[Congressional Record Volume 146, Number 56 (Tuesday, May 9, 2000)]
[House]
[Pages H2745-H2750]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
PATIENT'S BILL OF RIGHTS CONFERENCE
The SPEAKER pro tempore (Mr. Sherwood). Under the Speaker's announced
policy of January 6, 1999, the gentleman from Iowa (Mr. Ganske) is
recognized for 60 minutes as the designee of the majority leader.
Mr. GANSKE. Mr. Speaker, on last Friday, in the USA Today, I could
not help but notice on the front page an article. It was called ``HMOs
Take Spiritual Approach.'' It is written by Julie Appleby. It starts
out by saying ``Health plans, buffeted in recent years by their no-
frills approach to medical care, are pushing ever further into
alternative medicine, hoping to find low cost ways to boost patient
satisfaction. Need help understanding the meaning of life? No problem.
A Denver-based HMO offers spiritual counseling, six visits at $10 a
pop. Fearing surgery? Blue Shield of California unveils a new
prescription today, free audio cassettes for patients aimed at
harnessing their imaginations to promote healing.''
Mr. Speaker, when I read this and when I also read about some of the
abuses by some of the HMOs, I think patients will need some of this
spiritual healing to get over some of the ways that they have been
treated by HMOs.
I want to talk tonight for a little while about where we stand in
conference with the patient protection legislation that passed the
House and the Senate. My information on how the conference is going is
from my sources on the Republican side. There have been reports that
the conference is making some progress. Maybe a month ago, there was
reported progress on emergency care provisions and also on a couple
other smaller items that should be relatively noncontroversial. It
should be pointed out that there has been no legislative language
divulged from any of these earlier ``agreements in principle.''
But about a week or 2 ago, there was a report that there was progress
being made on one of the most important parts of the bill, which is,
how does one handle disputes between care that is requested by a
patient and care denied by the HMO. In both the bill in the House and
in the Senate, when there is a dispute on a denial of care by the HMO,
a patient could take that to an external appeals panel.
The reports in the press seem to indicate that progress was made and
that there was some sort of agreement between the Republicans and the
Democrats in the House-Senate conference on this point. Well, I am
sorry to inform my colleagues on both sides of the aisle here in the
House that these reports have been vastly overplayed.
As a result of that, President Clinton asked for a meeting for this
Thursday of conferees down at the White House to try to spur on
progress on the patient's rights. But let me just point out some of the
problems, these are from my Republican sources, on how there is not
agreement on some of the fundamental aspects of the external appeals
process.
For instance, there is not agreement on the standard for determining
whether cases are eligible for review. Mr. Speaker, this is sort of
fundamental. One has to know what kind of cases can go to review, and
this has not been decided.
In determining whether a case is eligible for review, the independent
reviewer should not be limited by a plan's definition or
interpretations where they involve applications of medical judgment.
This is what is in the House. This is the provision in the House where
we say that the independent panel can make a determination on medical
necessity that is not bound by the plan's own guidelines. They can be
considered. The plan's guidelines can be considered, but the
independent panel is not bound by those.
Also, it has not been decided in terms of protection, such as the
independent panel determining medical necessity disputes on coverage or
benefit determinations, and which of those are not subject to review.
Now, in the House bill, we say that if there is an explicit denial of
coverage in the contract, then regardless of whether the patient needs
that medical procedure or not, that independent panel cannot tell the
HMO to give the care.
For instance, the HMO could write a contract saying we do not cover
liver transplants. A patient could come along, maybe medically need a
liver transplant, but under the House bill, the independent panel
cannot tell the HMO to give that, because there is an explicit
exclusion of coverage. But aside from that, this crucial question has
not been decided in the conference.
Other things related to external review have not been decided in the
conference. For instance, there has not been a decision on what to do
with existing State laws that deal with external appeal systems. Now,
in my opinion, the independent review should have the authority to
direct the health plan to provide the care. That is what we passed here
in the House with a vote of 275 to 151.
{time} 1845
We said, okay, if there is a denial of care, if it has gone through
an internal appeals process and goes to the external independent review
panel, that that panel can tell the HMO to give the care. In our bill
that passed the House, if the HMO does not give the care, then they are
subject to a fine, a rather stiff fine. And if a patient is injured as
a consequence of not receiving that care, then that plan would be
liable for that. This has not been decided. This has not been decided
in the conference.
Furthermore, one would think that this would be an easy thing that
could have been decided, and that is that the panel should be
independent from the HMO. Apparently, this has not been decided in the
conference either. So all of those reports saying that significant
progress was being made on the appeals process, I think, are vastly
overblown.
