[Congressional Record Volume 154, Number 43 (Thursday, March 13, 2008)]
[Senate]
[Pages S2159-S2163]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. HARKIN (for himself, Mrs. Feinstein, and Mr. Kennedy):
  S. 2784. A bill to amend the Federal Food, Drug and Cosmetic Act to 
extend the food labeling requirements of the Nutrition Labeling and 
Education Act of 1990 to enable customers to make informed choices 
about the nutritional content of standard menu items in large chain 
restaurants; to the Committee on Health, Education, Labor, and 
Pensions.
  Mr. HARKIN. Mr. President, today I am introducing a bill, the Menu 
Education and Labeling Act, on behalf of myself and my colleagues, Ms. 
Feinstein of California, and Mr. Kennedy of Massachusetts.
  Poor nutrition and obesity are a major public health problem in the 
U.S. The issue is far from merely cosmetic. It is medical and economic. 
Diet-related disease are prevalent in the U.S. Cardiovascular disease, 
which is the leading cause of death in the U.S., is clearly linked to 
poor diets. Type-2 diabetes, results in amputation, blindness, and 
premature death.
  Diet is also clearly associated with rising rates of overweight and 
obesity. More than 65 percent of American adults are overweight, and 
more than 30 percent are clinically obese. We lead the world in this 
dubious distinction, which is growing worse. Increasingly the problem 
starts in childhood. According to the Institute of Medicine, since 
1963, obesity rates have quadrupled among older children ages 6 to 11 
years, and tripled for adolescents between the ages of 12 and 19. If we 
do not change course, kids attending school today will be the first 
generation in American history to live a shorter lifespan than their 
parents
  The obesity epidemic has far-reaching consequences. Overweight people 
have an increased risk of diabetes, cardiovascular disease, cancers and 
other illnesses. Sixty percent of overweight youth already have at lest 
one risk factor for heart disease, which is the leading cause of death 
in the U.S. Obesity also causes or contributes to $117 billion a year 
in health care and related costs, more than half borne by taxpayers.
  There is no single solution to the complex problem of poor nutrition 
and diet-related disease, but we must start taking meaningful steps to 
address this growing problem by giving people the tools necessary to 
consume healthier diets. The legislation that we are introducing today 
will extend nutrition labeling beyond packaged foods to include foods 
at chain restaurants with 20 or more locations, as well as food in 
vending machines. This common-sense idea will give consumers a needed 
tool to make wiser choices and live healthier lives.
  In 1990, Congress passed the Nutrition Labeling and Education Act, 
NLEA, requiring food manufacturers to provide nutrition information on 
nearly all packaged foods. The impact has been tremendous. Not only do 
nearly three-quarters of adults use the food labels on packaged foods, 
but studies indicate that consumers who read labels have healthier 
diets.
  American adults and children now consume a third of their calories at 
restaurants and nutrition and health experts say that rising caloric 
consumption and growing portion sizes are causes of obesity. However, 
restaurants were excluded from the Nutrition Labeling and Education 
Act. Consumers say that they would like nutrition information provided 
when they order their food at restaurants, yet, while they have good 
nutrition information in supermarkets, at restaurants they can only 
guess.
  Similarly, vending machine food sales also play a large role in 
contributing to the diets of Americans. Over the last three decades 
vending machine sales have shot up 85 percent after inflation. Most 
vending machine sales include foods of low nutritional value.
  The Menu Education and Labeling Act will require fast-food and other 
chain restaurants to provide point of sale information on calories, 
saturated fat, trans fat, and sodium and will require point of sale 
labeling of calories on foods sold in vending machines.
  I would also like to note that last night, one of the true lions of 
the Senate, my old friend Howard M. Metzenbaum from Ohio, passed away. 
Senator Metzenbaum was a good friend and a great senator. One of his 
great achievements in the Senate is that he was the author of and the 
driving force behind the Nutrition Education Labeling Act, which first 
established nutrition labeling for packaged foods. The bill that we are 
introducing today builds upon Senator Metzenbaum's work on nutrition 
labeling, and in honor of his work and his distinguished career, I am 
naming this bill after him.
