Recommendations of the Task Force on Medicaid and Related Programs*

In July 1969, the Secretary of Health, Edur ductirity of the economy, but also because human cation, and Welfare appointed a task force to compassion insists that essential individual health look into the deficiencies of Uedicaid-the Fed- needs shall be met. era&Xtate m-edical assistance program under title With rapidly rising costs, many misgivings XIX of the Social Xecurity Act--and to malce were expressed about the growing tendency to be- recommendations for improvements in that pro- come excessively preoccupied with cost at the gram and related programs. expense of community goals. The Task Force, The 27-n&ember Task Force included persona along with what is possibly a majority in the representing consumers: industry, labor, govern- health professions and certainly a majority of the ment. and the social sciences, M well as the medb population, considers the recent Federal enact- cnl profession and health in..titution~ and services. ments as intending that access to basic medical The report of the Taslc Force, submitted on June care shall be a right or entitlement of all citizens. $?g9:contnins 14% recommendations for program It is the position of the Task Force that t,he right improvements and for steps needed to prepare or entitlement is not fulfilled when millions in the Nation’s health system to m,eet increased the population do not know about or cannot get, demands. It a7so outlines the complexities and to the places where some care is available to dimensions of the national henlth insurance issue deprived populations, or when the millions who and provides objectives for assessing policy in do get to such places are given a kind of service the financing of national health care. that is woefully inferior by every standard known Twenty-on,e of the Task Force Recomm,enda- to man and doctor. Neither is the right or entitle- tiowy were included in the proposed amendm,ents ment concept honored just because physicians and to the #o&al Security Act, passed by the Hou‘se hospital administrators can say, “We never turn of Representatives in May and now before the away a patient.” However virtuous the declara- Senate. The Department of Zgealth, Education. tion may make the doctors and hospital people and Welfare has taken adminktratke action on feel, it does nothing to make good the right or several other recommendations, and the remaining entitlement for those who never get within sight proposals are to receive further study. of a docto$s office or hospital. . . . The Bulletin has excerpted the Introduction and Xummary of the Report below, as well as the section on extended-care benefits under Medicare. SUMMARY

. . . The scope of the inquiry was broad ; neither the purposes nor design of government programs INTRODUCTION can be comprehended adequately in today’s en- As the Task Force grappled with its charges, vironment without reference to the health system several themes emerged that merit recognition as a whole. The Task Force sees the current in setting the stage for recommendations. One system, overall, as a vital part of the Smerican that was expressed repeatedly during the dis- culture and economy, involving vast investments cussions was the conviction that health must re- in acute care and related biomedical research. At main high on the scale of social, economic and the same time, the Task Force sees serious flaws political priorities-not only because the health in the system that appear in particularly bold of the Nation is basic to the growth and pro- relief against the background of an economic and political structure able, if willing, to cope with them. In essence, significant numbers of people * Excerpted from Recommendutions of the Task Fowe do not have adequate access to care and the serv- on Medioaid and Related Programs, June 1970, Depart- ment of Health, Education, and Welfare, 1970. ices of many who do are so far below the mark,

