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the PSRO law have been submitted to both houses of Congress.

The report also noted that several legislators which it did not

name have submitted proposals to repeal PSRO, but whether or not

the Senate Finance and Claims and House Ways & Means Committee

are expected to pursue changes in the law is open to question.

MALPRACTICE INSURANCE CAUSES CALIFORNIA

DOCTORS TO WALK OUT

At midnight April 30, 4,000 doctors in the San Francisco area
elected not to renew their medical malpractice insurance policies
with Argonaut Insurance Co. of Menlo Park, California.

The result brought all but emergency surgery to a virtual
standstill as doctors refused to pay increased rates which reached
as high as 322 per cent.

Several days later a spokesman for San Francisco's anesthesiolo-
gists announced that the group would maintain their hard line against
the skyrocketing rates.

Dr. Dan Walker, chairman of the anesthesia section of the San
Francisco Medical Society is quoted as saying, "We are sorry for the
inconvenience to the public and the economic hardship imposed on
hospital employees, but once and for all this issue must be resolved."

Within a week, effects of the walkout were being felt as some
3,000 hospital workers in the area were laid off. Estimates of the
number of anesthesiologists who were remaining off the job were
between 165 and 250.

Dr. Hugh Vincent of the San Francisco Medical Society told the
Associated Press that: "This is not a union action. Each individual
is doing his own thing."

Donald Burns, State Business and Transportation Secretary and
California's top insurance official told AP, "The result is that I am
concerned that people are being thrown out of work, like orderlies
and nurses. But this is a problem that the doctors created for
themselves."

Argonaut reportedly was seeking increases from $5,377 to
$18,164 per year for anesthesiologists and other high risk specialists.
The increases were expected for some time as a number of insurance
companies have been bailing out of medical malpractice coverage
altogether in the last several years.



NWAHPC Studies

Federal

Regulations

The Northwestern Areawide
Health Planning Council with the
assistance of the Division of CHP
and John Short and Associates, a
consulting firm from Salt Lake
City, has recently completed a
study determining the impact of
federal regulations on the opera-
tion of long-term care facilities in
the area.

Such impact is the result of the
facilities' participation in the fed-
eral Medicare and Medicaid pro-
grams which is essential to the
operations of these facilities.

The study was prompted by con-
cern over alleged inequities in the
enforcement of federal regulations.
Specifically, the contention is that
the regulations governing staffing
levels do not take into considera-
tion small facilities such as those
in rural Montana where there is
an across-the-board manpower
deficit.

Says Health Researcher Joanne
Brothers, "Nobody questions the
value of providing increased staff
and services; but in a rural setting
the added cost of recruitment and
maintaining the additional health
manpower is passed on to the con-
sumer."

Brothers indicated that if the
federal philosophy continues to re-
quire the increased staffing levels
and services, then it would be eco-
nomically difficult for the small
long-term care facilities to comply
with the regulations.

Brothers also mentioned that the
state's moving developmentally dis-
abled patients from the state insti-
tutions to the facilities has had an
added impact on the nursing homes.
"Nursing homes will have to pro-
vide services to this type of pa-
tient that just are not available
right now," she added.

The Executive Board of the
Areawide Council made the follow-
ing recommendations to the federal
government, the state survey
agency, and the Montana Nursing
— continued on next page



PAGE SIX



Home Association after reviewing
the report:

That the federal government in
setting standards make geographic
distinctions such as size of facility,
available manpower and location.

That the federal government
either provide additional financial
assistance to rural providers to
make implementation standards
more feasible; relax some of the
restrictions that are detrimental to
small, rural long-term care facili-
ties; and/or make it possible for
the state survey agency (Montana
State Department of Health and
Environmental Sciences) to provide
development models and assist in
recruiting health manpower.

That a recruitment program for
specialized manpower should be set
up on a regional or state basis and
the responsibility should lie with
the state survey agency or the
Montana Nursing Home Associa-
tion.

That the federal agency respon-
sible for training the survey agency
should allow more time for training
before the implementation of regu-
lations. Also interpretive guidelines
should be available to providers
prior to implementation of the
standards.

