[Congressional Record Volume 155, Number 52 (Thursday, March 26, 2009)]
[Senate]
[Pages S3899-S3900]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. FEINGOLD (for himself and Ms. Collins):
  S. 712. A bill to amend title XVIII of the Social Security Act to 
improve the Medicare program for beneficiaries residing in rural areas; 
to the Committee on Finance.
  Mr. FEINGOLD. Mr. President, today, along with my colleague Senator 
Collins from Maine, I am introducing legislation to address the needs 
of the nearly one-quarter of all Medicare beneficiaries who live in 
rural America. These beneficiaries are systematically disadvantaged in 
the Medicare program. The beauty of Medicare is its equity, its 
universality, and its accessibility. But we have compromised these 
values by stratifying payments, by under-representing rural voices on 
the Medicare Payment Advisory Commission, and by continuing to use 
obsolete payment data that hurts rural America.
  First, we must stop indexing physician payments for work based on 
geographic differences. Rural areas already have a hard enough time 
recruiting and retaining the Nation's top talent. Currently, even 
though 25 percent of Medicare beneficiaries live in rural areas, only 
10 percent of the nation's physicians serve them. Lower payments to 
doctors in these areas only perpetuate this dangerous shortage of 
medical expertise. We should not be discouraging medical school 
graduates from moving to underserved rural areas by continuing to offer 
sub-par pay--in fact, we should be providing incentives to encourage 
them to work in underserved areas. My legislation proposes a project to 
help rural facilities to host educators and clinical practitioners in 
clinical rotations.
  Lack of dollars to rural health facilities has also prevented 
communities from investing in vital information technology. The 
Institute of Medicine published a report in 2005 detailing the ways in 
which health IT could assist isolated communities. For example, since 
rural physicians tend to be generalists rather than specialists, 
virtual libraries within physician offices would provide both doctors 
and patients with a wider and deeper source of information at their 
fingertips. Rural residents can also be quite far from health 
facilities, so technology that allows emergency room physicians to 
communicate with EMS workers in an ambulance can help patients receive 
life-saving treatment before they physically reach the hospital. These 
kinds of technologies will improve both the quality and efficiency of 
care given in rural areas. My legislation offers funding for quality 
improvement demonstration projects, to allow isolated communities to 
invest in this otherwise out of reach technology.
  Lastly, this legislation will end the disproportionately low 
representation of rural interests on the Medicare Payment Advisory 
Commission. This lack of representation has resulted in policies that 
hurt rural communities. Those policies have hurt--and continue to 
hurt--the people of my State of Wisconsin, and they hurt my colleague 
Senator Collins' constituents as well. For every dollar that Medicare 
spends on the average beneficiary in the average state in this country, 
Medicare spends only 82 cents on a beneficiary in Wisconsin. In Maine, 
Medicare spends only 80 cents per dollar it spends on the average 
beneficiary.
  How is this the case, if beneficiaries in Wisconsin and in Maine pay 
the same payroll taxes as beneficiaries in other states? Because the 
distribution of Medicare dollars among the 50 States is grossly unfair 
to Wisconsin, and to much of the Upper Midwest. Wisconsinites pay 
payroll taxes just like every American taxpayer, but the Medicare funds 
we get in return are lower than those received in many other States.
  With the guidance and support of people across my State who are 
fighting for Medicare fairness, I am introducing this legislation to 
address Medicare's discrimination against Wisconsin's seniors and 
health care providers. My bill will decrease some of the inequitable 
payments that harm rural areas. It will provide rural areas the help 
they need to grow crucial health information technology infrastructure. 
It will offer the necessary incentives to help attract the Nation's top 
medical talent to underserved rural areas. It will mandate rural 
representation on the Medicare Payment Advisory Commission. Rural 
seniors are already underserved in their communities; they should not 
be underrepresented in Washington as well.
  Rural Americans have worked hard and paid into the Medicare program 
all their lives. In return, they deserve full access to the same 
benefits as seniors throughout the country: their choice of highly 
skilled physicians, use of the latest technologies, and a strong voice 
representing their needs in Medicare policy.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                 S. 712

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

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Rural 
     Medicare Equity Act of 2009''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; table of contents.
Sec. 2. Elimination of geographic physician work adjustment factor from 
              geographic indices used to adjust payments under the 
              physician fee schedule.
Sec. 3. Clinical rotation demonstration project.
Sec. 4. Medicare rural health care quality improvement demonstration 
              projects.
Sec. 5. Ensuring proportional representation of interests of rural 
              areas on the Medicare Payment Advisory Commission.
Sec. 6. Implementation of GAO recommendations regarding geographic 
              adjustment indices under the Medicare physician fee 
              schedule.