  Let there be no doubt: poor nutrition in America is indeed an 
epidemic, and it is continuing to grow. This is a public health crisis 
and we must address it. Although this bill alone will not end poor 
nutrition or halt rising obesity in its tracks, it provides consumers 
with an important tool with which to make better choices about the food 
that they and their children consume.
                                 F_____
                                 
      By Mr. GRASSLEY:
  S. 2786. A bill to amend title XVIII of the Social Security Act to 
improve access to health care under the Medicare program for 
beneficiaries residing in rural areas; to the Committee on Finance.
  Mr. GRASSLEY. Mr. President, I am pleased to introduce the Medicare 
Rural Health Access Improvement Act of 2008.
  The purpose of this legislation is to continue ongoing efforts to 
ensure that Americans in rural areas have access to health care 
services. Much has been done in the past to improve access to rural 
providers such as hospitals and doctors. Much more still needs to be 
done.
  I hold town meetings in each of the 99 counties in the great State of 
Iowa every year. As many know, Iowa is largely a rural State, and a 
significant concern that I consistently hear during these meetings is 
the difficulty my constituents experience in accessing health care 
services. As the former chairman and currently the ranking member of 
the Finance Committee, it has, therefore, been a priority for me to 
improve the availability of health care in rural areas.
  In Iowa, as in many rural areas across the country, hospitals are 
often

[[Page S2160]]

not only the sole provider of health care in rural areas, but also 
employers and purchasers in the community. Moreover, the presence of a 
hospital is essential for purposes of economic development because 
businesses check to see if a hospital is in the community in which they 
might set up shop. As you can see, it is vital that these institutions 
are able to keep their doors open.
  In previous legislation, Congress has been able to improve the 
financial viability of rural hospitals. For instance, the creation and 
subsequent improvements to the Critical Access Hospital designation has 
greatly improved the financial health of certain small rural hospitals 
and ensured that community residents have access to health care.
  However, there are still a group of rural hospitals that need help. I 
am referring to what are known as ``tweener'' hospitals, which are too 
large to be Critical Access Hospitals, but too small to be financially 
viable under the Medicare hospital prospective payment systems. These 
facilities are struggling to stay afloat despite their tireless 
efforts. Like in many communities across the country, the staff of 
tweener hospitals and their community residents take great pride in the 
quality of care at these facilities. I have heard countless stories of 
the exemplary work tweener hospitals in Iowa perform not only as 
providers of essential health care, but also as responsible members of 
their communities. It is for this reason that many provisions in this 
bill are intended to improve the financial health of tweener hospitals 
and ensure that people have access to health care.
  Most tweener hospital are currently designated as Medicare Dependent 
Hospitals and Sole Community Hospitals under the Medicare program. 
There are provisions, both temporary and permanent, included in this 
bill that would improve Medicare payments for both types of hospitals. 
This includes improvements to the payment methodologies so that 
inpatient payments to these facilities would better reflect the costs 
they incur in providing care. Improvements are also proposed in this 
bill to Medicare hospital outpatient payments for both Medicare 
Dependent Hospitals and Sole Community Hospitals so they would both 
share the benefit of hold harmless payments and add-on payments.
  Also, a major driver of the financial difficulties that tweener 
hospitals face is the fact that many have relatively low volumes of 
inpatient admissions. This bill would improve the existing low-volume 
add-on payment for hospitals so that more rural facilities with low 
volumes would receive the assistance they desperately need.
  Over the years, many have commented that it is simply unfair for many 
rural hospitals to receive only a limited amount of Medicare 
Disproportionate Share Hospital, or DSH, payments while many urban 
hospitals are not subject to such a cap. This bill would eliminate the 
cap for DSH payments for those rural hospitals for a 2-year period.
  There are also other provisions that would continue to help rural 
hospitals. The rural flexibility program would be extended for an 
additional year. Certain rural hospitals that are paid on a cost basis 
for the outpatient laboratory services they provide would continue to 
do so on a permanent basis. And Critical Access Hospitals that provide 
outpatient laboratory services would be paid 101 percent of their costs 
regardless of whether the specimen was collected from a patient of the 
CAH or whether the specimen was collected in a skilled nursing facility 
or clinic associated with the CAH.
