[Congressional Record (Bound Edition), Volume 145 (1999), Part 16]
[Senate]
[Pages 22408-22414]
[From the U.S. Government Publishing Office, www.gpo.gov]




          STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS

      By Mr. SPECTER:
  S. 1623. A bill to select a National Health Museum site; to the 
Committee on Governmental Affairs.


               national health museum site selection act

  Mr. SPECTER. Mr. President, I ask unanimous consent that the text of 
the bill be printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                S. 1623

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

     SECTION 1. NATIONAL HEALTH MUSEUM PROPERTY.

       (a) Short Title and Purpose.--
       (1) Short title.--This section may be cited as the 
     ``National Health Museum Site Selection Act''.
       (2) Purpose.--The purpose of this section is to further 
     section 703 of the National Health Museum Development Act (20 
     U.S.C. 50 note; Public Law 105-78), which provides that the 
     National Health Museum shall be located on or near the Mall 
     on land owned by the Federal Government or the District of 
     Columbia.
       (b) Definitions.--In this section:
       (1) Administrator.--The term ``Administrator'' means the 
     Administrator of General Services.
       (2) Museum.--The term ``Museum'' means the National Health 
     Museum, Inc., a District of Columbia nonprofit corporation 
     exempt from Federal income taxation under section 501(c)(3) 
     of the Internal Revenue Code of 1986.
       (3) Property.--The term ``property'' means--
       (A) a parcel of land identified as Lot 24 and a closed 
     interior alley in Square 579 in the District of Columbia, 
     generally bounded by 2nd, 3rd, C, and D Streets, S.W.; and
       (B) all improvements on and appurtenances to the land and 
     alley.
       (c) Conveyance of Property.--
       (1) In general.--The Administrator shall convey to the 
     Museum all rights, title, and interest of the United States 
     in and to the property.
       (2) Purpose of conveyance.--The purpose of the conveyance 
     is to provide a site for the construction and operation of a 
     new building to serve as the National Health Museum, 
     including associated office, educational, conference center, 
     visitor and community services, and other space and 
     facilities appropriate to promote knowledge and understanding 
     of health issues.
       (3) Date of conveyance.--
       (A) Notification.--Not later than 3 years after the date of 
     enactment of this Act, the Museum shall notify the 
     Administrator in writing of the date on which the Museum will 
     accept conveyance of the property.
       (B) Date.--The date of conveyance shall be--
       (i) not less than 270 days and not more than 1 year after 
     the date of the notice; but
       (ii) not earlier than April 1, 2001, unless the 
     Administrator and the Museum agree to an earlier date.
       (C) Effect of failure to notify.--If the Museum fails to 
     provide the notice to the Administrator by the date described 
     in subparagraph (A), the Museum shall have no further right 
     to the property.
       (4) Quitclaim deed.--The property shall be conveyed to the 
     Museum vacant and by quitclaim deed.
       (5) Purchase price.--
       (A) In general.--The purchase price for the property shall 
     be the fair market value of the property as of the date of 
     enactment of this Act.
       (B) Timing; appraisers.--The determination of fair market 
