legislation itself, even in the law as it now stands. It does allow up to 49 percent of local PSRO's to be other than medical doctors, and is does specifically allow for members of the statewide councils to be other than medical doctors, including even consumer representatives or other health professionals.

Mr. PETERSON. Madam Chairman, I think our statement was that the primary congressional intent was for review of medical care by physicians.

We recognize, of course, that the broader thrust of the law was for a review of care furnished in institutions and by-and for care furnished under titles V, XVIII, and XIX of the Social Security Act with respect to the various types of care.

The point is that the law also provided the mechanism for the input of these other health care practitioners into the peer review mechanism, the PSRO law, and the further point is that while the primary responsibility was placed upon physicians, the PSRO's may draw upon the expertise of the various other health care practitioners in discharging this function.

For example, the statewide council was directed to be composed of other than physicians so that there would be input from the other health care practitioners.

And in addition, there is the advisory council to the statweide PSRO council which adds additional input into the PSRO function, and this advisory council is to be composed of other than physicians. In addition, the National Council, of course, can also draw uponis authorized to draw upon-assistance and expertise as it desires. Ms. KEY. But in spite of the recognition by Congress that encouragement should be given, recognizing that it should begin with physicians reviewing medical necessity, there has been very little involvement of other professionals under this system as it is now.

Of course, there is the glaring omission of a seat on the national governing board.

You spoke of the fact that you believe this fully represented the interests of Congress in setting up such a system and in continuing it that way. As a Member of Congress, I would suggest to you that I do not believe it does. The HEW Commission which studied our health care system, the Commission appointed by President Nixon, came out with a very long and detailed report in 1975 pointing to a very obvious problem in our health care delivery system-the monopolistic control of the medical profession and the lack of inclusion of other health professionals in decisionmaking.

Since that time, Congress has become more aware that health care is the name of the game and that our laws are keeping us from delivering quality health care. So I do take very strong issue with your statement regarding the satisfaction of Congress with the legislation which mandates the makeup of the board at the State, national, and even local level regarding other health care professionals.

Dr. GLASSON. The National Professional Standards Review Council, on which I understand the nurses' group is requesting representation, is an advisory council. I have heard that they do not like the advisory role, but this is actually an advisory council which advises HEW, as I understand it.

Mr. PETERSON. I would add an additional comment, Madam Chairman, because you have indicated some limited involvement

with respect to nurses in particular but others as well in the development of the PSRO program.

I think we should keep in mind that the program is relatively new. Moreover, there was the great deal of delay in the implementation of the program. It is now, I might say, just beginning to become more fully implemented. In some areas the PSRO's are still in the developmental stage.

I would remind the subcommittee that part of the delay in the implementation of the program has been through inadequate funding by the Congress. So I think as we observe the continuing development of the program, we would expect to see, also, a further involvement of all the various types of health care practitioners within the framework of the law as it is now constituted.

Certainly we would encourage the development and the use of these various practitioners as the law has requested and has created the role for them.

Ms. KEYS. I thank you, Mr. Peterson.

Dr. Glasson, do you see a difference in definition of "health care" and "medical care"?

Dr. GLASSON. Absolutely, and I agree with it completely.

Ms. KEYS. I appreciate that. I think that provides some hope. When you look at the responsibilities of the PSRO, that they review not only medical necessity but appropriateness of setting, length of stay, and even fraud and abuse questions-the Congress recently gave PSRO's a greatly broadened mandate to review in their individual States and communities the problem of fraud and abuse-it is hard to find that there isn't a mandate to review total health care delivery and not just medical care or medical necessity. Would you agree with that?

Dr. GLASSON. I did not state that it was limited to medical necessity. I agree completely and my association agrees completely that the basic objectives of the PSRO program included quality, appropriate site, and medical necessity.

I value greatly and recognize, and I think all of us recognize, that large and important role that nurses have played in the implementation of PSRO's. Indeed, the program wouldn't be where it is today or anywhere near where it is today without this participation.

As has been outlined by the nurses' group earlier this morning, the roles of nurse coordinators are vital, essential, and serve to make the program go well.

