years now, organized psychology's initiative to gain membership on the Joint Commission has been thwarted, even though the profession's status as an independent health specialty is well recognized in law and administrative precedent. Our hope is that the PSRO program can become a tool for identifying the actual health needs of patients. Data from the PSRO program could be of inestimable value in restructuring our health care delivery system to meet the real as opposed to the perceived needs of our citizens. PSRO can fulfill its mission if it focuses upon the totality of health care delivered to patients, and if the review system itself is given the flexibility to embrace new approaches to health care prevention and maintenance as they are proven and developed. We commend the Congress for undertaking a review of the progress made by PSRO to date. STATEMENT OF THE AMERICAN PUBLIC HEALTH ASSOCIATION The American Public Health Association (APHA) wishes to support H.R. 3167 to amend Part B of Title XI of the Social Security Act to assure appropriate participation by professional registered nurses in the peer review process. Some PSROS seek the participation of various health care practitioners in the development of criteria and standards, the selection of norms, the establishment of mechanisms to review the care provided by each type of practitioner, and the actual review of that care. In spite of this fact all PSROS still consist solely of physicians who, therefore, retain ultimate responsibility for decisions related to standards and to sanction procedures. APHA feels that since PSRO decisions related to quality of care affect a wide variety of health care disciplines, the direct involvement of these health professionals in the decision making process is desirable. In 1973, APHA adopted a policy stating that the public accountability of PSROS could be maximized by promoting the widest feasible participation and control both by health care professionals and by the beneficiaries of their services rather than by delegating the responsibility of review to any single discipline or organization. H.R. 3167 is an attempt to allow one important group of health professionals an opportunity to participate fully in the PSRO process. It is a known fact that registered professional nurses comprise the largest group of health care practitioners. More than 900,000 R.N.'s work in health care institutions, including over half a million nurses working in hospirals. Nurses are an integral part of the health care team and are often the health professionals most knowledgeable about social, physiological, and rehabilitative factors which affect the type and level of services needed by and provided for the patient. It seems evident that nurses should be involved in the evaluation and quality control processes of total patient care. Comprehensive guidelines for the involvement of nurses in the PSRO process have been drafted by representatives of the nursing profession. APHA believes that nurses are ready and capable to assume the PŠRO responsibilities detailed in H.R. 3167. Our support of H.R. 3167 in no way indicates a reversal of our previously stated position before this Subcommittee that it would be inappropriate at this time to add new decision making power to PSROS or to extend the scope of their review to services furnished in shared health facilities. AMERICAN SOCIETY FOR MEDICAL TECHNOLOGY, Hon. DAN ROSTENKOWSKI, DEAR MR. ROSTENKOWSKI: The American Society for Medical Technology (ASMT) is most pleased to have this opportunity to comment on the role of health care practitioners other than physicians in Professional Standards Review Organizations (PSRO's) which was the focus of hearings on September 30, 1977 before the Subcommittee on Health of the House Ways and Means Committee. ASMT is a national professional organization representing approximately 30,000 members who are engaged in the delivery of clinical laboratory services. As the largest professional association representing allied health personnel, our membership is made up of a variety of non-physician categories of personnel in various clinical settings, including hospital laboratories. It has long been our position that to insure both appropriate and high-quality health services, the federal government should encourage and support peer review mechanisms in our nation's health care system. In this regard, although the Society supports the basic concept of professional standards review outlined in Public Law 92-603, we would urge that the Congress focus on the need for providing a formalized mechanism whereby non-physician health care personnel may actively participate within the Peer Review process mandated under law. We therefore applaud the determination of the Health Subcommittee in evaluating the role of professional registered nurses in PSRO's and see this as an intermediate step in considering the larger issue pertaining to the involvement of health professions other than medicine within PSRO programs. To insure quality health care and aggressively pursue the containment of health care costs demands that both the public and private sectors appropriately evaluate the legitimate role of health practitioners other than physicians in providing necessary and appropriate