[Congressional Record Volume 145, Number 118 (Monday, September 13, 1999)]
[Senate]
[Pages S10746-S10748]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                                MEDICARE

  Ms. COLLINS. Mr. President, Senate Republicans are committed to 
enacting legislation to preserve, strengthen, and save the Medicare 
system for current and future generations. The Republican congressional 
budget plan has set aside $505 billion over the next 10 years 
specifically to address domestic issues such as Medicare. Moreover, $90 
billion of this amount has been set aside in a reserve fund that is 
dedicated exclusively to strengthening Medicare's financing and 
modernizing its benefits, including the provision of coverage for 
prescription drugs. Prescription drugs are as important to our senior 
citizens' health today as the hospital bed was back in 1965 when the 
Medicare program was first created. Medicare clearly should be 
restructured to reflect these changing priorities.
  The money to address this challenge has been set prudently aside as 
part of the Republican budget. We have the resources, we have the 
determination, and we have the will to address this critical issue. Now 
it is up to Congress to come up with the plan, which I hope our 
colleagues on the other side of the aisle will help us devise. We need 
to strengthen and modernize this critically important program to meet 
the health care needs of elderly and disabled Americans into the 21st 
century.
  In addition to addressing the long-term structural issues facing 
Medicare, it is essential that Congress also take action this year to 
address some of the unintended consequences of the Balanced Budget Act 
of 1997, as well as regulatory overkill by the Clinton administration, 
which is jeopardizing access to critically important home health care 
services for millions of senior citizens.
  The growth in Medicare spending has slowed dramatically, and that is 
due, in part, to the reforms that were enacted as part of the Balanced 
Budget Act of 1997. While it was Congress' intent in enacting this 
legislation to slow the rate of growth, it has become increasingly 
clear that the payment policies implemented by the Clinton 
administration as a consequence of the Balanced Budget Act have gone 
too far and that the cutbacks have been far

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too deep, jeopardizing our seniors' access to critical hospital, 
skilled nursing, and home health care.
  Nowhere is this problem more serious than in home health care. 
America's home health agencies provide services that have enabled a 
growing number of our most frail and vulnerable senior citizens to 
avoid hospitals, to avoid nursing homes, and to receive the care they 
need and want in the security and privacy of their homes, just where 
they want to be.
  I have visited with home health nurses in Maine who have taken me on 
home health visits. I know firsthand how vital these important health 
care services are to our frail seniors. I know of couples who have been 
able to stay together in their own home solely because of the services 
provided by our home health agencies. In 1996, home health was the 
fastest growing component of the Medicare budget. That, understandably, 
prompted Congress and the Clinton administration to initiate changes 
that were intended to make the program more cost-effective and 
efficient.
  There was strong bipartisan support for the provisions in the BBA 
that called for the implementation of a prospective payment system for 
home care. Unfortunately, until this system is implemented, home health 
agencies are being paid under a very flawed interim payment system, or 
IPS.
  In trying to get a handle on cost, Congress and the administration 
created a system that penalizes efficient agencies and that may be 
restricting access to care for the very Medicare beneficiaries who need 
the care the most. These include our sicker patients with complex 
chronic care needs, like diabetic wound care patients, or IV-therapy 
patients who require multiple visits.
  According to a recent survey by the Medicare Payment Advisory 
Commission, almost 40 percent of home health agencies indicated that 
there were patients whom they previously would have accepted for care, 
whom they no longer serve due to this flawed interim payment system and 
the regulatory overkill of the Clinton administration. Thirty-one 
percent of these agencies admitted they had actually discharged 
patients due to the inadequate payment system. The discharged patients 
tend to be those with chronic care needs who require a large number of 
visits and are expensive to serve. Indeed, they are the very people who 
most need home health services.

