On the average, about three times as many people will be required to work on UR activities as hospitals have had in the past. II. Discharge Planning Of the reporting under 200 bed hospitals: 9 people were designated for discharge planning responsibilities a year ago, 25 persons have the responsibility now, and 32 are projected for the future. Of the reporting 100-200 bed hospitals: 19 people were designated for discharge planning responsibilities a year ago, 31 have the responsibility now, and 37 are projected for the future. Of the hospitals over 200 beds reporting: 17 people were designated a year ago, 20 now and 24 projected for the future. III. Most Common Limitations and Problems with Implementation of UR Regs Increased Personnel Time Limited Physician Cooperation and Acceptance Limited Physician Time Increased Cost Availability of Qualified Personnel Number of 20 17 14 12 6 Need Unified Approach to Medicare and Medicaid Other limitations mentioned were: problems ir. writing criteria; motivating staff and physicians; lack of documentation on records; adverse public relations with patients and physicians, and legal implications. Senator NUNN. Thank you very much. I would like to ask some questions but I think we better move on to Dr. Rogers and Mr. Bishop because of the time pressure. TESTIMONY OF DR. HARRISON L. ROGERS, JR., CHAIRMAN, NATIONAL LEGISLATIVE COMMITTEE, MEDICAL ASSOCIATION OF GEORGIA Dr. ROGERS. Mr. Chairman and members of the subcommittee, I am Dr. Harrison L. Rogers, Jr., chairman of the National Legislative Committee of the Medical Association of Georgia. I also serve as a delegate to the American Medical Association for the Medical Association of Georgia and a delegate to the American Hospital Association. For your information, Mr. Chairman, our association represents some 4,300 physicians in the State. We are deeply concerned over the large number of regulations placed on the practice of medicine by an equally large number of agencies. We recognize the need for regulations. Many times, they add clarity to statutes that make working with them easier. I think with various agencies making regulations in similar areas there is always the danger of changing congressional intent or creating conflicting regulations. We are pleased to see the committee holding these hearings and are especially pleased to have remedial 1gislation introducd in the two Houses of Congress by members of the Georgia delegation. I would like to cite three recent examples that point up some of our reasons for concern with the regulatory process. The first example occurred when Social Security promulgated regulations dealing with utilization review in hospitals. These regulations were based on sections 207 and 237 of Public Law 92-603, and would have required physician certification of all-except emergency-hospital admissions prior to admission. These regulations were finally withdrawn by HEW but not until the American Medical Association had filed suit against the Depart ment. Before their withdrawal they were the focal point of much discussion in the profession and with the hospitals. These regulations had heen promulgated in spite of massive negative comments which, in addition to total opposition, called for extension of the comment period. The comments and request were disregarded by the agency which obviously had determined the issue, in its own mind, before the comment period even began. The second example I would call to the committee's attention is one again dealing with Public Law 92-603, this time section 224 of that law. Section 224 establishes an economic index which arbitrarily limits the prevailing charge level of physicians' fees recognized by medicare. As published in proposed form, HEW indicated it would base the index on nonmedical criteria, that it would apply the index on a procedure by procedure basis, and that it would not include the index in its regulations. The regulations were incomplete and inconsistent with the statute and with the language of congressional reports which spoke of regional indices, medical economic criteria and gave examples of how an index might be constructed. The AMA requested an extension of the comment period for thirty days beyond the 30 days set by HEW. This was denied in a letter dated one day after the close of the comment period. The final regulations were to take effect on July 1, 1975 and were published in final form on June 16. There was little substantive change in the final regulations, and to compound an already bad situation, HEW published concurrently, in the form of a notice, an economic index along with the relative values assigned to the components of the index. The index became effective also on July 1. No opportunity was given the public for comment on any major part of the index. Much to the credit of Congress, the House Ways and Means Subcommittee on Health held two hearings on these and other regulatory procedures of HEW and they have approved some proposals to relieve hardships resulting from the index. We happen to know in this case, HEW spent 212 years studying and preparing these regulations and allowed interested parties only 30 days to review and comment. The third example I would like to bring before the committee deals with the National Health Planning and Resources Development Act, signed into law on January 4, 1975. This act is intended to mandate a national system of health planning which will have an influence on all facets of health-everything from facilities and manpower to resources. One provision of the act allows a pilot project for rate setting in six States and requires that notification by a Governor be submitted to the secretary. On July 3, 1975, the secretary published a notice that such requests must be submitted by July 4. In the notice was a copy of a letter which was referred to as having been sent to all Governors on June 9. However, the July 3d, notice was the first given to the general public. On September 17, the Secretary published, as final rules, the regulations for a State seeking a grant for rate regulation. No proposed rules had been published at that time. On October 17, the secretary published proposed rules for the health systems agency, which is the basic operational unit of the health planning concept. These units will be responsible for planning, approving or denying health facilities and for carrying out the health plan for their area. You can appreciate the impact and importance of the regulations, which, as time goes by, will come at a rapid pace. It is a frightening prospect to think that only 30 days will be given for analysis and comment on rules and regulations that will touch the lives of every American. Mr. Chairman, I am sure you are aware of the recent law suits filed by the AMA on behalf of the public and its members. This process