Legal
Problems of the Aging
(64)






65


Marlin. David-National Council of Senior Citizens League of Rsenrch tnid
rVi,-, to the Elderly, \Vashbintun, DC
Morris, Dr. Rbliert-Lecturer, author. anid dire'rtr, Levir,.,n Gerontolo,'.ical
Policy I:s.,tittte. Brandek Univers-ity, Waltham, MA
Regan, John J.-Prcfessor, Univtersity ,if Ma-yl.mild Shiool otf Law, Bailti:.,ure,
MD
Squemmei. IIrbert-Center f<,r Law mad S.,'cial Policy, Wa!binl.,tor.. DC
Trautman, Donald D.-Chairmian. Leiative C'-,ummittee, National Asor.-iatinrj
of Hmie Health Agen'1. ie.-
'r,'.a rc1 ., tatemcn ts submitted by:
M3'-.ie. nIn. Edmund S.-U.S. Senator from the State of Maine
S.,r..iIr, Hon. Mir, tin J.-Lieutenant Governor of Wisconsin
Hcaring--"Innio retire Alt erra ticrs to Ins.titutio n0.w!izafion--July 8, 1975-Wyszh-
ingt.,,. D.C.
Ailin i',ich, (.eorge D.--Adijinistrator, Abbott Ho-?pital Division, Minnai.,iii, ,
MN:
Kraihi,-'j. Ri-h;.: rd J.-A-.-,,i..te A'.LuiiA;i'l- ra r .it Abl- u.t-Northwestern H.-, tal.
Lineh.i pllS, MN
Kra'.se. Da.lte II.-Exe.utive Dire,. tor, Minrieallis A, & Opp.,rtunity Cenrer,

T_: i.J'ert, Judith L.-A -itant to rtbe Executive Director, MAO
Mrte~L;c'n. Alie---PdI-K (Chj.lLLtt, SeiIlr I '.ti.>-'s C-,mmJttec, Ju1i ur I. *.,.uE
of Mi:nneapolis
Varl~ne-s. Jajes G.-Director of Field Services, MAO
",' ,k',wicz. Jose.ph H.-Attorney at law, Director of Legal Services, MAO
YZt- it-.'!vn, R. 'N.-Abbott-Northwestern Hospital, appearing on behalf of Dr.
Farber
Preliar.-d statement -ubmitted by: Farber, Dr. Roger Evan, Community M.dic.il
A-"'.'IZLte-. board member (neurologist)
Hcaring-"A 'litinj of _Vur.s;,,'i Hf:i- (S and'l Aiterntiu.c to Iv)'titutinfl(1i :o !',n'-
July 12, 1975-Providence, R.I.
Bo'day, Michael-C,( lair'ian. Rhode I'lnd Gray Panthers, ani CLAir.Ljan.
Senior Citiz,-n:l Buti.iun
Brown, Josep.h N.-Meal-On-Wheels. Inc.
CoL.n, Earle F., M.D.-Practicir!g phy,- Cu.rley, Ehii:h--F,-rmer Pr.sident. RR l,.e Islandl Council of Seio r Citlzvn-:
DiDomeni'-o, Robert J.-Exec-uti-.-e Dirt, tor, A0so:ia:tiii nf YIn- heal' A'.n-
cies of Rjhode Island. Inc.
Franklin, Peter-Special Assistant to the Secretary of Iit-alth.. Eiu..tion ,_I
Welfare
Accompanied y, :
Abde-llah. Faye G., Dr., Assisltant .I-.r'gon Geneiral ani Director f hEW
Offir.e if Nur-,ipr H, : c. Affairs
Benz. Albert T. J.,.1 A-it:it Dire tr of Stat an.l ] Ial a'ii vi, iEWV

Fall:,n. Neal. Ri-ir,nal C',.n. -ioier, SSA
Gavin, ViTf:-,it. tir;. F .'--icnal C 'i:nmir iv ine, SSA. R .:,n I, B,',, ,n
M.-Facwue, Warr-n. A-tihjg Regicionr.l Di',t'-tr, Ir.-:i,,ii I, BostII
Parisian, Edward A Rerional AniIr Li.. egion I, ...n
Sullivan. Thoni'a-, Dirpctor, Offi.e -if Long-Tr:-'i Care Stanlards En-
forcemnient. R'_zion I, Boston
Kalina. Charles R. -A-. i-tant Director, on 1eL:;lf of T<-l:h Plannino Council.
Inc., Rhnfce Island
MnIlvey, Dr. M.ry C.-C. ,',-iihirnan. Gvern )rs Ta-k Force to M 'ni,.r Bi:itlJrhly
Inspectio,. s f Nur.inn. H',,- mS: Dir,-_t,,r, Rhode Islanlid C'.uidil ,f S. ri,,r
Citizen,; anrid Board Membpr of the National Council of Senior Citizenri
Niel. Honora.ld Philip W.-Grvernonr ,-,f th State o-f R'1,.. Il-ri
Accompanied by:
At'I--k. Jrhlin J., D'rector, D-.partmrnent of Social an,! Reh ilit ativ,-
Serviept. Rhode Island
Cannon. Dr. Jo,-eplh E.. Dire.tcor. Department of H .altli. Rhid,. T!Il tnu
Slater, Eleanor F., Chief, Division uf Azing. Rh'dle Island
Pe.rre.'zux. Enimond A., Jr.-Exe(cutive DIire.tor, Hn-mnmaker-II',mie Health Aide
Services of Rhode I





66

Woulfe, Beverlie-Director, Scandinavian Home, and President for the Rhode
Island A-sociation of Facilities for the Aged
Appendix: Statements submitted by: Dupre, Kenneth, of the Catholic Inner City
Center of Providence, R.I.; Kent County Memorial Hospital
Miami, Fla., Hearings-"Home Health Services for the Eldcrly"-August 5, 1975
Bostrom, Flora-Miami, Florida
Dalrymple, Dack-On behalf of the Honorable Paul Rogers, a Representative in
Congress from the State of Florida
Dye, Lester-Citizen
Evans, Catherine-Case Supervisor
Friedman, Paul-On behalf of the Honorable Dante B. Fascell, a Representative
in Congress from the State of Florida
Friedson, Max-Director, National Council of Senior Citizens
Goldberg, Harry-Miami, Florida
Gordon, Irma-North Miami Beach, Florida
Gordon, Honorable Jack D.-A State Senator from the State of Florida
Gowan, Jamies-Mi mni, Florida
Hadi, Lucy-Director, Grants Management, State of Florida
Handelsman, Gene-Director, Aging, Health, Education, and Welfare, Washing-
ton, D.C.
Hayes, Thomas-On behalf of the Honorable Lawton Chiles, a United States
Se.i;tor from the State of Florida
Jacks, ,largaret-Director, Human Resources, Division on Aging, State of
Florida
Lehnhard, Mary-On behalf of the Honorable Dan Rostenkowski, a Representa-
tive in Congress from the State of Illinois
Rubel, Sarah-Miami, Fla.
Sharp, Bob-Chairman, Commission on Aging, City of North Miami Beach,
Regional Director of the National Council of Senior Citizens
Serchuk, Max-Regional Representative, National Council of Senior Citizens
Schwinghammer, Roger E.-Assistant Executive Director, Catholic Service
Bureau, Inc.
Suarez, Luis L.-Director, Region II, Division of Family Service, Miami, Fla.
Weinstein, Leonard-Member of the City Council, Miami Beach, Florida
Mia)Ji, Fla. Hcarings--"Home Health Sercvices for the Elderly"-August 6, 1975
Adair, Vera-Associate Director, Visiting Nurse Association
Colton, Hazel-Chairperson, Advisory Board, Neighborhood Family Services
Demann, Betty-Vice Chairperson, Advisory Board, Neighborhood Family
Services
Goldstein, Richard K.-Assistant Director, Department of Planning and
Budgeting, Greater Miami Jewish Federation
LaMendol i, Clark-Agency Operations Director, United Way
Mendel, Ed-Trade Union Counselor, New York City Central Labor Council,
Member of New York City Taxidrivers Union, Local 3056
McGovern, Patricia-Associate Health Planner, Health Planning Council
Petry, Joanette-Supervisor, Visiting Nurse Association
Resnick, Thomas-Grants Management, United Way
Rutherford, James T.-President, Florida Association of Home Health Agencies
Schabacker, Paul-Associate Director, Health Planning Council
Schensul, Stephen L., Ph. D.-Director, Community Mental Health Program,
Jackson Memiorial Hospital
Smith, Kathleen-Director, Nursing Service, Florida Home Health Services
Trice, Jessie-Director, Visiting Nurse Association
Udell, Leda M.-Vice President of Health Services, Florida Home Health
Services
Villaverde, Rafael-Executive Director, Little Havana Activity Center
Walker, Hattie-Geriatric Staff Member, Community Mental Health Program
Mliami, Fla. Hearings-"Home Health Services for the Eldcrly"-August 7, 1975
Abdellah, Faye, Dr.-Assistant Surgeon General, Director, Office of Nursing
Home Affairs, Public Health Services
Collines, Richard B.-Director, Family Health Center, Inc.
Dixon, Howard-Director, Legal Services of Greater Miami, Inc.
Dorsey, Joseph E., Dr.-






