[Congressional Record Volume 143, Number 23 (Thursday, February 27, 1997)]
[Senate]
[Pages S1737-S1738]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. GRASSLEY (for himself, Mr. Conrad, and Mr. Hollings):
  S. 371. A bill to amend title XVIII of the Social Security Act to 
provide for increased medicare reimbursement for physician assistants, 
to increase the delivery of health services in health professional 
shortage areas, and for other purposes; to the Committee on Finance.


             THE PHYSICIAN ASSISTANT INCENTIVE ACT OF 1997

 Mr. CONRAD. Mr. President, Senator Grassley and I are again 
introducing legislation to improve Medicare reimbursement policy for 
nurse practitioners, clinical nurse specialists, and physician 
assistants. The Primary Care Health Practitioner Incentive Act and the 
Physician Assistant Incentive Act of 1997 are very similar to S. 864 
and S. 863, which we introduced in the 104th Congress. This legislation 
passed both Houses as part of reconciliation in 1995. I am very hopeful 
that this bipartisan legislation will garner widespread support and be 
signed into law as part of a Medicare reform bill this year.
  We believe our legislation will help all Americans by making the best 
possible use of primary care providers who play a vital role in our 
health care delivery infrastructure. Throughout the country, nurse 
practitioners, clinical nurse specialists and physician assistants have 
the skills to provide needed primary care services. This is 
particularly important in rural and underserved areas that have 
shortages of physicians.
  In recent years, our Nation's health care system has put a renewed 
emphasis on the use of primary care and wellness. Nurse practitioners, 
physician assistants, and clinical nurse specialists are uniquely 
positioned to provide this care. Nurse practitioners are registered 
nurses with advanced education and clinical training, often in a 
specialty area such as geriatrics or women's health. Nearly half of the 
Nation's 25,000 nurse practitioners have master's degrees. Clinical 
nurse specialists are required to have master's degrees and usually 
work in teritary care settings such as cardiac care. Many, however, 
also work in primary care. Physician assistants receive an average of 2 
years of physician-supervised clinical training and classroom 
instruction and work in all setting providing diagnostic, therapeutic, 
and preventive care services. Each of these providers work with 
physicians in varying degrees usually in consultation.
  Within their areas of competence, these health care providers deliver 
care of exceptional quality. These practitioners play a vital role in 
communities that cannot support a physician but can afford a nurse 
practitioner or physician assistant; historically, these providers have 
been willing to move to both rural and inner-city areas that are 
underserved by health care providers. In fact, there are 50 communities 
in North Dakota that are taking advantage of the services provided by 
these care givers. Unfortunately, unless we make changes in our Federal 
reimbursement scheme, many areas of the country will not be able to 
benefit from these needed services.
  Current Medicare reimbursement rules were developed in an ad hoc 
fashion; as a result, they are inconsistent, incoherent, and nearly 
inexplicable. Current law provides reimbursement for advanced practice 
nurses in rural settings. But if the same patient sees the same nurse 
practitioner in a satellite clinic in an equally rural community that 
happens to be within an MSA county, reimbursement becomes subject to 
the ``incident to'' rule that HCFA has interpreted to require the 
physical presence of a physician in the building.
  In rural North Dakota and in rural communities throughout the 
country, that scenario is often inconsistent with the realities of 
health care delivery. Doctors in these areas often rotate between 
several clinics in a region that is staffed on a full-time basis by a 
physician assistant, nurse practitioner, or other provider. This allows 
physicians to cover a wider area and affords more rural residents 
access to basic primary care services. Current Medicare rules work 
against this, however. If a Medicare patient requires care when a 
physician is away at another clinic or out on an emergency call, the 
physician assistant or other provider will not be reimbursed by 
Medicare for the same care that would have been paid for if a physician 
was in the next room.
  Moreover, if the nurse practitioner crosses the street from a free-
standing clinic to a hospital-affiliated outpatient clinic, the 
reimbursement rules change once again. Physician assistants are subject 
to an equally bewildering set of reimbursement rules that serve to 
prevent their effective use by the Medicare Program.
  Other complications also cause problems. State laws are often 
inconsistent with the Medicare requirements. In North Dakota, care 
provided by a physician assistant is reimbursed even if a physician is 
not present. Across the country, there also are a wide variety of 
payment mechanisms that result in reimbursement variations in different 
settings and among different providers. The Office of Technology 
Assessment, the Physician Payment Review Commission, and these 
providers themselves have all expressed the need for consistency and 
sensibility in a reimbursement system that acknowledges

[[Page S1738]]

the reality of today's medical marketplace. Our colleagues shared those 
sentiments in 1995 by passing this legislation in both Houses.
  The legislation Senator Grassley and I are introducing today will 
provide each of these groups with reimbursement at 85 percent of the 
physician fee schedule. They will also provide a bonus payment to those 
providers who choose to practice in areas designated as Health 
Professional Shortage Areas [HPSA's]. The health care access problems 
faced by residents of these communities could be dramatically improved 
through the use of this special class of primary care providers. 
Finally, our legislation will ensure that a nurse practitioner who 
cares for a patient will get paid directly for that service.
  This legislation offers an example how Medicare can and should 
increase access to care by promoting the use of cost-effective 
providers to a much higher degree without compromising the quality of 
care that older Americans receive. There was a clear agreement on these 
issues in the 104th Congress, and we urge our Democratic and Republican 
colleagues to continue to support this legislation in the 105th 
Congress.
                                 ______