Furthermore, I would point out to my colleagues, and I really do not
need to tell them this, because all of them that have been here for
more than 6 months know this is the case, that unless we see
legislative language, we can talk all we want about ``principles,'' but
one simple clause in legislative language can totally turn the intent
of that provision around. And there is no legislative language
available.
So what do we have here? We have a situation where States all around
the country are saying we need to do something about this. State
legislature after State legislature have passed bills for patient
protection. In fact, in Oklahoma, the State legislature just passed a
law making it easier for patients to sue HMOs and other insurers for
unreasonable denials of medical care. Under the Oklahoma law, a health
plan can be required to pay damages if it fails to exercise ``ordinary
care'' in treating patients.
The chief sponsor of the Oklahoma bill, State Senator Brad Henry, has
said, ``The chairman of the House Senate conference is definitely out
of step with the public here in Oklahoma. Polling information shows
that 72 percent of Oklahomans support giving the patient the right to
sue.''
[[Page H2746]]
That Oklahoma measure was not even a close vote. It passed 94 to 5 in
the State House of Representatives in Oklahoma and 44 to 2 in the State
Senate, and it was signed by Republican Governor Frank Keating on April
28.
Mr. Speaker, I am sorry to say that as time has gone by since we
passed this in October last year, a lot of patients are being denied
care by some HMOs, and I think are being injured by it. I have here
some estimates for how many patients are being injured.
Now, I can give my colleagues specific examples of patients who have
been injured. I have done that many times on the floor. I have brought
up posters showing their faces. I have brought up posters showing the
families of women who have died because of HMO decisions and how they
are left without their mother or their wife. But just to give some idea
of the magnitude of the problem that we are dealing with, there have
been two recent studies from which we can extrapolate how many cases
each day in this country we are seeing of HMO denial and abuse causing
pain and suffering and injury to patients.
The studies that I am citing here are Helen Schauffler's California
Managed Health Care Improvement Task Force Survey of Public Perceptions
and Experiences with Health Insurance Coverage from the University of
California Berkeley School of Public Health and Field Research
Corporation. This was reported in Improving Managed Health Care in
California, Findings and Recommendations. And also a study from the
Committee Analysis Based on Kaiser Family Foundation and Harvard Public
School of Health called Survey of Physicians and Nurses, July 1999.
Here are some of the highlights that my colleagues can take from
these studies showing what is going on every day around the country.
According to these two studies, every day 59,000 patients, because of
HMO inappropriate denials of care, experience added pain and suffering.
According to these studies, every day, 41,000 patients experience a
worsening of their medical condition. According to these studies, every
day 35,000 patients have had needed care delayed.
Thirty-five thousand patients have a specialty referral delayed or
denied every day. Thirty-one thousand patients every day are forced to
change doctors. Eighteen thousand patients every day are forced to
change medications.
And every day 14,000 physicians see patients whose health care has
seriously declined because an insurance plan refused to provide
coverage for a prescription drug. Mr. Speaker, every day in this
country 10,000 physicians see patients whose health has seriously
declined because an insurance plan did not approve a diagnostic test or
a procedure.
And every day 7,000 physicians see patients whose health has
seriously declined because an insurance plan did not approve referral
to a medical specialist. And, Mr. Speaker, every day 6,000 physicians
see patients whose health has seriously declined because an insurance
plan did not approve an overnight hospital stay.
These are pretty amazing statistics. If we want to talk about the
number of patients each year in this country who experience HMO abuse
in delay of needed care, we are dealing with almost 13 million.
Each year, 12,800,000 patients experience HMO plan abuse in terms of
delay or denial of care. It is about 11 million patients each year in
this country that have to change their doctors because of HMOs. It is
about 6,500,000 patients each year in this country that are forced to
change medications. It is about 22 million patients in this country
that each year have added pain and suffering because of HMO decisions
and abuse, and about 15 million patients each year in this country see
their medical conditions worsen because of HMO abuse.
And here we are. It has been, what, 7, 8 months since we passed the
bill in the House? We have been working on this for 4 or 5 years. We
could multiply these annual numbers by four or five times and it would
begin to approach the magnitude of the problem that we are dealing with
on this.
A few years ago, in testimony before my committee, the Committee on
Commerce, a small, quiet woman, who was a medical reviewer for an HMO,
gave some very compelling testimony. She said that she had actually
made medical decisions that had cost patients' lives and that she had
been rewarded for that by HMOs. She said, and I am paraphrasing her,
``I am coming clean. I cannot tolerate this any more.'' She said, ``I
made a medical decision that cost a man his life. He needed an
operation on his heart and I denied it. It was medically necessary for
him.''
And then she pointed out what the smart bomb is of cost containment
for HMOs, and that is in the area of denials based on ``medical
necessity'', which HMOs can arbitrarily define, according to Federal
law, any way they want to. Some HMOs even define medical necessity as
``the cheapest, least expensive care.'' Now, think of that for a
minute. Would we like our health plan to define medical necessity for
us as the cheapest, least expensive care? Now, one might say, well,
that would help hold costs down. But it would also result in some
really bizarre activities.