  This legislation also seeks to improve incentives for physicians 
located in rural areas and increase beneficiaries' access to rural 
health care providers. It includes provisions designed to reduce 
inequitable disparities in physician payment resulting from the 
Geographic Practice Cost Indices, or adjusters, known as GPCIs. 
Medicare payment for physician services varies from one area to another 
based on the geographic adjustments for a particular area. Geographic 
adjustments are intended to reflect cost differences in a given area 
compared to a national average of 1.0 so that an area with costs above 
the national average would have an index greater than 1.0, and an area 
below the national average would have an index less than 1.0. There are 
currently three geographic adjustments: for physician work, practice 
expense, and malpractice expense.
  Unfortunately, the existing geographic adjusters result in 
significant disparities in physician reimbursement which penalize, 
rather than equalize, physician payment in Iowa and other rural states. 
These geographic disparities in payment lead to rural states 
experiencing significant difficulties in recruiting and retaining 
physicians and other health care professionals due to their 
significantly lower reimbursement rates.
  These disparities have perverse effects when it comes to realigning 
Medicare payment to reward quality of care. Let me put that into 
context. Iowa is widely recognized as providing some of the highest 
quality health care in the country yet Iowa physicians receive some of 
the lowest Medicare reimbursement due to these inequitable geographic 
adjustments. Medicare reimbursement for some procedures is at least 30 
percent lower in Iowa than payment for those very procedures in other 
parts of the country. That is a significant disincentive for Iowa 
physicians who are providing some of the best quality care in the 
country, and it is fundamentally unfair. Congress needs to reduce these 
disparities in payment and focus on rewarding physicians who provide 
high quality care.
  The inequitable geographic payment formulas have also exacerbated the 
problems that rural areas face in terms of access to health care. Rural 
America today has far fewer physicians per capita than urban areas. The 
GPCI formulas are a dismal failure in promoting an adequate supply of 
physicians in States such as Iowa, and more severe physician shortages 
in rural areas are predicted in the future.
  The legislation I am introducing today makes changes in the GPCI 
formulas for work and practice expense to reverse this trend. It 
establishes a 1.0 floor for the physician work and practice expense 
adjustments. It also revises the calculation of the work and practice 
expense formulas to reduce payment differences and more accurately 
compensate physicians in rural areas for their true practice costs. We 
must act now to help rural States recruit and retain more physicians so 
that beneficiaries will continue to have access to needed health care.
  Congress has previously enacted a number of other provisions to 
improve Medicare payment for health care professionals and providers in 
rural areas that will expire soon. This bill extends the five percent 
incentive payments for primary care and specialty physicians in 
scarcity areas through December 2009. It also extends the existing 
payment arrangements which allow independent laboratories to bill 
Medicare directly for certain physician pathology services.
  The bill includes several new provisions to improve beneficiary 
access to health care services. It increases rural ambulance payments 
by 5 percent for the next 18 months. It permanently increases the 
payment limits for rural health clinics. It allows hospital-based renal 
dialysis centers and skilled nursing facilities to provide telehealth 
services. It also allows physician assistants to order post-hospital 
extended care services and to serve hospice patients.
  Finally, the bill would protect rural areas from being adversely 
affected by the new Medicare competitive bidding program for durable 
medical equipment. It would ensure that home medical equipment 
suppliers who provide equipment and services in rural areas and small 
metropolitan statistical areas, MSAs, with a population of 600,000 or 
less can continue to serve the Medicare program by exempting these 
areas from competitive bidding. We must ensure that rural areas 
continue to have medical equipment suppliers available to serve 
beneficiaries in these areas.
  Mr. President, as you can see, we still have much to do when it comes 
to ensuring access to health care in rural America. I look forward to 
working with my colleagues on this important matter.
  Mr. President, I ask unanimous consent to have printed in the Record 
a summary of the bill.
   There being no objection, the material was ordered to be printed in 
the Record, as follows:

[[Page S2161]]

          Medicare Rural Health Access Improvement Act of 2008


             Title I--Provisions Relating to Medicare Part A

      Section 101. Extension of Medicare Rural Hospital 
         Flexibility Grant Program.
