should be fully involved in the policy development and procedural operation of the PSRO's quality assurance functions, particularly the medical care evaluation studies. Only through full voting membership on PSRO committees and through the mandated involvement in PSRO governing bodies, statewide professional standards review councils and the national professional standards reviews councils, will health care practitioners other than physicians have the authority to assure that appropriate disciplines are involved in the quality assurance activities of the PSRO's.

We recommend that health care practitioners other than physicians who serve as primary points of entry for patients in the medicare, medicaid, and title V programs be fully involved in the policy development and procedural operation of the PSRO's cost containment functions. Health care practitioners other than physicians who do not serve as such primary points of entry and who do not have admitting privileges to hospitals and long-term care facilities should serve in an advisory function relative to the cost containment procedures of the PSRO, specifically with regard to admission certification, continued stay reivews and profile analysis.

In recommending such involvement, we are not suggesting in any way that health care practitioners other than physicians should judge services provided by physicians. This is neither our interest nor our intent. Rather, we believe that without legislative mandate for full involvement in the policy development and procedural operations of PSRO's and specifically and operationally defined functions of health care practitioners other than physicians in the peer review procedures, including medical care evaluation studies, admission certification, continued stay review and profile analysis, their involvement and assumption of their appropriate roles will not occur.

Our recommendations are based on our firm belief that without the appropriate involvement of health care practitioners other than physicians in PSRO review activities, particularly in the quality assurance area, PSRO's mandated duties and functions will never be successfully accomplished.

Thank you.

Ms. KEYS. Thank you, Dr. Griffin.

Mr. Duncan?

Mr. DUNCAN. I have no questions, thank you, ma'am.

Ms. KEYS. I would just like to thank you for your testimony and say I have personally experienced a circumstance in which surgery was contemplated and the answer was not in surgery but was found in the speech pathology treatment and help.

Though some might think that it might be a little bit far removed from an actual decision regarding admission of a patient, I know personally that your statement is very true, that the speech pathologist often is involved in the decision of whether or not a patient would require surgery and would be admitted to a hospital where PSRO would be taking place.

Dr. GRIFFIN. Thank you.

Ms. KEYS. Thank you for your testimony.

I believe our last witness today is Mr. Charles Hull, Jr., who is the managing director of the National Federation of Licensed Practical Nurses.

STATEMENT OF CHARLES HULL, JR., MANAGING DIRECTOR, NATIONAL FEDERATION OF LICENSED PRACTICAL NURSES

Mr. HULL. May I ask our legislative consultant, Paul Tendler, to join me at the table?

Ms. KEYS. Certainly. I would like to suggest to you that if you have a long statement to make, you might like to insert it in the record and summarize. We are getting close to the end of the day.

Mr. HULL. Madam Chairman, my statement is very brief.

I am Charles Hull, Jr., an LPN and managing director of the National Federation of Licensed Practical Nurses. We are the professional organization for licensed practical nurses comprised exclusively of LPN's.

There are nearly 600,000 LPN's throughout the United States who are an integral part of the health care delivery system and who strongly support the basic principle of accountability of all health care providers. We are firmly dedicated to the concept that every American has the right to the highest quality of health care available. The National Federation of LPN's deeply appreciates the opportunity to testify before the Subcommittee on Health regarding the inclusion of professional registered nurses being represented on professional standards review organizations.

We endorse this concept because we believe that each practitioner should be accountable for their own professional actions and that only a practitioner actually engaged in that aspect of health care delivery is qualified to effectively evaluate the necessity, appropriateness and quality of nursing care. Because of this belief, we suggest that this principle be extended so that licensed practical nurses be included in any such review process because, like professional registered nurses, they too have the unique experience and educational background to evaluate the necessity, appropriateness and quality of practical nursing.

The National Federation of Licensed Practical Nurses supports this position because we see the necessity to distinguish between "medical care" and "health care." Health care encompasses a broad range of services designed to maintain the physical, mental, and social well-being of people. There is no one profession which can do all this, and if we are to provide the proper planning and evaluation of health care, we must ask each practitioner to be accountable for their own services.

