[Congressional Record Volume 153, Number 101 (Thursday, June 21, 2007)]
[Senate]
[Pages S8234-S8239]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Ms. COLLINS (for herself, Mr. Conrad, Mr. Smith, Ms. Mikulski, 
        and Mr. Inouye):
  S. 1678. A bill to amend title XVIII of the Social Security Act to 
ensure more timely access to home health services for Medicare 
beneficiaries under the Medicare program; to the Committee on Finance.
  Ms. COLLINS. Mr. President, I rise today on behalf of myself, Senator 
Conrad, Senator Smith, Senator Mikulski, and Senator Inouye, to 
introduce legislation to ensure that our seniors and disabled citizens 
have timely access to home health services under the Medicare Program.
  Nurse practitioners, physician assistants, certified nurse midwives, 
and clinical nurse specialists are all playing increasingly important 
roles in the delivery of health care services, particularly in rural 
and medically underserved areas of our country where physicians may be 
in scarce supply. In recognition of their growing role, Congress, in 
1997, authorized Medicare to begin paying for physician services 
provided by these health professionals as long as those services are 
within their scope of practice under State law.
  Despite their expanded role, these advanced practice registered 
nurses and physician assistants are currently unable to order home 
health services for their Medicare patients. Under current law, only 
physicians are allowed to certify or initiate home health care for 
Medicare patients, even though they may not be as familiar with the 
patient's case as the non-physician provider. In fact, in many cases, 
the certifying physician may not even have a relationship with the 
patient and must rely upon the input of the nurse practitioner, 
physician assistant, clinical nurse specialist or certified nurse 
midwife to order the medically necessary home health care. At best, 
this requirement adds more paperwork and a number of unnecessary steps 
to the process before home health care can be provided. At worst, it 
can lead to needless delays in getting Medicare patients the home 
health care they need simply because a physician is not readily 
available to sign the form.
  The inability of advanced practice registered nurses and physician 
assistants to order home health care is particularly burdensome for 
Medicare beneficiaries in medically underserved areas, where these 
providers may be the only health care professionals available. For 
example, needed home health care was delayed by more than a week for a 
Medicare patient in Nevada because the physician assistant was the only 
health care professional

[[Page S8238]]

serving the patient's small rural town, and the supervising physician 
was located 60 miles away.

  A nurse practitioner told me about another case in which her 
collaborating physician had just lost her father and was not available. 
As a consequence, the patient experienced a 2-day delay in getting 
needed care while they waited to get the paperwork signed by another 
physician. Another nurse practitioner pointed out that it is ridiculous 
that she can order physical and occupational therapy in a subacute 
facility but cannot order home health care. One of her patients had to 
wait 11 days after being discharged before his physical and 
occupational therapy could continue simply because the home health 
agency had difficulty finding a physician to certify the continuation 
of the same therapy that the nurse practitioner had been able to 
authorize when the patient was in the facility.
  The Home Health Care Planning Improvement Act will help to ensure 
that our Medicare beneficiaries get the home health care they need when 
they need it by allowing physician assistants, nurse practitioners, 
clinical nurse specialists and certified nurse midwives to order home 
health services. Our legislation is supported by the National 
Association for Home Care and Hospice, the American Nurses Association, 
the American Academy of Physician Assistants, the American College of 
Nurse Practitioners, the American College of Nurse Midwives, the 
American Academy of Nurse Practitioners, and the Visiting Nurse 
Associations of America.
  I urge my colleagues to sign onto this legislation as cosponsors. I 
ask unanimous consent that letters of support be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:


                                  American Nurses Association,

                                                     June 6, 2007.
     Hon, Susan Collins,
     U.S. Senate, Washington, DC.
     Hon. Gordon Smith,
     U.S. Senate, Washington, DC.
       Dear Senators Collins and Smith: I am writing on behalf of 
     the American Nurses Association, ANA, to express support for 
     the Home Health Care Planning Improvement Act of 2007. ANA is 
     the only full- service national association representing 
     registered nurses, RNs. Through our 54 state and territorial 
     nursing associations, we represent RNs across the nation in 
     all practice settings.
       ANA applauds your efforts to improve access to home health 
     services. Advanced practice registered nurses, APRNs, are 
     playing an increasing role in American health care delivery. 
     Nurse practitioners, clinical nurse specialists, and 
     certified nurse midwives can practice independent of 
     physicians in most states. Many studies have shown that APRNs 
     provide cost-effective, high quality care. In addition, they 
     are often willing to provide services in areas where access 
     to physicians is limited.
       Medicare has recognized the independent practice of APRNs 
     for nearly two decades, and these health care professionals 
     now provide the majority of skilled care to home health 
     patients. Unfortunately, a quirk in Medicare law has kept 
     APRNs from signing home health plans of care and from 
     certifying Medicare patients for the home health benefit. In 
     areas where access to physicians is limited, this outdated 
     prohibition has lead to delays in health care delivery. These 
     delays in care inconvenience patients and their families. In 
     addition, delays can also result in increased cost to the 
     Medicare system when patients are unnecessarily left in more 
     expensive institutional settings.
       The Home Health Care Planning Improvement Act of 2007 would 
     address these problems by specifically allowing nurse 
     practitioners, clinical nurse specialists, and certified 
     nurse midwives to certify home health services. ANA looks 
     forward to working with you to support the enactment of this 
     important legislation.
           Sincerely,