BULLETIN, SEPTEMBER 1970 23 with reference to the potential productivity of The statecl objective of Medicaid was to assure the system, that the credibility and accountability adequate health care to the Sation’s poor and near of the system it,self is at stake. poor. If this continues to be a primary goal-and The report contains recommendations under the Task Force believes emphatically that it these headings : Eligibility and Protection under should-a considerable inlprovement in financing Existing Financing Programs; Effecting Changes and delivery capabilities will be required. We and Improvements in the Delivery of Health recognize that expenditures on behalf of those C are; Management of Health Activities; Con- now lacking purchasing power and services will sumer Participation ; Comprehensive Health add initially to the problems of inflation within Planning; Long-term Care; and Long-term Fi- the health field. Rut against this, a double stand- nancing Policies. ard for a service so deeply rooted in human con- The recommendations vary widely in nature passion and so essential to a productive commu- and scope. Some of them deal with the logistics nity cannot be tolerated. Moreover, there remains of implementation. A critical few call for major the prosl)ect that if the new money, joined with changes in the orientation and strategems of the other government am1 private means, is spent total health system without which, the Task more wisely than in the past, inflation can be Force is convinced, revision of title XIX and minimized. To redeem the promise of Medicaid related programs would be ineffectual and un- and help give meaning to the declaration that productive. No attempt is made, in this sum- access to medical care is a right to all within the mary, to repeat all recommendations made in the context of current legislation : text. The major ones are cited in the context of themes derived from the debate of 1 year and set We recommend converting Medicaid to a program with forth in the introduction to the report. a uniform minimum level of health benefits financed 100 percent by Federal funds, with a further Federal matching with States for certain types of supple- mentary benefits and for indiriduals not covered under the minimum plan. There should be maintenante-of- Significant Deficiencies in Access to Care effort requirements upon the States to retain at least their present expenditure levels. Even after 4 years’ experience under Medicaid First priority for protection under a basic Federal and Medicare, and with parallel opportunities floor for Medicaid should be all persons eligible for for expansion in the private sector, a significant payments under the proposed Family Assistance Plan. Additional groups should be phased in until all persons number of Americans are not adequately protected with incomes at or below the poverty line are covered. against the cost of needed health services. As The disabled social security beneficiaries should be a direct result, too many do not get services they included as soon as possible under title XVIII. need. Approximately 26 million people in the Legislative changes are needed to establish Federal l’nited States live below the poverty line (about responsibility for the cost of medical rare and services for migrant workers and other eligible people who do $70 a week income for a family of four) and ap- not hare established residence in any State; migrant proximately 15 million more are near poor ($90 workers should be eligible for benefits of title XIX. a week income for a family of four). Only 13 million will be covered by Medicaid in 1971. Less Several recommendations are made to improve than 30 States, despite the availability of Federal the operation of title XIX, e.g., use a digni- matching money, have programs for persons who fied and simplified method of determining eligi- are medically needy but do not qualify for cash bility and payment; give greater protection to assistance. Two out of three children in poor or clients who are dissatisfied with actions or failure near-poor families are not included under Mater- to act ; make information about the program more nal and Child Health or Medicaid programs. widely and forcibly available; eliminate discrim- Among the poor and near poor, only a little over inatory practices by providers guaranteeing the a third below the age of 65 have private prepaid care of persons without permanent residence in medical care or medical insurance of some sort. any given State. In total, depending on different estimates, be- Other recommendations are directed at the tween 30 and 45 million people under age 65 are private sector to improve the coverage, scope and without any health insurance to speak of. efficiency of benefits. For example, means are

