[Congressional Record Volume 145, Number 69 (Thursday, May 13, 1999)]
[Senate]
[Pages S5261-S5262]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




              PROMOTING HEALTH IN RURAL AREAS ACT OF 1999

  Mr. FRIST. Mr. President, I rise to speak in support of S.980, the 
``Promoting Health in Rural Areas Act of 1999,'' which my colleagues 
and I on the Senate Rural Health Caucus introduced on May 6,1999.
  There is no single issue that unites rural Americans more than access 
to quality health care. It is one of the most important components of 
good quality of life in rural areas. The ability to receive high 
quality health care keeps people in and attracts them to small towns. 
Good health care services in a community can be both a source of great 
pride and security and many times local hospitals are a community's 
largest employer.
  But some of that security is being threatened. Access to health care 
in rural areas can be problematic. Distances are greater. Some 
hospitals have closed. There are fewer choices of health plans than in 
urban areas. The ``Promoting Health in Rural Areas Act of 1999'' will 
help to improve access for rural citizens, increase payments to 
providers in rural areas, and bring innovative technologies to rural 
areas.
  Approximately 20 percent of the nation's population, or more than 50 
million people, live in rural America. However, the rural population is 
disproportionately poor, experiences significantly higher rates of 
chronic illness and disability, and is aging faster than the nation as 
a whole. In rural areas, the elderly account for 18% of the population.
  Poverty is more widespread in rural areas and in 1995 the poverty 
rate was 15.6% there. Poverty was especially high in minorities--
affecting 35% of rural African Americans and 31% of rural Hispanics. 
22.4% of rural children live in poverty.
  Health insurance coverage is also a problem. In 1996, only 53.7% of 
residents in rural areas had private health insurance and in 1996 about 
10.5 million rural residents were uninsured. Medicare beneficiaries are 
more likely than the general population to reside in rural areas. 
Medicare spends less on rural beneficiaries than on urban beneficiaries 
and Medicaid covered only 45% of the rural poor. The government has a 
responsibility to rural communities and a responsibility to support the 
safety net upon which so many rural communities depend.
  Before coming to the Senate, I was a heart-lung transplant surgeon. 
In that capacity, much of my time was spent working with rural health 
care providers who were caring for trauma victims eligible for organ 
donation. I spent many late nights flying to remote areas to harvest 
organs for transplantation elsewhere in the country. In this situation, 
I entered into their communities and worked side-by-side with rural 
hospitals, and their physicians, nurses, and other health 
professionals. These providers do an excellent job. However they work 
under very difficult conditions and require special attention to their 
particular needs.
  To address the unique attributes of the health needs of the rural 
areas of America, I joined my colleagues in introducing this important 
legislation. The Promoting Health in Rural Areas Act of 1999 contains a 
number of provisions designed to enhance rural health.
  There are provisions in the legislation to assist rural hospitals. 
For example, our bill reinstates the Medicare Dependent Hospital 
program which expired last year. This special designation directs 
special Medicare payments to eligible hospitals. Medicare Dependent 
Hospitals include rural hospitals that are not Sole Community 
Hospitals, have 100 or fewer beds, and at least 60% Medicare patient 
discharges or days. The bill also protects the Sole Community Hospitals 
program which aids hospitals in remote areas that serve as the sole 
hospital in an area.
  There are also provisions to expand wage index reclassification. This 
means that hospitals in areas that are classified as rural can apply to 
use an urban wage index if they can show that their wages are similar 
to prevailing wages in urban areas. The provision would also direct the 
Health Care Financing Agency (HCFA) to establish separate wage indices 
for home health agencies and skilled nursing facilities so that their 
payments will be fairer and more accurate.
  This bill would exclude Critical Access Hospitals, Medicare Dependent 
Hospitals, and Sole Community Hospitals from the new Medicare 
outpatient prospective payment system (PPS) when it is implemented. The 
HCFA analysis has shown that these primarily small, rural hospitals 
would

