One of the things that we are most encouraged about is the fact that many PSRO's are beginning to do review across disciplines at the same time, particularly through what are called the medical care evaluation studies where they will look at the services not only provided by physicians but the other disciplines and do it through one study, a multidisciplinary approach. That is something that both our national council and the Department have been encouraging and it has been growing in frequency over the last year.

Ms. KEYS. The encouragement of the PSRO's to include other professionals is one thing, but could you tell me why I definitely had the opinion that you were going to come before us and recommend three health professionals on the national council, including at least one nurse, including other specific changes in the legislation which has been introduced?

Could you tell me why you changed your mind?

Dr. GORAN. I fully expected to come forth with specific proposals along the lines of the options I discussed in the statement. The fact that we presented them as options has to do with the desire of the Secretary and Under Secretary to continue to explore whether this is the best mechansim to expand the role of other health care practitioners.

I don't think it represents any backing off on the part of the Department. We do fully intend to come forward with specific proposals along these lines. The Secretary wanted an opportunity before finally making his mind up to consult with the PSRO's more thoroughly and with the affected health care practitioner groups other than physicians more thoroughly about these specific proposals.

They do include: Establishment of a nonphysician health care practitioner advisory council to represent all the disciplines, not just the nurses; expansion of the national council; a requirement that nurses participate on statewide advisory groups, and allowing PSRO's the option to include dentists locally.

Ms. KEYS. Might I ask you one last question before I ask the chairman to take his turn at inquiring or speaking, whatever he wishes.

Once again, the PSRO's are comprised of how many other health professionals or how many nurses, the ones you are going to consult with recommendations for changing this program?

Dr. GORAN. The current PSRO membership, as you know, is restricted to physicians.

Ms. KEYS. I realize that. It seems to show the fallacy of asking the PSRO's whether or not other health professionals ought to be included.

I would suggest to you that you listen to the message here today and take that message back to the Secretary. It might help him make up his mind.

Mr. Chairman?

Mr. ROSTENKOWSKI. I have no questions, Doctor, thank you.

Ms. KEYS. Thank you, Dr. Goran, for coming. The hearing will suspend for 10 minutes.

[Brief recess taken to vote.]

Ms. KEYS. We are back from the vote and hope we have a while to proceed before the next one.

I see sitting before us our next witness, the Honorable J. J. Pickle, a member of the Ways and Means Committee.

Welcome, Mr. Pickle.

STATEMENT OF HON. J. J. PICKLE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS

Mr. PICKLE. I thank you, Madam Chairman, and I want to thank you and other members of the committee for the opportunity to present my views on this question.

Public Law 92-603, which was signed in 1972, created the Professional Standards Review Organizations as a federally mandated review system. Initially, this system was to review care given to all title V, XVIII, and XIX, recipients in short stay general hospitals. The review system is expanding to include long-term facilities and outpatient care.

Congress created this view system to promote quality health care at a level which is most economical and consistent with the patient's needs.

Congress also decided that the best way to conduct this system would be through peer review-by those who are actually involved in providing health care.

However, when we passed this amendment to the Social Security Act, we excluded independent primary health care professions from any meaningful participation in the program.

I have introduced a bill, H.R. 8887, which would amend the Social Security Act to include optometrists in the professional standards review organizations. The main purpose of this legislation is to extend this concept of peer review to our Nation's third largest independent health care profession which provides two-thirds of our Nation's vision care.

While optometrists are subject to review by the PSRO, they have no formal mechanism to make suggestions or have a say in what kind of guidelines might be set. Since optometrists are undoubtedly more familiar with just what constitutes quality optometric care than are neurologists or obstetricians, I think optometrists should be represented on State and national supervisory boards. The same holds true for other independent health care professions, in and out of the hospital.

My bill would require each independent health care group to evaluate its own specific practices and needs, rather than assuming that only M.D.'s and osteopaths are qualified to draw up standards for the various areas of health care.

Optometry is the only professional health group qualified to review the care given by optometrists. By virtue of their specialized education, training, and practice, they are capable of fully reviewing optometric patient care situations to guarantee that each individual receives the quality care that he or she needs at a reasonable cost.