     value shall be made not later than 180 days after the date of 
     enactment of this Act by qualified appraisers jointly 
     selected by the Administrator and the Museum.
       (D) Report to congress.--Promptly upon the determination of 
     the purchase price, and in any event at least sixty days in 
     advance of the conveyance of the property, the Administrator 
     shall report to Congress as to the purchase price.
       (E) Deposit of purchase price.--The Administrator shall 
     deposit the purchase price into the Federal Buildings Fund 
     established by section 210(f) of the Federal Property and 
     Administrative Services Act of 1949 (40 U.S.C. 490(f)).
       (d) Reversionary Interest in the United States.--
       (1) In general.--The property shall revert to the United 
     States if--
       (A) during the 50-year period beginning on the date of 
     conveyance of the property, the property is used for a 
     purpose not authorized by subsection (c)(2);
       (B) during the 3-year period beginning on the date of 
     conveyance of the property, the Museum does not commence 
     construction on the property, other than for a reason not 
     within the control of the Museum; or
       (C) the Museum ceases to be exempt from Federal income 
     taxation as an organization described in section 501(c)(3) of 
     the Internal Revenue Code of 1986.
       (2) Repayment.--If the property reverts to the United 
     States, the United States shall repay the Museum the full 
     purchase price for the property, without interest.
       (e) Authority of Museum Over Property.--The Museum may--
       (1) demolish or renovate any existing or future improvement 
     on the property;
       (2) build, own, operate, and maintain new improvements on 
     the property;
       (3) finance and mortgage the property on customary terms 
     and conditions; and
       (4) manage the property in furtherance of this section.
       (f) Land Use Approvals.--
       (1) Effect on other authority.--Nothing in this section 
     shall be construed to limit the authority of the National 
     Capital Planning Commission or the Commission of Fine Arts.
       (2) Cooperation concerning zoning.--
       (A) In general.--The United States shall cooperate with the 
     Museum with respect to any zoning or other matter relating 
     to--
       (i) the development or improvement of the property; or
       (ii) the demolition of any improvement on the property as 
     of the date of enactment of this Act.
       (B) Zoning applications.--Cooperation under subparagraph 
     (A) shall include making, joining in, or consenting to any 
     application required to facilitate the zoning of the 
     property.
       (g) Environmental Hazards.--Costs of remediation of any 
     environmental hazards existing on the property, including all 
     asbestos-containing materials, shall be borne by the United 
     States. Environmental remediation shall commence immediately 
     upon the vacancy of the building and shall be completed not 
     later than 270 days from the date of the notice to the 
     Administrator described in subsection (c)(3)(A).
       (h) Reports.--Following the date of enactment of this Act 
     and ending on the date that the National Health Museum opens 
     to the public, the Museum shall submit annual reports to the 
     Administrator and Congress, regarding the status of planning, 
     development, and construction of the National Health Museum.
                                 ______
                                 