is distasteful, but appears necessary for the protection of physicians and our patients. As you may know, here in Georgia, our association has filed suit against the State medicade program seeking relief from regulations that directly and frontally attack the very heart of medicine, the inviolate physician-patient relationship. Mr. Chairman, there are many other examples of regulations and rules issued in direct contradiction to congressional statute and intent, examples where an agency has used its regulatory power to broaden legislative language or ignore a statute's mandate. The time has come to place closer control over regulations and those who would issue them. Many times we have seen that an agency avoids the rule making procedure by the nebulous terminology that it is "impracticable, unnecessary or contrary to the public interest." I submit to you that rules and regulations that impact on the health care of Americans are most necessary, and certainly not contrary to public interest. We think agencies should give full statements when they choose not to submit regulations to full rulemaking procedures. Presently, only a brief statement is required for not doing so. Extending the comment period to 60 days is more realistic than the current policy of 30 days. Additionally, we think that interested parties should have the right to request and be granted a public hearing on matters of significant interest to the public. Mr. Chairman, we cannot begin to relate many of the changes that could or probably should be made. Time does not permit. It is most important to us that we have been allowed to participate in these hearings today. We thank you for the opportunity and I would be pleased to answer any questions if the committee desires. [Additional information supplied for the record by Dr. Rogers follows:] Hon. SAM NUNN, HARRISON L. ROGERS, JR., M.D., SIR: I did appreciate the opportunity of presenting the Medical Association of Georgia's testimony to the Senate Subcommittee on 2/12/76 here in Atlanta. Organized medicine in the state and across the nation owe both you and Representative Levitas a debt of gratitude for your efforts on behalf of the American public, our patients. I received today the AMA Newsletter dated 2/23/76 which included a notice of HEW's plans requiring the Social Security number of patients and their attending physicians on forms for the "Uniform Hospital Data Set" used in Medicare, Medicaid, and other federal programs. It has been the policy of AMA as well as the Medical Association of Georgia to hold inviolate the right of a patient to confidentiality of his medical records, and in one great edict HEW has ordered this confidentiality surrendered! This is simply another example of the misuse of the Federal Register in the rule making process which I thought should be brought to the attention of your committee. Thank you once again for your kindness and courtesy. Sincerely, HARRISON L. ROGERS, JR., M.D., Chairman, National Legislative Committee, Medical Association of Georgia. * AMA NEWSLETTER, VOL. 8, No. 7, FEBRUARY 23, 1976 * * A Federal plan to identify patients and physicians in data collected by hospitals is not authorized by law, the AMA told HEW last week. The plan, which was published as a "notice" of implementation in the Jan. 16 Federal Register, requires the Social Security number of patients, attending physicians on forms for the Uniform Hospital Data Set used in such programs as Medicare, Melicaid and PSRO. HEW urged hospitals to adopt the form as soon as possible. The AMA said such a plan should have been promulgated through formal rulemaking procedures. In its comments to HEW, the AMA said it was "shocked" by the government's proposal for a Uniform Hospital Discharge Abstract, which would allow patients and physicians to be "clasified, identified, matched, compared, reviewed, and computerized with the impersonal ease of electronic machines." The AMA pointed out that HEW's own advisory group on data collecting had recommended that the government collect no information that would, by itself, permit identification of individuals. The HEW plan may be in violation of the 1974 Privacy Act, the AMA said. At the 1975 Clinical Convention the AMA House of Delegates voted to protest HEW's action setting up procedures involving Social Security numbers in violation of confidentiality. Senator NUNN. Thank you very much, Dr. Rogers. STATEMENT OF GENE BISHOP, THE GEORGIA NURSING HOME ASSOCIATION Mr. BISHOP. My name is Gene Bishop and I am speaking on behalf of the Georgia Health Care Association, formerly the Georgia Nursing Home Association, which is a nonprofit trade association representing approximately 273 proprietary and nonproprietary nursing homes in Georgia My remarks address the subject of the impact of Federal regulations on long-term health care. Currently in Georgia, more than 70 percent of the patients cared for in nursing homes receive reimbursement assistance from public health care programs such as medicaid, medicare, or veterans benefits. Of the 300 nursing homes licensed in Georgia, only three or four do not participate in any Federal program. The vast majority of nursing homes provide services and are reimbursed under the title XIX medicaid program. To participate in the skilled nursing program under medicaid, a facility must meet and maintain more than 526 Federal standards and conditions of participation. The facility must also meet the 1967 Life Safety Code as well as numerous other regulations which affect all businesses such as OSHA, wage and hour, et cetera. The nursing home of the 1970's would have to be considered one of the most highly regulated entities in America today, bordering on being considered a public utility. I would be remiss if I did not say that Federal programs in long-term health care have resulted in an improved quality of life for many Americans in need of nursing home care. But the myriad of regulations and requirements are beginning to reach a point of diminishing return and the system is breaking down. Georgia is in the throes of a medicaid crisis and more than $1 million per month in nursing home payments has been cut beginning December 1, 1975, in order to continue a viable program. Federal medical assistance percentages which match State funds for medicaid have decreased from 81.7 percent in 1968 to 66.1 percent in 1976, while at the same time, program costs have escalated out of sight. This places a tremendous burden on the State. The Social Security Amendments of 1972 are having a significant effect on long-term health but the regulations which interpret the statutes fail to evaluate economic impact of increased regulations. During 1972 and 1973. more than 160 Georgia nursing homes installed sprinkler systems and fire safety devices in accordance with the 1967 |