Before coming to Congress, I was a reconstructive surgeon. I took
care of a lot of kids with cleft lips and palates. The standard
treatment for a kid with a cleft lip and a cleft palate is surgical
correction. The hole in the roof of the mouth is surgically corrected
so that they can learn to speak normally, so that they do not have food
coming out of their nose. Under that irresponsible definition of
medical necessity, as the cheapest, least expensive care, that HMO
would be totally justified in just giving this little baby a piece of
plastic to shove up into the roof of his mouth so that food would not
come out. Sort of like an upper denture. I think that is really
ridiculous.
I have given some talk on this floor about some practice guidelines
that a company by the name of Milliman and Robertson, sort of the HMO
flack house, has created. If it were not for the fact they have sold
about 20,000 of these guidelines around the country to hospitals and
HMOs, we would not need to talk so much about this. But in a previous
talk here on the floor I gave a lot of examples of how wrong, how far
away from standards of care those guidelines are.
I recently got a letter from Milliman and Robertson trying to explain
where they come up with some of these. I think this article that is in
Pediatrics, the journal Pediatrics, Volume 105, No. 4, April 2000, is a
much more scientific approach to analyzing the validity of Milliman and
Robertson's guidelines.
Let me just read the conclusion. ``In New York State, during 1995,
length of stay for selected pediatric conditions was generally in
excess of published Milliman and Robertson guidelines.''
I love how these conclusions always understate what the article says.
They say, ``This raises concern about the potential effects of such
guidelines on both patients and the hospitals caring for them.'' They
go on and say in the text of this, ``Several studies have demonstrated
that certain length of stay related guidelines adversely affect patient
care,'' and then they list a number of them. I just want to quote some
of these to give a flavor for the analysis in the medical literature of
some of these ``guidelines.''
Jerome Kassirer, in the New England Journal of Medicine, wrote an
article on The Quality of Care and the Quality of Measuring It. Arnold
Relman, Reforming the Health Care System, the New England Journal of
Medicine. Wilson, in Medical Decision Making, Primary Care Physicians'
Attitudes Toward Clinical Practice Guidelines. Fitzgerald, in the New
England Journal of Medicine, The Care of Elderly Patients With Hip
Fracture: Changes Since Implementation of Prospect of Payment system.
Mitchell, Who Are Milliman & Robertson and How Did They Get in My
Face?, in the Journal of the Kentucky Medical Association.
Well, what do these articles have in common? They have in common what
this article in the journal Pediatrics found, and that was that the
length of stay recommendations put out by this company, Milliman and
Robertson, are really far out. They say in this article, ``Numerous
commentaries in both the lay and medical press have raised concerns
regarding the largely unknown impact of guidelines on health of the
more vulnerable populations, particularly the elderly, the young, and
the chronically ill. Our findings demonstrate that actual pediatric
length of
[[Page H2747]]
stay in New York State during 1995 exceeded, often markedly, the
Milliman and Robertson functional length of stay guidelines. The
difference was most marked in diagnoses with long courses of
antibiotics, for instance, bacterial meningitis, osteomyelitis, and
complicated appendectomy.''
In a previous talk I gave, I pointed out that the average length of
stay in a hospital for somebody with a really serious infection, this
is for a child, like bacterial meningitis, is somewhere around a week,
if not longer. That is usual and that is customary. These kids are
really sick. Milliman and Robertson recommends one or two days, one or
two days in the hospital for somebody who has a serious bacterial
infection of their brain or their spinal cord and who could die from
that.
{time} 1900
I know something personally about this because about 3 years ago now
I had a bad case of encephalitis. It is impossible for me to believe
that a patient with even a moderate case of encephalitis could be
discharged in 1 or 2 days. It just boggles my mind.
There are many quotes in this study. Let me just read a few. ``Both
the Institute of Medicine and the Agency for Health Care Policy and
Research have set high standards for the development of guidelines,
including the involvement of multi-disciplinary panels and the use of
explicit evidence-based approaches. This is a methodology used by
governmental groups such as the Institute of Medicine.
``At a minimum, we should expect that the data and methods
contributing to Milliman and Robertson's guidelines be available for
public discussion and debate.''
They are not, unfortunately.
That is why that lady who was a medical reviewer who testified for my
committee said those determinations based on plan guidelines are the
smart bomb of HMO's cost containment.
But there is something that needs to be dealt with in terms of the
external appeals process that we are dealing with in conference between
the House and the Senate. And if they are not dealt with, and as I
repeat, to date, my sources on the Republican side tell me they have
not been dealt with, then we should not be releasing reports to the
press saying that there is significant progress being made in that
conference.
