[Congressional Record Volume 160, Number 128 (Tuesday, September 9, 2014)]
[House]
[Pages H7339-H7341]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
EXTENSION OF ENFORCEMENT INSTRUCTION FOR OUTPATIENT THERAPEUTIC
SERVICES IN CRITICAL ACCESS AND SMALL RURAL HOSPITALS THROUGH 2014
Mr. BURGESS. Mr. Speaker, I move to suspend the rules and pass the
bill (H.R. 4067) to provide for the extension of the enforcement
instruction on supervision requirements for outpatient therapeutic
services in critical access and small rural hospitals through 2014.
The Clerk read the title of the bill.
The text of the bill is as follows:
H.R. 4067
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. EXTENSION OF ENFORCEMENT INSTRUCTION ON
SUPERVISION REQUIREMENTS FOR OUTPATIENT
THERAPEUTIC SERVICES IN CRITICAL ACCESS AND
SMALL RURAL HOSPITALS THROUGH 2014.
The Secretary of Health and Human Services shall continue
to apply through calendar year 2014 the enforcement
instruction described in the notice of the Centers for
Medicare & Medicaid Services entitled ``Enforcement
Instruction on Supervision Requirements for Outpatient
Therapeutic Services in Critical Access and Small Rural
Hospitals for CY 2013'', dated November 1, 2012 (providing
for an exception to the restatement and clarification under
the final rulemaking changes to the Medicare hospital
outpatient prospective payment system and calendar year 2009
payment rates (published in the Federal Register on November
18, 2008, 73 Fed. Reg. 68702 through 68704) with respect to
requirements for direct supervision by physicians for
therapeutic hospital outpatient services).
The SPEAKER pro tempore (Mr. Wenstrup). Pursuant to the rule, the
gentleman from Texas (Mr. Burgess) and the gentleman from New Jersey
(Mr. Pallone) each will control 20 minutes.
The Chair recognizes the gentleman from Texas.
General Leave
Mr. BURGESS. Mr. Speaker, I ask unanimous consent that all Members
may have 5 legislative days in which to revise and extend their remarks
and insert extraneous materials in the Record on the bill.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from Texas?
There was no objection.
Mr. BURGESS. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, I rise today in support of H.R. 4067, which provides for
the extension of the enforcement instruction on supervision
requirements for outpatient therapeutic services in critical access and
small rural hospitals through 2014. This was a bill introduced by
Congresswoman Jenkins of Kansas.
Mr. Speaker, this is a commonsense solution to a problem that has the
potential to limit or delay access to health care for America's seniors
in rural communities.
The bill would delay until the end of the year enforcement of
supervision requirements for outpatient therapeutic services in
critical access hospitals. This delay would give the Centers for
Medicaid and Medicare Services and provider groups time to identify
which services will eventually fall under the requirement.
I ask my colleagues to support this important piece of legislation
and reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, H.R. 4067 would suspend current enforcement of Medicare
rules relating to physician supervision of staff in rural and critical
access hospitals for certain outpatient therapeutic services.
Enforcement of these rules was delayed from 2009 through 2013, but
began again in January of this
[[Page H7340]]
year. My understanding is that there has not been any issue with
enforcement to date and that the Medicare program has not taken any
action against a facility for failure to meet physician supervision
standards since January. But as this bill did not follow regular order
through the committee process, we have not had an opportunity to hear
from interested parties about the issue and bring to light what the
implications might be of an additional delay. Frankly, the likely
result of such a bill would be confusion for hospitals.
Medicare's physician supervision requirement places a premium on
patient safety, and I understand that rural facilities sometimes face
difficulty in securing staffing. However, it seems reasonable to me
that outpatient clinics that provide services to Medicare beneficiaries
should meet some basic standards for having supervisory physicians
available if an emergency arises--for example, when patients are
receiving potentially lethal doses of chemotherapy medication.
