[Congressional Record Volume 143, Number 23 (Thursday, February 27, 1997)]
[Senate]
[Pages S1736-S1737]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. GRASSLEY (for himself, Mr. Conrad, and Mr. Hollings):
  S. 370. A bill to amend title XVIII of the Social Security Act to 
provide for increased Medicare reimbursement for nurse practitioners 
and clinical nurse specialists to increase the delivery of health 
services in health professional shortage areas, and for other purposes; 
to the Committee on Finance.


       THE PRIMARY CARE HEALTH PRACTITIONER INCENTIVE ACT OF 1997

 Mr. GRASSLEY. Mr. President, today, on behalf of myself, 
Senator Conrad, Senator Dorgan, and Senator Hollings, I am introducing 
two bills. If enacted, these bills would increase access to primary 
care for Medicare beneficiaries in rural and inner-city communities. 
The Primary Care Health Practitioner Incentive Act of 1997 would reform 
Medicare reimbursement to nurse practitioners [NP's] and clinical nurse 
specialists [CNS's]. The Physician Assistant Incentive Act of 1997 
would reform Medicare reimbursement for physician assistants. We 
introduced these bills in the last three Congresses. We are 
reintroducing them today to improve access to primary care services for 
Medicare beneficiaries, particularly in rural and underserved areas. 
This legislation would reform Medicare policies which, under certain 
circumstances, restrict reimbursement for services delivered by these 
providers. Similar measures are included in the President's Medicare 
proposal and were part of the Balanced Budget Act of 1995.
  The Medicare Program currently covers the services of these 
practitioners. However, payment levels vary depending on treatment 
settings and geographic area. In most cases, reimbursement may not be 
made directly to the nonphysician provider. Rather, it must be made to 
the employer of the provider, often a physician. The legislation 
authorizing these different reimbursement arrangements was passed in an 
incremental fashion over the years.
  The Medicare law, which authorizes reimbursement of these providers, 
is also inconsistent with State law in many cases. For instance, in 
Iowa, State law requires nonphysicians to practice with either a 
supervising physician or a collaborating physician. However, under Iowa 
law, the supervising physician need not be physically present in the 
same facility as the nonphysician practitioner and, in many instances, 
can be located in a different site from that of the nonphysician 
practitioner he or she is supervising.
  Unfortunately, Medicare policy will not recognize such relationships. 
Instead, the law requires that the physician be present in the same 
building as the nonphysician practitioner in order for the services of 
these nonphysician providers to be reimbursed. This is known as the 
incident to provision, referring to services that are provided incident 
to a physician's services.
  This has created a problem in Iowa, Mr. President. In many parts of 
my State, clinics have been established using nonphysician 
practitioners, particularly physician assistants, to provide primary 
health care services in communities that are unable to recruit a 
physician. The presence of these practitioners insures that primary 
health care services will be available to the community. Iowa's 
Medicare carrier has strictly interpreted the incident to requirement 
of Medicare law as requiring the physical presence of a supervising 
physician in places where physician assistants practice. This has 
caused many of the clinics using physician assistants to close, and 
thus has deprived the community of primary health care services.
  Mr. President, in 1995 the Iowa Hospital Association suggested a 
number of ways to improve access and cost effectiveness in the Medicare 
Program. One of their suggestions was that this incident to restriction 
be relaxed. They said:

       In rural Iowa, most physicians are organized in solo or 
     small group practices. Physician assistants are used to 
     augment these practices. With emergency room coverage 
     requirements, absences due to vacation, continuing education 
     or illness and office hours in satellite clinics, there are 
     instances on a monthly basis where the physician assistant is 
     providing care to patients without a physician in the clinic. 
     Medicare patients in the physician clinic where the physician 
     assistant is located have to either wait for the physician to 
     return from the emergency room or care is provided without 
     this provision.

  If enacted, this legislation would establish a more uniform payment 
policy for these providers. It would authorize reimbursement of their 
services as long as they were practicing within State law and their 
professional scope of practice. It calls for reimbursement of these 
provider groups at 85 percent of the physician fee schedule for 
services they provide in all treatment settings and in all geographic 
areas. Where it is permitted under State law, reimbursement would be 
authorized even if these nonphysician providers are not under the 
direct, physical supervision of a physician.
  Currently, the services of these nonphysician practitioners are paid 
at 100 percent of the physician's rate when provided ``incident to'' a 
physician's services. If enacted, this legislation would discontinue 
this ``incident to'' policy. Medicare reimbursement would now be 
provided directly to the nurse practitioners and clinical nurse 
specialists and it would be provided to the employer of the physician 
assistant. These bills also call for a 10-percent bonus payment when 
these practitioners work in health professional shortage areas 
[HPSA's]. Senator Conrad and I believe these provisions will encourage 
nonphysician practitioners to relocate in areas in need of health care 
services.
  Mr. President, legislation closely paralleling these bills we are 
introducing today is being introduced this week in the House by 
Representatives Nancy

[[Page S1737]]

Johnson and Ed Towns. In addition, these provisions are included in the 
President's Medicare proposal. Historically, this legislation has 
received bipartisan support in both Houses. Comparable legislation was 
included in the Balanced Budget Act of 1995, as well as several other 
health care measures in previous Congresses. Therefore, I urge my 
colleagues to support this legislation.
  Mr. HOLLINGS. Mr. President, I join my colleagues Senators Conrad and 
Grassley in introducing the Primary Care Health Practitioner Incentive 
Act of 1997. Today I specifically want to address the provision that 
would allow for direct Medicare reimbursement for services provided by 
nurse practitioners and clinical nurse specialists regardless of 
geographic location. For many years we have been trying to pass 
legislation that would allow these health care providers in urban 
settings the same direct Medicare reimbursement as those in a rural 
setting, and I am hopeful that this is the year it will actually be 
enacted.
  Currently, nurse practitioners and clinical nurse specialists may 
treat Medicare patients without a physician present if they practice in 
a rural setting or in a long-term care facility. I believe that it is 
time for this antiquated restraint to practice to be removed so that 
health care choices may be improved and increased for all Medicare 
patients. If we are to have any hope of providing adequate care with 
huge reductions in both Medicare and Medicaid, it is essential that 
service be provided by the least costly provider of quality care. We 
simply cannot afford to ignore the quality care of which nurse 
practitioners and clinical nurse specialists have proven they are 
capable.
  I would also like to point out that many times there is a discrepancy 
in the designation of rural and urban areas. In my home State of South 
Carolina, as in other States, a number of the areas listed as urban 
are, in reality, rural areas. Medicare patients in these areas are 
unable to receive home visits or utilize local community satellite 
offices staffed with nurse practitioners. Rather, they are required to 
travel miles to see a physician. As a result, many patients forgo 
preventive health care and wait to seek care until they become so ill 
that they must be hospitalized or they are forced to seek care in more 
expensive emergency rooms. Not only is access to physicians more 
limited, but their fees for services are usually higher as well. Recent 
figures published by the American Academy of Nurse Practitioners 
estimate a cost savings of greater than $54 million per year if nurse 
practitioners were utilized appropriately in the provision of Medicare 
services in ambulatory care settings.
  The primary objective of nurse practitioners and clinical nurse 
specialists is to provide routine care, manage chronic conditions, 
promote preventive health care, and make medical care more accessible 
and less expensive. Nurse practitioners and clinical nurse specialists 
have proven that they are able to provide high-quality, cost-effective 
primary care in all settings in which they provide services. It is 
foolish to restrict their ability to provide primary care services to 
the elderly based on setting or geographic location, and I urge your 
consideration and the passage of this bill.
                                 ______