[Congressional Record Volume 146, Number 113 (Thursday, September 21, 2000)]
[Senate]
[Pages S8874-S8877]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
HOME HEALTH CARE SERVICES
Ms. COLLINS. Mr. President, Senate Republicans are committed to
enacting legislation to preserve, strengthen, and save Medicare for
current and future generations. It is also critical that Congress take
action this year to address some of the unintended consequences of the
Balanced Budget Act of 1997 which has been exacerbated by a host of
ill-conceived regulatory requirements imposed by the Clinton
administration. The combination of regulatory overkill and budget cuts
is jeopardizing access to critical home health care services for
millions of our Nation's seniors.
If one thinks about it, health care has really come full circle.
Patients are spending less time in the hospital, more and more
procedures are being done on an outpatient basis, and recovery and care
for patients with chronic diseases and conditions increasingly takes
place at home. Moreover, the number of older Americans who are
chronically ill or disabled in some way continues to grow each year.
As a consequence, home health care has been an increasingly important
part of our health care system, and I know the Senator from Kansas has
been a very strong supporter of ensuring that these vital services are
provided for our senior citizens. The kind of highly skilled and often
technically complex services our Nation's home health care agencies
provide have enabled millions of our most frail and vulnerable older
citizens to avoid hospitals and nursing homes and receive care right
where they want to be--in the comfort and security of their own homes.
In 1996, however, home health care was the fastest growing component
of Medicare spending. This understandably prompted consideration of
some changes as part of the Balanced Budget Act that were intended to
slow the growth in spending to make the program more cost-effective and
efficient.
Mr. ROBERTS. Mr. President, will the distinguished Senator from Maine
yield for a question?
Ms. COLLINS. I will be happy to yield.
Mr. ROBERTS. First off, I thank the Senator so much for taking this
time to draw attention to a very serious problem. I know the Senator
from Maine is experiencing the same thing I am experiencing in Kansas
and all Senators are experiencing when they go back home. Every
hospital board--beleagured hospital boards--every hospital
administrator, all of the rural health care delivery system--it is not
only applicable to rural areas but all over--have been questioning me
and our colleagues about when are we going to do something with regard
to the Medicare reimbursement.
The Senator has indicated--I underlined it in the Senator's remarks:
It is also critical that Congress take action this year to
address some of the unintended consequences of the Balanced
Budget Act of 1997. . . .
We should have done it this spring. The Senator from Maine and I
talked about it. We should have done it last year. We did certainly
provide that assistance. I wish we could have done that earlier. We are
going to do that.
Then the Senator also said:
. . . [and also some problems] which have been exacerbated
by a host of ill-conceived regulatory requirements imposed by
the Clinton administration--
And the folks at HCFA.
[[Page S8875]]
That is a marvelous acronym, HCFA. I will tell you what, if that is
not a four-letter word in the minds and eyes of people who have to
provide health care services throughout our country, I do not know what
is. Asking HCFA for help, if you are a hospital board or a hospital
administrator, is like asking the Boston strangler for a neck massage.
It just does not work.
My question is this: as I recall, there was strong bipartisan support
for these provisions, but haven't they produced cuts in home health
care spending far beyond what Congress ever intended? It is my
understanding--and I want people to understand this--home health care
spending dropped $9.7 billion in fiscal year 1999, just about half of
the 1997 amount; is that correct?
Ms. COLLINS. The Senator, as always, is entirely correct. I know how
concerned he has been that inadequate reimbursements under Medicare,
plus regulatory overkill by HCFA, are really jeopardizing the provision
of care in our rural hospitals and our home health care agencies.
In fact, we know the Balanced Budget Act is already producing--or
expected to produce--four times the savings that we intended when the
1997 Balanced Budget Act was passed. Moreover--and I know the Senator
from Kansas shares my deep concern about this--looming on the horizon,
believe it or not, is an additional 15-percent cutback in home health
care reimbursements. That will put our already struggling home health
agencies at risk. I know the Senator from Kansas shares my belief that
it would, if allowed to go into effect, seriously jeopardize access to
care for millions of our Nation's seniors.
The effects of these home health care cuts have been particularly
devastating to the State of Maine. In Maine, I would inform my
colleague from Kansas, nearly 7,500 Maine seniors have lost access to
home health care due to the cutbacks and the regulatory overkill by
HCFA.
Those 7,500 seniors did not get well. That is not why they lost their
access to home health care. In fact, what has happened is some of them
have been forced prematurely into nursing homes or they are at risk of
increased hospitalization, which ironically costs the Medicare trust
fund more money than if they were still receiving home health care.
