Details for Submission of Requests to be Heard

Requests to be heard must be received by the Committee no later than the close of business, Friday, September 23, 1977. Requests should be addressed to John M. Martin, Jr., Chief Counsel, Committee on Ways and Means, U.S. House of Representatives, 1102 Longworth House Office Building, Washington, D.C. 20515. The telephone number is (202) 225-3625. Notification of a witness' scheduled date of appearance will be made as promptly as possible after the cutoff date. Requests to be Heard Must Contain the Following Information:

(1) The name, address and capacity in which the witness will appear;

(2) A topical outline or summary of the comments and recommendations which the witness proposes to make.

Each witness is requested to present his oral statement in summary form; a more detailed statement will be accepted for inclusion in the printed record of the hearing. If necessary, witnesses may be grouped into panels to expedite the hearing process.

It is also requested that persons scheduled to appear before the Subcommittee submit 30 copies of their prepared statements to the Ways and Means Committee office (Room 1102 Longworth House Office Building) no later than Thursday, September 29, 1977. An additional supply may be furnished for distribution to the press and public on the date of appearance.

If a witness cannot appear on the day of the hearing, he may wish to either substitute another spokesman in his place or file a written statement for the record of the hearing instead of appearing in person. In any event, if a change in the scheduled witness or cancellation is necessary, please advise the Committee office immediately.

Written Statements in Lieu of Personal Appearance-Any person or organization may, instead of a personal appearance, file a written statement for inclusion in the printed record of the hearing. For this purpose, 5 copies of the statement should be submitted by the close of business, Friday, September 30, 1977. Additional copies may be furnished for distribution to the Members of the Subcommittee, the staff, press and public, if submitted to the Committee during the course of the hearing.

Ms. KEYS. We have as our first witness, Dr. Michael Goran, the Acting Associate Administrator for Health Standards and Quality. Dr. Goran is testifying for the administration.

Welcome.

STATEMENT OF MICHAEL GORAN, M.D., ACTING ASSOCIATE ADMINISTRATOR, HEALTH STANDARDS AND QUALITY BUREAU, HEALTH CARE FINANCING ADMINISTRATION, DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

Dr. GORAN. Thank you, Madam Chairman.

I am pleased to have the opportunity to appear before the subcommittee this morning to discuss with you the issue of nurse particpation in the Professional Standards Review Organization (PSRO)

program.

It is important to state at the outset that we appreciate the initiatives of this subcommittee in its support of effective peer review through the PSRO program.

The PSRO program represents a significant effort to assure that the medical care provided to beneficiaries and recipients of the medicare, medicaid, and maternal and child health programs is of high quality and that such care is provided in a manner which reflects the most appropriate and efficient utilization of our Nation's health care resources. Since the program's authorization in 1972, considerable progress has been made in realizing this goal.

PHYSICIAN PARTICIPATION IN PSRO PROGRAM

As you know, membership in PSRO's is limited by statute to physicians. This is in recognition of the fact that physicians have the primary responsibility for ordering health care services and supplies reimbursed under titles 5, 18, and 19 of the Social Security Act.

They have responsibility for determining the medical necessity of the health care reimbursed under these programs. This exclusive role of the physician provided the rationale for the congressional decision placing physicians in charge of the PSRO review system.

NONPHYSICIAN PARTICIPATION IN PSRO PROGRAM

The statute also recognizes the need, however, to involve other health care practitioners in the peer review process. It authorizes the PSRO's to utilize in the review system-the services of persons who are not physicians but who are involved in health care.

The provision of health care services today involves many health care disciplines, each practicing under specific professional standards. From the program's inception, we have uniformly encouraged the local PSRO's to actively involve all health care practitioners in the program.

It is important to note that we have consistently held to the premise that these nonphysician health care practitioners should participate in review of care provided by their peers when such review is being conducted by the PSRO.

In addition, PSRO's have the option of including such practitioners on their governing boards, to a maximum of 49 percent of the members. Membership of health care practitioners other than physicians on the statewide professional standards review councils is possible as public representative appointees.

At least one-half of the 7 to 11 members of statutory advisory groups to PSRO's and statewide councils must be health care practitioners other than physicians.