So the statment that I made has nothing in it-nor was it intendedto indicate that this is not an important function. I think the issue is really one as to whether Congress wants to include in the policymaking level all health care providers or whether they want to center it in physicians.

Thus far they have centered it in physicians.

Ms. KEYS. Ďr. Glasson, one of the things that we faced in the oversight hearings last year which necessitated passing the fraud and abuse bill was the tremendous ripoff as a result of hospital stays that were longer than they should have been, double billing, and by many other things. If we were to effectively set standards for reviewing the appropriateness of this and since nurses certainly contribute a great deal to the recovery of the person that is hospitalized, how can one possibly do an adequate review if there is no involvement in policy

making by those persons who actually contribute to the recovery of the patient.

Dr. GLASSON. There can be no question but what they must be utilized in the decisions of the policymaking board.

Ms. KEYS. Do you share our concern about the abuse and fraud in the system which has contributed to a great deal of wasted Federal dollars?

Dr. GLASSON. We are very much concerned about this, and we are very interested in correcting any fraud and abuse that is uncovered.. Ms. KEYS. Then in the larger role that we have asked the PSRO's to accept in the fraud and abuse bill, would you not welcome help in policymaking by those who are probably at least equally involved in the determination of whether or not that patient recovers quickly or has the health education that will prevent them from returning to the hospital?

Mr. PETERSON. If I might make a comment at this time, Madam Chairman, the association is very much concerned, as Dr. Glasson has indicated, with any fraud and abuse that might exist wherever it exists-regardless of the type of setting that it may be found in.

Certainly the role of the PSRO should be examined very closely with respect to this. The question that I would raise at this point is whether you would visualize at this time the PSRO as being the primary agent for the uncovering of any fraud and abuse?

The Congress created the PSRO as the vehicle for review of services with respect to the medical necessity and the quality of care provided. Within that framework, the contemplation was that the quality of care could be improved and as a secondary aspect, then it would have a cost-effective role insofar as the quality would be improved.

As I have indicated, the PSRO is in many ways a rather fledgling organization. Physicians are responding, and they are responding very well, with respect to the program on the overall.

Now, if the character of the PSRO is going to be changed into one which is an investigative body, for instance, with respect to-and primarily addressed to-the question of fraud and abuse, I think that the basic intent and purposes would be changed and the beneficial goals that may be achieved could be thwarted.

With respect to your other aspect that you mention, that is, the role of the nurses in any function of the PSRO, we have indicated that they would certainly have a very vital role and that the law has already provided for the utilization of the various types of practitioners as the PSRO discharges its functions.

Ms. KEYS. I thank you, Mr. Peterson.

Of course, I agree with you completely in terms of any change of primary function. Nobody is suggesting that or desires it.

I appreciate your testimony, Dr. Glasson, and I appreciate your interest in making PSRO's effective. I certainly agree wholeheartedly with one statement you made. It is the crux of the situation. That is, physician support is absolutely needed-physician support and involvement as it was mandated in the beginning. But I would suggest. to you, as well, that not only nurse support but nurse involvement in policymaking is needed as well, if we are really to carry out the mandate of adequate review of hospital health delivery, long-term-care. and, thinking ahead, ambulatory-care.

I thank you both for your testimony.

Dr. GLASSON. Thank you very much.

Ms. KEYS. The next witness is Ms. Goldie Brangman, past president of the American Association of Nurse Anesthetists, who is accompanied by Mr. Kenneth Williamson, consultant.

STATEMENT OF GOLDIE BRANGMAN, PAST PRESIDENT, AMERICAN ASSOCIATION OF NURSE ANESTHETISTS, ACCOMPANIED BY KENNETH WILLIAMSON, CONSULTANT

MS. BRANGMAN. Madam Chairman, I am Goldie Brangman, CRNA, director of the School of Nurse Anesthetists, Harlem Hospital Center, New York City. I am here today representing the Association of Nurse Anesthetists as past president of the association. Accompanying me is Kenneth Williamson, Washington consultant for the association.