[[Page S5262]]

be disproportionately impacted by the outpatient PPS as proposed.
  The bill would improve Medicare payments to rural health clinics and 
allow HCFA to institute a prospective payment system. Medicare 
currently pays Rural Health Clinics for their reasonable costs up to a 
per-encounter cap of $60.40. The equivalent cap for Federally Qualified 
Health Center services, which was set using more recent data and a 
different methodology, is significantly higher ($80.62). S. 980 updates 
the methodology used to calculate the per-encounter cap, which will 
improve payments to rural health clinics.
  There are provisions in the legislation to enhance choice of health 
plans in rural areas. The payment formula for Medicare+Choice plans, as 
revised in the Balanced Budget Act of 1997 (BBA), contains substantial 
changes designed to lessen the variance in payments to health plans 
among geographic areas over time. Today, Medicare payments vary county 
to county by more than 350% because they had been tied to historical 
charges. This is not a true reflection of the cost of delivering health 
care and in fact penalizes rural areas with historically poor access to 
quality care. Therefore, S.980 adjusts the payment formulas for 
Medicare+Choice plans to help rural areas attract private health plans.
  Attracting health professionals to rural areas, and having them 
remain in the those communities, has been an ongoing problem. But 
access to high quality medical care is improved when there is an 
adequate supply of practitioners who remain in the community. S. 980 
improves the likelihood of attracting and retaining health care 
professionals in rural areas. S. 980 increases payments to 
practitioners serving in Health Professional Shortage Areas (HPSAs) and 
assists rural communities with recruiting efforts. Specifically a 10% 
bonus will be paid to physician assistants and nurse practitioners for 
outpatient services provided in these areas. Our bill also assists with 
recruitment of health professionals to serve rural areas. Currently a 
community is not allowed to recruit and hire a practitioner until the 
one being replaced has left. No longer would a community have to lose 
the practitioner, before the recruitment process could begin. In 
addition, tuition benefits provided as scholarships through the 
National Health Service Corps, would not be treated as taxable income. 
These changes help ensure that trained health care professionals are 
accessible to seniors and individuals with disabilities living in rural 
areas.
  The bill also makes changes to assist with training of physicians in 
rural hospitals. S.980 would allow rural hospitals to get credit for 
residents who spend time training outside a hospital and in rural 
health clinics. It would also allow hospitals with only one residency 
program to add up to three residents to their limit. BBA froze the 
reimbursement for residents at 1996 levels. This was detrimental to 
rural areas. These changes will allow for the training of more 
physicians in rural areas
  Mr. President, I am pleased that S. 980 would enhance telemedicine 
and telehealth. Under the Balanced Budget Act of 1997, Medicare has 
begun to pay for telemedicine consultations for patients living in 
rural areas that are designated as Health Professional Shortage Areas 
(HPSAs). The Promoting Health in Rural Areas Act would: (1) allow 
anything currently covered by Medicare to be reimbursed; (2) expand 
eligibility for telemedicine reimbursement to include all rural areas; 
and (3) state definitively that the referring physician need not be 
present at the time of the telehealth service, and clarify that any 
health care practitioner, acting on instructions from the referring 
physician or practitioner, may present the patient to the consulting 
physician.
  In addition, the bill would formally authorize an existing group of 
Cabinet level and private sector members and instruct them to focus on 
identifying, monitoring, and coordinating federal telehealth projects. 
The provisions also authorize the development a grant/loan program for 
telemedicine activities in rural areas.
  Mr. President, this bill was developed by the Senate Rural Health 
Caucus, of which I am a member. I am proud of the provisions directed 
towards rural health care providers and the benefits they will have for 
the citizens of rural communities.
  This bill sends a strong message to rural America: Washington cares 
about your problems and wants to help ensure access to quality health 
care. This is accomplished by strengthening the Medicare program and by 
making the newest technology available to rural areas.

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