67

Franklin, Peter, The Honorable-Sp1cial Assistant to the Secretary, IIealth,
Education, and Welfare
Godwin, Pauline, Dr.-Department of Health, Education, and Welfare
Goldbert, Bernard, B.-Director, Projcct Renew, Manpower Administration
Agency, Metropolitan Dade County
Kroner, Donald K.-Admninistrator, Home Health Services
McManus, Sister Margaret-O.S.F., ,Administrator, St. Francis IIospital, InJc.
Merlo, Thomas J.-CPA, financial consultant to Home Health Agencics
Petry, Joanette-Visiting Nurse Association
Quint, Bruce, Ph. D.-Director, Senior Centers of Dade County, Inc.
Richman, Gerry-President-elect of Dade County Bar A.sso)ciatioU
Schieider, Janet-Director of Nursing, Home Health Services
Steinberg, Edward-Vice President, Aircraft and White Taxi Conipanilos
Stirling. Mildred-Director, Social Work, Mercy Hospital
Thomas, Richard D.-Administrator, Coral Gables Hospital, Coral Gal)les. Fla.
Underwood, Walter-IIMO Project Director, Community Health of South Dade,
Inc.
Zack, Steve-President of Young Lawyers
Miami, Fla. Hearings-"IHome Health Services for the Elderly"-August 8, 1975
Barbieri, Betty Lou-Special Programs Coordinator, Community Action Agency
Brown, William-Senior Administrative Assistant, Dade County Office of Mau-
agement and Budget
Cainan, Mary-900 N.W. 145th Street, Miami, Fla. 33168
Compasori, Martha-Volunteer Services, City of Hialeah, Fla.
Dyer, Dr. John-Director, Dade County Office of Transportation Coordination
Ellis, Michele-Director of Paramedical Services, Florida Home Health Agencies
Fabacker, Father Ignasius-Gesu Church
Gibson, James-Director of Residential Homemaker Program
Gowan, James-8300 North Miami Avenue, Miami, Fla.
Hill, Hon. John-Representative in the Florida House of Representatives
Little, DuWayne-Federal Aid Coordinator, Dade County
Lotz, Aileen-Director, Department of Human Resources
Morrison, Isabelle-Robert King High Towers
O'Connell, Conleth S.-Director of Patient Services, North Shore Hospital
Perdue, Dr. Jean Jones-Director, Adult Placement Program, Division of Health
Services of Office of Human Resources
Simmons, Lillian-4511 Northwest 170th Street, Opalocka, Fla.
Smith, John B.-Legal Counsel, Medical Personnel Pool
Willis, Frances-Director of Service Programs for the Elderly, Department of
Human Resources
Willis, William-Director, IMPACT Program, Dade County, Fla.
Joint Senate-House Hearing-"Proprictary Home Healthi Carc"-Octobcr 28,
1975-Washington, D.C.
Brown, Richard P.-Executive V.P., Unihealth Services Corp., New Orle: :-:, LA
By mrne, John-President, National Association of Home Health Agencies
Dandstedt, Rudolph-Assistant to the President, National Council of Senior
Citizens
Etzione, Amati-Center for Policy Research, New York, N.Y.
Hall, Hadley D.-Executive Director, San Francisco Home Health Services
Hawes, Gerald-Audit Manager, Office of the Auditor General, Sacramento, Calif.
Koch, Hon. Edward I.-Member of U.S. Congress
Martin, John-American Association of Retired Persons, Washington, DC
Moore, Florence-Executive Director, National Council for IHomnemaker-Health
Aide Services
Pfau, Mary Ann-Coordinator of Ambulator and Home Care Nursing Services of
the American Nurses Association, Kansas City, MO
Rawlinson, Helen-Director of Home Care, Blue Cross Assn. of Greater Phila-
delphia
Reese, Eva-Director, Visiting Nursing Service of New York
Semmel, Herb-Center for Law and Social Policy, Washington, DC
Smith, John-Legislative Counsel, Medical Personnel, Personnel Pool of America,
Inc.
Starr, Janet-Executive Director, Coalition of Health Services, Syracuse, NY






68

Svahn, John-Acting Director, Social and Rehabilitation Services, Dept. of HEW
Tigar, Nancy-Asst. Director, Council for Home Health Services-Nat. League of
Nursing
Trautman, Donald D.-Chairman, Legislative Committee, National Association of
Home Health Agencies, Portland, OR
Warner, Dr. George-Special Assistant to the Commission of the New York State
Health Department, Albany, N.Y.
Weikel, Keith-Director, Medical Services Administration, Dept. of HEW
Wilsman, Edward J.-Presiieni, Upjohn Homemakers Home & Health Care
Services, Inc., Kalamazoo, MI
Hearing-""Compreh ci.sh'c Home Health Care: Recommendations for Action"-
November 19, 1975-Washington, D.C.
Blumenthal, MIelvin-Si-Speci;1l Program Advisor, Dept. of HEW
Cohen, Robert-Senior Staff Associate, National Association of Social Workers
Daii dsledt, Rudolph-Assistant to the President, National Council of Senior
Citizens
Dobrof, Rose-Associate Professor, School of Social Work, Hunter College, City
Univ. of New York
Dubrow, Evelyn-Legislative Director, International Ladies Garment Workers
Union
Erpenback, Dr. William J.-State Department of Public Intruction, Madison,
Wise.
TFlemming, Dr. Arthur S.-U.S. Commissioner on Aging, Dept. of HEW
Franklin, Peter--Special Assi-tant to the Secretary, Dept. of HEW
Lane, Lawrence F.-Legislative Representative, American Association of Retired
Persons
McDonough, Patrick J.-Assistant Executive Director, American Personnel and
Guidance Association
Sopper, Dale-Acting Deputy Assistant, Legislation and Health, Dept. of HEW
Trautman, Donald-Chairman, Legislative Committee, National Association of
Home Health Agencies
Willging, Dr. Paul R.-Deputy Commissioner, Medical Services Administration,
Department of Health, Education, and Welfare