Concerning impacts of the de-
velopmentally disabled on long-
term care facilities: Due to the sig-
nificant impact this population has
had, the recommendation is to re-
quire and implement group home
regulations defining the require-
ments for homes presently provid-
ing services for only the develop-
mentally disabled. Furthermore,
the State should be required to an-
nounce its long-range plans for the
developmentally disabled patients
that are presently residing in long-
term care facilities.

That the survey agency should
place at least one surveyor in the
region to expedite implementation
and supply technical assistance to
long-term care facilities to achieve
compliance in standards.

That due to the cost of locating
a nursing home within a hospital,
review criteria and guidelines be
developed to consider the feasibility
of "co-location" when a facility is
applying for such a designation.



HEALTH PLAN IMPLEMENTATION



The Environmental Health Com-
mittee is currently in the planning
stages of developing a workshop
which is designed to stimulate the
implementation of the Environ-
mental Health Plan included with-
in the State Plan for Health.

Intended to bring together those
key decision makers and implemen-
tors cited in the Environmental
Health Section's 33 objectives, the
workshop scheduled for September
25 and 26 will try and determine
to what extent those involved in
Environmental Health find the Plan
to be a working tool.



care, environmentalists, health pro-
fessionals, and concerned citizens
will attend the workshop.

Scheduled to take place over a
two-day period in Helena, the first
day will host a presentation of the
Environmental Health Plan by Jon
Tovson, author. That presentation
will be followed by a discussion of
the Plan. State and local officials
will be asked if they perceive the
plan to outline what they consider
to be areas of concern in environ-
mental heath.

The second day will deal with
prioritizing areas of concern, de-




Dave Stuart and Martha Dow of the Environmental Health Committee.



"The specific purposes of the
workshop will be to arrive at a
common understanding of and con-
sensus on the Environmental Plan,
agree upon priority areas of con-
cern in environmental health, de-
fine roles within the implementa-
tion process, and agree upon and
develop strategies to solve the
problems so identified as priority
areas," explained Martha Dow,
Chairperson of the Committee.

At this point, one major concern
of the Environmental Health Com-
mittee is the matter of funding for
the workshop. A grant application
was submitted to the Department
of Health, Education and Welfare
under the threat of deadline. How-
ever, no word of the application's
status has been received as yet.

It is hoped that federal, state and
locally-elected officials along with
providers and consumers of health



fining roles and responsibilities
within the environmental health
field, and outlining courses of
action.

Two professional facilitators
from the State Extension Service
at Montana State University, James
DeBree and Robert Neils, will as-
sist in the workshop.

Tentatively the workshop is to
be held at the Travelodge in Hel-
ena on September 25-26. The En-
vironmental Health Committee will
be finalizing plans within the next
month and a final, complete agenda
will be disseminated at that time.

Those wishing more information
on the workshop should write:
Environmental Health Committee
Comprehensive Health Planning

Division
Department of Health and

Environmental Sciences
Cogswell Building
Helena, Montana 59601.



PAGE SEVEN



Rural Health-

— from page 1

federal programs aimed at increas-
ing the number of physicians
choosing a rural practice. How-
ever, he added that perhaps the
rural needs could only be met by
some form of compulsory medical
service similar to a draft.

"If America is to enjoy its fair
share of physicians, some kind of
compulsary program — a doctor
draft — will probably have to be
enacted."

Margolis noted that both the
AMA and American Association of
Medical Colleges (AAMC) oppose
the concept of a draft.

"They oppose this (concept) on
the traditional grounds that volun-
tary schemes are always preferable
to compulsary ones. But voluntary
schemes thus far have solved
nothing.

"Besides, why shouldn't distribu-
tion of our new doctors be con-
sidered a question of public policy?
It is the taxpayer, after all, who
educates doctors by footing at least
half the medical schools' bills. Over
the past decade federal spending
for health manpower programs has
increased from $65 million a year
to $536 million a year," he said.
He further cited the concept of
regionalization of services as add-
ing to the problems of rural health
care in that they would force small
rural hospitals out of existence.

"To many rural Americans the
all too familiar look; it bears a
striking resemblance to notions
that for half a century have spelled
the decline of small towns: not
only the regionalization of hospi-
tals, but also the consolidation of
schools, the abandonment of rail-
roads, the mapping of highways
so as to bypass small towns, and
the denial of subsidies to commu-
nities unable to establish their cre-
dentals as 'growth centers.' These
are among the historic policies that
will soon have to be reversed if
small town citizens are to win an
equitable footing in the nation's
mainstream; if rural America, that
is, is ever to regain its health,"
Margolis said.

