In conjunction with its audit education program, the Association has also developed model screening criteria for seven diagnostic categories: cerebrovascular accident, adult rheumatoid arthritis, schizophrenia, manic-depressive illnesses, spinal cord dysfunction, depressive psychoses, and hand injury. The categories represent areas with the highest incidence of treatment in occupational therapy practice. Although the Association has taken the initiative in criteria development on a national scale, it also firmly adheres to the belief that criteria for audit studies must be developed locally to reflect problems specific to the area or facility. In light of our sincere interest in quality peer review, we are disturbed that the major legislation in this area fails to recognize the importance of a vast majority of health care practitioners. Under Section 1155(b) of the Social Security Act a Professional Standards Review Organization "is authorized in accordance with regulations prescribed by the Secretary to. make arrangements to utilize the services of persons who are practitioners of or specialists in the various areas of of medicine or other types of health care This authority is to be exercised "to the extent necessary or appropriate for the proper performance of its duties and functions." Authorizing the optional use of health care practitioners other than physicians hardly reflects an accurate understanding of actual medical care. The contribution of these professionals to peer review is always necessary and appropriate, and thus, their involvement in all phases of the review process should be mandated, and not just "authorized."

One philosophical foundation for the PSRO program is adherence to the concept of peer review. Peer review affirms the conviction that the quality of an individual's activities can best be assessed by other individuals with similar training and experience. As applied to the health field, peer review asserts that each health profession is best able to evaluate the quality of the health care which it provides. The Report of the Senate Committee on Finance (S. Rept. 92-1230) accompanying the PSRO amendments of 1972 supported this assertion by recognizing the appropriateness of organizations of professionals undertaking the review of members of their professions.

As the PSRO law's subsequent regulatory materials indicate, health care in the United States involves considerably more services than those which physicians provide. The services of nurses, occupational therapists and physical therapists, speech pathologists and audiologists, nutritionists, and many others all play important roles in the coordinated team approach which every patient requires. The physician must rely upon the professional judgment of other health professionals with training and experience in areas which are not generally emphasized in the physician's training and which are not regularly a direct part of the physician's daily practice. Many different health care practitioners provide individual patients with the services needed to restore and maintain health. These same practitioners must also be given ample opportunity to assess the quality of services which their peers provide.

In light of the integral role played by non-physicians in the health care system, we believe that there is a clear need to strengthen non-physician participation in the PSRO program. True peer review requires that, just as physicians should assess the services provided by physicians, so too other health care practitioners must review the services provided by their respective peers. The training and practice of each health care practitioner is to some degree unique in content. The basic and graduate level educational requirements for each profession are distinct in character and individually designed to meet the specialized needs of each professions' practice. The uniqueness of each profession mandates the need for providers of a service to assess the utilization or quality of that service as delivered by their peers. True quality review cannot afford to overlook this fact.

The cost effectiveness of health care services will be improved if the recognized capabilities of all practitioners are used in the review process. Money, time and quality of patient care can be preserved, only if the review process incorporates the expertise of the right persons at the right time. Physicians alone should not assess professional services with which they are only tangentially involved. This responsibility belongs with the members of the professions which provide those services. It would be ironic if an inappropriate review process under the PSRO program diminished the quality of patient care and failed to eliminate unnecessary Federal expenditures for health care. It would be incredulously wasteful and irresponsible if, at a time when inflationary health care costs are cited as reason for limiting patient benefits, PSRO dollars should result in less efficient return due to the failure to involve the right person at the right time in the review process.

Providing for the health care of American citizens encompasses a multi-disciplined effort which is not likely to change in the years ahead. If the review

standards for the PSRO program recognize this existing multiplicity now, the need for later revisions and amendment will be avoided, with the resulting benefit to both the health and pocketbook of the patient. For these reasons we believe that the involvement of all health care practitioners in the PSRO program must be strengthened and increased. We, therefore, recommend the following:

1. Adequate representation of all health care practitioners be required in the membership for all Professional Standards Review Organizations;

2. The National Professional Standards Review Council be reconstituted to include representation of all health care practitioners; and

3. The Statewide Professional Standards Review Councils be reconstituted to include mandatory representation of al health care practitioners.