                             By Mr. WARNER:

  S. 1624. A bill to authorize the Secretary of Transportation to issue 
a certificate of documentation with appropriate endorsement for 
employment in the coastwise trade for the vessel Norfolk; to the 
Committee on Commerce, Science, and Transportation.


        certificate of documentation for the vessel ``norfolk''

  Mr. WARNER. Mr. President, I ask unanimous consent that the text of 
the bill be printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                S. 1624

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

     SECTION 1. CERTIFICATE OF DOCUMENTATION.

       Notwithstanding section 27 of the Merchant Marine Act, 1920 
     (46 U.S.C. App. 883), section 8 of the Act of June 19, 1886 
     (24 Stat. 81, chapter 421; 46 U.S.C. App. 289), and section 
     12106 of title 46, United States Code, the Secretary of 
     Transportation may issue a certificate of documentation with 
     appropriate endorsement for employment in the coastwise trade 
     for the vessel NORFOLK, United States official number 
     1077852.
                                 ______
                                 
      By Ms. SNOWE:
  S. 1625. A bill to amend title XVIII of the Social Security Act to 
provide for a special reclassification rule for certain old agencies as 
new agencies under the home health interim payment system; to the 
Committee on Finance.

[[Page 22409]]




                       medicare home health care

 Ms. SNOWE. Mr. President, I rise today to offer legislation 
that will remedy a problem facing one of Maine's home health agencies--
Home Health & Hospice of St. Joseph, in Bangor, Maine. This bill would 
reclassify Home Health & Hospice of St. Joseph as a ``new agency'' 
under the Medicare Home Health Interim Payment System, allowing it a 
higher per-beneficiary rate.
  When Congress passed the Balanced Budget Act, the intention was to 
modestly control the dramatic growth rate of home health care agencies. 
But the broad financing constraints and administrative regulations 
codified in the Balanced Budget Act have had unintended consequences. 
Almost every week I hear concerns from home care agencies in Maine 
about the implementation of regulations and restrictions on these 
agencies.
  Since enactment of the Balanced Budget Act, many of our home 
healthcare agencies have found themselves in a position of financial 
insolvency. Nationwide, more than 2,000 agencies have closed since 
BBA's passage. The State of Maine had 90 Medicare/Medicaid certified 
home health care agencies in the beginning of 1998. By the beginning of 
1999, 16 of those agencies had closed.
  At the time of the BBA's enactment, the Congressional Budget Office 
expected home health care expenditures to drop by $75 billion over ten 
years. In March of this year, CBO examined the Medicare program 
expenditures of the home health agencies and increased the expected 
savings by $56 billion--a three-quarter increase over the same ten 
years!
  As a component of the general funding reductions enacted by the 
Balanced Budget Act, the law created detailed regulations in 
determining agency per-beneficiary payment limits. These regulations 
have had several unforeseen and unintended consequences when applied to 
real-life agencies.
  Home Health & Hospice of St. Joseph serves over 700 patients in 
Bangor, Maine and the surrounding area. Under the BBA, per-patient cost 
reimbursement is based solely on cost reporting ending in fiscal year 
1994. Unfortunately for Home Health & Hospice of St. Joseph--an 
established and vital component of Bangor's health care system--fiscal 
year 1994 was an unprecedented period of clinical and financial 
upheaval. As a result of these problems, the agency's per-patient 
reimbursement limitation is artificially low. And in spite of the 
extensive clinical and financial reforms enacted during this unique and 
transitional period, the cost data for this one year is significantly 
and permanently flawed.
  As a result of the anomalous cost report, the Medicare payment amount 
for Home Health & Hospice of St. Joseph is only 59 percent of the true 
costs of treating each patient. For every patient the agency treated in 
1998, it lost $1,148. The agency is a cost effective home health care 
agency: its actual per-patient cost of $2,752 is substantially below 
the national medial of approximately $3,200. Unfortunately, St. 
Joseph's anticipates an aggregate loss of $780,000 for its service to 
Medicare patients over 1998. Simply put, they cannot sustain such a 
deep loss of funding and continue to operate.
  Mr. President, I introduce this bill today in order to address the 
problem faced by Home Health & Hospice of St. Joseph. This legislation 
will reclassify Home Health & Hospice of St. Joseph as a ``new agency'' 
under the BBA, and is targeted to St. Joseph's. Mr. President, my state 
relies on home health agencies for much of its healthcare, and we 
cannot face the prospect of losing such a fine agency.
                                 ______
                                 
      By Mr. HATCH (for himself, Mr. Nickles, Mr. Breaux, Mr. Grassley, 
        Mr. Murkowski, and Mr. Bayh):
  S. 1626. A bill to amend title XVIII of the Social Security Act to 
improve the process by which the Secretary of Health and Human Services 
makes coverage determinations for items and services furnished under 
the Medicare Program, and for other purposes; to the Committee on 
Finance.


