"AGREEMENTS WITH PROVIDERS OF SERVICES

"SEC. 1710. (a) Any provider of services shall be eligible for payments under this title if it files with the Secretary an agreement not to charge any individual or any other person for items or services for which such individual is entitled to have payment made under this title (or for which he would be so entitled if such provider had complied with the procedural and other requirements under or pursuant to this title or for which such provider is paid pursuant to the provisions of section 1709 (g)), and to make adequate provision for return (or other disposition, in accordance with regulations) of any moneys incorrectly collected from such individual or other person, except that such provider of services may charge such individual or other person the amount of any deduction imposed pursuant to subsection (a) or (e) of section 1704 with respect to such services (not in excess of the amount customarily charged for such services by such provider) and, where the provider of services has furnished, at the request of such individual, items or services which are in excess of or more expensive than the items or services with respect to which payment may be made under this title, such provider may also charge such individual or other person for such more expensive items or services but not more than the difference between the amount customarily charged by it for the items or services furnished at such request and the amount customarily charged by it for the items or services with respect to which payment may be made under this title. "(b) An agreement with the Secretary under this section may be terminated— "(1) by the provider of services at such time and upon such notice to the Secretary and the public as may be provided in regulations, except that the time such agreement is thereby required by the Secretary to continue in effect after such notice may not exceed 6 months after such notice, or

"(2) by the Secretary at such time and upon such notice to the provider of services and the public as may be specified in regulations, but only after the Secretary has determined, and has given such provider notification thereof, (A) that such provider of services is not complying substantially with the provisions of such agreement, or with the provisions of this title and reguÎations thereunder, or (B) that such provider no longer substantially meets the applicable provisions of section 1706, or (C) that such provider of services has failed to provide such information as the Secretary finds necessary to determine whether payments are or were due under this title and the amounts thereof, or has refused to permit such examination of its fiscal and other records by or on behalf of the Secretary as may be necessary to verify such information.

Any termination shall be applicable

"(3) in the case of inpatient hospital services or skilled nursing facility services, with respect to such services furnished to any individual who is admitted to the hospital or skilled nursing facility furnishing such services on or after the effective date of such termination,

"(4)(A) with respect to home health services furnished to an individual under a plan therefor established on or after the effective date of such termination, or (B) if such plan is established before such effective date, with respect to such services furnished to such individual after the calendar year in which such termination is effective, and

"(5) with respect to outpatient hospital diagnostic services furnished on or after the effective date of such termination.

"(c) Nothing in this title shall preclude any provider of services or any group or groups of such providers from being represented by an individual, association, or organization authorized by such provider or providers of services to act on their behalf in negotiating with respect to their participation under this title and the terms, methods, and amounts of payments for services to be provided thereunder. "(d) Where an agreement filed under this title by a provider of services has been terminated by the Secretary, such provider may not file another agreement under this title unless the Secretary finds that the reason for the termination has been removed and there is reasonable assurance that it will not recur.

"(e) If the Secretary finds that timely review in accordance with section 1706(e) of long-stay cases in a hospital or skilled nursing facility is not being made with reasonable regularity, he may, in lieu of terminating his agreement with such hospital or facility, decide that, with respect to any individual admitted to such hospital or skilled nursing facility after a date specified by him, no payment shall be made for inpatient hospital services or skilled nursing facility services after the twenty-first day of a continuous period of such services. Such decision may be

made only after such notice to the hospital, or (in the case of a skilled nursing facility) to the hospital and the facility, and to the public as may be prescribed by regulations, and its effectiveness shall be rescinded when the Secretary finds that the reason therefor has been removed and there is reasonable assurance that it will not recur.

"PAYMENT TO PROVIDERS OF SERVICES

"SEC. 1711. The Secretary shall periodically determine the amount which should be paid to each provider of services under this title with respect to the services furnished by it, and the provider shall be paid, at such time or times as the Secretary believes appropriate and prior to audit or settlement by the General Accounting Office, from the Federal Hospital Insurance Trust Fund the amounts so determined; except that such amounts may be reduced or increased, as the case may be, by any sum by which the Secretary finds that the amount paid to such provider of services for any prior period was greater or less than the amount which should have been paid to it for such period.