Meanwhile, there are countless public health issues that the
committee could productively devote its time to, such as looking into
the recent outbreak of Ebola, the effects of e-cigarettes, or perhaps
the decline of routine vaccinations that has led to an explosion of
preventable illnesses like measles. Rather, the bill before us seems to
be only responsive to the fears of certain health care providers that
someone could file a complaint that a facility was allowing staff to
practice medicine on Medicare patients without any supervision. But
isn't that the kind of thing that we might be concerned about--and want
a whistleblower to report? Yet, that is just what this bill would
prevent.
It remains unclear to me why an additional delay of this Medicare
policy is needed. Simply saying that the Senate passed this bill by
unanimous consent in February is not sufficient justification--and
makes even less sense now that the calendar year is nearly over.
So, Mr. Speaker, we should be finding time to address the real and
pressing public issues facing our Nation rather than those that merely
cause an inconvenience or anxiety for certain health care providers.
I reserve the balance of my time at this time, Mr. Speaker.
Mr. BURGESS. Mr. Speaker, at this time, I would like to yield 3
minutes to the gentlewoman from Kansas, Congresswoman Jenkins, the
author of the bill.
Ms. JENKINS. Mr. Speaker, I thank the gentleman for yielding.
Mr. Speaker, I rise today in support of H.R. 4067, a bill to provide
for the extension of the enforcement instruction on supervision
requirements for outpatient therapeutic services in critical access and
small rural hospitals through 2014.
I was proud to introduce this legislation in February, and I am
pleased that Chairman Upton and the Energy and Commerce Committee
reported it favorably and brought it to the House floor today.
The 83 critical access hospitals in Kansas are the lifeblood of our
rural communities, and one of the many challenges these communities
face is access to health care. The presence of a facility such as a
critical access hospital in a community could be the deciding factor in
whether or not the next generation of children decide to raise their
family in their hometown, or perhaps whether or not a business decides
to locate there.
The Centers for Medicare and Medicaid Services made a decision on
January 1 of this year that will make it more difficult for these rural
hospitals to serve their communities. CMS informed these hospitals that
physicians are now required to directly supervise outpatient services,
such as drawing blood and activity therapy. This is a change in policy
that will put a strain on providers while providing no quality
improvements for the patients they serve.
This bill will correct that problem by reinstating the moratorium on
enforcement of these unnecessary regulations. It has broad bipartisan
support in Congress and the support of key stakeholders.
Mr. Speaker, I insert in the Record letters of support for H.R. 4067
from the American Hospital Association, the National Rural Health
Association, the Kansas Hospital Association, and Anderson County
Hospital, which is a critical access hospital in Garnett, Kansas, one
of 1,300 nationwide.
American Hospital Association,
Washington, DC, May 19, 2014.
Hon. Lynn Jenkins,
U.S. House of Representatives,
Washington, DC.
Dear Representative Jenkins: On behalf of our nearly 5,000
member hospitals, health systems and other health care
organizations, and our 43,000 individual members, the
American Hospital Association is pleased to support H.R. 4067
to provide for the extension of the enforcement instruction
on supervision requirements for outpatient therapeutic
services in critical access and small rural hospitals through
2014.
Approximately 46 million Americans live in rural areas and
depend on these hospitals as an important, and often the
only, source of care. Critical access and small rural
hospitals face unique challenges because of their remote
geographic location, scarce workforce, physician shortages
and constrained financial resources with limited access to
capital.