I think that the conferees, when they go down to the White House,
ought to really make an effort to move on this.
There are many other things that I could speak about in terms of
where we are at with various issues related to the patient protection.
I want to just deal with about four or five.
The first is that the bill that passed this House on patient
protection would lead to a flood of litigation. That is just not true.
Our bill was modeled after the bill that passed in Texas about 3 years
ago, and there have only been a handful of lawsuits since that time in
Texas.
Of those lawsuits, though, I would say several are meritorious. Let
me give my colleagues one example.
There is a patient named Mr. Piloseca who was in the hospital
suicidal. His doctor recommended that he stay in the hospital to be
treated for his suicidal tendencies. His health plan, NYLCare, said,
no, no, you are out the door.
Maybe they used their own guidelines. Maybe they used Milliman and
Robertson's guidelines. I do not know. They said, you are out the door
and we are not going to pay for any hospitalization.
Under that circumstance, under Texas law, where there is a dispute
between the physician and the health plan, the health plan is supposed
to go to an expedited review to that independent panel for a
determination.
What did they do? They just ignored it and said, we are not going to
pay for your hospitalization. Unless you want to pay for it yourself,
then you are out of here.
Well, this family is of average modest means and they do not have the
ability to do that. So Mr. Piloseca went home that night and, sure
enough, suicidal that he was, he drank half a gallon of antifreeze and
he committed suicide.
That health plan is being sued in Texas. That is one of the handful.
But they are being sued because they did not follow the law that was in
Texas.
Hardly a flood of lawsuits.
Then there are opponents to our bill that passed the House that say,
oh, employers could be sued under the bill that passed the House.
And I will tell my colleagues that, under the bill that passed the
House, the Norwood-Dingell-Ganske bill, the bipartisan consensus
Managed Care Reform Act, an employer can only be sued or held legally
accountable if that employer exercises discretionary authority in
making a decision that results in negligent harm to the patient.
Most employers are nowhere near that. I have got lots of small
businesses in my district. Those businesses hire an HMO to provide
health care for themselves and for their employees. They do not get
involved in the medical decision-making. And if they are not involved
in the medical decision-making, they cannot be held liable.
Furthermore, in our bill that passed the House, we expressly stated
that employers cannot be sued for choosing to contract with a
particular health plan, deciding which benefits to include in the plan,
or deciding to provide additional benefits not generally covered by the
plan.
Mr. Speaker, here is another myth. The myth is that, well, if you
just have a strong appeals process, there is no need for any legal
accountability.
I would just refer you back to the case I just told you about. If do
you not have accountability, what is going to make the HMO follow the
law?
I would point out this. Many times I have talked on this floor about
a little boy from Atlanta, Georgia, who, when he was 6 months old, was
really sick, his mom and dad had to take him to the emergency room in
the middle of the night, but he was only given an authorization to go
to an emergency room that was about 60 or 70 miles away instead of
stopping at any two or three emergency rooms that were very close to
their room.
That was a medical decision, a medical judgment, that that reviewer
made over the telephone. Unfortunately, he had a cardiac arrest in the
car before he got to this far-away emergency room. They managed to keep
him alive, but he suffered circulatory loss to his hands and feet and
he lost both of his hands and both of his feet.
Now, there was not any chance to have to go to an independent appeals
process in that situation. But that HMO made a medical judgment, and
they should be responsible for that.
I can give my colleagues several other real-life examples. How about
the patient who sustained injuries to his neck and spine in a
motorcycle accident. He was taken to the hospital. The hospital's
physicians recommended immediate surgery. But the health plan refused
to certify that surgery. Time and time and time went on. And what
happened? The patient was paralyzed.
How about the patient who was admitted to an Emergency Room in his
community hospital complaining of paralysis and numbness in his
extremities. The treating room emergency physician concluded that this
was a really serious case, he needed to go to the medical school
immediately. The health plan denied authorization for a transfer. Hours
and hours later, by this time, the patient is now quadriplegic, i.e.,
paralyzed in both his hands and both his legs.
You need to have accountability, not just on the more leisurely cases
that come along, but also from the get-go.
How about this: People say that the bill that passed the House could
significantly increase the cost of health insurance and the number of
insured. And I say baloney. The Congressional Budget Office looked at
our bill, and the legal accountability provision was estimated to raise
premiums one percent over 4 years.
A one percent equivalent over 4 years is equal to employers paying a
mere 4 cents per day for individual coverage with employees
contributing just one additional penny per day.
Now, opponents also of our bill have said, oh, for every one percent
increase in premiums, you are going to have 400,000 people lose their
jobs. That is baloney, too. Nobody has ever documented where that
statistic came from. But the General Accounting Office did a study of
it and they said, that is wrong, it is outdated, it does not account
for the relevant factors.