"HOSPITAL INSURANCE BENEFITS ADVISORY COUNCILS

"SEC. 1712. (a) For the purpose of advising the Secretary on matters of general policy in the administration of this title and in the formulation of regulations under this title, there is hereby created a Hospital Insurance Benefits Advisory Council which shall consist of 14 persons, not otherwise in the employ of the United States, appointed by the Secretary without regard to the civil service laws. The Secretary shall from time to time appoint one of the members to serve as Chairman. Not less than-4-6 of the appointed members shall be persons who are outstanding in the fields pertaining to hospitals and health activities of whom not less than 2 shall be physicians. Each appointed member shall hold office for a term of 4 years, except that any member appointed to fill a vacancy occurring prior to the expiration of the term for which his predecessor was appointed shall be appointed for the remainder of such term, and except that the terms of office of the members first taking office shall expire, as designated by the Secretary at the time of appointment, 3 at the end of the first year, 4 at the end of the second year, 3 at the end of the third year, and 4 at the end of the fourth year after the date of appointment. An appointed member shall not be eligible to serve continuously for more than 2 terms. The Secretary may, at the request of the Council, appoint such special advisory or technical committees as may be useful in carrying out its functions. Appointed members of the Advisory Council and members of its advisory or technical committees, while attending meetings or conferences thereof or otherwise serving on business of the Advisory Council or of such a committee or committees, shall be entitled to receive compensation at rates fixed by the Secretary, but not exceeding $100 per day, and while so serving away from their homes or regular places of business they may be allowed travel expenses, including per diem in lieu of subsistence, as authorized by section 5 of the Administrative Expenses Act of 1946 (5 U.S.C. 73b-2) for persons in the Government service employed intermittently. The Advisory Council shall meet as frequently as the Secretary deems necessary. Upon request of 4 or more members, it shall be the duty of the Secretary to call a meeting of the Advisory Council.

"(b) Specific language for provisions establishing State and local advisory councils will be drafted on request.

"REVIEW OF DETERMINATIONS AND GRIEVANCES

"SEC. 1713. (a) Any individual dissatisfied with any determination made by the Secretary that he is not entitled to insurance benefits under this title or that he is not entitled to have payment made under this title with respect to any class of services furnished him, shall be entitled to a hearing thereon by the Secretary to the same extent as is provided in section 205 (b) with respect to decisions of the Secretary, and to judicial review of the Secretary's final decision after such hearing as is provided in section 205 (g).

"(b) Specific language for provisions establishing local impartial hearing officers and appeal tribunals will be drafted on request.

*

*

*

TITLE IV-MISCELLANEOUS PROVISIONS

STUDIES AND RECOMMENDATIONS

SEC. 401. The Secretary of Health, Education, and Welfare shall carry on studies and develop recommendations to be submitted from time to time to the Congress relating to (1) the adequacy of existing facilities for health care for purposes of the program established by this Act; (2) methods for encouraging the further development of efficient and economical forms of health care which are a constructive alternative to inpatient hospital care; (3) the feasibility of providing additional types of health insurance benefits within the financial resources provided by this Act; (4) methods for improving the quality of health care provided under the program; and (5) such other aspects of the health needs of the aged and of the effectiveness of the program in meeting the health needs of the aged as may be recommended by the Health Insurance Benefits Advisory Council established by section 1712. Such studies may be carried on directly by the Department of Health, Education, and Welfare, by others under contracts negotiated for, or grants made by the Secretary, for such purpose; and may include appropriate demonstrations of health services for the aged and of activities for improving the quality of care and the effectiveness of administration in the program." and (4) the effects of the deductibles upon beneficiaries, hospitals, and the financing of the program:

[Editorial from J. chron. dis. 1963, vol. 16, pp. 1225-1227, Pergamon Press, Ltd., printed in Great Britain (received Oct. 8, 1963)]

KING-ANDERSON AND KERR-MILLS VERSUS THE AGED

The controversy over health care for the aged continues in the United States, and will become more heated during the election year of 1964. Lines have been clearly drawn between the Federal Government and organized medicine. Many lay and professional people are taking a firm stand with one group or the other. Debate rages principally over which method of payment for care is needed, but the question as to whether either program, at this time, can assure appropriate and adequate care has not been raised. It should be.

