[Congressional Record Volume 145, Number 60 (Thursday, April 29, 1999)]
[Extensions of Remarks]
[Page E808]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




  MEDICARE MODERNIZATION BILL NO. 3--RURAL CASE MANAGEMENT ACT OF 1999

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                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                        Thursday, April 29, 1999

  Mr. STARK. Mr. Speaker, it gives me great pleasure to introduce the 
Rural Case Management Act of 1999, a common sense approach to 
delivering high-quality, coordinated health care in rural America. This 
is the third week, and the third bill, in my campaign to modernize and 
improve Medicare.
  Health care needs in rural areas are unique. Whereas many 
metropolitan areas suffer from an over-supply of providers, often there 
is only one provider serving a vast number of rural communities. One-
size-fits-all solutions do not work for these opposite ends of the 
health care spectrum.
  Yet, Republicans continue to promote managed care as the solution for 
all problems and people. Most recently, they have asked taxpayers to 
subsidize private managed care companies in rural counties, despite the 
widely acknowledged reality that managed care cannot function in rural 
areas due to the lack of providers. Changes made in 1997 BBA result in 
outlandish over-payments to private managed care plans that serve rural 
markets. In some counties, health plans are being paid almost twice as 
much as it costs traditional fee-for-service Secretary to operate 
there. Putting more money into an idea that simply cannot work is 
ridiculous. It's like watering a garden that has no seeds.
  The Rural Case Management Act of 1999 would eliminate the waste 
established in the BBA by making payments directly to rural providers 
who coordinate care for their patients. This benefit would help 
coordinate care for the chronically ill, such as diabetes or HIV/AIDS 
patients, improve notification for preventive services, such as 
mammograms and flu shots, and provide follow-up care for people who 
need it. The choice to participate would be entirely voluntary: no one 
would be ``locked in'' to the web of a rural managed care plan that had 
limited providers and limited budgets.
  There is no evidence that managed care is better for consumers than 
fee-for-service Medicine. In fact, for the frail chronically ill, 
evidence suggests the contrary. If HMOs were established in rural 
communities, beneficiaries in the area might be forced to join in order 
to get any service from the few local doctors and the one local 
hospital. Then, if they needed expensive care at a specialty center, 
would their local providers be reluctant to refer them to that center 
for care, when the cost would come out of the small budget of the 
local, rural HMO?
  In light of the Patients Bill of Rights debate and the managed care 
horror stories I have shared with my colleagues in the past, I wonder 
if we should be subjecting rural America to monopolistic ``managed 
care'' unless much stronger consumer protections and quality measures 
are in place.
  Providers are also having a difficult time with managed care. In a 
recent Project Hope survey, providers reported very serious problems 
with HMO reimbursement, clinical review, and paperwork. We should not 
encourage the growth of a health system with this many problems.
  The most valuable thing managed care offers is coordinated follow-up 
care. This is an administrative function. Providers in areas without 
managed care can serve this function effectively. We can reap the 
benefits of managed care without throwing more money at an idea that 
simply will not work. The bill I am proposing would pay rural providers 
a special amount to provide the best thing that managed care has to 
offer: care management.
  Some Members believe that bringing managed care into rural areas 
would being prescription drug coverage to rural beneficiaries. This is 
not likely. Managed care needs competition in order to work. But there 
will never be competition in many rural areas. The problem is that 
rural areas do not have ``extra'' providers to compete against one 
other.
  Competition is also what results in extra benefits in Medicare 
managed care. Health plans vying for greater enrollment entice 
beneficiaries to their plan by providing extra benefits, such as 
prescription drug coverage and zero deductibles. Due to the lack of 
competition, these extra benefits will seldom be offered in rural 
areas. A recent GAO report noted that prescription drugs were the only 
extra benefit for which overall beneficiary access increased in 1999. 
However, access to prescription drugs actually decreased in lower 
payment (i.e., rural) areas. This decrease occurred despite the 23 
percent payment increase in low-payment counties (compared to only 4 
percent increase in all other counties). The GAO report proves that 
more money will not guarantee extra benefits in rural areas. We must 
find creative alternatives to solve the unique problems of health 
access in rural America.
  Managed care is not a silver bullet solution for delivering health 
care. In the best of worlds, managed care can offer coordinated health 
services for enrollees. The same function can be provided by providers 
who live in rural areas and have an established relationship with their 
patients. This bill eliminates the middle man by sending payments 
directly to providers in rural areas. Instead of spending money to 
create managed care plans in areas of provider shortages, this bill 
helps to improve the quality of care by putting the money where it is 
needed most. I strongly encourage members' support.

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