So people came back and said, well, maybe it is only 300,000 people
will lose
[[Page H2748]]
their insurance if premiums go up 1 percent. GAO came back again and
looked at that data and said, wrong, wrong, the statistics do not show
that.
And furthermore, I would point out this: Between 1988 and 1996, the
number of workers offered coverage actually increased in this country
despite increased premiums each year.
I would also point out to my colleagues that we did not pass this
bill and it has not become Federal law and premiums went up last year.
Why? Because the HMOs wanted to show it on their bottom line profit
statements for Wall Street.
Then opponents say, well, you know what, consumer support for this
bill will evaporate if consumers learn how much it is going to cost
them.
Let me cite to my colleagues a 1998 nationwide survey by Penn, Shown
& Burlin that showed that 86 percent of the public support a bill that
would give patients health plan legal accountability, access to
specialists, emergency services, and point-of-service coverage. When
asked if they would support such a bill if their premiums increased
between $1 and $4 a month, 78 percent, more than three-fourths of the
people in this country, said, you bet.
Now, I want to tell my colleagues what the bill that passed the House
would cost. The House-passed bill would raise insurance premiums an
average of 4.1 percent, covering to the Congressional Budget Office,
over 4 years. Do my colleagues know how much that would account for an
individual?
Remember, 78 percent of people in this country say that they want to
see Congress pass this law even if it means to them an increase in cost
between $1 and $4. Dollars. For an individual, that percentage increase
would cost $1.36 per month and, for a family of four, $3.75 per month.
Do my colleagues know what? That is less than what a Big Mac meal
costs me out at National Airport. And that is giving people assurance
that all the money that they are spending for their health insurance
actually means something when they get sick.
I think that is why a recent public opinion survey found that most
Americans believe problems with managed care have not improved, 74
percent, and most think that legislative action is either more urgent
or equally urgent as it was when this debate began several years ago,
88 percent. That is from the Kaiser Family Foundation survey of
February this year.
Mr. Speaker, it is clear, when we start looking at how many patients
every day are being injured or denied care because Congress is sitting
here doing nothing, or maybe because some Members of Congress are
listening to the insurance industry and the HMO industry, we need to
get something done on this.
I just want to go over these figures one more time for my colleagues.
According to a couple reports that I have cited earlier, every day, as
a result of inaction in this Congress for addressing this HMO problem,
we are seeing 59,000 patients experience added pain and suffering, we
are seeing 41,000 patients experience a worsening of their medical
condition, we are seeing 35,000 patients having needed care delayed,
35,000 patients with a specialty referral delayed or denied, 31,000
patients are forced to change doctors, and 18,000 patients are forced
to change medications needlessly.
Mr. Speaker, it should be clear that the conferees to the HMO reform
bill should really get off their fannies and get to work. When they go
down to the White House on Thursday, as I hope they do, I hope in good
faith they sit down and try to get something done and not just try to
ride out the time clock on this year.
Mr. Speaker, I am happy to yield to my friend and colleague the
gentleman from California (Mr. Horn). I know he wants to speak some
about health care, also.
Mr. HORN. Mr. Speaker, I thank the gentleman for yielding to me. He
has been marvelous in terms of bringing to the American people the need
for a decent health care program.
Mr. Speaker, health care paperwork has become a complex and often
confusing problem for many Americans. Many of us have experienced the
confusion of erroneous billings, lengthy delays in reimbursement, and
troubling disputes about what is and is not covered under a health care
plan.
These problems are of particular concern in the Medicare program, the
largest purchaser of health care in the world and a program that is
absolutely vital to nearly 40 million senior citizens who rely on its
services.
In the early 1990's, the Medicare program was designated as one of
the Government's high-risk programs by the Comptroller General of the
United States and his General Accounting Office.
Medicare's size, complexity, and lack of management controls are a
problem and worthy of our attention. Each year the House Subcommittee
on Government Management Information and Technology, which I chair,
conducts oversight hearings to determine what progress has been made in
resolving the management problems within Medicare. Each year we are
told that significant progress has been made and more is expected soon.
{time} 1915
Mr. Speaker, it is true that progress has been made. Two years ago,
the Inspector General of the Department of Health and Human Services
reported that erroneous bills in the Medicare program totalled an
estimated $20.3 billion in fiscal year 1997. That was 11 percent of all
Medicare billings that year. In short, one of every $10 spent by
Medicare was an improper payment. This year, the Inspector General, the
very able June Gibbs Brown, returned to testify that the error rate was
now estimated at $13.5 billion for fiscal year 1999, or about 8 percent
of total billings.