        Current Law
        Presently, the Medicare Rural Hospital Flexibility Grant 
     Program is authorized for $35 million from FY2005 through 
     FY2008.
        Explanation of Provision
        The provision would extend this grant program through 
     FY2009.
      Section 102. Improvements to the Medicare Dependent Hospital 
         (MDH) Program.
        Current Law
        MDHs are small rural hospitals with a high proportion of 
     patients who are Medicare beneficiaries (have at least 60% of 
     acute inpatient days or discharges attributable to Medicare 
     in FY1987 or in two of the three most recently audited cost 
     reporting periods). An MDH cannot be a Sole Community 
     Hospital (SCH) and must have 100 or fewer beds. Until October 
     1, 2006, MDHs were paid at the wage-adjusted national 
     standardized amount or, if higher, 50% of their adjusted 
     FY1982 or FY1987 hospital specific costs. Starting for 
     discharges on October 1, 2006, an MDH would be able to elect 
     payments based on its FY2002 hospital specific costs if that 
     would result in higher Medicare payments. Also, starting for 
     discharges on October 1, 2006, an MDH that elected to be paid 
     using its hospital-specific costs would have its payments 
     based on 75% of those costs.
        Explanation of Provision
        Starting for discharges on October 1, 2008 until October 
     1, 2011, an MDH that elects to be paid using the national 
     standardized amount would not have that per discharge payment 
     amount adjusted by an area wage adjustment unless such 
     adjustment will result in improved payments to the MDH. 
     Starting for discharges on October 1, 2008 until October 1, 
     2011, those MDHs would have their payments based on 85% of 
     their hospital specific costs.
      Section 103. Rebasing for Sole Community Hospitals (SCHs).
        Current Law
        Medicare payments to SCHs for inpatient hospital services 
     are made on the basis of the federal per discharge payment 
     amount or on the basis of its updated hospital-specific per 
     discharge amount from FY1982, FY1987, or FY1996, whichever 
     would result in the largest payment.
        Explanation of Provision
        Starting for discharges on October 1, 2008, SCHs would be 
     able to elect payment based on their FY2002 hospital-specific 
     payment amount per discharge. This amount would be increased 
     by the annual update starting in FY2008.
      Section 104. Temporary Improvements to the Medicare 
         Inpatient Hospital Payment Adjustment for Low-volume 
         Hospitals.
        Current Law
        Under Medicare's Inpatient Prospective Payment System 
     (IPPS), certain low-volume hospitals receive a payment 
     adjustment to account for their higher costs per discharge. A 
     low volume hospital is defined as an acute care hospital that 
     is located more than 25 road miles from another comparable 
     hospital and that has less than 800 total discharges during 
     the fiscal year. Under current law, the Secretary is required 
     to determine an appropriate percentage increase for these 
     low-volume hospitals based on the empirical relationship 
     between the standardized cost-per-case for such hospitals and 
     their total discharges to account for the additional 
     incremental costs (if any) that are associated with such 
     number of discharges. The low-volume adjustment is limited to 
     no more than 25 percent. Accordingly, under regulations, 
     qualifying hospitals (those located more than 25 road miles 
     from another comparable hospital) with less than 200 total 
     discharges receive a 25% payment increase for every Medicare 
     discharge.
        Explanation of Provision
        This provision would make a temporary adjustment that 
     would provide payments in FY2009 and FY2010 to more low-
     volume hospitals. A low-volume hospital could be located more 
     than 15 road miles from another comparable hospital and have 
     2,000 discharges of individuals entitled to or enrolled for 
     Medicare Part A benefits. The Secretary would determine the 
     applicable percentage increase using a linear sliding scale 
     ranging from 25% for low-volume hospitals below a certain 
     threshold to no adjustment for hospitals with greater than 
     2,000 discharges of individuals with Medicare Part A 
     benefits.
      Section 105. Temporarily Lifting the Disproportionate Share 
         Hospital (DSH) Adjustment Cap.
        Current Law
        Medicare will increase its payments to hospitals that 
     qualify for a DSH adjustment. In many instances, the size of 
     a hospital's DSH adjustment will depend upon the number of 
     patient days provided to poor Medicare patients or Medicaid 
     patients (DSH patient share). However, small urban hospitals 
     and many rural hospitals have their DSH adjustment capped at 
     12%.