14 SOCIAL SECURITY proposed to improve the protection of employees The Task Force is convinced that it no longer during short periods of disability or layoff, small makes sense to keep pouring new wine in old groups and self-employed individuals, part-t.ime casks-some of which are leaking. Additional and temporarily employed persons. Strong en- financing must, be accompanied now with oppor- couragements are given to greater exploitation tunities and encouragement to physicians, hos- of the work environment for health education and pitals and others to provide service in ways that prevention programs. permit a logical response to sound economic and patient-care incentives, and to engage in a com- petition of organization and method. The concept of planned intervention can be Improving Delivery of Health Services organized in three interacting and interdependent In the light of rapidly rising cost and trouble- categories : more responsible purchase of services, some inflation in the health field, the recom- better management of health services, and broader mended addition of new expenditures through concept of health care. Some basic recommenda- expanded and improved financing programs, and tions follow under each. the need for all to have more readily accessible services, it is essential to improve the delivery of health services. The Task Force has concluded More Responsible Purchase of Services that the necessary changes in a myriad of per- sonal transactions among consumers and providers The methods of purchase and conditions of will not come about simply in response to the participation in Medicaid and Medicare and the interaction of consumers’ interest and provider investment policies of all Federal financing pro- self-interest. If sufficient changes in effectiveness grams, with corresponding actions in the private and efficiency are to be achieved, much bolder sector, constitute powerful instruments for achiev- interventions will be needed than we have seen ing increased capacity and new organizational to date. These must be in the form of public patterns in the delivery of health services. policy reinforced through more aggressive man- agement . The Federal Government should provide leadership and It is a central conclusion of the Task Force funds to create and support systems of health care, that money is needed, but that money alone will through a variety of auspices and approaches, that will contain the following desirable elements: not guarantee either capacity or effectiveness to the system. In fact, if a benevolent and affluent 1. comprehensive services and continuity of care, government were to begin to pay for all the basic 2. contractual services for definable population groups, health care needed by all those who can’t pay for 3. integrated fiscal and managerial responsibility, and it themselves, but no other change were introduced 4. risk sharing through prepayment. into the existing system, the result would be a dis- Legislation should be enacted to make sums equivalent astrous rise in the cost of services that are already to 5 percent of Federal Medicaid appropriations per scarce. There isn’t enough money and there aren’t year available for the development and improvement of health care services and resources. enough doctors to provide the needed care just on a fee-for-service basis; thus any solution will These funds should be expended as “front-end” money to create new or expanded capacity for service in require new options, new goals and new attitudes. localities with a high proportion of low-income persons Without these, the health system cannot move and where the need for development and/or improve- forward to meet its growing responsibilities; ment of health care resources has been determined in cooperation with State and areawide comprehensive with them, the Task Force is convinced that the health planning agencies. recommendat,ion in this Report, most of which To support the development of needed services, priority relate in one way or another to this basic issue, should be given to: development of organized primary can show the way toward achieving more and health care services in neighborhoods, development of services and resources which can serve as alternatives better health care for all Americans. to inpatient hospital care, e.g., home health care pro- For two decades programs financing medical grams ; improvements in utilization, efficiency, and/or care, whether public or private, have been rein- quality of existing health services directed to producing more and better health care ; social and other outreach forcing traditional ways of providing service. services which are an integral aspect of appropriate

BULLETIN, SEPTEMBER 1970 25 utilization of services ; development of ways to link and care and Medicaid beneficiaries to elect to receive health relate new and existing health services with each other, services through a single organization that provides aiming toward comprehensive health care systems in coordinated services financed through prepaid capita- communities. tion. Consideration should be given to legislation which would provide a percentage of Medicare funds for The HMO proposal constitutes an important similar supply-influencing efforts. step towards possible long-range improvements in In order to encourage the use of efficient, innovative the organization and delivery of health services. and effective delivery systems, legislation should be enacted to provide the Secretary with discretionary Specific recommendations are made to improve authority to modify the Federal share of Medicaid and help flesh out the concept. payments for certain services to the States by providing increased Federal funds of 5 to 10 percent above the HEW should actively program experiments for usual matching formula, on a differential basis. The incentive reimbursement under Medicare and higher payments would be made to those States which Medicaid, with emphasis on experiments in pay- successfully develop and use such services and payment methods as contract payments to prepaid group prac- ment methods for physicians as the key generators tice plans, neighborhood health centers, and other of health services. arrangements for provision of comprehensive services to a definable population, or use of new types of health manpower and paramedical manpower. Reimbursement to providers of service under Medicare and Medicaid should be on a prospective instead of a ,411 appropriate sources of Federal funding, in par- retrospective basis. ticular the Sational Center for Health Services Re- search and Development and the Partnership for Fees and charges under the Medicare program also Health Program, should be encouraged to give high should not be recognized for benefit purposes when in priority to development, support and demonstrations excess of the 75th percentile of prevailing fees; and of model health-care delivery systems. this limit should not be permitted to rise except in keeping with an index made up of pertinent wage and To provide facilities for these programs, the Hill- price increases. Burton program should give priority to those projects and facilities which propose to use innovative methods Title XIX should be amended to permit varying bene- of delivering health care. fits for different population groups, or for different areas in a State if it is not feasible or possible to apply The provisions of title XIX that recipients will have “free choice” of vendor should be interpreted as broadly them uniformly elsewhere: e.g., States should be able as possible in order to promote use and reimbursement, to provide dental treatment to children 512 years of age as a first priority. under Medicaid, of new and effective organized forms of health-care delivery. Policy implementing the statute should be developed to require the States to take To guard against deterioration of quality of positive steps to arrange for reimbursement (preferably on a contract-payment basis) of neighborhood health care while pursuing efficiency, various forms of centers, community mental health centers, migrant professional review will be needed. These would health projects, children and youth projects, prepaid evaluate the delivery of health care and help group practice plans, and other such forms of organized health-care delivery. determine its adequacy or appropriateness.