The Federal Government's program, typified by the King-Anderson bill type of legislation, has been extremely well developed by experienced physicians, fiscal authorities, and politicians. The same can be said for the AMA endorsed program (Kerr-Mills bill). The proponents of each stand can demonstrate, with statistics, unmet needs and ways to meet these needs. There are many lay and professional people, not dealing directly with problems of health care for the aged, who want to take a stand only after acquainting themselves with the problems. They can look, without emotion, at these statistics; however, when they do, they are mystified as to which figures are fact and which are fiction. The results of statistics from each camp frequently demonstrate opposite conclusions about the same population. Someone is wrong; maybe both are. While the verbal conflict continues year in and year out about how one should pay for such care, no one is demonstrating in a total community what appropriate care should be and what it should cost. Knowing what kind of care in a total community is needed, and its cost, would clear the air and point out areas where the two views could be reconciled. A demonstration of this sort is urgently needed before any decision is made about how health care for the aged is to be paid for. The grim reality is that if either bill is now implemented to its fullest potential, there will be a substantial waste of money and a very inappropriate type of medical care. There is not one community in the United States today tooled up to make judicious use of the funds of either bill when totally activated.

Programs do exist which focus on the many-faceted needs of the ill aged. The best examples of these programs are the hospital-based home care programs which are organized to utilize all facilities and personnel needed by this group. These have been developed in many urban and rural areas, and have beautifully demonstrated appropriate care of a selected group of aged people. If one examines these home care programs, it becomes obvious that funds are limited and careful selection of patients, by necessity, has been in order. Patients with the best potential for a longer and more independent life are chosen; those with limited potential such as the senile, the incontinent, and those with hemiplegia of long standing are understandably rejected from the program. What happens to the rejected patients who make up a sizable group and whose care in the future will be paid for under either Federal Government or AMA type bills? Frequently, no one knows, and when an answer can be provided, it is tragic,

to say the least. In addition to being able to serve a relatively small and selected group in the community, the home care programs discharge patients after stabilization occurs. It is obvious that the aged sick never really stabilize. However, if continuous followup and care goes on until death, the caseload of the home care programs becomes impossible for the small number of personnel paid for by the limited budget. What happens to the discharged patients? Frequently, no one knows, but when answers are available, they also are all too often tragic.

Home care programs are usually started as 3-year pilot studies sponsored by funds from local, State, or Federal grants. For many reasons, both good and bad, the designers of an inordinate number of these studies make their reports after 3 years and the programs fold. The community, which was being served in a limited fashion, no longer is served at all. The personnel involved in the study publish the report and move to another type of study. The home care programs can list ways to give excellent care for the aged, and outline needed improvements in the community, but more often than not, the recommendations are ignored. If a home care program is given ongoing financing after the 3-year pilot study, the financing continues to be very limited so that the community is still served only by an ongoing demonstration, and a communitywide service is not developed. There are good and bad reasons for this too. The money needed and gargantuan headaches involved in developing a communitywide service are the main reasons. As a result of the failure of these home care programs to take in their entire communities, no community in the United States exists which can serve as a demonstration to the rest of the Nation of what services are needed or what costs should be for its total aged population. One cannot extrapolate in this business. It is not sound to say that a program which is successful for a limited and selected group will be successful for an unlimited and unselected group.

Proponents of the Federal Government bill constantly point to the British Isles and Scandinavia as examples of how successful programs can be when financing is mediated through a nationwide plan. It may well be that health care for the younger population is a success in these countries, but health care of the aged is as inadequate and inappropriate there as in the United States. The general hospitals are crowded to capacity with the chronically ill aged; chronic hospitals are giant custodial care homes; nursing homes are taking care of people either in desperate need of acute hospitalization or not needing institutional care at all. These communities have long waiting lists of people trying to gain entrance to some institution, no matter how inappropriate or inadequate. There are exceptions to this in small, closely knit communities where an individual physician has dramatically transformed the health care of the aged, but one always worries that his program will collapse when he is no longer available to charge the batteries of the various institutions and agencies in the community. Also, there are a few remarkable demonstrations of health care for the aged in certain larger communities, but, not infrequently, these are so artificially created that they would not be adaptable to other communities where those engaged in sociomedical research were not in abundance. Rural areas with a large population, rural areas with a small but vastly scattered population and large urban areas in Europe are really not able to teach us what we need to know. While it is true that proponents of the Federal Government program have exaggerated ideas about European successes, it is also true that proponents of the AMA point of view are equally wrong to state, before a trial is made, that centralized programs cannot work if creatively and humanely conceived. The major point is that we need first to see, through several major demonstrations, what can be developed in different parts of the country in both urban and rural areas to meet local needs of all aged sick, and how much it will cost. Then we can decide what the best method for administering the program is and how most efficiently to pay for it.