ADDITIONAL VIEWS


ADDITIONAL VIEWS OF WM. J. IANDAzLL.( CA1 U'MAN
First let me make it ci-lar that tlie reason th<,-e viev.-- are submitted
is because of the importance and far-reachli1: d effect of hle contelit of
the report enti! V..L "New Persi ; in >ealtli Care for Older
Am I'lri .ci ns."
I have asked that these ('omments to ,;company the report be
described l-. additional views. It v.-ould be ui.- -adimG< to -Iay thl:ey are
dissenting views. It would be, unv-:e to d.s.cribe thi., cOihil'.,ts a
minority views. )Moreover, to call the following separate vie'".- would
not be true because I am not. separating myself from all of the relpyrt.
Rat1:er, I cmi':. te much, indeed mo,-t, of its contents. It would Li,. in-
accurate to call this effort supplemental view.- because I have not had
the tiime to do the rw:.-rch to supplement some of the conclusion- and
recorimiendations.
I have had ,., opportinitv to read and zstidv lte subcommittee re-
port, and after doing ro I offer the following additional views.
In between and found amidst a total of 22 separate recommenda-
tions there are two principal or paramount goals or objectives which
-tand out as the dominant thrusts of the report as follows:
1. A reduction in proliferation and fragmentation of programs for
the aging as culminated in the proposal to create a new Committee on
Health in the House; and
2. The recommendation for alternative care or "a right to choos,"
to avoid institutionalization of our a ,in.- Americans.
Considered from its four corners, the report represents the diligent
and dedicated effort of the gentleman from Florida, Mr. Pepper, and
the members of his subcommittee to respond to the challenge of one of
the most important problems of all of our older Americans--(hea,:lth
and long-term care. Only income protection would have priority over
long-term health care and that only because, in the last analysis, it
is income maintenance that makes possible any creature comforts.
including health.
In commenting upon the second of the two dominant targets of
the report, that which the subcommittee describes as "inappropriate
institutionalization," let me say as enthusiastically as I cani expres-
it that my hat is off in salute to the subcommittee for its proposal to
extend and expand home health benefits under existing programs.
The subcommittee is to be congratulated upon its proposal for in-
novative alternatives to institutionalization. About the only complaint
that I would have is that this is not really a separate subject at all but.
could well have been included in Chapter II. But that is a matter of
editorial choice.
Such proposed innovations as outpatient clinics specializing in ger-
iatrics. multi-purpose senior centers wvitl both health and nutritional
(69)






70


facilities, elderly day care centers, and mobile health units are all
quite meritorious.
The subcommittee is, moreover, to be commended for its idealistic
(although thought by some to be an unattainable) goal which is ex-
pressed in the proposal to establish community long-term care centers,
to avoid institutionalization. This proposal may very well become, in
the future, the needed linkage to bring together the current frag-
mented health delivery system for older Americans.
The proposal to create a new committee on health in the House is
one of the most important proposals in the report. In general I con-
cur with the proposal, conditioned upon a few reservations and quali-
fications which I shall now recite.
It is noteworthy that the old and now dissolved Select Committee on
Committees, in a Staff Report issued in 1973 mentioned the need for
a separate committee on health in the House. But to me it was signifi-
cant that the proposal was never contained in the final draft which
made recommendations to the House. I suspect the likely reason for
the omission is that the Select Committee on Committees recognized
the difficulty to obtain favorable approval of such a proposal in the
House.
It would be an over-statement to say that this propo-al will be
greeted with enthusiasm among the committees which now hold this
fragmented jurisdiction.
It would be an under-statement to say that we can look forward to
any generous applause from the respective committees. Certainly
there will be no clapping of hands by the members of the Ways and
Means Committee, the Interstate and Foreign Commerce Committee,
or the Committee on Education and Labor. But the absence of en-
thusiasm or acceptance by those whose jurisdiction would be affected
does not mean that the proposal is not sound. Perhaps some day such
a committee will come into existence.
About the only complaint that I could register is that the recom-
mnendation was not based upon more extensive hearings. For example,
I think the members of the standing committees affected should have
been given the opportunity to recite their reasons for the formation
of such a new committee in open hearing, or to voice their object ions,
if any, to the formation of the new committee. I also have concluded
there should have been a larger number of outside witnesses heard and
cross-examined on the proposal rather than the few who were heard
prior to making the recommendation.
A point to be made as a compliment rather than a criticism is the
fact that this report is an almost totally or completely revised ver-
sion of a report which was submitted to the full committee on De-
cember 11, 1975. I think the revised report could be characterized as
a condensation of the original draft of the subcommittee in the sense
that the old report contained 62 recommendations while the pre.:ent
report, covering the same subject matter, contains 22 separate recom-
mendations.
Now, if I am to be straightforward, I must cite a few specific com-
plaints which I am left with no choice but to voice and no alternative
to avoid unless I let the record stand as being in total and complete
agreement with each and every one of its recommendations, as follows:







1. While the proposal for a clearinighoulse in hEW for home health
services is quite meritorious, it is difficult to understand why such a
ccla ringhouse should be limited to home health services. Why should
we fail to go beyond such a limited purpose, and instead provide tliat
the .U:..e leaie'ringhouse serve as a source of information and riiidance
on all health po-,ramns and benefits for the a:,ingi within the Delpart-
ment of HEW?
2. I read with considerable interest the proposal to fund certain
counseling services out of medicaid and medicare funds. On its surface
this proposal seems quite acceptable, but if we look just a little be-
neath the. surface we have to consider that such a drain on medicare
and medicaid funds could become so excessive as to render the two
existing funds insufficient to carry this additional burden. Moreover,
the proposal for counseling would be conditionally acceptable as long
as it wcre limited to the elderly themselves who may be sick or dis-
abled. Yet when the recommendation goes beyond that and calls for
the counseling of all of the families of the elderly who are sick or dis-
abled, then such a recommendation becomes so broad that it could very
well include all of the families in the United States and thereby be-
come a financial burden upon medicare and medicaid funds which
would be intolerable.
3. It is my view that those recommendations which contain pro-
posals for demonstration or pilot projects and which call for increased
expenditures should have been costed out by some comparative showing
or presentation of probable costs in relation to potential benefits.
4. The proposal that there be a funding of programs to encourage
older persons to make periodic visits to other elderly persons is. in my
judgment, not a proper subject for legislation. In fact, the Lou Harris
Survey has shown that no urging is needed to encourage older per-
sons to viskt, as long as they are physically able and as long as they
have any means of transportation. They enjoy visiting those of their
samle a fe.
In the nature of a compliment rather than a criticism, I note that
there is a chapter of the report entitled "Important Areas for Future
Study in Long-Term Care." It is my hope that the subcommittee might
benefit from some experience gained by this report as it goes about the
preparation of its second report. One thought which I advance, as an
additional view, is that there are enough good proposals in this report
to provide the basic material for half a dozen reports rather than
including so many matters of such great importance in one single re-
port. I would hope that in the future in the areas considered in Chap-
ter V such reports will be broken down into separate subjects rather
than have several important subjects all combined in one report.
In the final analysis the report is an example of pushing ahead the
work of better long-term health care. One of our wiser men, whose
name I cannot momentarily recall and therefore cannot attribute to
him credit for his idea, expressed the thought that the only way to
avoid criticism is to do nothing. This report is an example of doing
something constructive rather than failing in its duty to pursue its
work and present a report on long-term health care. On that score the
subcommittee rates A-plus.