        Explanation of Provision
        The provision would eliminate the DSH adjustment cap for 
     these hospitals for discharges occurring in FY2009 and 
     FY2010. For discharges on or after October 1, 20010, the DSH 
     adjustment cap would revert to 12%.


            Title II--Provisions Relating to Medicare Part B

      Section 201. Extension and Expansion of the Medicare 
         Hospital Outpatient Department Hold Harmless Provision 
         for Small Rural Hospitals.
        Current Law
        Small rural hospitals (with no more than 100 beds) that 
     are not Sole Community Hospitals (SCHs) can receive 
     additional Medicare payments if their outpatient payments 
     under the prospective payment system are less than under the 
     prior reimbursement system. For CY2006, these hospitals will 
     receive 95% of the difference between payments under the 
     prospective payment system and those that would have been 
     made under the prior reimbursement system. The hospitals will 
     receive 90% of the difference in CY2007 and 85% of the 
     difference in CY2008.
        Explanation of Provision
        The provision would establish that in CY 2009 and CY 2010, 
     small rural hospitals, including Medicare Dependent Hospitals 
     and SCHs, would receive 100% of the difference between 
     payments made under the Medicare Hospital Outpatient 
     Prospective Payment System and those made under the prior 
     reimbursement system.
      Section 202. Expansion of the Medicare Hospital Outpatient 
         Department Add-on Payment for Rural Sole Community 
         Hospitals (SCHs).
        Current Law
        Under Medicare Prescription Drug, Improvement, and 
     Modernization Act of 2003 (MMA), the Secretary was required 
     to study to determine whether the costs incurred by rural 
     hospitals were greater than urban hospitals and whether the 
     prospective payment system (PPS) for hospital outpatient 
     departments (HOPD) accounted for those cost differences. The 
     Secretary was authorized to provide a payment adjustment for 
     rural hospitals by January 1, 2006 if such an adjustment was 
     warranted. Starting in CY2006, rural SCHs have had their 
     Medicare payments for outpatient services increased by 7.1%.
        Explanation of Provision
        This provision would establish that the Secretary's 
     authority to provide a payment adjustment would apply to 
     services furnished in 2006, 2007 and 2008. The Medicare 
     statute would be amended so that SCHs and Medicare Dependent 
     Hospitals (MDHs) in rural areas would receive a 7.1% increase 
     in payments for covered HOPD services for services starting 
     January 1, 2009. The increase would be applied before 
     calculating outliers and coinsurance. The Secretary would be 
     able to revise this percentage starting for services 
     furnished after January 1, 2010 through promulgation of a 
     regulation. The increase would not apply to pass-through 
     drugs and biologicals. The increased payments as they relate 
     to SCHs and MDHs would not be implemented in a budget-neutral 
     manner.
      Section 203. Permanent Treatment of Medicare Reasonable 
         Costs Payments for Certain Clinical Diagnostic Laboratory 
         Tests Furnished to Hospital Patients in Certain Rural 
         Areas.
        Current Law
        Generally, hospitals that provide clinical diagnostic 
     laboratory services under Part B are reimbursed using a fee 
     schedule. Hospitals with under 50 beds in qualified rural 
     areas (certain rural areas with low population densities) 
     receive 100% of reasonable cost reimbursement for the 
     clinical diagnostic laboratories covered under Part B that 
     are provided as outpatient hospital services. Reasonable cost 
     reimbursement for laboratory services provided by these 
     hospitals will expire on July 1, 2008.
        Explanation of Provision
        This provision would add Section 1833(v) to the Social 
     Security Act which would make reasonable cost reimbursement 
     for laboratory services provided by qualified rural hospitals 
     permanent starting July 1, 2008. The Secretary would be 
     required to apply the current rules that are used to 
     determine whether clinical diagnostic laboratory services are 
     furnished as an outpatient Critical Access Hospital service 
     (without regard to amendments enacted in this legislation.)
      Section 204. Clarification of Payment for Clinical 
         Laboratory Tests Furnished by Critical Access Hospitals 
         (CAHs).