Some of them--and this is most tragic of all--are going without care
altogether.
Cuts of this magnitude, particularly for the home health agencies in
your section of the country and mine, which were historically low cost
to begin with, cannot be sustained without ultimately adversely
affecting patient care.
Mr. ROBERTS. Mr. President, will the Senator yield?
Ms. COLLINS. I am happy to yield.
Mr. ROBERTS. The same complaints are made in Kansas. The same
complaints are made throughout the country. The home health care
agencies in my State--in fact, since January of about 2 years ago, 68
Medicare-certified agencies in Kansas have closed their doors, more
than a 25-percent drop, more than a quarter drop.
These were not the ``fly-by-night'' agencies that some in the Federal
Government and others in regards to various inspections--and you have
talked about that we have heard about so much--many of these agencies
had been in existence for 20 years.
The latest numbers from HCFA show that the total home health care
visits are down by over 45 percent--almost half. The losers of this
situation are not just numbers. It is just not accounting in regards
to, say, HCFA. These are our Nation's seniors; in particular, those who
are really sick. We are talking about the Medicare patients who are
suffering through complex and chronic care needs who are already
experiencing a lot of difficulty in the home care services they need.
So the same thing is true in Kansas as the Senator has pointed out in
Maine. I, obviously, think it is true in every State.
Ms. COLLINS. The Senator has, as always, summarized the situation
exactly right. The real losers are the sickest seniors because what is
happening is, because they are more expensive to treat, our home health
agencies are turning away some of the more expensive patients because
they simply cannot afford to provide them care.
I met recently with a group of very dedicated and highly skilled,
compassionate home health nurses from the Visiting Nurse Service in
Saco, ME. That is southern Maine's largest independent, not-for-profit
home health agency. It performs more than 250,000 home visits per year.
During my discussions with these nurses, I heard absolutely hard-
breaking stories of how recent cutbacks and regulatory restrictions
have affected both the quality and the availability of home health
services.
Let me tell my colleague of just one example the nurses related to
me. Consider this case. It involves an elderly Maine woman who suffered
from advanced Alzheimer's disease, pneumonia, and hypertension, among
many other illnesses. She was bedbound, verbally nonresponsive, and had
a series of serious health issues, including serious infections.
This woman had been receiving home health care for approximately 2
years, and that had allowed her condition to stabilize through the care
and coordination of a skilled nurse. Unfortunately, the care provided
to this patient abruptly came to an end when HCFA'S intermediary sent
out a notice denying further home health care for this woman.
That is an example of the kinds of regulatory problems that the
Senator was talking about.
Let's look at what happened in this case.
The fact is, it produced a tragedy. Less than 3 months later, this
woman died. She died as a result of a wound on her foot that went
untreated. Undoubtedly, the home health nurse would have caught that
problem before it got out of control.
That is just one of the heart-wrenching stories that I have heard not
only during that visit but in discussions with patients and health care
providers throughout my State.
Mr. ROBERTS. Will the Senator yield?
Ms. COLLINS. I am happy to yield.
Mr. ROBERTS. The home health care agencies in my State, as I have
indicated, also complain about their exacerbating financial problems.
That is a very fancy word to say it has been made a whole lot worse by
a host of the new regulatory requirements imposed by HCFA, including
the implementation of another marvelous acronym called OASIS. The
thought occurs to me, if there is an ``oasis'' that is proposed by
HCFA--we all remember the ``Survivor'' show that was so popular--there
would be no survivors in regards to this OASIS, I can tell you.
OASIS stands for the new outcome and assessment information data
set--new outcome and assessment information data set--new requirements
for surety bonds, new requirements for sequential billing, new
requirements for overpayment recoupment, new requirements on a 15-
minute reporting requirement. And all of this adds up.
I just concluded a 40-county tour in my State. I will go on another
65-county tour. At every stop was a hospital administrator. They said:
I don't know who reads this stuff. I think they must weigh it somewhere
in Kansas City--which is the regional center.
I am not trying to deprive from the purpose and the intent and
responsibility that HHS and HCFA and OASIS have here, but it just seems
to me that just about the time you have one requirement promulgated--
there is another fancy word--then it is changed, and it is changed
overnight. This is the kind of thing that a small rural hospital, or
any hospital, just cannot put up with, with that very tight margin. We
are down to the morrow of the bone.
Naturally, we are going to put in some money in regards to Medicare
reimbursement, but this regulatory overkill is something that just has
to stop.
Ms. COLLINS. The Senator is entirely correct. I could not agree with
his point more.