72

The subcommittee has worked hard. There is no question about that
fact. It has moved forward the work of the new Select Committee on
Aging and in particular the mandate cast upon its shoulders by the
House in October 1974, when the committee was created to conduct
a continuing and comprehensive study of the problems of older
Amnericans.
As chairman of the full committee of the new House Select Com-
mittee on Aging, I am grateful and appreciative for the hard work of
all of the members of subcommittee No. 2.
WM. J. RANDALL, Chairman.











ADDITIONAL VIEWS OF REPRESENTATIVE
BOB WILSON

The recommendations of the subcommittee are generally worthy of
serious consideration.
I am, however, concerned about the proposed changes in medicare
and medicaid. It would seem to me that the proposed additional serv-
ices will impose a substantial economic burden.
I am not convinced that sufficient attention has been given to the
actuarial implications of these proposed additional services. The finan-
cial integrity of the Social Security Trust Funds might well be
jeopardized by some of the proposed additional services.
BOB Wmso-.
(73)












ADDITIONAL VIEWS OF REPRESENTATIVE WILLIAM
F. WALSH
While the report of the Subcommittee on IHealth and Long-Term
Care does, in fact, offer some excellent and far-reaching recommenda-
tions for an end to the proliferation and fragmentation of laws deal-
in" with elderly health and for alternatives to institutionalization for
senior citizens, there exist several areas in which those recommenda-
tions are ill-conceived.

NEW COMMITTEE ON IHEALTHI IN TIHE HOUSE OF REPRESENTATIVES
The creation of a new committee on health in the House of Rep-
resentatives would not effectively lessen the confusion in dealing with
health issues of the elderly; rather, such a restructuring attempt would
serve only to intensify existing jurisdictional disputes. Additionally,
a new House committee on health would necessarily address itself to
health matters pertaining to the entire populace, rather than limiting
jurisdiction to the area of elderly health. A more realistic approach
would make this committee a permanent one. This committee is be-
coming experienced in the problems of the aged; additionally, the ever-
increasing proportion of our elderly population suggests this is an
issue which must be codified and dealt with as a whole. The elderly now
make up about 10 percent of the population of the United States or
21 million people. This is expected to climb to about 29 million in the
year 2000.
PROLIFERATION OF DEMONSTRATION PROJECTS
While the subcommittee's report calls for a number of alternatives
to institutionalization, it calls for demonstration projects to test the
feasibility for such suggestions with wild abandon, often when proto-
types already exist. Such a policy would effect the expenditure of un-
necessary funds which would ultimately serve to benefit those engaged
in the creation and administration of the projects rather than the
elderly themselves. Additionally, the time involved in attempting to
deminnsti.rate a fact which in many instances has already been proven
means t here will be a substantial delay in providing the recommended
alternative services to the aging population. Examples from the report
clearly serve to illustrate this contention:
1. The subcommittee's recommendation No. 9 calls for a series of
demoist ration and pilot projects to determine the effectiveness of var-
ious home health and supportive services. Testimony before the sub-
committee on June 16, 1975, in fact, cites a number of studies in this
area which have shown that home health and supportive services are
desirable and additionally, that they are cost effective. Demonstration
and pilot projects of this nature would, therefore, be completely
nncessa(y.
(74)








2. That part of the s-iibcomnlittes recoinmeiiidat i ", 14 c.illinc for
legislation cominenioraiting the Mininealolis A and Opportunity C(en-
ter as an excellent prototype for other outpatient, ,1iiW)r centers. aId
appropriating $r'.i.-)0.000 to the Center for a demonstration pr'ject of
collating relevant information on its nu-tliol of o.eiition anL 1 -
seminating those materials to State Health Comm o;- i.-. St.,te C,(om-
missioners of Agino. and other interested parties acro-.-, thl, co',:trv
is. on its face. unnece--;iry and, therefore, cost exhorbitanlt. Tie Mi-
neapolis Center is available for the inspection of all interc-ted piartio..
Those State officials who are intere.-ted in the methods e.:ploved ieed!
only contact the appropriate officials at this or the i,!,':ly other cit' 'iters
of this type acreo-: the country for any information they might dc-i 1,.
Other recommendations for demonstration projects are eittier, not
well enough conceived or provide a cost figure which seeir.is to 1w,
purely arbitrary, as no docuineiitation has been provided by t' :e sub-
committee. For instance,
1. Thie. report calls for pilot programs under the Older Americans
Act to provide home services to the terminally ill of low income so that
patients. can d(lie in the dignity of their own homee, rather than in
institutions. Such a recommendation is. of course, social an l-
mnanely desirable; yet, the recommendation fails to provide any cost
estimate.
2. The report calls for legislation authorizing $10,0,. 0,000 for dem-
onstration projects ince:,singr the outreach capabilities of existinli non-
profit, outpatient clinics specializing in the care of the elderly by the
development of related miniclinics located in nearby cities and coun-
ties. In addition to being duplicative in nature, no documentation has
been furnished to justify the cost estimate.
3. The report recommends that a minimum of .150 million in addi-
tional funding be authorized for the modernization, construction, and
conversion of medical facilities for outpatient clinics specializil"r iu
care of the elderly; again, however, no documentation has 1,en pro-
vided to justify the $150 million figure.

INCLUSION OF FPrIL-STANDIXG CLINICS UNDER MEDICAID
The subcommittee report recommends that the states be re iiiired
to include free-standing clinic services under medicaid. We nmust bea] r
in mind that while the Federal Government doe- provide some f iid-
ing for the medicaid program, it is administered by the State-: as. stip-
ulated in the enacting legislation. Therefore. requiring that free-
standing clinic services be required under medicaid is an unwarranted
Federal intrusion on State jurisdiction.
Each of these points, as well as the other recommendations of tle
subcommittee, should be considered carefully with an effort to iiailuin1
the lives of the agincz as pleasurable as possible at. the earli.-t po--iblle
date in the most efficient cost-effective manner available.


WXrr.TlT-LIAM F. WALSH.















SUPPLEMENTAL VIEWS


SUPPLEMENTAL VIEWS OF REPRESENTATIVES
MICIIAEL T. BLOUIN, TIHOMAS J. DOWNEY, AND
WILLIAM J. HUGHES
Our views are written not in opposition to this report nor do we
take issue with any particular part of the report. Rather we would
like to use this opportunity afforded us by the committee to both com-
mend Congressn an Pepper and his staff, along with tlhe other mem-
bers of the Subcommittee on Health and Long-Term Care, for the
excellent job they did in preparing this report. We would i lso urge
the full conimittc, to take whatever action is necessary to present the
views of this report to the full Congress and to those committees hav-
ing jurisdiction over this legislative area.
The facts as presented in support of the recommendations presented
in this repot,'.- represent months of hearings and we know the sub-
committee members spent much of their valuable time going over the
facts as prescmted to them by the wide assortment of witnesses who
were asked to testify before them.
It seems to us that this report provides credence to what we have
considered to be a major problem regarding elderly health care, that
problem being that current health care programs for the elderly are
so fragmented at all levels of government that it is difficult to not only
bring continuity to elderly health care, but it is just as difficult to
fully understand just what health care services are available to serve
the elderly.
In addition to the problem of proliferation and fragmentation of
health programs for the elderly, the report also substantiates the need
for redirection in elderly health care from one of institutionalization
to that of home-health care. Although HEW has maintained that
home-health care should be a goal of government health care assist-
ance programs, the fact remains that it has not been carried out. If
anything, current policy as interpreted in both Federal statute and
HEW regulations. has almost made permanent the concept of insti-
tutionalized health care. A new focus by the Congress on this issue is
badly needed.
It is our feeling that the full committee should study the recommen-
dations of this report thoroughly and discuss them as a committee,
perhaps identifying what we as a committee feel are the major pri-
orities of this report and then to formulate the mechanism by which
to best implement these recommendations into law.
Our major concern in presenting this supplemental report to the
committee, is to echo the concerns expressed by our colleague from
California, Mr. Roybal. that being that this report should be one that
will help bring about substantive change in elderly health care and
that it will be used as a foundation by the committee to enact the
(77)






78

legislation needed to make adequate health care for the elderly a
reality in this country. It should not be considered by the committee
members as just another report to be shelved among the many reports
received each Congress.
MICHAEL T. BLOUIX.
THOMAS J. DowNEY.
WILLIAM J. HUGHES.