As I said, that is in fact progress. We are moving in the right
direction, but I am still stopped cold by those numbers. Medicare
improperly paid out $13.5 billion last year for claims that were not
covered by the program, for claims that were, to quote the General
Accounting Office, ``not reasonable, necessary and appropriate.''
Mr. Speaker, all of us know that the Medicare program is a very large
and complex operation and presents an enormous management challenge.
The program still operates under the rules set in 1965. Medicare uses
private insurance companies as the contractors and intermediaries
between the patient, the doctor, the hospital to process bills and
those that go to Medicare. That paper flow is a virtual Niagara Falls.
Every day, the Medicare program's contractors process about 3.5 million
claims worth an average of more than $650 million a day. That is every
day of the year. Managing this flow is indeed a major challenge.
But, Mr. Speaker, the challenges in the Medicare program are not new.
Medicare has been in existence for 35 years and its specific management
problems have been documented in excruciating detail by a long list of
reports from the Inspector General and the Comptroller General of the
United States, the head of the General Accounting Office. Even with all
of the attention and concern, serious management deficiencies continue
to plague this program and waste or misspent billions of Medicare
dollars.
In all of the reports on Medicare's problems, the key recommendation
has been this. Medicare must develop a fully integrated financial
management system, standardized with all of its contractor
intermediaries so that timely, accurate and meaningful information can
be developed to control this $300 billion a year program.
Mr. Speaker, today I am introducing H.R. 4401. This legislation can
move us toward the goal of first rate management. This bill has been
introduced in the other body by Senator Richard Lugar of Indiana. I
have a very high regard for Senator Lugar. His bill in the other body
is S. 2312, and H.R. 4401 is similar to his legislation. In brief, we
are working together and the two of us believe that enacting sound and
effective controls on the Medicare program must be made a very high
priority.
The Health Care Infrastructure Investment Act is designed to force
the creation of an advanced information infrastructure that will allow
the Medicare program to instantly process the vast number of
straightforward transactions that now clog the pipeline and drain off
scarce health care resources. The bill calls for the development and
implementation of an integrated system so that Medicare and its
contractors can serve seniors with immediate points of service and
[[Page H2749]]
verification of insurance coverage, point of service checking for
incomplete or erroneous claim submission, and point of service
resolution of simple, straightforward claims for doctor's office
visits, including the delivery of an explanation of benefits and
payment that the patient can understand. That means that when Medicare
beneficiaries walk into the doctor's office, they can know immediately
what their benefits are and what copayments or deductibles apply. When
they leave, they will receive a simple statement of what was done and
what is owed.
Our bill is careful to avoid mandates that would undermine privacy
rights. Privacy is of paramount concern and must be safeguarded in the
design of an advanced network of financial management systems for
Medicare. The goal of H.R. 4401 is to reduce and, where possible, to
eliminate paperwork. Greater efficiency will free doctors to spend more
time treating patients, doctor's offices and insurance companies should
be able to reduce the cost of claims processing, and patients will be
fully informed about treatments and costs.
Mr. Speaker, this legislation could save the taxpayers billions of
dollars every year, and it would not be wasting Medicare access,
either. It would get us to modernize the paperwork and the
inefficiencies and put an end to many time-consuming and confusing
complications in the billing process for doctor office visits, and both
for doctors and for patients.
This bill, H.R. 4401, also can lay the foundation for modernizing
Medicare's financial management systems so that the annual reports of
billions of dollars misspent will become a thing of the past. Then we
can be assured that every Medicare dollar is being properly used to pay
for the health care our seniors need. Our bill, H.R. 4401 in the House,
will be sent to the Committee on Commerce, the Committee on Government
Reform and Ways and Means.
Mr. Speaker, I ask that H.R. 4401 be printed below.
H.R. 4401
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Health
Care Infrastructure Investment Act of 2000''.
(b) Table of Contents.--The table of contents of this Act
is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Moratorium on delayed payments under contracts that provide for
the disbursement of funds.
Sec. 3. Establishment of the Health Care Infrastructure Commission.
Sec. 4. Study and final recommendations; timetable for implementation
of advanced informational infrastructure.
Sec. 5. Application of advanced informational infrastructure to the
FEHBP.
Sec. 6. Authorization of appropriations.
SEC. 2. MORATORIUM ON DELAYED PAYMENTS UNDER CONTRACTS THAT
PROVIDE FOR THE DISBURSEMENT OF FUNDS.
Section 1842(c) of the Social Security Act (42 U.S.C.
1395u(c)) is amended by striking paragraph (3).
SEC. 3. ESTABLISHMENT OF THE HEALTH CARE INFRASTRUCTURE
COMMISSION.
(a) Establishment.--There is established within the
Department of Health and Human Services a Health Care
Infrastructure Commission (in this section referred to as the
``Commission'') to coordinate the expertise and programs
within and among departments and agencies of the Federal
Government for the purposes of designing and implementing an
advanced informational infrastructure for the administration
of Federal health benefits programs.