In recognition of the basic premise of the PSRO program that those providing health care services must be the ones performing the review, the department's proposed regulations on procedures for the review of hospital services requires early involvement on the part of nonphysician health care practitioners, both in the development of review criteria and standards and in the actual review of services reimbursed under titles 5, 18, and 19.

The PSRO program policies reflect this concept. Presently 31 PSRO's include nonphysician members on their governing boards. With the establishment of statutory advisory groups pursuant to July 1976 regulations, 15 advisory groups to PSRO's have been established.

Of these, all have at least one nurse member and four have more than one. Furthermore, reports of medical care evaluation studies being carried out under PSRO auspices indicate that, through December 1976, nurses participated in a growing number of MCE studies.

The Arkansas PSRO and the Minnesota PSRO conduct multidisciplinary medical care evaluations of which nurses play a vital role. In addition, Montgomery County, Md., and eastern Connecticut PSRO's have established nonstatutory advisory committees comprised exclusively of nurses.

The Department recognized the importance of nurse participation in the program when, in 1974, a contract was awarded to the American Nurses Association in the amount of a quarter of a million dollars to develop sample criteria for assessing nursing care to be used as technical assistance for PSRO's.

The criteria which were developed have been disseminated to all PSRO's and short stay hospitals in the country. Sensitivity has been consistently displayed to: One, the need to provide input to the council from such practitioners regarding policy recommendations; two, the degree of physician acceptance of the PSRO program and the degree of physician readiness to expand the program to include health care practitioners other than physicians; three, the options of the physician membership of the local PSRO's; and four, the desire to treat all disciplines equitably.

At the national council's request, an option paper dealing with the issue of expanding membership of the council and PSRO's to include dentists, was presented during its March 1977 meeting.

Because dentists are recognized as independent initiators of care, are often accorded medical staff privileges in hospitals, and are permitted under medicare to independently certify the need for hospital admission, it was concluded that the profession of dentistry held a special status distinct from the other nonphysician disciplines.

The decisions of dentists over hospital admissions and lengths of stay obviously impact upon hospital utilization and costs of care. The council recommended an amendment to the Social Security Act to permit the PSRO to exercise a local option to expand its membership to include independently licensed health care practitioners other than physicians who are members of hospital medical staffs and who hold independent hospital admitting privileges.

In light of the knowledge that other disciplines were pursuing legislative action to accord PSRO membership privileges to their members or seats in the national council, the council requested another option paper dealing with the issue of further changes in the PSRO statute or administrative actions to assure appropriate participation of health care practitioners other than physicians and dentists in peer review under the aegis of the PSRO program.

This paper was considered by the council during its May 1977 meeting. Although the council decided against recommending any further legislative action at this time, the council strongly urged PSRO's to implement existing policies with respect to participation of health care practitioners other than physicians in the review system, and advised the Bureau of Health Standards and Quality to assist PSRO's in their implementation of the current policies. The council also encouraged PSRO's to establish optional committees of health care practitioners other than physicians to provide assistance to the PSRO's in implementation of existing policies.

HEW RECOMMENDATIONS

Registered nurses not only comprise the largest number of health care professionals in the Nation (961,000) but represent the health care practitioner other than physician group contributing service in the majority of all health care episodes and over the greatest continuum of time. The significance of the potential for registered

professional nurses to impact upon the quality of health care to beneficiaries under the act is, therefore, greater than any other single health care practitioner other than physician discipline.

As you are well aware, the Department does not support legislation to mandate the membership of nurses in PSRO's and has resisted similar proposals in the past. I am pleased to announce, however, that we now support increasing the participation of nurses and other health care practitioners in the professional standards review process. Their participation is deemed important to its integrity, quality, and thoroughness. A number of options are under serious consideration, including expansion of the National Professional Standards Review Council to include nonphysicians, establishment of a health care practitioner advisory council, participation by them in advisory groups to statewide professional standards review councils, and granting local PSRO's the option of including dentists. Were nonphysicians to be included on the national council they would not be eligible to vote on matters only affecting physicians.

In conclusion, it is fair to say the Department is pleased with the growing support for nonphysicians that is taking place in local PSRO's throughout the country and does recognize the need for additional support at the national level.

It is currently exploring the options I mentioned above and should shortly have recommendations to make to you.