SUPPLEMENTAL VIEWS OF REPRESENTATIVE
DON BONKER
I would like to commend the Chairman, Rep. Claude Pepper, and
the Subcommittee on Health and Long-Term Care for focusing atten-
tion on the need to provide older citizens with alternatives to institu-
tionalized care. I am also pleased to note the general support for the
subcommittee's recommendations on home health care from the Na-
tional Cancer Foundation, the National Council of Senior Citizens,
and the National Association of Social Workers. The subcommittee,
I believe, has been extremely helpful in pointing out the institutional
bias of our existing legislative programs.
While I am impressed by the sense of concern and commitment
which permeates the report, I do have reservations about some of its
recommendations. Since many of the recommendations require fur-
ther study, I agree with the statement in the report on page 3:
The subcommittee intends to conduct further research into
the issues raised and to strengthen and revise the recommen-
dations as changing national health situations and new docu-
mentation may direct. The subcommittee will continue to
work toward implementation of both the current and new
recommendations as justified by the facts.
We should know more about the problems of enforcement of existing
regulations and standards; dissemination of information; providing
an adequate accounting system; coordinating existing programs; and
restructuring, before we can improve the delivery of services for the
elderly. I hope that eventually the committee will be in a position to
make suggestions to Congress that would, for example, facilitate the
retraining of retired firemen as nursing home inspectors wherever a
shortage existed, and retraining of retired auditors, to help whL- there
is a backlog of claims to be verified.
The committee should look at the entire question of enforcement of
all the regulations pertaining to the elderly, which might incidentally
be a good time to ferret out the conflicting regulations. Until this is
done, I am hesitant to endorse s'gnestions to increase IIEW's regula-
tory responsibilities, especially ones which are the equivalent of self-
regulation, since we are dissatisfied with HEW's performance as
regulators.
As far as improving outreach methods, I would like to know how
many people would be served by existing programs if they were aware
of them, and how many people have problems which have not been
touched by legislative programs. This analysis would enalve us to
provide the most effective methods of outreach. The idea of a clearing-
house which provides information, gives assistance with gr"nntsman-
shit. helps States with coordination of plans :.ndtl prorVams, and co-
ordinates all Federal programs for the aging is very appealing. I would
prefer that such a clearinghouse be concerned not only with health
(79)
1,(, 5-5076--7






80


but with all the programs for the elderly. Also, I would like to see
such a cleariinghouse employ senior citizens, especially on a part-time
basis. While I am reluctant to provide HEW with more duties, we
might consider strengthening the clearinghouse in the office of the
aging and making our intentions very clear. The clearinghouse should
naturally utilize a computer system if needed, but I think it should be
independent of existing systems and provide information about all
progr:l ims for the elderly.
And finally, it is obvious that a thorough reorganization of HEW
is needed, but it would be precipitous to take such measures without
the benefit of further study.
Again, Chairman Pepper and his colleagues on the subcommittee
deserve a great deal of credit for an extraordinary amount of work
in such a short time. This report represents a significant contribution
to the further understanding of elderly health care problems, and the
attached recommendations are a good starting point for ameliorating
the many difficulties faced by senior citizens today.
DoN BONKER.












SUPPLEMENTAL VIEWS OF REPRESENTATIVES II. JOIN
HEINZ III, WILLIAM S. COHEN, WILLIAM F. WALSh,
CIhARLES E. GRASSLEY, JOHN PAUL IIAMME R-
S( 'I I II )T, AND GILBERT GUDE
SUMMARY OF VIEWS
This report focuses on what is missing in our laws and our regula-
tions directed at the elderly-a sense of the person. It moves away, at
last, from an outdated concept of institutionalization as the only
answer to the problems of the elderly and addresses their urgent and
pervasive health needs. Institutionalization was a solution that sepa-
ratedI t li' elderly from their community and the society from the many
contributions they have to offer.
We join with our colleagues in calling for alternatives to institu-
tional <':Ire. We would go beyond this to advocate a pro-iaji
for developing more humane alternatives for the elderly within
instit utions.
We believe that local and state as well as Federal initiatives are
urgently needed in ending the emphasis on institutionalization and
focusing on improving the health of the elderly. Proliferation and
fr&ii'::entation of ev,:iv.. exist at all levels of government.
We will work for the development of policy and the passage of
le-islation that would provide not only home care progranis, bufi also
programs of congregate housing with health and social services.
We advocate a program for health care reform for the elderly which
includes the following:
(1) Changes in the payment system for long term care. Instead of
per-capita reimbursement, we favor compensation on the basis of
disability similar to the veterans disability payment system. This will
leave the elderly free to choose the type of care they need.
(2) A system of community information and personal services that
will give older persons the assistance they need to make an informal
choice.
(3) A new set of legislative and regulatory initiatives at all levels
of government that makes care in-titutions and providers of health
services directly accountable to the person who is receiving care.
(4) Clo-e scrutiny of the use of public funds through the develop-
ment, of provisions such as community advisory panels composed of
consumers, providers, and the general public.
(5) Adequate Federal support for State and local governmental
regulatory activities, to ensure adequate review of relevant programs.
(6) Development of state responsibility for establishing public
receivership for the administration of provider groups who do not
keep the public trust until competent administration and quality of
care is restored.
(81)






82


(7) Employment and retraining of older Americans for the purpose
of administering, monitoring, and reviewing the delivery of their
own and others health and social services.
Many of the recommendations of the subcommittee are worthy of
adoption. We offer supplemental views only on those which we feel
might lead to unfavorable consequences for care of the elderly if they
were adopted. We agree with our colleagues that the establishment
of a spectrum of coordinated health and social services for the elderly
should be among the highest priorities of Congress as it considers new-
legislation. To this end we pledge our full cooperation and effort.

GENERAL COMMENTS
We are in strong agreement with our colleagues who in this report
call for recognition by Congress and the tax payers of America that
our elderly are entitled to support for a broader spectrum of health
care services. Several of the recommendations proposed have the-
potential to improve the delivery of health services in the community.
The general thrust of the report set forth in the introduction, and the-
follow-through advocated by the subcommittee in Chapter 5-Im-
portant Areas for Further Study in Long-Term Care-are vital con-
tributions to a new Congressional and public dialogue on the health
care needs of the elderly. Many of the general goals outlined in Chap-
ters 2, 3, and 4 concerning the development of alternatives to institu--
tionalization, extending home health benefits, and improving quality
control, enforcement procedures and standards in long term care
facilities, are worthy ones which we wholeheartedly endorse.
We are concerned, however, that the individual recommendations.
are not in every case sufficiently supported by the narrative which
precedes it.1 Fuller evaluation than this report is able to provide is-
needed to examine the impact of its recommendations on existing
health programs for the elderly and on the health financing, admin-
istration, and delivery. In particular, more work could be done on the
recommendations which call for specific or substantial additional
funding or transfer of funds. We believe these should be reexamined
as soon as the subcommittee receives studies and expert testimony.
We believe that it is important for the subcommittee to share its
initial findings and goals with both the legislative committee and the
public at large. It is unfortunate but probably unavoidable that the
approach taken by the report-that of proposing unprioritized
multiple recommendations-does not lend itself as much as we would
like either to immediate legislative enactment of needed, remedial
measures or to the development of new approaches.
We hope that this report will be effective-both as a vital communi-
cation document to other committees and as a catalyst for effective
legislative response. It is our feeling that if the report retained its
broad scope but made fewer recommendations, analyzed those that it
made more thoroughly, and clearly placed remedial actions and long
term solutions in some priorities, perhaps the standing legislative com-
mittees of the House would be able to move more quickly in the areas
of greatest need.
An example of an initiative that we would like to see fully developed
is home health care. The report asserts that home health care "would
1 See comments on Individual recommendations below.