Since 1972, efforts have continually been made to ensure that PSRO policy and program development benefited from the involvement of all health care practitioners. The Department of Health, Education, and Welfare has supported the activities of numerous health professions whose recommendations, advice, and active involvement were offered to improve the effectiveness of the system. An occupational therapist on staff, Patricia Curran Ostrow, worked closely with the Department in her role as liaison between the National Professional Standards Review Council and those health practitioners not represented on the Council. Although these efforts have been commendable and accomplished much, the lack of a legislative mandate has seriously diminished the benefits to the program which otherwise would have accrued.

We, therefore, urge the Subcommittee to consider our recommendations in light of the clearly demonstrated need to amend the PSRO law and ensure full participation of all health care practitioners in the peer review process.

I appreciate the opportunity to submit these comments. If the Association can provide further clarification or assistance to the Subcommittee in its deliberations on this issue, it will be most willing and ready to do so.

Sincerely,

JAMES J. GARIBALDI,

Executive Director.

STATEMENT OF THE AMERICAN OPTOMETRIC ASSOCIATION

The American Optometric Association represents over 20,000 doctors of optometry, who provide vision care to the nation. Optometry is the 3rd largest independent health care profession, providing two-thirds of our nation's vision care. Optometrists practice in over 5,800 municipalities, in forty percent of the country, doctors of Optometry are the only vision care practitioners.

As an independent primary health care profession, Optometry is greatly concerned with delivering the highest quality care to the American public.

Optometry, like other professions, is also very concerned about the rapid rise in cost to deliver this care. Optometry is concerned about the delivery of vision care to the poor and the disadvantaged, which have almost eight times as many visual impairments as any other group in the population. This concern has been shown by the high percentage of optometrists who are providers under the Title 19 Act and by the fact that 70-80 percent of all Medicaid vision services are delivered by Optometrists. To insure that Optometrists remain enthusiastic providers under federal programs, the American Optometric Association would like to voice its concerns about peer review and quality assurance procedures for Medicare and Medicad.

Any quality assurance procedures for federal programs should guarantee true peer review for Optometry and for this reason we feel that the amendments offered by Congressman J. J. Pickle in his legislation H.R. 1156 and the subsequent bills be given serious consideration.

The profession of Optometry has been a leading proponent of true peer review and is understandably disturbed when amendments to the Social Security Act excludes members of the optometric profession from meaningful participation in these quality assurance programs.

Quality assurance programs should be designed to meet the following two objectives:

1. Be sure that the public benefits from the quality health care at reasonable cost by assuring that true peer review takes place. This would best be accomplished by a specific provision requiring each independent profession group to evaluate his own specialty.

2. Ensure the continuity of minimum cost quality care by the viability and creation of independent primary care advisory groups composed of optometrists and dentists and other similar health care providers.

Optometrists must review care by optometrists. By virtue of specialization, education, training and practice they are the only health care practitioners capable of fully reviewing optometric patient care situations to guarantee that each individual receives the care he needs at a reasonable cost. Given that the state of the art of quality assurance is in ambulatory care, the impact of knowledgeable optometrists can assure success of quality assurance programs in these

areas.

As federal review programs now stand, a profession not familiar with another professionals procedures and education will be establishing criteria for evaluation and assume final review. Evaluation implies that the evaluator will rely on judgement based on his own professional background and experience.

The patient cannot receive the best health care an optometrist is trained to offer when the final criteria before evaluation of that care is by another professional not familiar with the full round of optometric care and procedures.

Optometrist have initiated many programs in quality assurance. Currently the American Optometric Association is developing screening criteria to evaluate optometric care. It is anticipated that these criteria will be field tested during the 1977 fiscal year. To further insure quality optometric care, 46 states currently require continuing education for renewal of optometric licensure. Currently there is an optometric peer review board in every state.

Because optometric services are very price elastic and involve the dispensing of materials, utilization control procedures are very important. Without proper optometric input these utilization procedures could be unsuccessful and exclude people who need vision care. With optometric input utilization review techniques could be implemented for federal programs to insure that those recipients that need care receive it and at the same time keep overall expenditures for vision care at acceptable levels.

In conclusion, Optometry stands ready, willing and able to assist the Committee and the Congress to enact legislation in the best interest of the beneficiary.

STATEMENT OF THE AMERICAN PSYCHOLOGICAL ASSOCIATION

The legislation which in 1973 amended the Social Security Act to establish the Professional Standards Review Organization (PSRO) Program must be regarded as a landmark in the development of the health sciences. In entrusting the responsibility for health care quality assurance to the professions involved in the actual delivery of health services to the patient, the Congress has underscored its willingness to work with the health care community in developing uniform standards of health care for all Americans.