Your bill attempts to address one of these unique
challenges--the issue of direct supervision for outpatient
therapeutic services. In the 2009 outpatient prospective
payment system (PPS) final rule, the Centers for Medicare &
Medicaid Services (CMS) mandated a new policy for ``direct
supervision'' of outpatient therapeutic services that
hospitals and physicians recognized as a burdensome and
unnecessary policy change. CMS's policy required that a
supervising physician be physically present in the department
at all times when Medicare beneficiaries receive outpatient
therapeutic services. Hospital outpatient therapeutic
services have always been provided by licensed, skilled
professionals under the overall direction of a physician and
with the assurance of rapid assistance from a team of
caregivers, including a physician, should an unforeseen event
occur. While hospitals recognize the need for direct
supervision for certain outpatient services that pose high
risk or are very complex, CMS's policy generally applies to
even the lowest risk services. Your bill would provide a
needed delay in enforcement of the direct supervision policy
through 2014 for critical access and small rural hospitals
with fewer than 100 beds.
Again, we are pleased to support this bill and applaud your
commitment to America's rural hospitals and health care
providers.
Sincerely,
Rick Pollack,
Executive Vice President.
____
National Rural Health Association,
Washington, DC, July 28, 2014.
Hon. Lynn Jenkins,
U.S. House of Representatives,
Washington, DC.
Dear Representative Jenkins: The National Rural Health
Association applauds your leadership in introducing H.R.
4067. This bill will provide for the extension of the
enforcement instruction on supervision requirements for
outpatient therapeutic services in critical access and small
rural hospitals through 2014.
NRHA is a national nonprofit membership organization with
more than 21,000 members. Our mission is to provide
leadership on rural health issues. NRHA membership is made up
of a diverse collection of individuals and organizations, all
of whom share the common bond of ensuring all rural
communities have access to quality, affordable health care.
NRHA supports your efforts to put a moratorium on the
physician supervision of outpatient services requirement at
CAHs and small rural hospitals until the end of 2014. If you
have further questions, please do not hesitate to call Erin
Mahn on my government affairs staff at 202-639-0550 or by e-
mail [email protected].
We thank you for sponsoring this important legislation. You
are truly a stalwart champion for rural America.
Sincerely,
Alan Morgan, CEO,
National Rural Health Association.
____
Kansas Hospital Association,
July 30, 2014.
Hon. Lynn Jenkins,
U.S. House of Representatives,
Washington, DC.
Dear Representative Jenkins: On behalf of our 128 member
hospitals, the Kansas Hospital Association is pleased to
support H.R. 4067. This important legislation provides a one-
year extension on the non-enforcement of the direct
supervision policy for therapeutic services provided in
critical access hospitals and rural hospitals with 100 or few
beds.
Effective January 1, 2014, the Centers for Medicare and
Medicaid Services' decided to not extend its policy to not
enforce the direct supervision policy for therapeutic
services provided in CAHs and rural hospitals with less than
100 beds. This new policy of enforcement on CAHs and small
rural hospitals may limit the hospital's ability to provide
their outpatients with basic therapeutic services. These are
services that have been provided safely in rural communities
throughout the years. H.R. 4067 would provide a much needed
delay in enforcement of the direct supervision policy for
therapeutic services through 2014.
[[Page H7341]]
We are pleased to support your legislation and appreciate
your commitment to Kansas hospitals.
Sincerely,
Tom Bell,
President and CEO.
____
Anderson County Hospital,
Garnett, KS, May 18, 2014.
Hon. Lynn Jenkins,
Longworth HOB,
Washington, DC.
Dear Representative Jenkins: As you know, I have
communicated with you in the past about the consequences of
the physician supervision requirements that were included in
the Outpatient Prospective Payment Final Rule (OPPS) for
2014, as published in the Federal Register on December 10,
2013. These rules will have an unintended impact on the
provision of outpatient therapeutic services in Critical
Access Hospitals and to patient care in rural settings.
Anderson County Hospital (ACH) is a Critical Access
Hospital (CAH) located in Anderson County, Kansas. Since
1994, we have operated a hospital-based rural health clinical
staff by employed physicians and mid-levels, the only primary
care clinic currently operating in our county. Additionally,
our emergency room is staffed with physicians and mid-level
practitioners 24/7. For the past two years, ACH has continued
to struggle with how to meet the supervision requirements.