What I heard from the home health nurses is not only do all these
excessive regulatory requirements and paperwork cost a lot of money to
the agency, but they detract from the time that otherwise would be
spent caring for patients. Instead of focusing on patients, they have
to complete paperwork. Indeed, at that visit in Saco, ME, that I
mentioned, the nurses--to illustrate the OASIS paperwork which the
distinguished Senator from Kansas has
[[Page S8876]]
just talked about--put it up all over the room. It covered the walls of
the entire room. That was just one OASIS questionnaire.
Last year, I chaired a subcommittee hearing of the Permanent
Subcommittee on Investigations. We heard about the problems that
excessive regulation was imposing. We heard about the cash-flow
problems that agencies across the country are experiencing.
One nurse from Maine, who runs a home health agency, terms HCFA's
approach as being one of ``implement and suspend.'' In other words,
HCFA requires these agencies to go through all these regulatory hoops
to fill out all this paperwork and then says: Never mind. This really
isn't what we meant.
Meanwhile, tremendous cost and energy has gone into complying with
these burdensome regulations.
Mr. ROBERTS. Will the Senator yield again, please?
Ms. COLLINS. I am happy to yield.
Mr. ROBERTS. This OASIS business, in regard to all the complaints we
have heard, as I have indicated--I think I ought to go into that a
little bit more than explaining what the acronym is. OASIS is a system
of records containing data on the physical, mental, and functional
status of Medicare and Medicaid patients receiving care from home
health agencies.
HCFA tried to implement OASIS as a tool to help the agency improve
the quality of care and form the basis for a new home health care
prospective payment system. The problem is--and my colleague chaired
the subcommittee and asked all the very pertinent questions--the
collection of data is so burdensome and expensive for agencies, it
invades the personal privacy of the patients. It must be collected for
non-Medicare patients as well as those served by Medicare.
Just yesterday, I learned that the whole OASIS information system in
Kansas is not working; the computer system has failed. Agencies across
the State are having a lot of difficulty in transmitting any kind of
data. This burden is being felt by agencies all over the country. The
question I have for the Senator is, Does she have any idea how long it
takes? She has already spoken about this to some degree. Can we put a
timeframe on it? Can we get more specific as to how long it takes for
nurses to collect this information for HCFA? What does it cost in terms
of nurse time?
Ms. COLLINS. I inform the Senator from Kansas that the testimony at
my hearing indicated that it generally takes a nurse as long as 2 hours
to complete these forms with one patient. The patients do not welcome
this intrusive questionnaire in any way.
Mr. ROBERTS. I certainly agree with that. Will the Senator yield for
another question?
Ms. COLLINS. I am happy to yield.
Mr. ROBERTS. The OASIS document includes an 18-page initial
assessment that must be completed by a registered nurse and a 13-page
followup assessment that is required every 60 days. This reminds me of
a situation quite a few years ago, when the Department came out with a
requirement that all Medicare patients would have to be reviewed by a
doctor every 24 hours. At the time I said I was for that, stunning all
of the health care folks in my district. I was in the House of
Representatives then. I said: Surely, if they are going to require a
24-hour reporting requirement by a doctor, they will furnish us the
doctor. There was sort of a method to the madness.
At any rate, as I have indicated, there is an 18-page initial
assessment that must be completed by a registered nurse. A 13-page
followup assessment is required every 60 days. This is on top of
assessments already required by the State. That is very important. It
isn't as if there is no regulatory function to safeguard the interests
of the patients and the taxpayer. The paperwork burden is immense. I am
curious about what is included in this assessment. Is the Senator aware
of the nature of the questions?
Ms. COLLINS. Mr. President, this is one of the problems. The Senator
from Kansas has put his finger right on it. OASIS collects information
not only about the patient's medical condition or history, but about
living arrangements, medications, sensory status--I am not even sure
what that means--and emotional status as well. That raises a host of
problems.
Mr. ROBERTS. Emotional status? I see that patients must answer
questions about their feelings. Have they ever been depressed? Have
they ever had trouble sleeping? Have they ever attempted suicide? In
some cases, that might be necessary, but do we really think we need a
nurse to bother a physical therapy patient for this information so that
he or she can send the answers over computer to someplace in
Baltimore--hopefully Kansas City, but probably in Baltimore?
Does the Senator from Maine have any idea how patients have reacted
to this survey? Talk about emotional distress, if somebody were to ask
me in a hospital what I felt or how would I feel, do I feel depressed,
I think they would learn pretty doggone quick.
Ms. COLLINS. That has been the experience of the nurses in Maine,
that the patients believe this is unnecessarily intrusive. We are not
talking about patients, in these cases, who are receiving home health
because of emotional problems. Obviously, those questions might be
appropriate in some cases, but they are clearly not in these cases.