We are pleased that this subcommittee has chosen to carefully monitor the developments of Professional Standards Review Organizations. Once the professional standards review program is fully implemented, the program will be the greatest single influence on the quality of health care, impacting on the entire system and on the direction of Federal health expenditures. Thus, every stage of Professional Standards Review Organizations development must be scrutinized. All foreseeable inequities must be corrected. To do otherwise is to risk misinterpretation of legislative intent and to do an injustice to the professional and paraprofessional providers who serve within the health care system.

The National Federation of Licensed Practical Nurses, more so than ever before, supports uniform and professional review of health care services and standards. Moreover, the Federation endorses

Professional Standard Review Organizations as a viable structure within which such review and evaluation can be carried out most effectively. We believe that professional accountability will better serve health care consumers. Our members are proud of their profession and take great pride in their performance as health care providers. It is our contention that unless the composition of the national boards and councils of the Professional Standards Review Organizations is broadened to include licensed practical nurses and representatives of other health care professions as well as physicians, the program will fall short of the goals toward which this subcommittee and Congress as a whole are aiming.

One of the prime responsibilities of the Professional Standards Review Organizations is to assure that health care is being provided within the bounds of sound professional standards. Yet these very standards can only be as sound as the judgment of those conducting the review and rendering the evaluation. The authors of the original Professional Standards Review Organizations legislation seem to have assumed that anyone possessing a degree in medicine is qualified automatically to define and judge the quality of the services done by health care providers. The National Federation of Licensed Practical Nurses strongly disagrees with that assumption. We contend that the performance of any given health provider can best be judged by one who possesses expertise and firsthand knowledge and experience of the work which that profession performs. In other words, peer review is the strongest, most reliable foundation for evaluation.

As a nation is moving quickly toward a national health insurance plan, it becomes obvious that what will eventually emerge is a broad plan which will provide both health and medical benefits. Clearly, the burden of providing necessary care will not fall on one group providers, but rather many different disciplines who are skilled and educationally prepared to offer a wide range of services.

of

When the Congress enacted Public Law 92-603, it defined the primary responsibilities of PSRO's to be to assure that health services which are to be reimbursed under medicare, medicaid, and maternal and child health and crippled children's programs are medically necessary, meet professionally recognized standards of care and are appropriately provided in the most economical settings. As you know, PSRO's are required under law to possess certain organizational characteristics. Until January 1, 1978, a PSRO is required to be a nonprofit, professional association whose members are composed solely of licensed doctors of medicine or osteopathy engaged in the practice of medicine or surgery in the PSRO area. Presently, Public Law 92-603 fails to provide for the appropriate involvement and participation of health providers other than physicians. We join with other organizations who seek to participate in PSRO's.

We believe that other professionals can offer valuable contributions to an overall review. They can. They do. But physicians alone do not make up the whole fabric of our health care system. Rather it is made up of the threads of many health professionals and support groups, some of whom have no direct connection with one another beyond the fact they they are parts of the whole. In this way, a physician may know something of a licensed practical nurse's work or a licensed practical nurse of a physician's, but neither may know the entire scope of the other's duties, priorities, or practice.

It is more than job enough for each to carry out his or her own responsibilities without becoming an instant expert on another's profession. For this reason, we believe it is unfair to bestow on any one group of health care providers the power of judgment on all others. Instead, we would like to see that responsibility and power shared by a coordinated group of professionals dedicated to providing the quality health care Americans demand and deserve.

As you and your colleagues are well aware, Madam Chairman, Americans are making very strong demands for better and more costeffective health care programs. It is not our intention to cast aspersions on any one profession, but we do feel this is an appropriate moment to make mention of the increasing reports of fraud and abuses in the medicare and medicaid programs. These programs, and these reports, bear heavily on the Professional Standards Review

Organizations.

Last April, the Oversight Subcommittee of the House Ways and Means Committee heard testimony which called for the involvement of paraprofessionals in PSRO's. As health and medical care has increased and become more specialized, the role and participation of paraprofessionals have increased. Though PSRO's are encouraged to have input from such personnel in both review and development of criteria, they are not required to do so. Many States are concerned that one group of health providers will assume full control of standard. and review activities and ignore other qualified professional and paraprofessional health care providers.