With respect to State implementation of recommenda- I:tilization review, including professional review pro- tions relating to use of earmarked Medicaid funds for grams presently required under Medicare, Medicaid or development of resources, model development, and others, the advice and consultation of the health- related programs should be given thorough study to planning agencies should be sought and encouraged. evaluate effectiveness. Other aspects of financing including participation re- A standard definition of professional review should be quirements and reimbursement policy should support adopted for all medical programs, and review require- planning activities. ments should be made uniform for comparable services To promote the early removal of State legal barriers, covered by all Federal programs. the Department of Health, Education, and Welfare should take steps to require that States permit prepaid A legislative amendment is needed requiring uniform group practices through a variety of approaches in- provisions and unified State standard-setting, certifica- cluding regulations or legislation that would tie the tion, and consultation functions with respect to pro- receipt of grants that flow directly to State agencies viders of service under both Medicaid and Medicare. such as Hill-Burton, 314 (a) and (d) , and Commu- (To the extent possible, also consistent with desired nity Mental Health Center Construction to such a State flexibility to exceed Federal minimum standards, requirement ; and other alternatives such as Federal State-controlled licensure of health facilities and agen- charters for prepaid systems. cies should be integrated with these related functions.) The Task Force strongly endorses the innovative ap- The State agency with primary responsibility for proach of the Administration’s Health Maintenance health functions in the State should be responsible for Organization proposal to provide an option for Medi- all standards functions. Incentives, guidance and as-

26 SOCIAL SECURITY sistance should be provided to the States in bringing markedly in recent years as the result of con- this about. siderable legislation. Too many new programs are not coordinated well, nor integrated suffici- Antiquated licensure laws contribute to man- ently with the old. HEW must be strengthened power shortages and rising costs. to assume a new role conceptually and to con-

HEW should undertake a major, intensive, study of solidate better the responsibilities assumed to date. State health personnel licensing laws and their influ- The Task Force sees a “governing” role concen- ence on the utilization of manpower and make recom- trating on goals and objectives, establishing mendations to the States for changes and revisions of licensure laws. policy, fashioning incentives, checks and balances, firmly protecting the public interest and evalu- The Task Force supports the Administration’s ating results-presaging, perhaps, less extensive proposed “Health Cost Effectiveness Amend- operation of programs with greater decentraliza- ments.” Particularly worthy of note are the tion of operating responsibility. coupling of reimbursement to areawide and in- stitutional planning and the call for wider ex- A restructuring of HEW should have the following features : an under secretary for health and scientific perimentat,ion and demonstration among delivery affairs ; a career deputy with extensive background systems. in health administration in a public setting; major executive agencies headed by assistant secretaries in: Scientific Affairs (NIH), Health Services Systems and Resources (HSMHA) , Consumer Protection, Environ- Better Management of Health Services mental Quality, and Management and Budget ; a health systems analysis and planning staff, which would serve as the motive force for goal setting, analysis, planning Controls and incentives will not be realized and evaluation and may also serve as staff for a without more forceful leadership and better or- National Council of Health Advisors. ganization within the health field. The total job There is an urgent need to establish a National to be done will take the concerted efforts of Council of Health Advisors responsible for assessing both the public and private sectors. Many of the the Nation’s health status and the status of the health system, for generating national health goals, and for key considerations devolve upon HEW. It is here outlining objectives for all Federal health programs. that primary leadership for the health system must be established and exercised. The Task Force made the following recom- “Fragmentation” of health service began when mendations : the doctor could no longer get everything he Install, within the health component of HEW, an in- needed in his saddle-bags ; it has been going on ternal management system based on the “corporate ever since, an inevitable result of the increasingly management model” adapted to the peculiar require- ments of a public administration setting. specialized technology. Fragmentation of serv- Provide the Under Secretary (HSA) with increased ices may be unavoidable at times and, of itself, flexibility in the allocation of Federal resources, espe- is not always bad. What is bad is that, for lack of cially for the purposes of encouraging new institutional overall leadership, we have allowed organization arrangements and the building of health-system and management to become fragmented, along capacity. with service, to the point where patients may be The operation of health-service activities should be decentralized through contractual agreements with handed off from one institution or service or public and private agencies. The principal features program to another in a kind of medical bucket of such agreements should be specification of desired line, with nobody in charge determining where outcomes rather than specific methods of operation, and evaluation and information systems that can the line begins, which way it goes, and where it assess performance in terms of output or results. ends. The result is that cost mounts and care suffers, not just for the poor but for the whole Good progress has been made recently in the population. To find the beginning, chart the way, revitalization, reorganization and staffing of the and determine the end will require leadership not Medical Services Administration (the agency ad- just of the parts but of the whole. The Task ministering the Medicaid program at the Federal Force believes this leadership is the proper role level), but substantial additional staffing and of the Federal Government. other administrative resources must be provided The Federal role in health has expanded for this program. A redirection of effort is called