What the nurses explained to me is that the patients say: What does
this have to do with what you are treating me for? The nurses expressed
concern that this ``exercise of Olympian endurance'' inevitably elicits
a negative response from their patients. That is a problem because that
patient-nurse relationship is very important. It is a relationship that
respects the confidentiality and the privacy of patients, or it should.
Unfortunately, the OASIS information mandated by HCFA immediately
erects a barrier that is often difficult to overcome. There is one
example I want to share with my colleague from Kansas, one 76-year-old
Medicare patient about whom I was told was being treated for a wound to
his left shoulder. The wound care and teaching provided by the home
health nurse took approximately 30 minutes. Completing the OASIS form
took an hour and a half. The patient understandably asked: What does
all this have to do with my shoulder? A very common response.
Mr. ROBERTS. Will the Senator yield for another question?
Ms. COLLINS. I am happy to yield.
Mr. ROBERTS. I agree with my colleague. That is too much to ask. That
is ridiculous. I also point out that the time filling out the forms
would be much better used actually caring for the patients. There is an
hour and a half that the nurse could have been doing that.
The PRESIDING OFFICER. The Senator's time has expired.
Mr. ROBERTS. Mr. President, I ask unanimous consent for an additional
10 minutes.
Mr. WELLSTONE. Mr. President, I will not object, but with the
indulgence of my colleagues, I ask unanimous consent to then be allowed
to speak for 15 minutes of the Democrats' time?
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. ROBERTS. I thank my colleague from Minnesota. I will try to keep
my remarks certainly more brief and more pertinent.
The point I was trying to make--I know that the same is true with
regard to Texas--the Senator from Texas is here--and also Minnesota and
Maine--is the time to travel great distances, many miles. Our health
care providers spend an awful lot of time traveling from one patient's
home to another. What happens is that the first patient may be located
many miles away from the next patient. It requires the home health care
nurse to work virtually nonstop to meet the deadlines required for the
submission of the data to HCFA, which interferes with the personal care
and the travel time. This is like 24-hour duty that is exacerbated by
all of the data requirements.
Ms. COLLINS. Will the Senator yield on that point?
Mr. ROBERTS. Yes.
Ms. COLLINS. The Senator has spent a lot of time understanding OASIS.
One of the complaints I have heard is that OASIS even requires, in some
cases, the collection of data for non-Medicare patients; is that
correct?
Mr. ROBERTS. I tell my distinguished friend that unfortunately that
is correct. Any Medicare-approved home health agency must comply with
all Medicare conditions of participation, including the collection of
[[Page S8877]]
OASIS. This means that patients who do not participate in Medicare are
still subject to the Medicare assessment. That is exactly correct.
Last year, HCFA amended this regulation to say that these agencies
don't have to transmit the data on non-Medicare patients for the time
being. However, the agency still must spend the time making the
assessment. So it is sort of a Catch-22. I am certainly sympathetic to
the concerns raised by my constituents that these new regulations and
spending cuts will harm, again, the senior. But aren't these policy
changes necessary to achieve the Medicare saving goals established by
the Balanced Budget Act, I ask my colleague?
Ms. COLLINS. As the Senator's rhetorical question implies, these are
not necessary. The fact is that it now appears the savings goals set
for home health have not only been met but far exceeded.
According to CBO, spending for home health care fell by 35 percent in
1999, and CBO cites the larger-than-anticipated drop in the use of home
health services as the primary reason that total Medicare spending
actually dropped, overall Medicare spending, by 1 percent last year.
The CBO now projects that the post Balanced Budget Act reductions in
home health care will be approximately $69 billion. That is over four
times the $16 billion Congress expected to save. It is a clear
indication that the cutbacks have been far deeper and far more wide
reaching than Congress ever intended.
Mr. ROBERTS. Will my distinguished colleague yield for another
question?
Ms. COLLINS. I am happy to yield.
Mr. ROBERTS. My colleague referred to--and I referred to it in my
opening comments--the additional 15-percent cut across the board in
these payments to go into effect on October 1, 2001. With regard to
what she has just related to the Senate, given the savings that have
already been achieved, the question is obvious, is this additional cut
necessary?
I tell my colleagues and all those interested in this particular
issue that last year we had to come up with an emergency bill. Nobody
likes to do that.
We would prefer it to go through authorization and appropriations.
Nobody likes to be faced with an emergency bill. This year is the same
way. We are wrestling with that in terms of the budget caps we should
live with. We are trying to figure that out. Here we are willing to
provide more emergency money and we turn around and go through another
15-percent cut. It seems to me that is not conducive to what we are
about with regard to consistency. What effect would that have with
regard to home health care agencies?