Thank you. I would be happy to answer any questions.

Ms. KEYS. Thank you, Dr. Goran. I am a bit disappointed in the substance of your testimony. I had hoped that some of the conversations we had been having with the Department would be a bit more fruitful in terms of actual substantive legislative subjects for change. Mr. Pike?

Mr. PIKE. Thank you, Madam Chairman.

I don't know whether I am disappointed or not, I guess the best thing to say is I am not surprised. I enjoyed your statement very much. It was a classic statement. Nurses are magnificent, they are great, we need them, don't do it.

Having said that, I guess I will wait and listen to the other witnesses. Ms. KEYS. Mr. Duncan.

Mr. DUNCAN. Thank you, Madam Chairman.

First, I have a statement I would like to put in the record at this point.

[The statement referred to follows:]

INTRODUCTORY REMARKS OF THE HONORABLE JOHN J. DUNCAN

Mr. Chairman, I am very pleased that we are conducting this hearing today, on a very important topic. At our recent markup on H.R. 3, there was a great deal of discussion with respect to the role that nurses should play in professional standards review organizations. Although a great many issues were raised, we lacked sufficient time to obtain information and develop alternatives in this area. I commend the chairman for the promptness with which he has scheduled this hearing, so that we may now go forward.

The role of PSRO's in our health care delivery system appears to be growing with each passing day. As might be anticipated, this growth has produced many benefits, and also some puzzling questions. One of the most significant questions concerns the role that health professionals, other than physicians, may play in determining policy and performing activities that PSRO's are required to undertake. There can be no doubt that the nursing profession, with its wide-ranging

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responsibilities for patient care, has a great deal to contribute to appropriate development of the peer review process, and I very much look forward to learning from our witnesses of the problems and proposed solutions that we must face in developing legislation in this area.

I therefore am pleased to welcome our witnesses to this hearing, and want to thank them for the testimony that they will provide.

Mr. DUNCAN. Dr. Goran, do you have utilization committees in the hospitals that do service for the PSRO's?

Dr. GORAN. Yes; in many hospitals the committees are in the hospitals. They are always comprised of physicians and they may include other health care practitioners as well. When other practitioners other than physicians are being reviewed, they must include those practitioners.

Mr. DUNCAN. Are you talking about nurses?

Dr. GORAN. Nurses, dentists, podiatrists, et cetera.

Mr. DUNCAN. That is all, Madam Chairman.

Thank you, very much.

Ms. KEYS. Mr. Burleson.

Mr. BURLESON. No questions, Madam Chairman. Thank you.
Ms. KEYS. Mr. Ford.

Mr. FORD. No questions.

Ms. KEYS. Mr. Gradison.

Mr. GRADISON. No questions.

Ms. KEYS. Mr. Goran, how many nurses do we have in this country? Dr. GORAN. I believe a little under 1 million.

Ms. KEYS. What are the specific responsibilities of the PSRO? I think I am correct in my understanding but I would like you to state for the record the specific actions they are authorized to take regarding hospitals review, long-term care review, and ambulatory review.

Dr. GORAN. As you know, statutorily PSRO's are responsible for reviewing the medical necessity, the appropriateness of the level of care, and the quality of services provided to medicare's medicaid beneficiaries.

Most of these services are provided by physicians and other health care practitioners. PSRO's throughout most of the country are initially focusing their review work in hospitals, and initially on physician services within hospitals.

As they developed, they are to expand not only outside the hospital setting to other institutions but to the other disciplines that provide services and as they do that they are to involve the other disciplines in the review process, so that, for example, nurses are to set the standards of care that are to be used to review nursing services and to be involved in decisions about the quality of nursing services and the same would be true of other health care practitioners.

Ms. KEYS. I have a real problem figuring out how the determination can be made about quality of care in those setttings without the inclusion of the nurse as a primary care provider since she, or he, and I don't mean to limit my comments to what happens to be the majority of the profession at this time, but since that person is involved consistently with every single patient whose care is reviewed.

Dr. GORAN. So do we. That is why in all the program policies and the hospital regulations that have been proposed it is explicitely required that when other disciplines are to be reviewed they must participate not only in the review process but in the establishment of the standards that are to be used.