The argument against the above point of view is that one must start somewhere. The fact is ignored that the patients rejected by existing demonstrations make up the lion's share of any population in need of health care. We must know what needs to be done for them or we will freeze the existing gross inadequacies in the care of this group. If either type of bill is implemented, the marginal terminal nursing homes and hospitals, which everyone bemoans, will continue to flourish. If either type of bill is implemented, payment for this type of inadequate care will be made and will make up the largest share of the cost of any program. Why should anyone pay for care which everyone admits is

27-166-64-pt. 5-24

poor? It is too easy to say that, for this rejected group, nothing more can be done. We must know what the best care for this group is just as we know now what the best care for the smaller selected group is.

Certain countries in Western Europe have paid millions of dollars every year for the past 30 years for health care of the aged, and yet tens of thousands of aged sick in these countries are inadequately cared for. Health officials abroad admit the care of these people is inadequate, but are doing little to demonstrate better, and perhaps less costly, ways of handling the problems. This inadequate care has been frozen because moneys were made available before appropriate care for all was developed. Why should the United States make the same mistake? We should not put into effect any health care bill before we are satisfied that each community has an understanding of what appropriate care is and what facilities, personnel and teaching are necessary. Then we will know that every dollar we spend is being used for enlightened care for all, no matter how poor the potential of each patient might be. There is no doubt that the American public, the leadership of which must come more and more from physicians, will be more willing to pay the cost of health care for the aged if it has the assurance that that care is the best which can be provided for every older person in need of medical attention, no matter how far advanced his disease may be or how little potential for return to physical independence he may have. Today we cannot give the American public that assurance.

In summary, there is too much talk today about how health care for the aged is to be paid for and how administered, and very little about what the care should consist of and how developed. We need to know a great deal more about what the finest care should be and how best to dispense this care. Large sums of money made available to all the Nation's aged at this time will only perpetuate the chaos and inadequacy which now exist.

MASON FAULCONER LORD, M.D.,

Physician in Chief, Department of Chronic and Community Medicine; Associate Chief, Department of Medicine, Baltimore City Hospitals, Baltimore, Md.

PORTION OF RADIO BROADCAST, January 6, 1964, AL QUINN "MARYLAND REPORT" A Baltimore physician of national note and with broad experience in chronic ailments, and particularly in geriatics, has published in a British medical magazine an article that could create considerable consternation in both camps of the U.S. debate over medical care for the aged. If it doesn't, it should.

The author of this rebellious article, reprints of which are now being distributed in this country, is Dr. Mason Faulconer Lord. He is physician-inchief of the department of chronic and community medicine, and associate chief of the department of medicine of the Baltimore City hospitals-and his piercing paper is published in the Journal of Chronic Diseases.

Now don't jump to the conclusion that Dr. Lord is against Federal medical aid to the aged. Far from it.

What he says in effect to both the proponents of the Kerr-Mills law, which has the blessing of the American Medical Association, and the King-Anderson type of proposed legislation, which is supported by the national administration is not a murrain on both your houses for your desires to help the aged ill-but rather for the inadequacies of both your programs.

What he states with emphasis is that, in all of the conflict between the two plans, no one is demonstrating in a total community what appropriate care for the aged is or should be and that such knowledge is absolutely necessary before the making of decisions as to how the costs of a program should be met. "The grim reality is," writes Dr. Lord, "that if either bill is now implemented to its fullest potential, there will be a substantial waste of money and a very inappropriate type of medical care."

Dr. Lord concedes that hospital-based home-care programs in many urban and rural areas have beautifully demonstrated appropriate care of a selected group of aged people-but the emphasis on the word "selected" is his.

Chosen for such care, he writes, are patients with the best potential for a longer and more independent life.

But, he demands, "What happens to the rejected patients-the senile, the incontinent, and those with hemiplegia of long standing?"