83

reduce costs as much as $700,000,000 nationwide (subcommittee report
p. x). We fear that this statement is insuiiicicntlv support,,l by the
analysis. It is based in large part on rough estimates of the number
of elderly persons who are currently inappropriately institutionalized
and some selected case studies of potential hospital savings under
programs of home care, such as those of the Minneapolis Age and
Opportunity Center. But nowhere in the report is a specific definition
of home care given. Nor is empirical evidence offered which identifies
the levels of functional impairments of older persons or those for
which home health care, homemaker and supportive services, foster
care, or congregate housing are appropriate. Accurate data on the
proportion of presently institutionalized persons who could be better
served if less expensive, more humane settings is missing. Data on the
proportion of the elderly population who are inappropriately placed
in noninstitutional settings is lacking in the report.
In fact it may well be that the number of elderly persons who have
need for home health, personal, and domiciliary care are under-
estir.mated in the report. Analysis of studies conducted by Hill and
his associates in Rochester,2 Sproat of the Levinson Institute at Bran-
deis. Massachusetts.3 Dunlop,4 and others indicate that there may be
over 6 million elderly persons who require or could benefit from such
services.
We agree completely with our colleagues that expansion of such
forms of care are urgently needed. We are less certain than they that
present or future costs of long term care can be reduced by providing
a broad spectrum of unlimited home health and home care services
as the primary alternative to institutionalization. To put forth
specific figures of how much money can be saved is misleading. There
is little doubt that some institutionalized persons who do not have
major functional impairment can be better served by providing alter-
native care. However, there is also clearly a potential for home
health services if defined too broadly or for patients of high dis-
a ability, to be more expensive alternatives to nursing home care for
elderly persons.5 G 7
In considering the cost of providing care to the elderly Congress
mut look not only at cost to the government, or number of institu-
tiofal 1)ed days saved, but also to "the social cost of providing care
to a given quality to an individual with a specified level of functional
competence and family status".7 This cost presently varies by region
and lccale in the U.S. as a function of different prices and different
standards of care. The report fails to address this aspect sufficiently.
The subcommittee must confront the prospect that the home health
recommendations it has made in the report may not only lead to some
2 Hill. J. C.. et al, Health Care of The Aged Stfidy, Rochester, New York, University
of lRochester. School of Medicine and Dentistry, 1968.
8 Sprout. PB. J.. Three Approache.R to Etimatinq Need for Personal Care ,fo'ricrr ,
Waltham. Mass.. Levinson Gerontologlcal Policy Institute. Brandeis University, June 1972.
S Dunlop, B. D., Long-Term Care: Need Versti, Utilization, Urban Institute Working
Paipr 0975-05. Wnshinaton. D.C., RPv. Foh. 7. 1975..
SMarie Callander and July Lavor, Home Health Care De'elopmrnt, Problems and Po-
tential Di-al-ility Long Term Care, DREW, Office of The Assistant Secretary for Planning
and Evaluation. Anril 1975..
OWilliam Pollak. Utilization of Alternative Care Settings by The Elderly: Normative
ETstimates and Current Patterns, Urban Institute Working Paper 963-12, Washington, D.C.,
March 13, 1973.
7Willinm Polltk. Costs of Alternative Care Sfttino.q for The Elderly, Urban Institute
Working Paper 468-11, Washington. D.C., March 12, 1973






84


long" term cost-e1iectiven( ss for some proportion of the elderly pop-
ulation, but also may lead to significant short term increases in cost
as people who marginally need such services take advantage of their
availability. Home health care is better viewed, but as a basic part
of the continuum of health care needs. This continuum of care must
include better and more humane care alternatives within institutions
as well as alternatives to institutions.
We are in substantial agreement with and have chosen not to com-
ment on the recommendations numbered 1, 5, 7, 10, 11, 12, 15, 16, 17,
18, 19,20, 21, and 22. Most of the above recommendations would benefit
from more careful analysis, in line with our general comments above,
but they are clearly steps in the right direction. The recommenda-
tions below, numbered and ordered to conform with their number-
inn' in the report, are those for which we wish to submit supplemental
views. It is our hope that these views will lead to a fuller understand-
ing of the complex problems facing both our elderly and our society.
Recommenddl.'on, No. 2: Creation of a new House Health Committee
The findings of overlapping Congressional jurisdiction in the health
area cited in the report are necessarily true for any broad area of
public concern. In a nation of over 210,000,000 people such issues are
complex and often require the attention of policy makers with diverse
legislative charges. Consideration of bills through the joint or sequen-
tial referral powers of the. Speaker of the House are quite appropriate
in matters which affect both health and the general economy, as do
all proposals for national health reform.
Health as a separate subject matter is one of the least fragmented
areas in the Congress. There are only two subcommittees that share
legislative jurisdiction in the House of Representatives with health
as the specific concern. Both subcommittees, the Health Subcommittee
of Interstate and Foreign Commerce and the Health Subcommittee
of Ways and Means. have considernl)le expertise in health care issues
as well as i'eneral backgrounds that equip them to deal with health
delivery and health financing issues. We know of no reason why such
committees cannot work effectively together.
The creation of a new health committee also raises the basic ques-
tion of whether we should grant the power of taxation to a committee
besides the House Ways and Means Committee. It appears likely that
any comprehensive national health program will involve some form of
direct taxation and funding through the general revenue. We believe
that a reasonable case can be made for keeping the powers of taxation
under the jurisdiction of one committee. To split these powers, and
give them to additional committees may lead to additional problems
in achieving equitable income security on the one hand and health
security on the other.
The problem as we see it does not concern so much the number of
committees or subcommittees that have jurisdiction over matters which
affect the health of the elderly. Rather, it is getting the committees
which have jurisdiction over the health of the elderly, to start paying
attention to the health needs of the elderly, that needs our attention.
Furthermore, to specify the exact mix of Members for the new Health
Subcommittee without careful study which justifies this particular
organizational structure is premature at best.