     SEC. 2. ELIMINATION OF GEOGRAPHIC PHYSICIAN WORK ADJUSTMENT 
                   FACTOR FROM GEOGRAPHIC INDICES USED TO ADJUST 
                   PAYMENTS UNDER THE PHYSICIAN FEE SCHEDULE.

       (a) Findings.--Congress finds the following:
       (1) Variations in the geographic physician work adjustment 
     factors under section 1848(e) of the Social Security Act (42 
     U.S.C. 1395w-4(e)) result in inequity between localities in 
     payments under the Medicare physician fee schedule.
       (2) Beneficiaries under the Medicare program that reside in 
     areas where such adjustment factors are high have relatively 
     more access to services that are paid based on such fee 
     schedule.
       (3) There are a number of studies indicating that the 
     market for health care professionals has become nationalized 
     and historically low labor costs in rural and small urban 
     areas have disappeared.
       (4) Elimination of the adjustment factors described in 
     paragraph (1) would equalize the reimbursement rate for 
     services reimbursed under the Medicare physician fee schedule 
     while remaining budget-neutral.
       (b) Elimination.--Section 1848(e) of the Social Security 
     Act (42 U.S.C. 1395w-4(e)) is amended--
       (1) in paragraph (1)(A)(iii), by striking ``an index'' and 
     inserting ``for services provided before January 1, 2010, an 
     index''; and

[[Page S3900]]

       (2) in paragraph (2), by inserting ``, for services 
     provided before January 1, 2010,'' after ``paragraph (4)), 
     and''.
       (c) Budget Neutrality Adjustment for Elimination of 
     Geographic Physician Work Adjustment Factor.--Section 1848(d) 
     of the Social Security Act (42 U.S.C. 1395w-4(d)) is 
     amended--
       (1) in paragraph (1)(A), by striking ``The conversion'' and 
     inserting ``Subject to paragraph (10), the conversion''; and
       (2) by adding at the end the following new paragraph:
       ``(10) Budget neutrality adjustment for elimination of 
     geographic physician work adjustment factor.--Before applying 
     an update for a year under this subsection, the Secretary 
     shall (if necessary) provide for an adjustment to the 
     conversion factor for that year to ensure that the aggregate 
     payments under this part in that year shall be equal to 
     aggregate payments that would have been made under such part 
     in that year if the amendments made by section 2(b) of the 
     Rural Medicare Equity Act of 2009 had not been enacted.''.

     SEC. 3. CLINICAL ROTATION DEMONSTRATION PROJECT.

       (a) Establishment.--Not later than 6 months after the date 
     of enactment of this Act, the Secretary shall establish a 
     demonstration project that provides for demonstration grants 
     designed to provide financial or other incentives to 
     hospitals to attract educators and clinical practitioners so 
     that hospitals that serve beneficiaries under the Medicare 
     program under title XVIII of the Social Security Act (42 
     U.S.C. 1395 et seq.) who are residents of underserved areas 
     may host clinical rotations.
       (b) Duration of Project.--The demonstration project shall 
     be conducted over a 5-year period.
       (c) Waiver.--The Secretary shall waive such provisions of 
     titles XI and XVIII of the Social Security Act (42 U.S.C. 
     1301 et seq. and 1395 et seq.) as may be necessary to conduct 
     the demonstration project under this section.
       (d) Reports.--The Secretary shall submit to the appropriate 
     committees of Congress interim reports on the demonstration 
     project and a final report on such project within 6 months 
     after the conclusion of the project, together with 
     recommendations for such legislation or administrative action 
     as the Secretary determines to be appropriate.
       (e) Funding.--Out of any funds in the Treasury not 
     otherwise appropriated, there are appropriated to the 
     Secretary to carry out this section, $20,000,000.
       (f) Definitions.--In this section:
       (1) Hospital.--The term ``hospital'' means a subsection (d) 
     hospital (as defined in section 1886(d)(1)(B) of the Social 
     Security Act (42 U.S.C. 1395ww(d)(1)(B)) that had indirect or 
     direct costs of medical education during the most recent cost 
     reporting period preceding the date of enactment of this Act.
       (2) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (3) Underserved area.--The term ``underserved area'' means 
     such medically underserved urban areas and medically 
     underserved rural areas as the Secretary may specify.