BULLETIN, SEPTEMBER 1970 27 for toward : strengthening the Federal Govern- tions that view health in the context, of total life ment’s leadership role; employing state-of-t’he- style and that can evaluate the effectiveness of art management techniques, including the devel- various courses of action including intervention opment of relevant and cost-effect.ive manage- in the home and working situations. Without a ment control and information systems; and de- refocus on prevention and a broader orientation velopment of performance standards for States toward health generally, neither more responsible related to using Medicaid’s purchasing power to purchase of services nor better management will increase accessibility of care to the needy and give health the status it deserves in an economy improve the effectiveness of the care. A series of of scarcity. specific recommendations are made regarding im- plementation, primarily under management of Federal health act,ivities although there are others under effecting changes and improvements in the Consumer Participation delivery of health care. The Task Force viewed institutional areawide Not only do millions of consumers get care planning as a major arm of the new management. on a hit-or-miss basis or lack access to care Currently, considerable confusion and overlap except in medical crises, but virtually all con- exists among planning efforts and agencies. Al- sumers lack access to the decisionmaking ma- so, there are important gaps by section of the chinery that can bring about change. Few in- country. Results to date have been generally dis- stitutions and programs include representatives appointing. The Task Force made several recom- of everyday users of their services on policy- mendations in this area that (1) clarify roles making or governing boards, in spite of their and functions of public and private planning nonprofit, and presumably “community,’ char- agencies at the national, State and local levels; acter. The result is that medical care is still too (2) call for more Federal support of State and often delivered at the time and place and in the local efforts; (3) spell out the relations among way convenient to provider rather than con- the purchaser of care, the planning agencies, the sumer. Old patterns persist in the face of new constituent health institutions and the official demands-a basic cause of rising dissatisfaction sanctions to be exercised by Government. with the health services. Federal support was seen to include stronger A basic tenet of the report is that greater leadership, greater financial assistance (man- consumer involvement in decisionmaking is re- power and program) and more extensive technical quired to overcome deficiencies in the health assistance. system with reasonable dispatch and to achieve better management of resources. Without sub- stantial consumer input, health institutions can Broader Concept of Health become excessively self-serving and, in fact, tangential to even fundamental community health Although not concentrated in any given section, problems. Also, without consumer input, user various references are made in the report to the identity with service can deteriorate and inappro- need to promote and finance a broad range of priate use can occur. Perhaps it should be added facilities and services in order to forestall ex- that, as in the management of other affairs, the cessive preoccupation with and use of acute serv- consumer “wants in”-a valid reason for involve- ices. Currently, the health-care system is geared ment in its own right. There is no national means primarily to care for acute illness. This is a of providing the consumer the assistance he needs distortion of investment in both economic and to become a positive force for improving the Na- human terms. A better balance, with heavy em- tion’s health-care services, nor do the means now phasis on primary care to prevent illness, and on exist for bringing the consumer and provider rehabilitation to restore function, is needed and together to work jointly for improvements. A frequently cited. In discussing total health serv- number of recommendations bear on the prob- ices and long-term care in particular, the report lem of decisionmaking, involvement and educa- points up the necessity of supporting organiza- tion for this purpose.