85


The as-ertion that the creation of one committee is "the ,i lv \v, v
to guarantee future. rational health planning" (see p. 47) is unproven.
The groundwork for such planning has already ta ken place, having
originated in the Health Sulboinimittee of tlhe Hou1-e ColjlIIerce C(m-1
mittee (Public Law 93-641).
IHearings on the relationa-hip of long term care to national health
insurance have been scheduled by the Health Subrommittee of Inter-
state and Foreign Commerce with the help from this :liihovrjinttee.
The ctli iiwmn of the subcomm-iittee has a.-ked a ..Member of the Way-
and Means Committee and a Member of tlhe Select Finance ColmITittee
(both of whom have introduced bill referred to in Recommendation
No. 1) to testify. Both have accepted. We believe that that type of
coordinated action will do far more to insure congressional re'iPon-
siveness to tlhe problems of the elderly than will setting up a new
committee, which itself may take months or years to establish and
whose credibility-with other committees may take months longer
to cement-as all members of our new committee will surely admit.
The creation of a new health subcommittee in the name of non-
proliferation, delay, and fragmentation in our view would lead to
additional delay and fragmentation.
Recommendation To. 3: Creation of a comprehenrsi.e home health
clearingho?'.se
We believe that locally based community wide clearinghouses are
needed in the first instance to provide the elderly with increased infor-
mation on home health and other services available to them. Placing
heavy emphasis on a nationwide computer-based information network
as a means of achieving individual access to information is a costly
and circuitous route to take.
A computer will not necessarily solve the problem of giving the
elderly a means to understand what benefits are available to them.
and how they may best receive them. First priority should go to the
strengthening and coordination of local services (including informa-
tion services, on home health). Part of this effort will involve giving
the elderly individual assistance in their own community so that their
needs may be determined and their ability to choose, maximized.
Recommendation No. 4: HEW reorganization under r an Assistant
Secretary for Elderly-Health of all health and health-social
matters for persons over 60
Long-term care is presently organized and administered along
statutory rather than functional lines. It is this fact that would make
it difficult for an Assistant Se'retary for Elderly Health to practically
achieve the leadership, line authority, and responsibility for coordina-
tion of home health and other "alternative" programs which the report
finds lacking in the Office of Nursing Home Affairs. A principal blo'-l,
to a more rational or coordinated long term care policy within HEW
is the fact that medicaid as a Federal-State revenue sharing program
has different and incompatible arrangements for program manage-
ment, delivery, payment, and quality control, from that of medicare.
or the Older Americans Act. Even othir structurally similar Federal-
State revenue sharing programs like Title XX (Public Law 03-647)





86


the Social Security Act have little potential for integration with
title XIX or Federally managed categorical programs for the elderly.
Until such time as medicaid which presently has most of the long-
term care dollars and services is Federalized or otherwise radically
changed, or, alternatively, the other programs are structurally re-
vised to give the states the same control over delivery of services and
regulation as exists in title XIX, it will be difficult to significantly
alter the situation.
Programs such as legislation under Recommendation No. 1 of this
report may have significant potential to change the situation by virtue
of the fact that they contain provisions that will coordinate all long-
term care services under one system of administration and regulatory
,control.
The recent experience of HUD, which has an Assistant Secretary
for the Elderly, also should give pause as we recommend the creation
of an additional high office within HEW for the elderly, an Assistant
Secretary for the Elderly, as the best way to solve the problem. A
recent briefing with representatives of the Assistant Secretary for
Elderly Housing, before the Housing and Consumer Affairs Sub-
committee indicated that having a high official advocate for the elderly
within HUD has not produced the kind of implementation activities
that will lead to material gains in the provisions of additional commu-
nity and home services for them. There has not been significantly
greater utilization of existing programs or laws to increase the quan-
tity and quality of housing for the elderly since the office was created.
In part this is because the responsibilities of the Assistant Secretary
for Elderly Housing include no line responsibility of administration
authority; the Secretary's functions are "to review policies, * *
participate in planning for inspection and evaluation of HUD assisted
housing * and represent HUD in meeting with other * *
organizations." 8
It is obvious that some form of functional reorganization within
HEW is necessary. What form this might take is not yet clear. We
have reason to believe on the basis of past experience that the creation
of an Assistant Secretary for Elderly Health with actual line au-
thority over all health and health-social matters as the report suggests
would be impractical and might further split-off and isolate the needs
of the elderly from the general health resources available within
HEW. The Commissioner on Aging already offers older Americans
a high ranking official advocate within HEW. The creation of an
additional bureaucracy within HEW has the potential to create as
many problems as it solves.
Recommend(ton ANo. 6: Home health benefits under medicare and
Medicaid
We strongly favor the general intent of the recommendations, but
take issue with some of the sub-recommendations under No. 6:
The first recommendation for legislation under No. 6-the addition
,of a full range of homemaker and other correlative services to medi-
care's current coverage of doctor and nurse visits and full provision of
medical supplies and appliances are not accompanied by estimates of
cost of benefits, eligible population, or estimated utilization of those
8 Annual Report to Senate Special Committee on Aging-1974 Highlights.






87


eligible. An inforImal study done of hoiimala;er services n:-i l n- lation-
wide figures for title XIX cash as.-istaice recipients as the ,a.s- popu-
lation yields the following results:9
Under medicare part B approximately 21 .3 million per.on-' would
be eligible for homemaker and other correlative services. Asstiirnie that
40 percent of the elderly population utilize these services and that
costs for a "full" spectrum of services average about $4.05 per indi-
vidual. As an alternative, assume that 40 percent of the eligible popu-
lation who utilize these, services will on the average only i;.e about
one half of the total services-in cost-then, the costs of including
such services under medicare would range from a low of $2.5 billion
to a high of $5.1 billion a year.
The above rough cost projection does not take into account the pro-
vision of medical supplies, hearing aids, dental care, podiatry, and
sight aids, for which no utilization and cost data were readily avail-
able, and what burden either medicare or medicaid as presently
constituted could carry.
If we add to these a full home health benefit with estimates of the
eligible population at 25 million people under part B of medicare, and
an estimated utilization ranging from a low of 6.1 percent (derived
from the Pennsylvania State and New Hampshire figures on utiliza-
tion) 10 to a high of 16.9 percent using a general definition of "unable
to remain at home without such support"-as estimated from national
studies-the cost of home health under the medicare arrangement
ranges from $345 million to $1 billion. Of course these estimates are
gross and the assumptions upon which these figures were generated are
tentative at best. However, it does point to the need to consider the full
impact of such a program on our existing Medicare system.
Arthur E. Hess, Deputy Commissioner of the Social Security Ad-
ministration speaking at a gerontology conference at the University
of Michigan on August 14,1975, has said,
for reasons of cost and because I do not think medicare should
really get into long term care, I propose * to continue
the present skilled nursing care provision * For the long
run, we ought to put more money into home care * A re-
vised program which would do away with distinctions be-
tween Part A and Part B could provide 200 home health
visits per calendar year without any prior hospital stay re-
quirement subject to the present medicare. criteria. Then.
I would rely on emerging experience from a number of ex-
periments which are now being conducted to determine the
appropriateness of the situation in which the services of the
home health aide or other relaxation of the medicare cri-
teria for organized home health services are shown to make a
useful difference in the individual and his familv.-Arthur
E. Hess: "Next Steps in Medicare, Speech at the University
of Michigan, August 14, 1975, Conference on Gerontology,
pp. 24 and 25.
SSource: Social and Rehabilitation Service (Medical Service Administration), M.C.S.S
A-2 Reports. July 1972, June 1973.
0 Using Pennsylvania and New Hampshire averaged estimates of the cost of home
health services-which have the most complete home health benefits under medical.