(b) Duties.--The Commission shall--
(1) establish an advanced informational infrastructure for
the administration of Federal health benefits programs which
consists of an immediate claim, administration, payment
resolution, and data collection system (in this section
referred to as the ``system'') that is initially for use by
carriers to process claims submitted by providers and
suppliers under part B of the medicare program under title
XVIII of the Social Security Act (42 U.S.C. 1395j et seq.)
after conducting the study under section 4(a)(1);
(2) implement such system in accordance with the final
recommendations published under subsection (a)(2) of section
4 and the timetable set forth under subsection (b) of such
section; and
(3) carry out such other matters as the Secretary of Health
and Human Services (in this section referred to as the
``Secretary''), in consultation with the other members of the
Commission, may prescribe.
(c) Membership.--
(1) Number and appointment.--The Commission shall be
composed of 7 members as follows:
(A) The Secretary, who shall be the chairperson of the
Commission.
(B) One shall be appointed from the National Aeronautics
and Space Administration by the Administrator.
(C) One shall be appointed from the Defense Advanced
Research Projects Agency by the Director.
(D) One shall be appointed from the National Science
Foundation by the Director.
(E) One shall be appointed from the Office of Science and
Technology Policy by the Director.
(F) One shall be appointed from the Department of Veterans
Affairs by the Secretary.
(G) One shall be appointed from the Office of Management
and Budget by the Director.
(2) Requirements.--Each of the members appointed under
subparagraphs (B) through (G) of paragraph (1) shall--
(A) have been appointed as an officer or employee of the
agency by the President by and with the advice and consent of
the Senate; and
(B) be an expert in advanced information technology.
(3) Deadline for initial appointment.--The members of the
Commission shall be appointed by not later than 3 months
after the date of enactment of this Act.
(d) Meetings.--
(1) In general.--The Commission shall meet at the call of
the chairperson, except that it shall meet--
(A) not less than 4 times each year; or
(B) on the written request of a majority of its members.
(2) Quorum.--A majority of the members of the Commission
shall constitute a quorum, but a lesser number of members may
hold hearings.
(e) Compensation.--Each member of the Commission shall
serve without compensation in addition to that received for
the services of such member as an officer or employee of the
United States.
(f) Staff.--
(1) in general.--The chairperson of the Commission may,
without regard to the civil service laws and regulations,
appoint and terminate an executive director and such other
additional personnel as may be necessary to enable the
Commission to perform its duties.
(2) Compensation.--The chairperson of the Commission may
fix the compensation of the executive director and other
personnel without regard to the provisions of chapter 51 and
subchapter III of chapter 53 of title 5, United States Code,
relating to classification of positions and General Schedule
pay rates, except that the rate of pay for the executive
director and other personnel may not exceed the rate payable
for level V of the Executive Schedule under section 5316 of
such title.
(3) Detail of government employees.--Any Federal Government
employee may be detailed to the Commission without
reimbursement, and such detail shall be without interruption
or loss of civil service status or privilege.
(g) Procurement of Temporary and Intermittent Services.--
The chairperson of the Commission may procure temporary and
intermittent services under section 3109(b) of title 5,
United States Code, at rates for individuals which do not
exceed the daily equivalent of the annual rate of basic pay
prescribed for level V of the Executive Schedule under
section 5316 of such title.
(h) Termination.--The Commission shall terminate on the
date on which the system is fully implemented under section
4(b)(3).
SEC. 4. STUDY AND FINAL RECOMMENDATIONS; TIMETABLE FOR
IMPLEMENTATION OF ADVANCED INFORMATIONAL
INFRASTRUCTURE.
(a) Study and Final Recommendations.--
(1) Study.--The Commission shall conduct a study during the
3-year period beginning on the date of enactment of this Act
on the design and construction of an immediate claim,
administration, payment resolution, and data collection
system (in this section referred to as the ``system'') that--
(A) immediately advises each provider and supplier of
coverage determinations;
(B) immediately notifies each provider or supplier of any
incomplete or invalid claim, including--
(i) the identification of any missing information;
(ii) the identification of any coding errors; and
(iii) information detailing how the provider or supplier
may develop a claim under such system;
(C) allows for proper completion and resubmission of each
claim identified as incomplete or invalid under subparagraph
(B);
(D) allows for immediate automatic processing of clean
claims (as defined in section 1842(c)(2)(B)(i) of the Social
Security Act (42 U.S.C. 1395u(c)(2)(B)(i)) so that a provider
or supplier may provide a written explanation of medical
benefits, including an explanation of costs and coverage to
any beneficiary under part B of the medicare program under
title XVIII of the Social Security Act (42 U.S.C. 1395j et
seq.) at the point of care; and
(E) allows for electronic payment of claims to each
provider and supplier, including payment through electronic
funds transfer, for each claim for which payment is not made
on a periodic interim payment basis under such part.
