[Congressional Record Volume 149, Number 58 (Thursday, April 10, 2003)]
[Senate]
[Pages S5209-S5210]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BINGAMAN (for himself, Mr. Cochran, Mrs. Lincoln, Mr. 
        Hatch, Mr. Jeffords, Ms. Landrieu, and Mr. Dayton):
  S. 881. A bill to amend title XVIII of the Social Security Act to 
establish a minimum geographic cost-of-practice index value for 
physicians' services furnished under the Medicare program; to the 
Committee on Finance.
  Mr. Bingaman. Mr. President, the legislation I am introducing today 
with Senators Cochran, Lincoln, Hatch, Jeffords, Landrieu, and Dayton 
entitled the ``Rural Equity Payment Index Reform Act of 2003'' is 
designed to reduce the work payment inequity between urban and rural 
localities under the Medicare physician fee schedule. This legislation 
is a companion bill to HR 33, introduced by Representative Doug 
Bereuter, which now has over 65 House cosponsors.
  In my own State of New Mexico, recruitment and retention of 
physicians in rural areas is an ongoing problem, which is contributed 
to, in a part, by inequities in payments these physicians receive in 
comparison to their urban counterparts. With only 170 physicians per 
100,000 people, New Mexico ranks well behind the national average with 
regard to primary care and specialist physicians.
  Lack of adequate reimbursement, in the face of increasing costs, is a 
critical factor leading to the shortage of physician services in my 
state, and in other rural areas. The State of New Mexico ranks 32nd in 
the nation in terms of Medicare reimbursement, as defined by the 
geographic adjustment factor used to set reimbursement rates. Yet, an 
office visit to a rural physician is no different in time, effort, or 
workload compared to an office visit to an urban physician. 
Geographically adjusting the quantifiable workload simply makes no 
sense; physician work should be valued equally, irrespective of where a 
physician works.
  This inequity unfairly ``punishes'' physicians in non-metropolitan 
areas, where there are often proportionately larger populations of 
Medicare beneficiaries. In effect, the rural areas subsidize healthcare 
in urban areas, while they struggle to attract health care 
professionals. Since Medicare beneficiaries pay into the program on the 
basis of income and wages, and beneficiaries pay the same premium for 
part B services, these inequitable physician fee payments result in 
substantial cross-subsidies from people living in low payment States to 
people living in higher payment States.
  Targeted efforts to provide relief to rural doctors in low payment 
localities with more equitable payments would improve access to primary 
and tertiary services. The bill I am introducing would lessen the 
disparity that currently exists between rural and urban areas. It 
gradually phases in a floor that upwardly adjusts reimbursement rates 
for rural providers, without lowering the reimbursement for urban 
providers, so that the discrepancy will progressively be corrected.
  This bill would phase-in a floor of 1.000 for the Medicare 
``physician work adjuster'', thereby raising all localities with a work 
adjuster below 1.000 to that level. This proposed change would be put 
in place without regard to the budget neutrality agreement in the 
present law. The phase-in approach softens the budgetary implications 
by spreading it out over four years.
  It is estimated that payment rates to New Mexico physicians will 
increase by 2.8 million dollars over a 4-year period. In my state, this 
represents an important increase in reimbursements for physicians, but 
it also represents a tangible acknowledgement of the hard work and 
efforts that our physicians commit to patient care, particularly rural 
based physicians.
  Some of the following organizations, which have expressed support for 
this legislation, include the National Rural Health Association, the 
American College of Physicians/American Society of Internal Medicine, 
and the American Physical Therapy association.
  I ask unanimous consent that letters of support and the text of the 
bill be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                 S. 881

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE; FINDINGS.

       (a) Short Title.--This Act may be cited as the ``Rural 
     Equity Payment Index Reform Act of 2003''.

[[Page S5210]]

       (b) Findings.--Congress makes the following findings:
       (1) Variations in the physician work adjustment factors 
     under section 1848(e) of the Social Security Act (42 U.S.C. 
     1395w-4w(e)) result in a physician work payment inequity 
     between urban and rural localities under the medicare 
     physician fee schedule.
       (2) The amount the medicare program spends on its 
     beneficiaries varies substantially across the country, far 
     more than can be accounted for by differences in the cost of 
     living or differences in health status.
       (3) Since beneficiaries and others pay into the program on 
     the basis of income and wages and beneficiaries pay the same 
     premium for part B services, these payments result in 
     substantial cross-subsidies from people living in low payment 
     States with conservative practice styles or beneficiary 
     preferences to people living in higher payment States with 
     aggressive practice styles or beneficiary preferences.
       (4) Congress has been mindful of these variations when it 
     comes to capitation payments made to managed care plans under 
     the Medicare+Choice program and has put in place floors that 
     increase monthly payments by more than one-third in some of 
     the lowest payment counties over what would otherwise occur. 
     But this change addresses only a very small fraction of 
     medicare beneficiaries who are presently enrolled in 
     Medicare+Choice plans operating in low payment counties.
       (5) Unfortunately, Congress has only begun to address the 
     underlying problem of substantial geographic variations in 
     fee-for-service spending under traditional medicare.
       (6) Improvements in rural hospital payment systems under 
     the medicare program help to reduce aggregate per capita 
     payment variation as rural hospitals are in large part 
     located in low payment counties.
       (7) Many rural communities have great difficulty attracting 
     and retaining physicians and other skilled health 
     professionals.
       (8) Targeted efforts to provide relief to rural doctors in 
     low payment localities would further reduce variation by 
     improving access to primary and tertiary services along with 
     more equitable payment.
       (9) Geographic adjustment factors in the medicare program's 
     resource-based relative value scale unfairly suppress fee-
     for-service payments to rural providers.
       (10) Actual costs are not presently being measured 
     accurately and payments do not reflect the costs of providing 
     care.
       (11) Unless something is done about medicare payment in 
     rural areas, as the baby boom cohort ages into medicare, the 
     financial demands on rural communities to subsidize care for 
     their aged and disabled medicare beneficiaries will progress 
     from difficult to impossible in another 10 years.
       (12) The impact on rural health care infrastructure will be 
     first felt in economically depressed rural areas where the 
     ability to shift costs is already limited.