18 SOCIAL SECURITY Any board or group set up to advise policy-making spectrum and of income maintenance at the other. officials at any level of Government must provide for Long-term care is something less than one and consumer representation to protect and present the interests and needs of the consumer. In addition, something more than the other. Distortions have executive committees, subcommittees, and ad hoc com- inevitably occurred, such as caring for essential mittees of such boards or groups should have a signifi- personal needs in a medical environment (which, cant number of consumer representatives as members. if unchecked, could bankrupt the health system), Federal agencies involved in planning, delivering and purchasing health services must make provisions in or returning persons with medical problems sta- budget for special orientation programs for new mem- bilized to an unaltered and unsuitable social en- bers of policy-making groups, including the consumer vironment. There are no easy answers, but the representatives on such groups. Task Force tried at least, to point the way toward State and local agencies as well as nongovernmental modest improvements. agencies involved in planning for, delivering, and pay- ing for health services should be required to make Importantly, the Task Force thought that provisions for orientation and training of policy-making although classifying patients is sound, patients groups, with special emphasis on consumer representa- should not be summarily discharged from skilled tives. nursing homes or other health facilities if al- Still with focus on the consumer, the Task ternate facilities are not available. Keeping a Force underscored the desirability of instructing patient in a health facility when his needs for users of services on their rights and benefits and support services cannot be met elsewhere does how to best use available services. not represent misuse ; it represents a default on the part of the community to match services with Programs of health education, provided they meet adequate standards set by the Federal Government, needs. Investments in alternative services are should be considered integral components of any health- the only humane way to solve the problems. care service and therefore included in the budget of In regard to Medicaid, Medicare, and public such service. All agencies and institutions providing assistance programs, a number of specific recom- health services that receive Federal support must pro- vide continuing programs of health education to their mendations are made : consumers. State Medicaid Programs should be required to under- take educational efforts designed to: improve recipi- Skilled nursing home regulations under title XIX ents’ use of the Medicaid program ; improve the health should require activities programming. of Medicaid recipients through preventive education ; Federal regulations for title XIX should require that improve providers use of the program; and provide all recipient-patients in nursing homes be visited by a for greater participation by provider and consumer in public assistance agency staff member as needed, but the planning, implementation, and evaluation of the not less often than quarterly. program. The extended-care benefit should be redefined and re- vised to eliminate existing confusion and reduce ad- ministrative complexity. THROUGHOUT ITS deliberations, the Task The Department of Health, Education, and Welfare Force was deeply concerned about two issues that, should consider : were given separate status at the end of the re- -that the Intermediate Care Facility remain generally port, i.e., long-term care and long-term financing defined as a zone of personal and residential service between the Skilled Nursing Home and the domici- of health services. Each is complex and calls for liary institution to allow flexibility to the States for extensive definition and debate. Our evaluation further definitions. of title XIX and related programs has high- -that the regulation on Intermediate Care Facilities pointed both. be strengthened to require activity programming to provide a creative and constructive environment in these institutions. -that in relation to the Medicare program the In- termediate Care Facility be considered a long-term Long-Term Care care and not a medical-care institution, particularly that a stay in an Intermediate Care Facility should Nearly one out of three medical dollars is be considered to break a “spell of illness” ; and after being spent on skilled nursing-home care, and a stay for a sufficient period of time, the person is again these expenditures have been growing far beyond eligible for hospital insurance benefits. expectations. Major attention has been focused -that the benefits for Skilled Nursing Home and the Intermediate Care Facility Programs should be ad- on the problems of medical care at one end of the ministered through a single administrative structure.