services. In this regard, ASMT believes that the exclusion of health care practitioners other than physicians in the peer review process is both shortsighted and counter productive. The government has defined professional standards review (peer review) as: "The formal assessment by health care practitioners of the quality and efficiency of services ordered as performed by other health care practitioners in the same health care practitioners in the same health care profession." We believe that peer review activities are particularly important in the laboratory setting as a way of determining the necessity and appropriateness of tests as well as their quality. Given the increasing complexity of the health care system, it is ASMT's view that good patient care can best be enhanced by allowing each health profession to be held directly accountable to the public for the development of its own standards of practice. To this end we would recommend that Public Law 92-603 be amended to mandate that health care practitioners other than physicians play a substantive role in the quality assurance activities of PSRO. In conclusion, ASMT trusts that the complexity of the health care field and the public demands for its increased effectiveness and improved quality, will encourage the Congress to insure a better defined and more structured role on PSRO's for health care practitioners other than physicians. We firmly believe that without such mandated involvement the desirable outcomes Congress anticipated from the PSRO mechanism will never be successfully realized. ASMT respectfully requests that this statement be made part of the official hearing record to evaluate the role of professional registered nurses in Professional Standards Review Organizations (PSRO's). Sincerely, L'NORA WELLS, President. COALITION OF AMERICAN PUBLIC EMPLOYEES, Mr. JOHN MARTIN, Jr., Chief Counsel, House Ways and Means Committee, DEAR MR. MARTIN: I am writing to you to urge support and passage of H.R 3167, a bill to assure appropriate participation by professional nurses in peer review. One finds it almost unbelievable at this point in time that professional nurses, as well as numerous other workers delivering direct health care services, are not voting members of the PSRO review process. The problem in one sense may lie within the definition of terms. Certainly in light of current discussion, "medical services" is antiquated. I urge the use of "health care" and "health services" as proposed in the various sections of H.R. 3167. This seems most appropriate particularly as we now have the opportunity, way overdue, to overhaul the fragmented system of health care in this country-through a national health initiative. The American Nurses Association, one of our member organizations, recognizes that its constituents are well prepared to step immediately into this evaluation and planning process. After all, registered nurses have been doing it for years. Peer review in all aspects of health care delivery is a crucial and productive factor in development of total health care. The current escalating cost figures in health care strongly point to the need to limit the control of this reviewing process from any one provider-namely the physicians. As responsible providers, one would welcome their co-workers. Certainly, professional nurses are and have been there in mass. The Coalition of American Public Employees represents over 4 million public workers. One third of our members are in the health field. Health care is team work. If PSRO's are to function effectively, they need to be strengthened and must be representative with full participation of all health services providers. The time for registered nurses is now. We urge the support and passage of this bill to make this a reality. Sincerely, PATRICIA FORD-ROEGNER, ACSW, [Mailgram] Representative DAN ROSTENKOWSKI, ILLINOIS NURSES ASSOCIATION, Rayburn Office Building, Washington, D.C.: CHICAGO DISTRICT, Chicago, Ill., September 27, 1977. Concerning H.B. 3167 sponsored by Representative Keyes, Chicago district, Illinois Nurses Association, representing over 4,000 nurses in the Chicago area believe that nurses must be involved on a policymaking level in PSRO's. Many nurses are already active participants in quality assurance and health care services would benefit immensely from their expertise in PSRO's. JANE ENGLE, President. Executive administrator. STATEMENT OF JOHN F. HORTY, PRESIDENT OF THE NATIONAL COUNCIL OF COMMUNITY HOSPITALS, ON H.R. 3167 My name is John F. Horty. I am President of the National Council of Community Hospitals, an organization serving the non-profit hospitals that provide hospital care to the thousands of communities across the country. To that end, NCCH assesses major Federal legislative proposals that might affect community hospitals and expresses its views on such proposals. NCCH appreciates the opportunity to present this statement to the Committee. NCCH supports the principle that responsibility for determinations with respect to appropriateness and necessity of health care as well as with respect to the quality and quantity of services rendered should be in the hands of those who possess the qualifications and capability of making such judgments. If the PSRO system is to be continued, it is