The federation was heartened by the consideration by the Health Care Financing Administration Office of Health Standards and Quality to involve health care practitioners other than physicians in peer review in short-stay hospitals. We are disappointed that neither the study nor the proposed charter made reference to LPN's.

In this regard, we wish to point out two basic reasons why LPN's should be included in any changes regarding the present status of health care providers in PSRO's.

1. No one discipline in health care has the expertise and skill to operate independently of another. To do so would be inefficient and detrimental to the comprehensive care of the patient.

2. Likewise, there are different levels of nursing. Practitioners in each level are specifically prepared to function at a level commensurate with their educational background. To exclude one level of nurse from participating in all of the activities of PSRO's would be just as improper as limiting PSRO's to one profession. No one group of practitioners or one professional association can speak for or evaluate another's profession.

Professional Standards Review Organizations were designed as a solution to what Congress saw as a dual problem of rising cost and high incidence of medically inappropriate services rendered to patients under medicare and medicaid.

Yet, despite the establishment of the Professional Standards Review Organizations, the number of fraud and abuse cases in these programs has increased and are still increasing at an alarming rate. From this, we can only conclude that the professional standards review program is not effectively meeting its responsibilities. We believe that if the Professional Standards Review Organizations had a broader base of representation from Licensed Practical Nurses and

other health care professionals and paraprofessionals, the cases of fraud and abuse would not be so wide spread. Also, the detection of illegal practices would have been brought to the attention of Congress and the Executive Branch at an earlier date.

We would also like to point out that the law should be changed so that there is a distinction made as to "health care" and "medical care." The Federation believes this distinction to be critical if we are to provide comprehensive care in its fullest terms.

In conclusion, Madame Chairman, the authorizing legislation encouraged PSRO's to actively solicit input from health care providers other than physicians. This aspect of the legislation has been ignored. Nurses, both professional registered nurses and practical nurses, should be recognized as providers of care so that the patients can be assured of the highest quality of care. This situation is discriminatory and costly. In view of this, we respectfully urge the Congress to take corrective action and expand the membership of PSRO's to include health care providers other than physicians. Until this action is taken, the PSRO's cannot provide a true evaluation of sound functional operations of the health care delivery system.

Thank you, we are willing to answer any questions.

Ms. KEYS. Thank you, Mr. Hull.

Mr. Duncan?

Mr. DUNCAN. I have no questions. Thank you, Mr. Hull, for waiting and being with us most of the day.

Thank you.

Ms. KEYS. I would like to thank you and all of the other witnesses and assure you that Mr. Duncan and I and other members of the committee are intent on pursuing and using this hearing as a springboard to action on H.R. 3167.

Thank you, very much.

Mr. HULL. Thank you, Madam Chairman.

Ms. KEYS. The committee is adjourned.

[Whereupon, at 1:59 p.m., the hearing was adjourned.]

[The following was submitted for the record:]

AMERICAN ASSOCIATION OF COLLEGES OF Nursing,

Hon. DAN ROSTENKOWSKI,

Chairman, Subcommittee on Health,

Washington, D.C., September 28, 1977.

Committee on Ways and Means, Washington, D.C.

DEAR MR. ROSTENKOWSKI: Almost four years have passed since the Social Security laws were amended to create the Professional Standards Review Organizations. The dual goals of the law, to cut the costs while improving the quality of health care, have been fraught with many problems, but there have been significant advances in reviewing standards, utilization, and improvement of the quality of the care to people in many sectors of our society.

The American Association of Colleges of Nursing strongly supports the extension of the Professional Standards Review Organization activities to ambulatory care facilities and further emphasizes the need for mandatory inclusion of nurses in Professional Standards Review Organization activities. Nurses comprise the single largest group of professional health care providers and can offer many strengths to the Professional Standards Review Organization program. The nursing profession has long been involved in identifying and improving standards of care. Nurses as co-partners in the health care team can contribute significantly to the Professional Standards Review Organization program because of their contact with patients over a long period of time. Nurses can contribute to the process of developing methodologies for examination of standards of care and health to rationalize the professional decision-making process and thus improve health care.