     SEC. 2. PHYSICIAN FEE SCHEDULE WAGE INDEX REVISION.

       Section 1848(e)(1) of the Social Security Act (42 U.S.C. 
     1395w-4(e)(1)) is amended--
       (1) in subparagraph (A), by striking ``subparagraphs (B) 
     and (C)'' and inserting ``subparagraphs (B), (C), and (E)''; 
     and
       (2) by adding at the end the following new subparagraph:
       ``(E) Floor for work geographic indices.--
       ``(i) In general.--Notwithstanding the work geographic 
     index otherwise calculated under subparagraph (A)(iii), in no 
     case may the work geographic index applied for payment under 
     this section be less than--

       ``(I) 0.976 for services furnished during 2004;
       ``(II) 0.987 for services furnished during 2005;
       ``(III) 0.995 for services furnished during 2006; and
       ``(IV) 1.000 for services furnished during 2007 and 
     subsequent years.

       ``(ii) Exemption from limitation on annual adjustments.--
     The increase in expenditures attributable to clause (i) shall 
     not be taken into account in applying subsection 
     (c)(2)(B)(ii)(II).''.
                                  ____


               NRHA Supports ``Equal Pay for Equal Work''

       Washington, DC., Jan. 7.--The National Rural Health 
     Association (NRHA) today strongly endorsed legislation 
     introduced by Representative Doug Bereuter (R.-Neb) that 
     would provide rural physicians with Medicare payments closer 
     to those of their urban counterparts. The Rural Equity 
     Payment Index Reform Act addresses the little known fact that 
     the federal government pays rural doctors at a lower rate.
       ``An office visit to a rural physician is no different than 
     an office visit to an urban physician,'' NRHA President Wayne 
     Myers, M.D., said. ``The idea that physicians are reimbursed 
     for their work and their skills at a lower rate simply on the 
     basis that they choose to practice in a rural area and serve 
     our rural communities is completely ludicrous.''
       The Bereuter bill would lessen the disparity that currently 
     exists between urban and rural areas. By gradually phasing in 
     a floor that upwardly adjusts reimbursement rates for rural 
     providers, without lowering the reimbursement in urban areas, 
     the discrepancy in payment will progressively be corrected. 
     ``These health care providers put as much or even more time, 
     skill and intensity into a patient visit as their urban 
     counterparts,'' Rep. Bereuter said, ``yet they are paid less 
     for their work under the Medicare program. This is a formula 
     that is punishing non-metropolitan areas.''
       Under the current Medicare physician payment formula, 
     residents of non-metropolitan areas essentially subsidize the 
     delivery of health care in metropolitan areas. Even though 
     rural areas tend to have larger populations of Medicare 
     beneficiaries, they are subsidizing health care in urban 
     areas, while their own communities are struggling to attract 
     health care professionals.
       ``This is a top priority issue for the NRHA,'' Myers said. 
     ``In fact, this disparity in health care is among the basic 
     reasons the NRHA exists. ``For far too long, rural American 
     health care has been overlooked in Washington. We applaud 
     Congressman Bereuter for his efforts and look forward to 
     working with him to ensure rural physicians--and rural 
     residents alike--receive an equitable deal.''
       The NRHA is a national nonprofit membership organization 
     that provides leadership on rural health issues. The 
     association's mission is to improve the health of rural 
     Americans and to provide leadership on rural health issues 
     through advocacy, communications, education and research. The 
     NRHA membership is made up of a diverse collection of 
     individuals and organizations.
                                  ____



                        American Physical Therapy Association,

                                                   March 25, 2003.
     Hon. Doug Bereuter (R-NE),
     Rayburn House Office Building,
     Washington, DC.
       Dear congressman Bereuter: The American Physical Therapy 
     Association (APTA) would like to express its appreciation for 
     your legislation to correct an inequity in Medicare payments 
     to rural health care providers. APTA strongly supports HR 33, 
     The Rural Equity Payment Index Reform (REPaIR) Act. This 
     legislation is a positive step to ensuring improved access to 
     quality health care services, including those delivered by 
     licensed physical therapists, in rural America. The current 
     inequity of payment to health care providers under the 
     Medicare physician fee schedule and its Geographic Medical 
     Practice Index needs to be corrected to ensure that qualified 
     providers continue to serve the needs of our rural 
     communities.
       Physical therapists are highly qualified and recognized 
     providers under Medicare who bill for their services under 
     the Medicare Physician Fee Schedule. Your legislation (HR 33) 
     would improve access and payment for appropriate physical 
     therapy services in rural and underserved areas. This 
     legislation would also go a long way to attract and retain 
     physical therapist to consider rural areas for practice and 
     service. Access to qualified health care providers is a 
     growing problem in rural America and your legislation is one 
     of many steps to reverse this trend.
       We applaud your dedication to rural health and express our 
     support that Congress pass HR 33, The Rural Equity Payment 
     Index Reform (REPaIR) Act in this Congress. If you have 
     questions, please feel free to contact Justin Moore at 703-
     706-3162 or [email protected].
           Sincerely,
                                                   G. David Mason,
                               Vice President, Government Affairs.
                                 ______