The association is a professional organization whose membership is comprised of certified registered nurse anesthetists CRNA's, practitioners and educators who are engaged in anesthesia practice. There are approximately 15,000 currently practicing CRNA's who are recorded as providing at least half of all the anesthetic services in hospitals throughout the United States. However, we note that the total number of anesthetics provided by nurse anesthetists is substantially greater than this. The association and its members are vitally interested in peer review activities and the participation of professional registered nurses in such activities. We strongly support the provisions of H.R. 3167 which are intended to accomplish this purpose.

The goal of professional standard review is to promote the effective, efficient and economical delivery of health care services and to assure the proper quality of services. I believe this is a much broader purpose than that which was given by the previous witness speaking for the American Medical Association.

The attainment of this goal requires the effective functioning of a PSRO within individual health care institutions. In fact, we would say this is the basis of the whole PSRO structure and that without a wellorganized and functional PSRO within individual institutions, there is little likelihood for success of PSRO at the community or at the State level.

It is well recognized within the health field, that the quality of patient care cannot be reviewed effectively without the involvement of the professional registered nurse. This is understandable because patient care, to a very great extent, is provided by nurses. The essential role of professional nurses in such matters is recognized in many hospitals where PSRO's are well organized and believed to be effective. Professional nurses in such hospitals function as members of the PSRO team along with physicians. Their services are not only acceptable but are essential because they have the required clinical knowledge which is not otherwise available except through a physician. As the law is presently written, no health professional other than physicians is required to serve in PSRO's.

Any involvement of professional registered nurses is at the discretion of the physicians and as far as we know, participation is limited to serving within health care institutions. We believe this constitutes a major weakness in the law. Therefore, we support the provisions of H.R. 3167 which would rectify this situation by mandating the repre

sentation and participation of professional registered nurses in all PSRO's approved within a State and as members of all review and advisory bodies provided for in the law. We note that the amendments proposed would require a 30-percent membership of professional registered nurses, while still leaving physicans with a 70-percent majority in the membership of PSRO's.

Čertified registered nurse anesthetists are vitally concerned with peer review activities both in respect to the quality of care and to the economics related to the provision of anesthetic services. As I have stated before, more than half of all anesthetics provided in surgical procedures within hospitals in the United States are provided by nurse anesthetists. In 40 percent of the hospitals throughout the country a nurse anesthetist is the sole provider of anesthetic services. Consequently, it is essential that nurse anesthetists be involved in peer review activities at each level as they are the individuals who must be looked to in relationship to this phase of the care of hospital patients. The amendments proposed in H.R. 3167 will result in the involvement of nurse anesthetists in peer review activities and we definitiely believe this would be in the interest of hospital patients and all those agencies or organizations responsible for financing the cost of patient care.

Madam Chairman, we appreciate the opportunity for appearing here today in support of H.R. 3167. We ask that this statement be made a part of the record of the hearings, and we urge prompt enactment of the amendments proposed in this bill.

Thank you.

Ms. KEYS. Thank you, Ms. Brangman, and it will be made part of our record.

Mr. Duncan?

Mr. DUNCAN. I have no questions other than to thank you, Ms. Brangman, for coming here and giving us a good presentation. Ms. KEYS. May I just ask again, was it 40 percent of the hospitals served by nurse anesthetists?

Ms. BRANGMAN. Yes.

Ms. KEYS. That is a great many. That is the case in my State of Kansas where we have a great number of rural hospitals.

MS. BRANGMAN. That is the type of hospital particularly involved in this, yes.

MS. KEYS. Thank you very much for your testimony.

We next will hear from Dorothy Telega, past president of the Nurses Association of the American College of Obstetricians and Gynecologists.

STATEMENT OF DOROTHY J. TELEGA, THE NURSES ASSOCIATION OF THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS

Ms. KEYS. Welcome to the committee, and forgive me if I mispronounced your name.

MS. TELEGA. No, you pronounced it right but sometimes there are a lot of problems with it.

I am Dorothy J. Telega, supervisor of obstetric, gynecologic and neonatal nursing at the Franklin County Public Hospital. Greenfield, Mass. I am here today on behalf of the Nurses Association of the