I don't see how we can expect or require one professional to set standards for evaluating and reviewing another profession. I think that this violates the entire concept of peer review.

Madam Chairman, I would hope that you and the other members of the subcommittee would agree with me that the main purpose of this debate is to insure that we protect individuals from inadequate or

unreliable health services and to protect the public funds that are used to pay for these services. When you consider the fact that threefourths of all medicaid vision services are delivered by optometrists, I don't see how we can continue to shut this group out of our professional review system.

Peer review was the idea behind the professional standards review organization in the first place. I think we should strengthen that principle by allowing optometrists professional supervision of themselves.

I am confident that you will give this proposal your full consideration because I believe it is a fair and reasonable approach to protecting those who receive and provide health care under our Federal programs. Madam Chairman, that concludes my statement. I would be pleased to answer any questions or respond to any inquiry.

Ms. KEYS. I thank the gentleman for his testimony. I know you have had an interest in the inclusion of other health care professionals for a long time as we have talked together before on the issue. Mr. Ford?

Mr. FORD. I just want to ask our colleague, Mr. Pickle, one question. I have a tendency to agree with you. What if the physicians put up an argument about ophthalmologists being those who would serve on the PSRO Council?

Mr. PICKLE. Ophthalmologists are M.D.'s and they are represented now by virtue of the present system.

Mr. FORD. What if they would say that they could represent the optometrists on the PSRŎ?

Mr. PICKLE. I assume that is their argument now that they are knowledgeable in the field of vision care, put their knowledge is one particular area, primarily that which pertains to operations and that type of thing.

Their knowledge is not as thorough in the field of vision as optometrists and that is their sole responsibility. That is not true in the case of ophthalmologists. I have never heard of an ophthalmologist that says we are represented because we are on that board.

They are not the same group.

Mr. FORD. I am not in disagreement with you, Mr. Pickle, I just wanted to ask the question.

Ms. KEYS. Mr. Duncan?

Mr. DUNCAN. Thank you, Madam Chairman.

I want to thank our colleague for his usual good presentation. You always contribute much to any particular piece of legislation you take an interest in. What would be your views on other professions such as dentists, oral surgeons, and the like?

Mr. PICKLE. My bill limits it to optometrists but my statement I hope left the impression that I think other groups should be included. I admit you may have a problem in trying to include everybody but at least you ought to include two or three of the major groups that are not included right now. I would say, for instance, nurses.

I understand that in many respects, the dentists are not represented in any way except in very limited matters. So I would include my bill says for optometrists but I don't see how you could exclude oneor two others.

Suppose you did include three more, that does not make the organization cumbersome or unwieldy. In the case of optometrists that would give representation to 30,000 or 35,000 optometrists throughout

the United States. I don't see now the medical group can legitimately object to that, so I would expand it.

I think, Mr. Duncan, I don't see how we can do anything except admit that we are heading in that direction. I am told the administration testified this morning that they would be against including, I think, nurses at this instance, but they go on to say that they recognize it is a coming thing and they want to have a review committee to study different options and bring them into it at some point either on a local basis or administratively.

So I think they see we have to expand this in some capacity. We acted this week on H.R. 3, that is the medicaid and medicare abuse program and one section of that mandated developments of ambulatory care review methodologies for use by PSRO's and requiring PSRO's to review ambulatory care not later than 2 years after it is to achieve operational function ability.

We are saying in the case of optometrists or outpatient care in th field of medicaid and vision; you must have this kind of service and we are mandating it.

If we are. then, surely we ought to put representation on these committees of those groups that are so directed.

Mr. DUNCAN. Do you see any useful purpose coming from a long study on this as suggested by the administration?

Mr. PICKLE. I do not. It does constitute problems and I know the committee would have to decide what groups would be included. Mr. DUNCAN. I am not talking about us.

Mr. PICKLE. I don't think it would constitute any problems. I think they could have done it administratively in some ways. I don't think there is any need for a long study.

I think we have reached a point now where we ought to do it or not do it.

Mr. DUNCAN. Thank you very much, sir.

Thank you, ma'am.

Ms. KEYS. Mr. Gradison?

Mr. GRADISON. No questions.

Ms. KEYS. Mr. Brodhead?

Mr. BRODHEAD. No questions.