88


Thui,. while we are in agreementt (as is the administration and many
other mrces) that there is a need to increase both the home health and
homeii.tiker :-rvices under medicare and medicaid, the call for im-
mediate implementation of a full range of benefits is premature. We
must first know the consequences both in terms of dollars and in terms
of direct health benefits for the individual per dollar spent before
embar:in-r on this full scale program."
Similarly we believe t!at the provision under No. 6 which permits
the state Medicaid programs to cover payment of rent, mortgage, re-
pairs and property taxes for the elderly or disabled person, may lead
to serious imbalance in the reimbursement system under medicaid, and
constitutes an inappropriate use of a services fund. In effect this rec-
ommendation may siphon off dollars from already over-taxed service
delivery components and thus cripple the program. While the recom-
meIndation is left as a state option, it might also lead to regulatory
problems of compar',ble magnitude to those encountered in nursing
homes. [See the reports of the New York State Mo.-eland Act Com-
nmission on Nursing Home and Residential Facilities: "Reimburse-
mnent of Nursing Home Property Costs: Pruning the Moniey Tree;
Regulating Nursing Home Care: "The Paper Tiger"; New York State
Moreland Act Commission, January 1976. Morris B. Abram, Chair-
man, Jonathan Weiner, Staff Director.] Mr. Abram states in the pref-
ace to these reports,
When government funds flow in ever increasing sums, there
is no assurance of anything except there will be a sufficiency
of outstretched hands to receive the money. That the hands
perform depends on government regulators.
Such use of medicaid funds, especially if through fiscal intermediaries
could produce at best more bureaucracy, and at worst more fraud.
Rather than see the purpose of medicaid compromised by such a recom-
mendation, we would prefer to see this handled either by some form
of increase in an income maintenance program or specific measures
such as property tax relief-both of which address the issue more
(dii'-tly and equitably.
Tlhe provision that Medic:i re and -Iedicaid home health agencies
and nursing home be required to utilize "cost-related" purchase has
not proven to be an effective means of cost control.12 In a situation
where the government reimburses the states who in turn contract
with defined organizations or "providers" who in turn may subcon-
tract with physicians, nurses, meal services, suppliers, etc., the line of
audit control is so tenuous as to be impossible to enforce. To make fine
distinction between transaction of this variety would require investiga-
tory efforts. It may well be that under these circumstances the term
cost-related has no substantative economic meaning in terms of con-
trolling medicaid nursing home costs.
The advisability of including the chore services under medicare can
be seriously questioned. The medicare program is primarily an insur-
"'Note experimental programs under 92-608, section 222 and as referred to below.
12 Cost-related reimbursement (not purchase) as the term is presently used and en-
foreed will go into effect under medicaid on July 1, 1976. However, divided opinions on
what the term actually means, had lead to the contention on the one hand that states
may place a limit on nir,,dien1d reimbursement and on the other hand that cost-related
really means cost plus some amount in excess of cost.






89


ance program for the elderly which covers acute illness-ho-spitaliza-
tion and physician care. It may b. dilliriiult to cha;, iehle alr:;ini- ra-
tive and regulatory limitation-;s of thi. priimjarily m.v,'nlj i-,J piiin
when nonmedical services are inclludled. Chore -111 a 1 <' c1"!'tlv
handled as part of title XX. Perhi:ip.. s,,, n for-in of c,'.') 'fli,1tion of
title XX and XVII1 benefits would be poss--ible un'L,,.r n nlw ,i.ogi:1(m
designed especially for the elderly who are eli,,ilt, inder m,',li,.',.
Other recommendations under #6 which warrant further study
include analysis of the. impact of broadening provider eligibility status
under medicare provision of home health care. Whazt effect would
inclusion of nurses, home health aides, etc. as registered providers have
on all malpractice liability claims? Who would be legally responsible,
if not a physician? How would this new provider arrangement affect
underwriting of risks and cost of care?
The recommendation concerning Department of Prof:--i,,nalSt :d-
')ris Revie." Organlization (PSIRO(-) for long-teni, i c- i.- already
contained as part of legislative mandate under the PSEO, Act. Cur-
rently this mandate is being contested by provider organi:izations .nud
HEW has !'o, vet developed definite ;-.,_i'ulation- in this area. alt]ou
there is a PSRO manual which could be used for long-term Inri re view.
We do not question comprehensive home health care as outlimnul in
the recommendations in a legislatively compatil)le national lalth in-
surance program. However, some of the specific proposals for naItional
health iniiura.ce have goals which may be incompatible with those
bene_.t; dii-Ceted ..',o.ot exclusively toward the acute ,edi':ml nec,1- or
catastrophicc illnesses of the general population. Unler such sv-tems of
national health insurance it may be more appropriate to c.-,nsider a
separate comprehensive long term care program which would include
ho"ie hlIealth c.,.re, s,,ial and supportive community care through
CHMIC's and other fa.lilities. day care centers, fo-ter homes. ongre-
gate care facilities, as well as skilled and intermediate nursing
facilities.
We wish also to clarify a po,-ible misunderstand (inr' which may re-
sult from the reading of the reports version of the recommendation
under No. 6 to increase 100 visit home health limit of both Part A and
Part B. The present medicare regulations under part B reads as fol-
lows: "Iome health visits may be utilized only -fter Part A visits
are exhausted." 13 T.is in effect does away with the non-h)ospital ia ;ilion
requirement and therefore does not allow home health care unless there
has been prior hospitalization. This regulation clearly reflects an "in-
stitutional bias." We would recommend that post-hospitalization be re-
moved from part A through legislation or at the minimum require the
regulation under part B be changed to comply with the intent of the
I aw.
Recomrmerndation No. 8: "Amendment of T;tle XX of the Soeal V(,-
curity Act to provide further financwl i7wentives to .n.m'm;>e the
prevent on in reduction, of iiwnapprop;rate istfit7fi ial care as
; I...' as 1,O.. -;n in mal;n-,q home a(nd com rr',-h, .her/e.

Of additional benefit to the elderly under this progrram would be a
change in the title XX provisions to specifically define the elderly as
1 M^iicire Rp-ulattonc. 20 CFR Part 407..






90


a group eligible for services under title XX. To date only Pennsyl-
vania has chosen to separate services directed at senior citizens from
services directed at the adult population as a whole. Without such a
definition in title XX, it becomes difficult to account for amount of
funds or the quantity and variety of services which are directed at
senior citizens under any of the program objectives.
Recommendation No. 9: A series of demonstrations and pilot pro-
grams to determine the effectiveness of various home health and
supportive services
We believe that demonstration projects such as outlined in the
recommendations are appropriate means to determine the effect of
particular home health benefits and services on defined populations,
when such information is lacking. However, the report is somewhat
inconsistent with its earlier mention of such demonstrations programs
as proposed by HEW as superfluous or "delaying tactics" (SRC
p. 24). If indeed there was sufficient data demonstrating the cost
effectiveness and care advantages of home health additional demon-
stration programs would not be required. Apparently the subcommit-
tee sees a need for several of them, including one calling for older
persons to make "periodic visits to other elderly persons who are
chronically ill and alone which already has been proven effective-"
the so-called "friendly visitor programs" now eligible for support
under the Administration on Aging. In this context we do not under-
stand the statement made on p. 24 of the report, "that the time for
relying on new experiments had ended and the time for meaningful
legislative reform to make home health care reality is now."
Recommendation No. 13: Calls for a realistic open minded attihtde
by HEW toward home health legislation
There should be specific follow-up on the mandates of Congress in
the home health area which have not yet been implemented.
We like our colleagues would urge the implementation of the White
House Conference recommendations. One problem in calling on
initiative by HEW in this report is that as an agency of the Adminis-
tration, DHtEW is in no position to require benefits or regulate more
effectively where not under legislative mandate. For example, HEW
can and should be more active in the area of enforcement of existing
laws and regulations which govern the individual care of older Ameri-
cans. To cite one example, HEW has never adequately enforced dis-
charge planning requirements under medicaid and other Federal pro-
grams.14 Consequently, while we theoretically have a mechanism
which could back where deinstitutionalized persons are located and
what care they receive, in fact such plans have not been adequately
evaluated either with respect to their appropriateness to the patients
need or adequacy of followthrough. The subcommittee should consider
specific suggestions or oversight activities that would enable Congress
and the Administration to work together to see that the elderly receive
better home health care.
Recommendation No. 14: Establishing and expansion of outpatient
clinics specializing in geriatrics
We support some of the recommendations contained under this
rubric. We believe, however, that any construction of additional facil-
14 GAO study of Discharge Planning Requirements. In process.