The vehicle that the Congress has selected to guarantee quality care is, of course, peer review. To very great extent, the success or failure of the PSRO program will depend upon the professionals who will constitute the review system itself. Since the program confers so much authority to PSRO's at the local level, we would encourage the Congress to monitor the progress of the program on an ongoing basis. The possibility will always be great that if left unattended, the program might end up becoming something much different than the peer-based review system that the Congress originally had in mind.

After careful observation of the progress that has been made by the PSRO program to date, the American Psychological Association would like to point out several areas that are of great concern not only to our membership involved in health care delivery but also to their patients and to the other health specialties as well. First among our concerns is the overall thrust of the review program itself. Time and time again, we have seen terms such as "medical care" and "medically necessary" appear in the Department of Health, Education and Welfare's implementational guidelines for PSRO. We have seen focus of PSRO review shift from the totality of the health services delivered to the patient, to the purely medical aspects of the health package alone. The consequence of this shift is clear. By failing to take a broad perspective on health services delivered to a patient, the PSRO program will find it difficult to fulfill its quality assurance mandate. By stressing the medical necessity for health services, the review process will overlook the many other non-medical health services that can have a dramatic impact on a patient's well being. Should the program continue to focus solely upon the medical aspect of health service, PSRO will do a disservice to Medicare, Medicaid and Maternal and Child Health Program patients.

Section 730153 of the PSRO Program Manual stresses the necessity for multidisciplinary review of the broad range of health services provided to a patient. In reality, the program is straying from this principle, to the extent that true

multidisciplinary review does not take place at all. At present, PSRO membership is limited to physicians and osteopaths. Physicians and osteopaths are likewise guaranteed a majority of the available seats on the PSRO's governing board. A wide range of independent health professions recognized by state law are presently excluded from the local PSRO structure. Among the recognized health professions left out are dentistry, oral surgery, optometry, podiatry and psychology. In theory, these professions may work on multidisciplinary review methodology as part of the "other than physician" Advisory Council to the local PSRO, or Statewide PSRO Council. Unfortunately, Advisory Councils are either meeting regularly or being called upon by the PSRO to begin work on multidisciplinary review structure in only a handful of districts.

The number of seats available to recognized independent health professional representatives on the Advisory Councils is inadequate. In the field of mental health alone, several established "other than physician" professional representatives will find themselves competing for the few available seats on the Advisory Councils. An adequate number of seats should be available for qualified professional representatives. In order for peer review to work, the professionals involved simply must have a voice in the process through which review procedures are promulgated. Failing that, much stronger encouragement from the Department of Health, Education and Welfare will be needed before individual PSRO's seriously begin to form their Advisory Councils and to give the Councils a meaningful role in the multidisciplinary review process.

We call the Congress's attention to the fact that legislation has already been proposed which would either confer PSRO membership privileges or establish a separate review status for several of the "other than physician" health specialties, including those mentioned above. We would encourage the Congress to treat this problem as one issue. We feel that the criteria for membership in a PSRO should be uniform, and based upon whether or not the particular health specialty representative is either licensed or certified by the state government in which state their practice is located, and that the health specialist recognized for membership adheres to an established code of professional conduct. We also recommend that a fixed number of PSRO governance structure seats be allocated to the recognized independent health specialties, particularly in the mental health field. While Advisory Councils may be established at the individual PSRO and PSRO statewide council levels, no parallel mechanism exists at the national level. Consequently, the National Professional Standards Review Council, which meets quarterly in Washington, has the sole authority to influence both the tone and the content of Federal policy on PSRO peer review. The independent health professions other than physicians and osteopaths have no representation on the Council, and no systematic channels of communication currently exist for them to make their concerns known to the Council.

During 1976, the Bureau of Quality Assurance did assist in the development of a liaison network for the non-represented independent health specialties. While a good deal of Bureau of Quality Assurance staff time was allocated to the project, no Federal funds were directly involved in the operation of the liaison network that was subsequently established. The project relied soley upon the voluntarism of the health professional organizations interested in the goals of PSRO. After a promising start, and only one formal meeting, the Liaison Network was disbanded. The reason that was given at the time was that the network was a Federal advisory group defacto, operating without a charter approved by the Federal Government. Work on the required charter was slowed because it was said that then Secretary of HEW David Mathews was observing a Nixon/Ford Administration moratorium on the formation of Federal advisory groups, pending "immenent" governmental reorganization.