        Current Law
        Medicare outpatient covered clinical laboratory services 
     are generally paid based on a fee schedule. Clinical 
     diagnostic laboratory services provided to patients who 
     receive services directly from CAHs on an outpatient basis 
     are paid 101% of reasonable costs. Clinical laboratory 
     services provided by CAHs to those who are not patients are 
     paid on the basis of the Medicare fee schedule. In no 
     instance are Medicare beneficiaries liable for any 
     coinsurance or deductible amounts.
        Explanation of Provision
        Under this provision, clinical diagnostic laboratory 
     services furnished by a CAH starting in January 1, 2009 would 
     be reimbursed at 101% of costs as outpatient hospital 
     services without regard to whether the specimen was collected 
     from a patient of the CAH or whether the specimen was 
     collected in a skilled nursing facility or clinic that is 
     owned by or co-located with the CAH.

[[Page S2162]]

      Section 205. Extension of Medicare Incentive Payment Program 
         for Physician Scarcity Areas.
        Current Law
        MMA provided for an additional 5% in payments for certain 
     physicians in scarcity areas for the period January 1, 2005 
     through December 31, 2007. The Medicare, Medicaid, and SCHIP 
     Extension Act of 2007 (MMSEA) extended these payments through 
     June 30, 2008. The Secretary was required to calculate, 
     separately for practicing primary care physicians and 
     specialists, the ratios of such physicians to Medicare 
     beneficiaries in the county, rank each county (or equivalent 
     area) according to its ratio for primary care and specialists 
     separately, and then identify those scarcity areas with the 
     lowest ratios which collectively represented 20% of the total 
     Medicare beneficiary population in those areas. The list of 
     counties was to be revised no less often than once every 
     three years unless there were no new data. There would be no 
     administrative or judicial review of the designation of the 
     county or area as a scarcity area, the designation of an 
     individual physician's specialty, or the assignment of a 
     postal zip code to the county or other area. The listing of 
     counties appeared in Appendix I and Appendix J of the 2005 
     physician fee schedule update.
        Explanation of Provision
        The provision would extend the add-on payments through 
     December 31, 2009.
      Section 206. Revisions to the Work Geographic Adjustment 
         Under the Medicare Physician Fee Schedule.
       Current Law
        Medicare's physician fee schedule assigns relative values 
     to services that reflect physician work (i.e., the time, 
     skill, and intensity it takes to provide the service), 
     practice expenses, and malpractice costs. The relative values 
     are adjusted for geographic variations in costs. The adjusted 
     relative values are then converted into a dollar payment 
     amount by a conversion factor.
        The geographic adjustment factors are indices that reflect 
     the relative cost difference in a given area in comparison to 
     a national average. An area with costs above the national 
     average would have an index greater than 1.00 while an area 
     with costs below the average would have an index below 1.00. 
     The physician work geographic adjustment factor is based on a 
     sample of median hourly earnings in six professional 
     specialty occupational categories. Unlike the other 
     geographic adjustments, the work adjustment factor reflects 
     only one-quarter of the cost differences in an area. The 
     Secretary is required to periodically review and adjust the 
     geographic indices.
        MMA required the Secretary to increase the value of any 
     work geographic index that was below 1.00 to 1.00 for 
     services furnished on or after January 1, 2004 and before 
     January 1, 2007. TRHCA extended the provision for an 
     additional year, through December 31, 2008, and MMSEA 
     extended the provision for an additional six months, for 
     services provided before July 1, 2008.
        Explanation of Provision
        Subsection (a) would extend the 1.0 work floor through 
     December 31,2009. Subsection (b) would recognize the equality 
     of physician work in all geographic areas and eliminate 
     differing work index values by establishing a national value 
     of 1.0, effective 2010.
      Section 207. Revisions to the Practice Expense Geographic 
         Adjustment Under the Medicare Physician Fee Schedule.
        Current Law
        Medicare's physician fee schedule assigns relative values 
     to services that reflect physician work (i.e., the time, 
     skill, and intensity it takes to provide the service), 
     practice expenses, and malpractice costs. The relative values 
     are adjusted for geographic variations in costs. The adjusted 
     relative values are then converted into a dollar payment 
     amount by a conversion factor.