our opinion that its acceptance in the health care field and the development of public confidence in the system will depend upon participation at all levels by qualified practitioners of the health care professions, other than physicians. No single professional group should determine the solution to all health care problems in every circumstance. In terms of quantity as well as cost, nursing represents the largest element in the delivery of health care. Therefore the assessment and promotion of quality and the control of costs of nurse care must be a significant factor in the effort to establish an effective review system. As your Committee well knows, the medical care plan for the patient can be most effectively carried out by supportive nursing care. The nurse is the professional who spends the most time in direct patient care, develops additional significant information as to his condition, provides an assessment of needs for services, and thus often avoids complications and reduces the total costs of treatment. We believe that nurses should be involved in the development of the policies designed to evaluate the quantity and quality of their services. Accordingly, we support this legislation as a first step in the establishment of a structured system for review of patient care which will be fully representative of those health care professions and institutions substantially and directly responsible for such care. STATEMENT OF THE NATIONAL COUNCIL OF STATE PUBLIC WELFARE ADMINISTRATORS OF THE AMERICAN PUBLIC WELFARE ASSOCIATION The National Council of State Public Welfare Administrators of the American Public Welfare Association represents the administrators of the nation's welfare agencies. Most of these agencies administer the Medicaid program and thus have daily contact with health care providers. The charge of Professional Standards Review Organizations (PSROs) is to evaluate the medical necessity of health services financed by Medicare and Medicaid. As a result, PSROs should relate closely to state Medicaid agencies. A number of states have, however, encountered difficulties in negotiating and contracting with PSROS. This is a particularly troublesome problem in that PSRO divisions have a tremendous impact on the fiscal liability of states. The states believe that current monitoring mechanisms are insufficient to assure the accountability of PSROs to the states. The impending enactment of H.R. 3 (the Medicare and Medicaid Anti-Fraud and Abuse Amendments) is likely to ameliorate some of these difficulties. Among other things, the measure substantially strengthens the authority of states to monitor PSRO performance. The Council does believe that additional improvements are necessary in the structure and administration of PSROs. It has, for example, been a long-standing position of the Council that health professionals other than physicians be required to participate in PSRO activities. The Council is on record in support of HEW proposed regulations which would have mandated the involvement of non-physicians. The final version of these regulations did not include this requirement. We still believe that allied health professionals are essential to the effective and unbiased performance of PSROs and, therefore, urge enactment of legislation which would assure such participation. STATMENT OF THE NATIONAL LEAGUE FOR NURSING The National League for Nursing is pleased to have this opportunity to present its written testimony in support of Representative Martha Keys' bill, H.R. 5341, to amend part B of Title XI of the Social Security Act to assure appropriate participation of professional registered nurses in peer review and related activities authorized thereunder. The National League for Nursing (NLN) with over 17,000 individual members and over 1,850 agency members is headquartered in New York City, with branch offices in Atlanta, Chicago and Burlingame, California, and has 44 local leagues across the country. Supported by an annual budget of nearly $7,000,000, NLN's programs and services are designed to meet the national, state and local health needs of the people. The League accomplishes this mission by identifying the nursing and health care needs of the nation and fostering programs and services to meet those needs. Simply put, we share the goals and aspirations of the Subcommittee on Health and other Congressional Committees, Subcommittees thereof, Federal Departments and agencies and many dedicated health organizations throughout the country. The Health Care industry is often described as "fragmented" and few would quarrel with this assignation. Our common efforts must always be directed toward eliminating fragmentation and achieving the maximum feasible coordination between and among health professionals and institutions. H.R. 5341 is an essential legislative prescription to remedy the obvious disparity between health care realities and the existing statutory provisions for peer review. What are the realities from our perspective, that is to say, the perspective of the largest group of health professionals, nurses? First, studies of American Hospital budgets reveal that nursing services comprise between 60 and 80 per cent of the total budget of the average hospital. Second, if we look at the personnel structure