Rose Gonzalez, MPS, RN Director, Government Affairs.
                                  ____


                                               American College of


                                               Nurse-Midwives,

                                 Silver Spring, MD, June 14, 2007.
     Hon. Susan Collins,
     U.S. Senate, Dirksen Senate Office Building, Washington, DC.
       Dear Senator Collins: On behalf of the certified nurse-
     midwife, CNM, and certified midwife, CM, members of the 
     American College of Nurse-Midwives, ACNM, I am writing to 
     express strong support for the legislation you plan to 
     introduce this week to ensure appropriate and timely access 
     to necessary home health services for women that might be in 
     the care of a certified nurse-midwife or other primary care 
     provider.
       As you know, currently Medicare only allows a physician to 
     order home health services for Medicare beneficiaries. ACNM 
     believes this is an antiquated requirement that fails to 
     recognize the role advanced practice nurses, including 
     certified nurse-midwives, play in the delivery of high 
     quality, primary care services. Your legislation would ensure 
     that a patient under the care of a certified nurse-midwife 
     can receive necessary home health services in a timely 
     manner. This is particularly important for those women with 
     disabilities who are covered by the Medicare program and are 
     of childbearing age. It is also important for senior women 
     who might be under the care of a certified nurse-midwife for 
     primary care services.
       Thank you again for your leadership on this important 
     matter. ACNM looks forward to working with you to see this 
     legislation's passage during the 110th Congress. For further 
     information on this matter, please contact Mr. Patrick 
     Cooney, ACNM's Federal Representative, at (202) 347-0034.
           Sincerely,
                                                Eunice K.M. Ernst,
     CNM, MPH, DSn(Hon), FACNM, President.
                                  ____

                                          National Association for


                                          Home Care & Hospice,

                                     Washington, DC, June 6, 2007.
     Hon. Susan Collins,
     U.S. Senate,
     Washington, DC.
       Dear Senator Collins: On behalf of the National Association 
     for Home Care & Hospice, NAHC, I am writing to offer our 
     appreciation and support for the Home Health Care Planning 
     Improvement Act of 2007 that would allow nurse practitioners, 
     NPs, clinical nurse specialists, CNSs, certified nurse 
     midwives, CNMs, and physicians' assistants, PAs, to sign 
     Medicare home health plans of care. We commend you for this 
     much needed legislation that will help ensure timely access 
     to home health services while reducing Medicare expenditures 
     on more costly institutional care.
       NPs, CNSs, CNMs, and PAs are playing an increasing role in 
     the delivery of our nation's health care, especially in rural 
     and underserved areas, and are providing necessary medical 
     services to Medicare beneficiaries. They are often more 
     familiar with particular cases than the attending physician. 
     In addition, they are sometimes more readily available than 
     physicians to expedite the processing of necessary paperwork, 
     ensuring that home health agencies will be reimbursed in a 
     timely manner and that care to the beneficiary will not be 
     interrupted. Studies have shown that the expanded use of 
     these professionals can result in dramatic decreases in 
     expensive hospitalizations and nursing home stays.
       We appreciate the outstanding leadership you have shown in 
     helping make home and community-based services more readily 
     available to our nation's elderly population and those with 
     disabilities.
           With our highest regards,
                                              Val J. Halamandaris,
     President.
                                  ____

                                                 American Academy,


                                       of Nurse Practitioners,

                                     Washington, DC. June 7, 2007.
     Senator Susan Collins,
     U.S. Senate,
     Washington, DC.
       Dear Senator Collins: I am writing in behalf of the 
     American Academy of Nurse Practitioners to endorse the 
     introduction of the Home Health Improvement Act of 2007. This 
     bill will authorize nurse practitioners to order home health 
     services for patients for whose care they are responsible.
       As you know, nurse practitioners have been authorized Part 
     B Medicare providers since 1998. Under the provisions of this 
     law, nurse practitioners render, order and refer for services 
     under their own PIN and UPIN numbers. They may order physical 
     therapy, occupational therapy, bill as consultant and 
     consultees when providing services through telemedicine and 
     order and bill for performing and interpreting diagnostic 
     tests within their scope of practice. Despite their ability 
     to provide and bill for services in all of these areas, they 
     are still unable to refer patients for home health care.
       Nurse practitioners have been demonstrated to provide safe 
     and responsible care to the patients they serve. They have 
     expert knowledge that allows them to provide high level 
     assessments of patient needs and recognize when additional 
     care, such as home health care is needed or not needed by 
     their patients. Given their proven track record in the care 
     of the elderly, it is not logical that nurse practitioners 
     are authorized to be Part B providers, but are unable to 
     order home health care and hospice care for their patients.
       Currently nurse practitioners with patients needing home 
     health care services must locate a physician who will see the 
     patient and write the orders for this care. Not only is the 
     patient's well being jeopardized by the delays that are 
     incurred by this requirement, but added cost is incurred by 
     the Medicare program through extra visits to providers with 
     higher reimbursement rates than nurse practitioners. Passage 
     of this bill will increase the quality and timeliness of care 
     to patients who need home health nursing services.
           Sincerely,
                                Jan Towers PhD, NP-C, CRNP, FAANP,
     Director of Health Policy.
                                  ____