BULLETIN, SEPTEMBER 1970 29 Decisionmaking on placement is a discriminating ac- second, a set of specific issues and questions, by which tion, It is now sometimes performed by a health or different proposals can be compared and appraised. welfare agency, or by the individual’s physician, or several sources in concert. It requires an evaluation of the medical, nursing care and personal services In an economy of scarcity, decisions regard- needed by an individual, an appraisal of the financial ing even such valued considerations as good health resources available, a knowledge of the types and of come hard. With this in mind, the Task Force the financial resources available, a knowledge of the types and quality of existing community services, and believes strongly that a sizable unmet need for the ability to fashion congruence among these factors. health service is a disgrace and cannot be toler- Good information, a high degree of technical skill, and ated in an affluent society. We must be prepared great sensitivity to individual, family and community needs are required. It is unreasonable to expect that as a Nation to spend more money so that all citi- each physician, hospital, or family faced with this zens have reasonable access to health care. This decision can make an informed judgment when each target will not be reached unless interim objec- must gather information through their own resources. The continual outcry about misuse of services and tives are set, commitments are made, and the sys- public money is additional incentive for an informed, tem is more aggressively managed. The report community-wide process. points out ways to move ahead and identifies HEWas a critical leadership force. HEW’s com- mitment is now the key to improving health of the Nation in the decade ahead. Long-Term Financing Policies

In evaluating title XIX, the Task Force con- cluded that the present financing arrangements The following excerpt is from the section on for the existing and potentially eligible popu- Long-temn Care under the heading “Issues and lation are not adequate and that a nevv national Recommendntiom~.” policy for health-care financing is essential. Current arrangements, internally and as they re- late to other financing systems, lack the structure EXTENDED-CARE BENEFITS IN TITLE XVIII and resources to impact sufficiently on problems of both access and productivity. The purpose of the Medicare program is to re- The Task Force thought that HEW should de- move the major financial burden of acute medical- velop a policy position on this critical and com- care services from the aged population. The pro- prehensive health-care issue as the basis of any gram has had great success in achieving this goal. legislative recommendations to be made in 1971 However, since its inception, there has been dif- and as a measure against which to appraise ficulty in differentiating acute medical conditions proposals currently before the Congress, as well from terminal conditions, chronic disability and as those forthcoming, The issue is far too im- related social factors which influence t,he insti- portant to be debated hastily or conceived quickly tutional placement of patients. . . . in politically expedient terms. As the hospital insurance program has evolved, During its tenure, the Task Force had neither increased administrative emphasis has been given the resources nor the time, in the light of its to assuring the appropriateness of determinations full agenda, to examine closely the full dimen- dealing with coverage of care provided to bene- sions of the problem. Such an examination is ficiaries in extended-care facilities. Operationally needed. Major economic, fiscal and social policy it has been necessary t,o stress that the Medicare implications are involved. However, the Task legislation provided extended-care benefits as an Force did examine current financing systems and extension of the hospital benefit, on a relatively their relationship to delivery of services, and short-term basis, and not. within the context of develop observations that should be useful to the traditional, long-term nursing-home experi- those who follow. These are presented in two ence. . . . parts : While the concept of a post-hospital benefit is valid, the medical circumstances of some hos- First, a list of central and necessary objectives against pitalized patients (who could be moved to less- which, we believe, long-range financing proposals should be evaluated ; intensive levels of institutional care for an

30 SOCIAL SECURITY immediate period of recuperation or who may be- istrative complexity. This restructuring should include come destined to long-term care) do not lend the following elements : themselves to the tine coverage distinctions re- 1. Eligibility for admission to an extended-care facility quired by present law. It would seem, therefore, should be determined in the same manner as admission to a hospital, i.e., on the clearly stated determination by to be more equitable, more manageable adminis- the physician of the need for admission. tratively, and more comprehensible to benefici- 2. The extended-care-facility benefit should not exceed aries to define program financial responsibility a relatively short period of fixed duration to be deter- by providing access to a limited number of days mined by analysis of the extended-care-facility program of covered services, rather than attempting to experience and of its cost. set tight medical criteria for admissions, based 3. The definition of a skilled nursing home in title XIX on the key element of “continuous skilled nurs- should be incorporated by reference in the extended- care-facility definition in title XVIII, or other steps ing care.” should be taken to eliminate subtle and unnecessary The extended-care benefit should be redefined and re- distinctions between the institutions eligible to furnish vised to eliminate existing confusion and reduce admin- these two types of services.

BULLETIN, SEPTEMBER 1970 31