This year, the Bureau of Quality Assurance has completed a draft charter for an advisory group to the National Professional Standards Review Council, and the document has gained the approval of the Assistant Secretary for Health. It was only within the last few days that we have learned that the draft charter is once again delayed, this time at the level of the Secretary of HEW. The reason being given is that a moratorium on the formation of advisory groups is again being observed while Federal reorganization progresses. The creation of an Advisory Council to the NPSR Council would be an essential first step in reorienting the PSRO program toward the track of true patient-oriented, multidisciplinary peer review. The role of "other than physician" independent health specialties in Medicare, Medicaid and Maternal and Child Health Care is vastly underestimated. The involvement of these professions in the review process cannot be ignored without doing substantial damage to the quality assurance program itself.

As one of the involved independent health professions, a review of psychology's status in regards to Medicare, Mediciad and the Maternal and Child Health Program is in order. Seventeen states, representing over forty percent of the U.S. population, have opted to recognize psychological services provided independently of physician supervision for reimbursement purposes, under the terms of their Medicaid (Title XIX) plans. At present, the Department of Health, Education, and Welfare and the Social Security Administration are evaluating the quality and cost performance of psychological services provided and reviewed independently under the Medicare program in the State of Colorado.

Preliminary information gained from the Colorado Clinical Psychology Experiment can be expected to greatly enhance the chances for the passage of Senate Bill 123 and its House counterpart, HR 2270. Both of these pieces of legislation would extend the principle of direct recognition for psychological services to the entire Medicare system. It is interesting to note that psychological services are held to be reimburseable independently of physician supervision under the Federal Employees Program (over three million individuals covered) and under the Civilian Health and Medical Program for the Uniformed Ssrvices (CHAMPUS) over six million covered).

Federal health planners with a special interest in peer review as a cost and quality oriented management approach will want to know that the Department of Defense has entered into a contract with the American Psychological Association to develop an independent peer review system to evaluate the delivery of psychological services provided through the CHAMPUS program. The CHAMPUS program is the largest organized health plan in America, and many see it as one of several working prototypes for national health care. The Department of Defense has entered into a similar contract with the American Psychiatric Association. The review systems for psychological and psychiatric services will be separate and independent, in recognition of the unique and special skills of each profession. We would hope that the PSRO program would follow this model in recognizing the independent status of the other-than-physician health specialites in the review process. We believe that it will be counterproductive and harmful for physical and osteopathic medicine to assume the review responsibilities for services about which they are uninformed and which lie outside their professional expertise.

Legislation recognizing psychological services for reimbursement purposes provided independently of physician supervision has been enacted in twenty-seven states and the District of Columbia. These laws, which are frequently known as "Freedom of Choice" laws, cover nearly seventy percent of the U.S. population. Psychological services provided independently of physician supervision are also recognized in a substantial number of other Federal programs and their administrative regulations.

As extensively as psychology is currently recognized as an independent health specialty, its future growth prospects are even more interesting. Human behavior, which can be studied and influenced through well established scientific techniques, represents possibly the most under-estimated factor in health care prevention and maintenance today. As a profession and a science, psychology is eager to contribute its skills and techniques to the general problems of health care. Psychology has pioneered in the development of specific techniques such as program evaluation, which could play a major role in the management of a comprehensive health care plan.

While psychological services have traditionally been associated with ambulatory (outpatient) care, professional psychology aspires to a greater role in in-patient hospital care delivery. Already, two separate but related actions on the subject of inpatient care privileges are being undertaken. While the Joint Commission on the Accreditation of Hospitals (JCAH) and the American Psychological Association are engated in an ongoing discussion on hospital privileges and facility accreditation, the Association for the Advancement of Psychology has filed a memorandum of complaint with the Federal Trade Commission regarding those JCAH policies which the AAP sees as constituting restraint of trade. In essence, the issue is that psychologists in a significant number of in-patient teaching and care facilities are fighting to preserve those health care responsibilities that they have earned as individuals over the years from various facilities.

Due to a shift in JCAH accreditation policies, the important and often pioneering work that these psychologists have been doing in these in-patient facilities is now threatened. Some of our colleagues have actually lost their jobs, and their patients have been denied continued access to their care. While psychologists view this occurance as a great professional indignity, we are even more concerned about the thousands of patients who are being and will be denied the benefits of psychological services because of the policies of the Joint Commission. For several