PAGE EIGHT



Under Observation

by Dennis Taylor

The specter of National Health Insurance is once again rearing its
head on the Congressional horizon. Like a perennial mirage, NHI is
touted as being just around the corner. "NHI, not if, but when," goes the
now all too familiar battle cry. As escalating health care costs continue
unabated and the realities of recession close in, the 94th Congress may
indeed be forced to act this session to establish a system of National
Health Insurance which will provide all residents of this nation protection
against the economic catastrophe of illness. Several key prepatory pieces
of the NHI puzzle are beginning to fall into place as PL 93-641, the
National Health Planning and Resources Development Act, and the
Professional Standards Review Organization law begin to set up mecha-
nisms for cost containment, systems rationalization, and some measure
of quality control. What is missing, however, is the most important
preparation for NHI — the state response — a comprehensive system of
local public health.

If NHI is going to work, it must be supplemented and predated by
a system that insures the promotion of optimum health and the prevention
of illness. The National Health Insurance proposals, which thus far have
been advanced, consist primarily of a method for paying sickness costs
and amount to only a financial mechanism to maintain the current chaos
of our health care delivery system. Dr. C. Arden Miller, President of the
American Public Health Association, thinks the problem is worsening.
In a recent column he states, "During most of this century a patchwork
of public health programs has developed, not to replace the marketplace
of health care, but to compensate for its deficiencies. These deficiencies
are still there but the compensatory patchwork, never adequate to the
need, is being torn away."

Montana's patchwork of local public health has always been thread-
bare and fragmented. Efforts of the two-year HJR 18 Study Committee
outlined the problem and offered a skeleton of workable recommendations
to begin to implement a system of local health promotion for Montana. In
the last Legislature, HB 478, a proposal introduced by Rep. John Driscoll
(D-Hamilton) which would have gone a long way towards the goal of
insuring a minimum level of public health services for all Montanans,
fell on deaf ears in the House Public Health, Welfare and Safety
Committee.

The substance of health promotion and health protection through
enhanced local public health capacity in Montana remains wanting. Its
significance is yet to be fully understood by health policy decision makers
in Montana. Our situation may not be as dire as states such as Mississippi,
but it is certainly not as good as some of our sister states, such as Idaho,
where the framework for local public health has been enacted and
numerous state legislators have surfaced as informed, aggressive and
articulate advocates of public health policy initiatives.

Montana has yet to produce a single legislator with prime interest
in health, much less the requisite core of health policy advocates necessary
to prepare for and respond to the requirements of any national health
insurance scheme with direct and cohesive action.

Once again, Montana is taking the "ostrich approach" to problem
solving in the health area, feeling that if you bury your head in the sand
the problem will go away. The Montana State Plan for Health calls for
the adoption of "the concept of regionalization for the delivery of public
health services" and for "the gradual building of an integrated public
health program that will provide comprehensive public health services
of optimum quality equally available and accessible to all Montanans."
This study, too, threatens to go with the way of the HJR 18 Study, facing
little chances for implementation in the near future due to the lack of
serious consideration by Montana policy decision makers — another study
to gather dust on the library shelf.

What needs to be done and needs to be done now, is to begin
gathering momentum for the next legislature with a strong and resolute
plan of action that will insure a long overdue system of health promotion
in Montana — local public health. Time is running out for the preparation
for NHI. The puzzle begins to take shape. Let's not let Montana be left
with several key pieces missing. The time for local public health for all
Montanans is now.



HEALTH LEGISLATION SUMMARY

44th Montana Legislature



The following is a summarization
of how key health-related bills
fared in the 1975 Montana Legis-
lature.

HB 29 — Gerke. Would require
that 5 members of the Board of
Health and Environmental Sciences
be nonprofessionals and the other
two members be from health-re-
lated professions. (Signed by the
Governor, 4/8/75)

HB 42 — Luebeck, et al. Would
require prescription price posting
and quotations and the listing of
related services. (House, Killed in
Business and Industry, 1/28/75)

HB 45 — Gunderson, et al.
Would provide for the licensure
and regulation of radiologic tech-
nologists under the Department of
Professional and Occupational
Licensing. Creates a Board of
Radiologic Technologists. (Signed
by Governor, 4/9/75)



shall supervise more than one PA;
and limits the practice of a PA to
his practitioner's place of business
or physical presence. (Died when
four conference committees could
not reach a compromise.)