  I know that Congress simply did not intend to construct a payment 
system that inevitably discourages home health agencies from caring for 
those senior citizens who need the service the most. These problems are 
all the more pressing because they have been exacerbated by the failure 
of the Clinton administration to meet the original deadline for 
implementing a prospective payment system. As a result, home health 
care agencies will be struggling under a flawed IPS system, the interim 
payment system, for far longer than Congress ever envisioned when it 
enacted the Balanced Budget Act of 1997.
  Moreover, it now appears the savings from the Balanced Budget Act 
were greatly underestimated. Medicare spending for home health care 
fell by nearly 15 percent last year and the CBO now projects that the 
post-Balanced Budget Act reductions in home health care will exceed $46 
billion over the next 5 years. This is three times greater than the $16 
billion that CBO originally estimated for that time period. That is 
another indication that the cutbacks have been far too deep, far too 
severe, and much more wide-reaching than Congress ever intended.
  Again, the flaws in the Balanced Budget Act have been exacerbated by 
regulatory decisions made by this administration. Earlier this year, I 
chaired a hearing held by the Permanent Subcommittee on Investigations. 
We heard firsthand about the financial distress and cash-flow problems 
of very good, cost-effective, home health agencies from across the 
country. We heard about the impact of these cutbacks on our senior 
citizens. Witnesses expressed concern that the problems in the system 
are inhibiting their ability to deliver much needed care, particularly 
to chronically ill patients with complex needs. Some agencies have 
actually closed because the reimbursement levels under Medicare have 
fallen far short of their actual operating costs. Many others in Maine 
and throughout the Nation are laying off staff or declining to accept 
new patients, particularly those with the more serious health problems 
that require more care and more visits.
  This points to the most critical and central issue: Cuts of this 
magnitude simply cannot be sustained without ultimately affecting the 
care that we provide to our senior citizens. Moreover, the financial 
problems that home health agencies have been experiencing have been 
exacerbated by a host of onerous, burdensome, and ill-conceived new 
regulatory requirements imposed by the Clinton administration through 
HCFA, including the implementation of what is known as OASIS, the new 
outcome and assessment information data set; new requirements for 
surety bonds; sequential billing requirements; IPS overpayment 
recoupment; and a new 15-minute increment home health reporting 
requirement requiring nurses to act as if they were accountants or 
lawyers, billing every 15 minutes of their time.
  Witnesses at our hearing before the Permanent Subcommittee on 
Investigations expressed particular frustration with what the CEO from 
the Visiting Nurse Service in Saco, ME, Maryanna Arsenault, termed as 
the Clinton administration's regulatory policy of ``implement and 
suspend.'' She and others pointed to numerous examples of hastily 
enacted, ill-conceived requirements for surety bonds and sequential 
billing. No sooner had HCFA imposed the cost burden of a specific 
mandate on America's home health agencies, than it then had second 
thoughts and suspended the requirements--but only after damage had been 
done, only after our home health agencies had invested significant time 
and resources they do not have, trying to comply with this regulatory 
overkill.
  Responding to the excessive regulation of the Clinton administration, 
as well as the problems in the Balanced Budget Act of 1997, my 
colleague from Missouri, Senator Bond, and I have together introduced 
legislation titled, ``The Medicare Home Health Equity Act,'' which is 
cosponsored, I am pleased to say, by a bipartisan group of 26 of our 
colleagues. It makes needed adjustments in the Balanced Budget Act and 
related Federal regulations to ensure that our senior citizens have 
access to necessary home health services.

  One of the ironies of the formula enacted in the Balanced Budget Act 
is that it penalizes the low-cost nonprofit agencies that had been 
doing a good job of holding down their expenses. The program needs to 
be entirely revamped.
  The most important provision of our bill eliminates the automatic 15-
percent reduction in Medicare home health payments that is now 
scheduled for October 1 of next year, whether or not a prospective 
payment system is enacted. I am not overstating the situation when I 
say that if another 15-percent cut is imposed on America's home health 
agencies, it would be a disaster. It would threaten our ability to 
provide these services to millions of senior citizens throughout this 
country.
  A further 15-percent cut would be devastating. It would destroy the 
low-cost, cost-effective providers, and it would further reduce our 
seniors' access to home health care. Furthermore, as I mentioned 
earlier, it is entirely unnecessary because we have already achieved 
the budget savings that were anticipated in the Balanced Budget Act of 
1997. We have not only exceeded them, we have exceeded them by a factor 
of three.
  Our legislation also provides for what we call supplemental 
``outlier'' payments to home health agencies on a patient-by-patient 
basis. This is needed because there are some patients who are expensive 
to care for because they have complex and chronic health conditions 
that need a great deal of care. We heed to have a formula that 
recognizes that there are certain higher cost patients who are higher 
cost in a legitimate sense. It is still far cheaper to treat those 
patients through home health care than in a nursing home or hospital 
setting.
  The provision in our bill removes the existing financial disincentive 
for agencies to care for patients with intensive medical needs. We know 
from the recent studies from GAO and the Medicare Payment Advisory 
Commission that those are the individuals who

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are most at risk right now of losing access to home health services 
under the current interim payment system.
  To decrease total costs in order to remain under their per-
beneficiary limits, too many home health agencies have had to 
significantly reduce the number of visits, which in turn has increased 
the cost of each visit. We need to deal with the regulatory issues that 
I have mentioned, including OASIS, surety bonds, sequential billing, 
and the 15-minute incremental reporting requirement. Our legislation 
accomplishes these goals.
  The Medicare Home Health Equity Act of 1999 will provide a measure of 
financial and regulatory relief to beleaguered home health agencies in 
order to ensure that our senior citizens have access to medically 
necessary home health services.
  It has been a pleasure to work with the Senate majority leader, 
Senator Lott, as well as Senator Abraham, Senator Santorum, Senator 
Bond, and others who have been real leaders in this effort to come up 
with a solution to this very pressing problem. My hope is that we will 
make reforming the payment system for Medicare home health services a 
top priority this fall.
  I yield back the remainder of my time to the Senator from Wyoming.
  Mr. THOMAS. I thank the Senator from Maine, not only because of the 
good job she does all across the board but particularly on this matter 
of health care, rural health care. As cochairman of the Rural Health 
Care Caucus, I am particularly interested in those kinds of things. For 
example, in Wyoming, home health care is so important and sometimes 
quite expensive, particularly because of the amount of miles that have 
to be traveled. But for the patient, and because of the cost, home 
health care is the right way to go.
  I now yield to the Senator from Missouri to talk a little more about 
the future and our plans with respect to taxes.
  The PRESIDING OFFICER. The distinguished Senator from Missouri is 
recognized.
  Mr. ASHCROFT. Mr. President, I commend the Senator from Maine for her 
sensitivity to a crisis which is looming in American health care and 
that she is willing to constructively deal with that crisis. I thank 
her for her thoughts on this matter and for her cosponsorship of 
important legislation.

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