Ms. COLLINS. A further 15-percent cut would be devastating. It would
sound the death knell for those low-cost, nonprofit agencies in our
States, which are currently struggling to hang on. It would further
reduce our seniors' access to critical home care services. As we have
discussed, we don't need to do it. We already have more than achieved
the savings goals that were put forth in 1997.
Mr. ROBERTS. If the Senator will yield for an additional question,
what are we going to do to help remedy this serious problem? I know the
Senator has legislation, but would she summarize what she thinks is the
answer to that.
Ms. COLLINS. The Senator from Kansas has been a strong supporter
along with my colleagues, Senators Bond and Ashcroft from Missouri, as
well as many colleagues, in cosponsoring legislation introduced to
eliminate the automatic 15-percent reduction in Medicare payments that
would otherwise occur. It would provide a measure of financial relief
for those home health agencies that already are cost-efficient and
doing a good job. That is what we need to do--to pass that legislation
before we adjourn.
Mr. ROBERTS. If I may ask one additional question, what kind of
support do we have in the Senate? I think the magic number is 55. I
would like for the Senator to tell our colleagues.
Ms. COLLINS. I am pleased to confirm to the Senator from Kansas that
my legislation has strong support not only from the Senator from Kansas
but many of our colleagues. It has 55 Senate cosponsors, including 32
Republicans and 23 Democrats, showing that this is a nationwide
problem. It also has strong backing of many consumer and patient
groups, including the American Diabetes Association, American Nurses
Association, National Council on Aging, and the American Hospital
Association. All of these groups have come together because they know
that an additional 15-percent cutback would be absolutely devastating
to American seniors and people with disabilities.
So if we allow this to go into effect, any of our other efforts to
strengthen Medicare and home health, to help improve that benefit will
really be meaningless.
Mr. ROBERTS. I have one final question. First, I thank the Senator
from Maine for all her leadership and her hard work in this effort, for
tapping not so gently on the shoulders of the leadership and, in a
bipartisan way, attracting all sorts of support for this bill. I
believe it is possible for Congress to bring this much needed relief to
the home health care industry, as well as to the small rural hospitals
and the teaching hospitals that are feeling the pinch of all these
regulatory and legislative changes made in the last few years--with
every good intent.
But this is the law of unintended consequences personified. We must
work quickly. Time is of the essence for many of our home health
agencies and hospitals, especially the small rural providers. I don't
want to have to go out again on a 105-county listening tour in Kansas
and have people come and say; Senator Roberts, thank you so much for
your past help on a whole litany of things we have gone through
regarding the home health care delivery system, only to find out that
their doors may close.
I will continue to work with my colleague from Maine to pass
legislation before Congress adjourns this year. We have a good team and
we have good support. We cannot go home without providing help. I thank
the distinguished Senator for her leadership in heading up a home
health care posse for fairness and justice.
Ms. COLLINS. I thank the Senator from Kansas for his kind comments
and his strong support and leadership. He clearly understands the
issues involved. Time is of the essence. I appreciate the opportunity
to discuss this issue this morning.
I yield the floor.
The PRESIDING OFFICER. The Senator from Louisiana.
Ms. LANDRIEU. Mr. President, I ask unanimous consent that after my 5
minutes of remarks Senator Wellstone and Senator Harkin be recognized.
Mr. GRAMM. Mr. President, does that reserve my 20 minutes?
The PRESIDING OFFICER. The Senator's 20 minutes is not affected by
this request.
Ms. LANDRIEU. Is it the understanding of the Senator from Texas that
after I speak Senator Harkin and Senator Wellstone will speak
immediately after me? I am under the impression that we have about 20
or 30 minutes on our side.
The PRESIDING OFFICER. The total is 25 minutes.
Mr. GRAMM. As I understand the schedule of the Senate, I think there
would be no problem, as long as it didn't exceed 30 minutes.
The PRESIDING OFFICER. Without objection, it is so ordered.
Ms. LANDRIEU. Mr. President, I thank the Senator from Texas. I will
be very brief, and then Senator Wellstone will need about 10 minutes.
I thank my colleagues from Maine and Kansas for taking time to speak
on the floor about such an important issue as health care. As we wrap
up this session, I am very hopeful, in a bipartisan way, we can address
specifically many of the questions that were raised in terms of the
tough situation facing our home health care agencies and hospitals, our
rural health clinics. It is something this Congress must address in the
last few weeks. I thank them for their leadership.
____________________