Initially, it was that we would use a combination of ER and
primary care providers to provide the direct supervision; if
one of them was not immediately available, we would provide
the service and not bill for it. Please keep in mind that
while direct supervision does not require the provider to be
in the room with the patient, they do need to be immediately
available. The location of both our clinic and ER providers
meet this requirement.
In a clarification received from CMS in January, they
further instructed us that hospital employed practitioners in
hospital-based rural health clinics, even those that are
located on the same campus and adjacent to the hospital,
cannot meet the direct supervision requirement for outpatient
therapeutic services. This makes it nearly impossible for us
to meet the supervision requirements. Although we have a full
complement of staff that could provide direct supervision,
the ability to use them to provide services is not in
question.
These requirements present a significant hardship and
expense to rural hospitals and is in direct conflict to the
Conditions of Participation for CAHs. It will limit the
ability to provide our outpatients with basic therapeutic
services such as IV infusions, initial antibiotic therapy,
emergency cardiac drugs and blood transfusions. These are
services that have been provided in rural communities safely
throughout the years, and will ultimately impact access to
important services for the patients and communities we serve.
For those CAHs who have emergency room coverage provided by
their own employed physicians, the requirements are even more
difficult to meet. Since CAH conditions of participation say
that the physician does not need to be in the ER, must
respond to the emergency room within 30 minutes, most
hospitals have protocols that allow a registered nurse to
begin life saving IV therapy on a verbal order from the
provider. The physician supervision requirements seem to
contradict this.
The strangest part of the interpretation of these rules is
that they only impact payment, not the actual provision of
the services, so this is not really an issue of quality or
patient safety. We are told that we are able to provide the
services when needed, but unless there is documented direct
supervision, we are not able to bill or be paid for the
services provided.
Because of the implications of these rules and their
interpretation on the provision of outpatient therapeutic
services at our hospital and many others in rural settings, I
ask for your support of H.R. 4067, which would put a hold on
enforcement of the supervision requirements through 2014.
This additional time would hopefully allow the opportunity to
re-visit the many issues raised by these rules and would go a
long way in alleviating the consequences of the policy that
I've outlined in this letter. We must keep in mind that the
intent of the CAH program was to provide access to quality
patient care in rural communities. A delay in enforcement
would help us refocus on that goal.
Sincerely,
Dennis A. Hachenberg, FACHE,
Chief Executive Officer,
Anderson County Hospital.
Ms. JENKINS. Mr. Speaker, I was born and raised in a small town in
Kansas, and I feel strongly that folks in rural communities deserve
access to quality health care.
I urge my colleagues to support this legislation, and I am hopeful
that the Senate will soon act on it so that it may become law.
Mr. PALLONE. Mr. Speaker, I have no other speakers at this time, and
so I yield back the balance of my time.
Mr. BURGESS. Mr. Speaker, I urge my colleagues to support the bill,
and yield back the balance of my time.
Mr. WAXMAN. Mr. Speaker, H.R. 4067, reinstates a four month delay in
the enforcement of the current Medicare rules relating to physician
supervision of staff who administer certain therapeutic services in
rural and critical access hospitals.
The Medicare physician supervision requirement protects patients by
ensuring that Medicare beneficiaries have access to someone capable of
dealing with unforeseen emergencies. While I understand that rural
healthcare providers often have difficulty acquiring adequate staffing,
we should not place greater value on their convenience than on the
safety of Medicare beneficiaries.
Reinstating a delay of these requirements until the end of the year
only potentially confuses healthcare providers and lowers the bar on
patient safety that Medicare has put in place.
The SPEAKER pro tempore. The question is on the motion offered by the
gentleman from Texas (Mr. Burgess) that the House suspend the rules and
pass the bill, H.R. 4067.
The question was taken; and (two-thirds being in the affirmative) the
rules were suspended and the bill was passed.
A motion to reconsider was laid on the table.
____________________