HB 119 — Johnson, et al. Would
appropriate one hundred thousand
dollars ($100,000) to the Depart-
ment of Health and Environmental
Sciences, so that Department can
in turn contract with the Univer-
sity of Montana for five studies on
the adverse health effect of air
pollution on Missoula Valley resi-
dents. (House, Killed in Appropria-
tions, 3/20/75)

HB 123 — Murphy, Dassinger.
Would allow the Board of Medical
Examiners to waive personal ap-
pearances before the Board prior
to license issuing. (Senate, Indefi-
nitely postponed on Second Read-
ing, 3/5/75)




House of Representatives — 44th Legislature



HB 60 — Palmer, et al. Would
appropriate $40,000 for family
planning services throughout the
state and provides that no minor
could be served without parental
consent. (Signed by Governor
4/8/75)

HB 72 — Jack Moore, et al.
Would provide for certification of
emergency medical technicians by
the Board of Medical Examiners.
Provides for the acts they may
perform and limits their liability.
(Signed by the Governor, 3/19/75)

HB 73 — Moore, et al. Provides
for the certification of physicians'
assistants (PA) by the Board of
Medical Examiners in accordance
with rules and regulations of said
Board; provides that no practitioner



HB 124 — Murphy. Would al-
low the Board of Medical Examin-
ers to revoke or suspend a license
to practice medicine and surgery
when the holder of the license has
had his license revoked or suspend-
ed by another jurisdiction. (Signed
by Governor, 3/18/75)

HB 129 — Brand, Menahan.
Would regulate odoriferous estab-
lishments (feed lots and poultry),
defines public nuisances and au-
thorizes the Department of Health
and Environmental Sciences to
make rules. (House, Killed on Sec-
ond Reading, 2/25/75)

HB 133 — South. Would require
all counties to participate in the
cost of regional mental health cen-
ter programs in Montana. (Died in



Senate Public Health, Welfare and
Safety Committee.)

HB 170 — Federico. Would re-
peal the Montana contraceptive
law thereby removing all restric-
tions on sale. (House, Killed in
Public Health, 2/8/75)

HB 171 — Federico. Would au-
thorize counties to legalize prosti-
tution outside of incorporated
towns and cities. (House, Killed in
Public Health, 2/8/75)

HB 174 — Lockrem. Would pro-
vide a state income tax credit to
doctors and dentists who practice
in Montana cities and towns with
less than 10,000 population.
(House, Killed in Judiciary,
2/21/75)

HB 186 — Huennekens. Would
require any person conducting an
industrial or commercial process
that discharges designated critical
materials into the air and water to
file annual reports on the source
and amount of these materials. The
Department of Health and Environ-
mental Sciences shall investigate
the reports. The Attorney General
shall enforce the act. (House, Died
in Natural Resources for Lack of
Transmittal.)

HB 201 — Hager, et al. Would
authorize a veterans nursing home
and hospital at Billings. It shall be
constructed and run to obtain fed-
eral monies. Would require an out-
lay of State funds. (House, Killed
in Appropriations, 4/17/75)

HB 239 — Conroy, et al. Would
control the distribution of sample
drugs, limiting them to practition-
ers of medicine, dentistry, and
podiatry upon their written request.
(Senate, Indefinitely postponed on
Second Reading, 3/21/75)

HB 256 — Finley. Would permit
citizens with medically acknowl-
edged terminal conditions to die if
they so choose. Would allow any-
one after filing a document of dec-
laration to die. Provides for non-
liability on the part of doctors and
nurses. (House, Killed in Public
Health, 2/6/75)

— continued on next page

PAGE NINE



Health Legislation-



continued



HB 262 — Palmer, Federico.
Would enact the Uniform Residen-
tial Landlord and Tenant Act which
equalizes the rights and duties of
landlords and tenants in rented
dwellings. (Senate, Killed on Third
Reading as Amended, 4/3/75)

HB 296 — Federico, Holmes.
Would require anyone operating a
foster home or institution where
seven (7) or fewer people live and
are cared for to obtain a license
from the Department of Health and
Environmental Sciences. (House,
Died in Public Health for Lack of
Transmittal.)