        The geographic adjustment factors are indices that reflect 
     the relative cost difference in a given area in comparison to 
     a national average. An area with costs above the national 
     average would have an index greater than 1.00 while an area 
     with costs below the average would have an index below 1.00. 
     The practice expense geographic adjustment is calculated by 
     measuring variations in employee wages, office rents, and 
     miscellaneous. The Secretary is required to periodically 
     review and adjust the geographic indices.
        Explanation of Provision
       Subsection (a) would establish a practice expense floor of 
     1.0 for 2009 by requiring the Secretary to increase the value 
     of any practice expense geographic index that was below 1.0 
     to 1.0 for services furnished on or after January 1, 2009 and 
     before January 1, 2010. Subsection (b) would reduce the 
     geographic adjustment for practice expense to 50 percent of 
     the current adjustment for employee wages and rent, effective 
     2010.
     Section 208. Extension of Treatment of Certain Physician 
         Pathology Services Under Medicare.
       Current Law
       BBA 97 specified that independent labs that had agreements 
     with hospitals on July 22, 1999, to bill directly for the 
     technical component of pathology services could continue to 
     do so in 2001 and 2002. The provision has been periodically 
     extended. TRHCA extended the provision through 2007, and 
     MMSEA further extended it through June 30, 2008.
       Explanation of Provision
       The provision would be extended through December 31, 2009.
     Section 209. Extension of Increased Medicare Payments for 
         Rural Ground Ambulance Services.
       Current Law
       Ambulance services are paid on the basis of a national fee 
     schedule, which is being phased in. The fee schedule 
     establishes seven categories of ground ambulance services and 
     two categories of air ambulance services. The payment for a 
     service equals a base rate for the level of service plus 
     payment for mileage. Geographic adjustments are made to a 
     portion of the base rate.
       Explanation of Provision
       The provision would provide for an increase in the rates 
     otherwise established for ground ambulance services of 5% in 
     rural areas for the period July 1, 2008-December 31, 2009.
     Sec. 210. Adding Hospital-Based Renal Dialysis Centers 
         (Including Satellites) As Originating Sites for Payment 
         of Telehealth Services.
       Current Law
       Medicare may cover a telehealth service for beneficiaries 
     who are located (i) in an area designated as a rural health 
     professional shortage area; (ii) in a county that is not 
     included in a Metropolitan Statistical Area; or (iii) at an 
     entity that participates in a federal telemedicine 
     demonstration project that has been approved by (or receives 
     funding from) the Secretary of Health and Human Services as 
     of December 31, 2000. If a beneficiary is located in those 
     areas, counties, or entities, then the beneficiary is 
     permitted to receive telemedicine at one of the following 
     sites: (1) a physician or practitioner's office; (ii) a 
     critical access hospital; (iii) a rural health clinic; (iv) a 
     federally qualified health center; or (v) a hospital.
       Explanation of Provision
       This provision would permit a hospital-based or critical 
     access hospital-based renal dialysis center (including 
     satellites) to serve as a telemedicine site. The provision 
     would be effective for services furnished on or after January 
     1, 2009.
     Section 211. Expansion of Telehealth Services to Skilled 
         Nursing Facilities.
       Current Law
       Medicare covers certain services including professional 
     consultations, office and other outpatient visits, individual 
     psychotherapy, pharmacological management, psychiatric 
     diagnostic interview examinations and end stage renal disease 
     related services delivered via an eligible telecommunications 
     system. The originating site (the location of the beneficiary 
     receiving the telehealth service) can be a physician or 
     practitioner's office, a critical access hospital, a rural 
     health clinic, a federally qualified health center, or a 
     hospital. The originating site must be in a rural health 
     professional shortage area or in a county that is not in a 
     metropolitan statistical area or at an entity that 
     participates in a specified federal telemedicine 
     demonstration project.
       Explanation of Provision
       The provision would permit otherwise qualifying skilled 
     nursing facilities to be the originating site for the 
     provision of covered telehealth services furnished on or 
     after January 1, 2009.
     Section 212. Rural Health Clinic Improvements.