(2) Final recommendations.--
(A) Publication.--Not later than 3 years after the date of
enactment of this Act, the
[[Page H2750]]
chairperson of the Commission shall publish in the Federal
Register final recommendations that reflect input from each
interested party, including providers and suppliers,
insurance companies, and health benefits management concerns
using a process similar to the process used for developing
standards under section 1172(c) of the Social Security Act
(42 U.S.C. 1320d-1(c)).
(B) Considerations.--In developing the final
recommendations to be published under subparagraph (A), the
Commission shall--
(i) make every effort to design system specifications that
are flexible, scalable, and performance-based; and
(ii) ensure that strict security measures--
(I) guard system integrity;
(II) protect the privacy of patients and the
confidentiality of personally identifiable health insurance
data used or maintained under the system; and
(III) apply to any network service provider used in
connection with the system.
(b) Timetable.--The timetable set forth under this
subsection is as follows:
(1) Initial implementation.--Not later than 5 years after
the date of enactment of this Act, the system shall support--
(A) 50 percent of queries regarding coverage
determinations;
(B) 30 percent of determinations regarding incomplete or
invalid claims; and
(C) immediate processing at the point of care of 40 percent
of clean claims submitted by providers and suppliers under
part B of the medicare program.
(2) Intermediate implementation.--Not later than 7 years
after the date of enactment of this Act, the system shall
support--
(A) 70 percent of queries regarding coverage
determinations;
(B) 50 percent of determinations regarding incomplete or
invalid claims; and
(C) immediate processing at the point of care of 60 percent
of clean claims submitted by providers and suppliers under
part B of the medicare program.
(3) Full implementation.--Not later than 10 years after the
date of enactment of this Act, the system shall support--
(A) 90 percent of queries regarding coverage
determinations;
(B) 60 percent of determinations regarding incomplete or
invalid claims; and
(C) immediate processing at the point of care of 40 percent
of the total number of claims submitted by providers and
suppliers under part B of the medicare program.
SEC. 5. APPLICATION OF ADVANCED INFORMATIONAL INFRASTRUCTURE
TO THE FEHBP.
(a) In General.--The Office of Personnel Management (in
this section referred to as the ``Office'') shall--
(1) adapt the immediate claim, administration, payment
resolution, and data collection system established under
section 3 (in this section referred to as the ``system'') for
use under the Federal employees health benefits program under
chapter 89 of title 5, United States Code; and
(2) require that carriers (as defined in section 8901(7) of
such Code) participating in such program use the system to
satisfy certain minimum requirements for claim submission,
processing, and payment in accordance with the timetable set
forth in subsection (b).
(b) Timetable.--The timetable set forth in this subsection
is as follows:
(1) Initial implementation.--Not later than 5 years after
the date of enactment of this Act, the Office shall require
that carriers use the system to process not less than--
(A) 50 percent of queries regarding coverage
determinations;
(B) 30 percent of determinations of incomplete or invalid
claims; and
(C) immediate processing at the point of care of 10 percent
of the total number of claims.
(2) Intermediate implementation.--Not later than 7 years
after the date of enactment of this Act, the Office shall
require that carriers use the system to support not less
than--
(A) 70 percent of queries regarding coverage
determinations;
(B) 50 percent of determinations regarding incomplete or
invalid claims; and
(C) immediate processing at the point of care of 20 percent
of the total number of claims.
(3) Full implementation.--Not later than 10 years after the
date of enactment of this Act, the Office shall require that
carriers use the system to support not less than--
(A) 90 percent of queries regarding coverage
determinations;
(B) 60 percent of determinations of incomplete or invalid
claims; and
(C) immediate processing of 35 percent of the total number
of claims.
SEC. 6. AUTHORIZATION OF APPROPRIATIONS.
(a) In General.--There are appropriated to the Health Care
Infrastructure Commission established under section 3, out of
any funds in the Treasury that are not otherwise
appropriated, such sums as may be necessary to carry out the
provisions of this Act.
(b) Availability.--Any sums appropriated under subsection
(a) shall remain available until the termination of the
Health Care Infrastructure Commission under section 3(h).
The SPEAKER pro tempore (Mr. Sununu). The gentleman from Iowa (Mr.
Ganske) has 18 minutes remaining.
Mr. GANSKE. Mr. Speaker, I just point out that my colleague from
California has been a stalwart in working on matters of health concern
for his constituents and in particular has been very strong on
supporting a Patient's Bill of Rights. I appreciate his work and effort
in that very much.
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