HB 326 — Conroy, et al. Would
delete the wording that allows pre-
scriptions to be refilled when no
limitation is provided on the pre-
scription. Also would provide
punishment for persons found
guilty of forging prescriptions.
(Senate, Killed in Public Health,
3/19/75)

HB 340 — Sheldon, Bradley, et
al. Would authorize each state
agency to adopt rules imposing a
fee to be paid by an applicant for
a lease, permit, contract, license or
certification when an agency is re-
quired to compile an environmen-
tal impact statement. (Signed by
Governor, 4/8/75)

HB 342 — Gerke, Driscoll, Bar-
danouve, et al. Housing Act of
1975. Would create a Board of
Housing, provides powers and
duties relating to financing to as-
sist private enterprise and govern-
mental agencies to meet housing
needs. (Signed by Governor,
4/16/75)

HB 351 — Holmes, et al. Would
provide for a penalty for smoking
in enclosed public places that are
posted as non-smoking areas. (Sen-
ate, Killed on Third Reading as
Amended, 3/24/75)

HB 352 — Dussault, et al. Would
make unlawful the use of junked
motor vehicles for flood control of
a stream or for reinforcement of
the banks of a stream. (Signed by
Governor, 3/24/75)

HB 353 — Dussault. Would pro-
vide for community-based services

PAGE TEN



for the developmentally disabled.
Would make the Department of
Social and Rehabilitation Services
the responsible agency. (Signed by
Governor, 4/3/75)

HB 356 — Dussault, Holmes.
Provides for a hospital and hos-
pital-related facility annual licens-
ing fee based on the number of
beds; 20 beds or less, $20; $1 per
bed over 20 beds. (Signed by Gov-
ernor, 4/7/75)

HB 357 — Dussault, Holmes.
Would provide staggered terms for
the members of the Board of Nurs-
ing Home Administrators. (Signed
by Governor, 3/19/75)

HB 360 — Murphy. Would allow
the use of quarter and semester
hours in computing the four years'
instruction required to obtain a
license to practice podiatry. Also
provides for licensure if the appli-
cant has passed the National
Podiatry Board Examination. (Sign-
ed by Governor, 3/19/75)

HB 370 — Meloy (By Request
of SDHES). Would revise the water
pollution control laws to conform
with federal requirements, to im-
prove enforcement procedures and
to provide for user charges for in-
dustrial and other users of public
sewage treatment systems. (Signed
by Governor, 4/16/75)

HB 387 — Rasmussen. Would
prevent physicians from delegating
their exemption from the provi-
sions of the optometric law to any
non-physician. (House, Died in
Public Health for Lack of Trans-
mittal.)

HB 414 — Rasmussen. Would
establish an interagency committee
with members from the Depart-
ment of Health and Environmental
Sciences, Social and Rehabilitation
Services, and Institutions. The
Committee shall establish a pro-
gram of problem pregnancy coun-
seling and for the training of coun-
selors. (Senate, Killed in Public
Health, 3/19/75)

HB 425 — Ellis, et al. Would
establish a program of litter con-
trol. Provides for the Department
of Natural Resources and Conser-
vation as enforcing agency. (House,
Died in Natural Resources for Lack
of Transmittal.)



HB 434 — Lory, Ellis. Would
authorize the Department of Social
and Rehabilitation Services to
make rules relating to care of
"medically needy" and to estab-
lish the income level for such per-
sons but not in excess of 300%
of the general medical assistance
income level. (Signed by Governor,
4/10/75)

HB 467 — Menahan, Brand.
Would allow certain masters level
psychologists to obtain a licensed
private practice in Montana.
(House, Killed in Public Health,
2/21/75)

HB 471 — Kimble. Would es-
tablish the county attorney as the
legal advisor for county and city
boards of health. Also widens the
legal powers of local boards by
increasing fines, granting injunc-
tive powers and by declaring each
day of violation a separate offense.
(Signed by Governor, 4/7/75)

HB 478 — Driscoll. Would re-
quire the Department of Health
and Environmental Sciences to de-
velop programs to insure a state-
wide minimum of public health ser-
vices. (House, Died in Public
Health for Lack of Transmittal.)

HB 509 — Bengston, Finley.


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