     SEC. 4. MEDICARE RURAL HEALTH CARE QUALITY IMPROVEMENT 
                   DEMONSTRATION PROJECTS.

       (a) Establishment.--
       (1) In general.--Not later than 6 months after the date of 
     enactment of this Act, the Secretary of Health and Human 
     Services (in this section referred to as the ``Secretary'') 
     shall establish not more that 10 demonstration projects to 
     provide for improvements, as recommended by the Institute of 
     Medicine, in the quality of health care provided to 
     individuals residing in rural areas.
       (2) Activities.--Activities under the projects may include 
     public health surveillance, emergency room videoconferencing, 
     virtual libraries, telemedicine, electronic health records, 
     data exchange networks, and any other activities determined 
     appropriate by the Secretary.
       (3) Consultation.--The Secretary shall consult with the 
     Office of Rural Health Policy of the Health Resources and 
     Services Administration, the Agency for Healthcare Research 
     and Quality, and the Centers for Medicare & Medicaid Services 
     in carrying out the provisions of this section.
       (b) Duration.--Each demonstration project under this 
     section shall be conducted over a 4-year period.
       (c) Demonstration Project Sites.--The Secretary shall 
     ensure that the demonstration projects under this section are 
     conducted at a variety of sites representing the diversity of 
     rural communities in the United States.
       (d) Waiver.--The Secretary shall waive such provisions of 
     titles XI and XVIII of the Social Security Act (42 U.S.C. 
     1301 et seq. and 1395 et seq.) as may be necessary to conduct 
     the demonstration projects under this section.
       (e) Independent Evaluation.--The Secretary shall enter into 
     an arrangement with an entity that has experience working 
     directly with rural health systems for the conduct of an 
     independent evaluation of the demonstration projects 
     conducted under this section.
       (f) Reports.--The Secretary shall submit to the appropriate 
     committees of Congress interim reports on each demonstration 
     project and a final report on such project within 6 months 
     after the conclusion of the project. Such reports shall 
     include recommendations regarding the expansion of the 
     project to other areas and recommendations for such other 
     legislative or administrative action as the Secretary 
     determines appropriate.
       (g) Funding.--Out of any funds in the Treasury not 
     otherwise appropriated, there are appropriated to the 
     Secretary to carry out this section, $50,000,000.

     SEC. 5. ENSURING PROPORTIONAL REPRESENTATION OF INTERESTS OF 
                   RURAL AREAS ON THE MEDICARE PAYMENT ADVISORY 
                   COMMISSION.

       (a) In General.--Section 1805(c)(2) of the Social Security 
     Act (42 U.S.C. 1395b-6(c)(2)) is amended--
       (1) in subparagraph (A), by inserting ``consistent with 
     subparagraph (E)'' after ``rural representatives''; and
       (2) by adding at the end the following new subparagraph:
       ``(E) Proportional representation of interests of rural 
     areas.--In order to provide a balance between urban and rural 
     representatives under subparagraph (A), the proportion of 
     members who represent the interests of health care providers 
     and Medicare beneficiaries located in rural areas shall be no 
     less than the proportion, of the total number of Medicare 
     beneficiaries, who reside in rural areas.''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply with respect to appointments made to the Medicare 
     Payment Advisory Commission after the date of the enactment 
     of this Act.

     SEC. 6. IMPLEMENTATION OF GAO RECOMMENDATIONS REGARDING 
                   GEOGRAPHIC ADJUSTMENT INDICES UNDER THE 
                   MEDICARE PHYSICIAN FEE SCHEDULE.

       Not later than 180 days after the date of enactment of this 
     Act, the Secretary of Health and Human Services shall 
     implement the recommendations contained in the March 2005 GAO 
     report 05-119 entitled ``Medicare Physician Fees: Geographic 
     Adjustment Indices are Valid in Design, but Data and Methods 
     Need Refinement.''.
                                 ______