[[Page S8239]]

                                                 American College,


                                       of Nurse Practitioners,

                                                     June 7, 2007.
     Hon. Susan Collins,
     United States Senate,
     Washington, DC.
       Dear Senator Collins: On behalf of the American College of 
     Nurse Practitioners (ACNP), a national, non-profit membership 
     organization whose mission is to ensure a solid policy and 
     regulatory foundation that enables Nurse Practitioners to 
     continue providing accessible, high quality healthcare to the 
     nation--I am writing to express our appreciation to you for 
     introducing the Home Health Care Planning Improvement Act of 
     2007.
       The Home Health Care Planning Improvement Act importantly 
     will amend the Social Security Act by broadening access to 
     home health services for Medicare beneficiaries. A patient's 
     Nurse Practitioner, physicians' assistant, or certified nurse 
     midwife will now have the right to make changes to their home 
     health care plan. Your critical legislation will safeguard 
     the patient's continuity of care by preventing interruptions 
     due to delays in paperwork from an oftentimes off-site 
     physician who may never have even seen the patient.
       The bill also recognizes the professional training and 
     qualifications of Nurse Practitioners and ensures quality 
     patient care, especially in rural and underserved areas where 
     Nurse Practitioners are often more familiar with particular 
     cases than the attending physician. ACNP thanks you for your 
     ongoing support of the Nurse Practitioner community. Please 
     know that ACNP stands ready to work with you and your staff 
     to ensure Medicare beneficiaries have access to the highest 
     quality care. If we can be of any assistance, please feel 
     free to contact our Health Policy Advisor, Jodie Curtis 
     (Jodie.C[email protected]) or our Chief Executive Officer, 
     Carolyn Hutcherson (C[email protected]).
           Sincerely,
                                            Susan Apold, PhD, ANP,
     President.
                                  ____

                                                  American Academy


                                      of Physician Assistants,

                                     Alexandria, VA, June 6, 2007.
     Hon. Susan M. Collins,
     United States Senate,
     Washington, DC.
       Dear Senator Collins: On behalf of the more than 60,000 
     clinically practicing physician assistants (PAs) in the 
     United States represented by the American Academy of 
     Physician Assistants (AAPA), I thank you for introducing the 
     Home Health Care Planning Improvement Act of 2007. The AAPA 
     strongly supports this important piece of legislation, and 
     looks forward to working with you to secure its passage 
     during the 110th Congress.
       In 2006, nearly 231 million patient visits were made to 
     physician assistants (PAs) and over 286 million prescriptions 
     were written by PAs. PAs have a longstanding history of 
     providing care in medically underserved communities, and have 
     been credited with improving access to quality and cost-
     effective health care for many among the nation's most 
     vulnerable patient populations.
       Although the 1997 Balanced Budget Act extended Medicare 
     coverage of medical services provided by PAs, as allowed by 
     state law, PAs are not able to order home health care for 
     Medicare beneficiaries. At best, PAs and their supervising 
     physicians are forced to go through unnecessary extra steps 
     to ensure that all home health orders are signed by the 
     physician before the care is provided. At worst, Medicare 
     beneficiaries experience needless delays in receiving home 
     health care because a physician is not available on-site to 
     sign the form.
       The inability of PAs to order home health care is 
     particularly burdensome for Medicare beneficiaries in 
     medically underserved communities where a PA may be the only 
     health care professional available. For example,
       Needed home health care was delayed by over a week for a 
     Medicare patient in Nevada, because the PA's supervising 
     physician was located 60 miles away. The PA, who holds a 
     full-time job in another part of the state, is the only 
     health care professional for the patient's small rural town, 
     providing care two weekends a month;
       critical access hospitals in Nevada and other states are 
     having difficulty with discharge planning. By law, critical 
     access hospitals must have a PA or nurse practitioner on site 
     fifty percent of the time. However, Medicare will not accept 
     home health orders that have been signed by a PA;
       PAs in orthopedic practice regularly work after-hours and 
     on weekends. However, necessary home health care must be 
     delayed for Medicare beneficiaries until a physician is 
     available to sign the order.
       The Home Health Care Planning Improvement Act of 2007 
     increases Medicare beneficiaries' access to needed care by 
     allowing PAs to order home health care. The AAPA is pleased 
     to endorse the Home Health Care Planning Improvement Act of 
     2007.
           Sincerely yours,
                                        Mary P. Ettari, MPH, PA-C,
                                                        President.
                                 ______