       Current Law
       Most rural health clinics (RHCs) receive cost-based 
     reimbursement from Medicare, subject to per-visit payment 
     limits and certain productivity standards. Each year the 
     limit is increased by the percentage increase in the Medicare 
     Economic Index (MEI). For CY2007, the RHC upper payment limit 
     is $74.29 per visit.
       Explanation of Provision
       The provision would establish the RHC upper payment limit 
     at $92 per visit in 2009. The limit would be increased in 
     subsequent years by the limit established for the previous 
     year increased by the percentage increase in the MEI 
     applicable to primary care services.
     Section 213. Exemption for suppliers in small MSAs and rural 
         areas.
       Current Law
       The MMA established Medicare competitive bidding for 
     durable medical equipment, supplies, and other items. The 
     Secretary is required to establish competitive acquisition 
     areas, but has discretion to exempt rural areas and areas 
     with low population density within urban areas that are not 
     competitive, unless a significant national market exists 
     through mail order for a particular item or service. The 
     programs are required to be phased-in so that competition 
     under the programs occurs in 10 of the largest metropolitan 
     statistical areas (MSAs) beginning in 2007, 80 of the largest 
     MSAs in 2009, and remaining areas after 2009.
       Explanation of Provision
       The provision would require the Secretary to exempt rural 
     areas and small MSAs with a population of 600,000 or less. 
     Competitively bid prices would not apply to rural and small 
     MSAs exempted under this section. The provision would be 
     effective as if included in the MMA, other than for contracts 
     entered into pursuant to implementation of competitive 
     bidding prior to September 1, 2008.

[[Page S2163]]

     Section 214. Permitting Physician Assistants to Order Post-
         Hospital Extended Care Services and to Provide for 
         Recognition of Attending Physician Assistants as 
         Attending Physicians to Serve Hospice Patients.
       (a) Ordering Post-Hospital Extended Care Services.
       Current Law
       In a skilled nursing facility (SNF), Medicare law allows 
     physicians, as well as nurse practitioners and clinical nurse 
     specialists who do not have a direct or indirect employment 
     relationship with a SNF, but who are working in collaboration 
     with a physician, to certify the need for post-hospital 
     extended care services for purposes of Medicare payment. 
     Section 20.2.1 of Chapter 8 of the Medicare Benefit Policy 
     Manual defines post-hospital extended care services as 
     services provided as an extension of care for a condition for 
     which the individual received inpatient hospital services. 
     Extended care services are considered ``post-hospital'' if 
     they are initiated within 30 days after discharge from a 
     hospital stay that included at least three consecutive days 
     of medically necessary inpatient hospital care.
       Explanation of Provision
       The provision would allow a physician assistant who does 
     not have a direct or indirect employment relationship with a 
     SNF, but who is working in collaboration with a physician, to 
     certify the need for post-hospital extended care services for 
     Medicare payment purposes.
       (b) Recognition of Attending Physician Assistants as 
     Attending Physicians to Serve Hospice Patients.
       Current Law
       Under the Medicare program, hospice services may only be 
     provided to terminally ill individuals under a written plan 
     of care established and periodically reviewed by the 
     individual's attending physician and the medical director 
     (and by the interdisciplinary group of the hospice program). 
     For purposes of a hospice written plan of care, Medicare 
     defines an attending physician as a physician or nurse 
     practitioner who may be employed by a hospice program and who 
     the individual identifies as having the most significant role 
     in the determination and delivery of medical care to the 
     individual at the time the individual makes an election to 
     receive hospice care.
       For an individual to be eligible for Medicare-covered 
     hospice services, the individual's attending physician (not 
     including a nurse practitioner) and the medical director (or 
     physician member of the interdisciplinary group of the 
     hospice program) must each certify in writing that the 
     individual is terminally ill at the beginning of the first 
     90-day period of hospice.
       Explanation of Provision
       For purposes of a hospice written plan of care, the 
     provision would include a physician assistant in the 
     definition of an attending physician. The provision would 
     continue to exclude physician assistants from the authority 
     to certify an individual as terminally ill.
       Both provisions would apply to items and services furnished 
     on or after January 1, 2009.
                                 ______