of intermediate and long term care facilities, we find that they are almost entirely staffed by registered and licensed practical nurses. Thus, through its Medicare and Medicaid reimbursement mechanisms the Federal Government is a major payor for nursing services. And this is true throughout the health care system regardless of the financing mechanisms. Yet, we find that since the Professional Standards Review Organizations were established in 1972 to review services provided under Medicare, Medicaid and Maternal and Child Health programs, nursing knowledge and the nursing perspectives, so essential to health care have been absent from local PSROs. The National League for Nursing believes that Section 3 of this measure appropriately and responsibly seeks to overcome a previous oversight, the exclusion from membership, inputs, guidance and knowledge of professional registered nurses on and in the PSROs. We are particularly supportive of this provision and suggest only one modification, the effect of which would be to require that before designating the two nurse members of the PSRO, the State nursing association of a state consult with nursing organizations. Our suggestion is that the phrase "after consulting with other nursing organizations in such state" be inserted after the word "State" and before the comma, which are found on line 16 of page 2 of H.R.5341. This we feel would provide the broadest possible inputs from all of nursing by specifying that the State nursing associations consult with the constituent leagues of the NLN in a state as well as the constituent associations of the National Student Nurses' Association, where such organizations exist. We hope the Subcommittee will consider such an amendment during its deliberations on this measure. We are equally supportive of the provisions of H.R. 5341 which would expand the membership of Peer Service Review Council (PSRC) from 11 physician members to 14 members, three of whom would then be registered nurses. Once again, nursing knowledge and inputs would be directed where they are needed since the PSRC, as do the PSROS, review the provision of services by all health care practitioners, not just physicians. So too, does the PSRC and the PSROs review health care delivery in many settings other than the hospital and in intermediate and long-term care facilities, nursing is the paramount profession. Decisions made by the PSRC as well as the PSROS affect more than the nurse practicing at the bedside. These nurses are held accountable by Directors of Departments of Nursing. Consequently, any decisions made by the PSRC and PSROS must be implemented by these nurse executives. It is essential that nurses holding top echelon positions in hospitals or long-term care facilities have the opportunity for direct participation in the decision making process at the Peer Service Review Council level, as well as membership and inputs to PSROS. We in nursing have the essential knowledge that has long rounded out the expertise of the health care team, as it is often called. We are, by profession, "team players," and feel that we should be included in the skull sessions as well as the game. The National League for Nursing is confident that this measure will receive your full consideration. We are grateful to the Chairman and the members of the Subcommittee on Health for this opportunity to present our view. STATEMENT OF HON. CLAUDE PEPPER, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF FLORIDA, AND CHAIRMAN, SELECT COMMITTEE ON AGING AND THE SUBCOMMITTEE ON HEALTH AND LONG-TERM CARE Mr. Chairman, I am pleased to have the opportunity to provide comment in connection with your hearing on the role of registered nurses in Professional Standards Review Organizations. In a report last year entitled, "New Perspectives in Health Care for Older Americans," the Subcommittee on Health and Long-Term Care and the full Select Committee on Aging, both of which it is my privilege to chair, called for expansion of PSROS to include, as appropriate, a nurse, social worker, guidance counselor, and/or other expert. The report also recommended legislation to make it clear that PSROs are responsible for review in long-term care facilities. We believe that the work of PSROs can only be enhanced and improved by the inclusion of other health professionals in the review process. The prohibition in current law against the inclusion in local PSROS of practitioners other than physicians and osteopaths serves, in my view, to diminish the effectiveness PSROS might otherwise bring to bear regarding the utilization of health facilities and the assurance of a high standard of health care. The beneficial effects of bringing other health professionals into the review process has been indicated by the inclusion in the law of authority for these professionals to participate as members of the advisory councils to local and statewide PSROs. The concept embodied in this practice should be extended to provide actual membership in PSROs for a broad range of health personnel and others who are able to assess those other needs of patients which might not perhaps be strictly medical. Moreover, the National Professional Standards Review Council should be required to include representatives of these groups, as well. |