Ms. KEYS. Mr. Pickle, would you agree that optometrists as a profession are not involved in all or even a very large majority of the cases that are really reviewed or the delivery of services to persons that are reviewed by PSRO's?

Mr. PICKLE. Their responsibility is limited to that which pertains to vision, that is true.

Ms. KEYS. Would I have your agreement that in the present exercise of PSRO responsibility, that is, the review of hospital care, the review of long-term care, and ambulatory care review which PSRO's have not begun to do yet-there is one other health care profession that is involved in the service that is delivered to every patient being reviewed?

Mr. PICKLE. I don't know whether there is or is not, Madam Chairman. I would admit that vision and vision care is something that optometrists would be concerned with only and it would not be in the broad spectra of health facilities. But the problem we face in this whole entire matter is that so far it has been limited to just the M.D.'s and the M.D.'s alone.

You might expand it and you might say the optometrist might have a little more limited coverage, but I think that is just an argument and is not based really on the facts of the situation.

Ms. KEYS. I am not trying to object to the gentleman's interest in optometry; I merely hoped to have your recognition that there is one profession which delivers primary health care the nursing profession that is involved in every patient case under the review of PSRO's at the present time.

Mr. PICKLE. Yes; I would certainly admit that or agree to that. That is why I would say the nurses certainly ought to be included on it.

Ms. KEYS. I thank the gentleman for his testimony.

Mr. PICKLE. Thank you.

Ms. KEYS. We now have a panel and I would invite them to come forward and take their places at the table.

Russell Tranbarger, president-elect, North Carolina State Nurses' Association; Judy Zoellner, chairperson, committee on practice, Illinois State Nurses' Association; Patsy B. McClure, president, Tennessee State Nurses' Association; Roberta Thiry, president, Kansas State Nurses' Association.

Mr. DUNCAN. Could I interrupt?

I wonder if they could sit right to left the way you called them. Ms. KEYS. Mr. Tranbarger beginning on the right, Miss Zoellner, Miss McClure, Miss Thiry, then Ruth Stewart, president, Texas State Nurses' Association; Dr. Virginia Barker, president, New York State Nurses' Association; Dr. Charles White, executive director, California Nurses' Association; Miss Claire O'Neil, president, Connecticut Nurses' Association; and Miss Sandy Byers, president, Ohio Nurses' Association.

Are there enough chairs there?

Beginning the testimony of the panel is Miss Joan Guy, secretary of the American Nurses' Association, accompanied by Connie Holleran and Marie Zimmer.

A PANEL FROM THE AMERICAN NURSES' ASSOCIATION CONSISTING OF JOAN GUY, SECRETARY; ACCOMPANIED BY MARIE ZIMMER, SECRETARY OF THE DIVISION OF MEDICAL-SURGICAL NURSING AND DIRECTOR OF NURSING SERVICE/CLINICAL PROFESSOR OF NURSING AT THE UNIVERSITY OF WISCONSIN; AND CONNIE HOLLERAN, DIRECTOR OF ANA'S WASHINGTON OFFICE; CHARLES WHITE, PH. D., EXECUTIVE DIRECTOR, CALIFORNIA NURSES' ASSOCIATION; JUDY ZOELLNER, CHAIRPERSON, COMMITTEE ON PRACTICE, ILLINOIS STATE NURSES' ASSOCIATION; PATSY B. MCCLURE, PRESIDENT, TENNESSEE STATE NURSES' ASSOCIATION; SANDRA BYERS, OHIO NURSES ASSOCIATION; RUTH STEWART, PRESIDENT, TEXAS STATE NURSES' ASSOCIATION; ROBERTA THIRY, PRESIDENT, KANSAS STATE NURSES' ASSOCIATION; RUSSELL TRANBARGER, PRESIDENT-ELECT, NORTH CAROLINA STATE NURSES' ASSOCIATION; DR. VIRGINIA BARKER, PRESIDENT, NEW YORK STATE NURSES' ASSOCIATION; AND CLAIRE O'NEIL, CONNECTICUT NURSES ASSOCIATION

Ms. GUY. Good morning.

I am Joan Guy, secretary of the American Nurses' Association and executive secretary of the Michigan State Nurses' Association. With