         The Medicare Patient Access to Technology Act of 1999

  Mr. HATCH. Mr. President, I rise to introduce the Medicare Patient 
Access to Technology Act of 1999. I am pleased to be joined by the 
distinguished Assistant Majority Leader, Senator Nickles, and Senators 
Breaux, Grassley, Murkowski, and Bayh in introducing this legislation.
  While we all recognize that medical technologies and treatments are 
improving the lives of millions of Americans daily, gaining access to 
these innovations is becoming more difficult. Each day, new implantable 
medical devices are correcting or repairing failing organ systems in 
patients. People are receiving new tests that permit the diagnosis of 
diseases in their earliest stages without the use of surgery or other 
more complicated procedures. Tens of thousands of individuals owe their 
lives to small, powerful miniature devices that monitor and regulate 
vital physiological functions and allow patients to live more 
productive lives.
  The latest advances in pharmaceutical and biologics are not only 
extending the length of life, but significantly improving the quality 
of life for hundreds of millions of people. Lifesaving and life-
enhancing innovations must be available to all Americans, and it is our 
duty to ensure that those patients who need them most, America's nearly 
40 million Medicare beneficiaries, have access to them.
  As part of the Balanced Budget Act (BBA) of 1997, we authorized the 
Health Care Financing Administration (HCFA) to adjust periodically 
Medicare's coverage and payment systems to account for changes in 
technology, treatment, and medical care. Unfortunately, without 
Congressional input, there is no guarantee that these expedited 
procedures will take place.
  The Medicare Patient Access to Technology Act of 1999 has arisen out 
of growing evidence that without intervention, Medicare beneficiaries 
will be denied access to the most modernized treatments and innovations 
in health care.
  After medical technologies, devices, and drugs are approved by the 
Food and Drug Administration, they still must meet several critical 
HCFA requirements before they are available to Medicare beneficiaries.
  First, before technologies are approved by HCFA for reimbursement, 
they must be covered, that is fulfill the definitions of ``reasonable 
and necessary.'' Second, they must have an identifying procedure code. 
New device technologies receive this ``procedure code,'' a four or five 
digit identification number that allows health care providers to submit 
claims to payers. Finally, the technologies must be reimbursed through 
one of Medicare's payment systems. The problems arise because each of 
these levels is plagued by inefficiency, coding delays, and lack of 
data usage by HCFA.
  My legislation addresses these concerns in five specific ways.
  First, Medicare payment levels and payment categories will be 
adjusted at least annually to reflect changes in medical practice and 
technology. A recent Institute of Medicine study reported that most 
medical technologies have an average life span of 18 months with many 
modernizations occurring rapidly. These innovations must, therefore, be 
rapidly processed so that they are accessible to beneficiaries. While 
BBA 97 authorized HCFA to adjust payment systems ``periodically'' to 
account for changes in technology, there is little promise that this 
will occur in a systematic, timely and beneficial manner.
  My bill requires HCFA to review and revise payment categories and 
payment levels for all prospective payment systems (PPS) at least 
annually. These prospective payment systems include hospital inpatient 
and outpatient, physicians, ambulatory surgery facility services. It 
also calls for public input on the review process.
  Second, this legislation mandates that valid external sources of 
information be used to update payment categories if Medicare's data are 
limited in scope or, are not yet available. Traditionally, HCFA has 
only used its own data set, known as the Medicare Provider Analysis and 
Review (MEDPAR)

[[Page 22410]]

data systems, to evaluate a given technology before assigning an 
appropriate code. The average waiting period for the assignment of a 
new code is 18 months or longer.
  Furthermore, HCFA refuses to consider partial year or externally 
generated data in its decision-making processes. My bill directs HCFA 
to use external sources of data on the cost, charges and use of medical 
technologies. This language allows HCFA to utilize high quality data 
from private insurers, manufacturers, suppliers, providers, and other 
sources.
  Third, my legislation will require that national procedure codes are 
updated more frequently to reduce delays in accessing new technologies. 
Currently, new products must have an identification code before they 
are eligible for appropriate reimbursement by Medicare. Assigning this 
code can take 18 months or longer because of the way HCFA has 
structured its calendar year.
  This legislation allows HCFA to accept applications quarterly, on a 
rolling basis, thereby allowing the processing of new technologies 
throughout the year instead of bundling them at one annual submission.
  Furthermore, the Medicare Patient Access to Technology Act will 
eliminate the HCFA requirement that new products be on the market for 
six months before they are eligible for a new code. This provision will 
ensure that new technologies are brought to Medicare beneficiaries more 
rapidly.
  Fourth, the bill guarantees that local procedure codes for medical 
technologies will continue to be used. HCFA has proposed to eliminate 
Common Procedure Coding System (HCPCS) Level III Local Codes beginning 
in 2000 and replace it with the Level II National Codes. This is 
potentially detrimental to new technologies that are often introduced 
into local, smaller health care systems before they are expanded into 
nationwide markets. Without the Level III Local Codes, new technologies 
must be placed into a ``miscellaneous'' code that is often rejected by 
payers thereby denying access of the technology to beneficiaries. The 
maintenance of the current system will ensure that technologies will be 
encoded at the earliest possible date and processed before moving to 
the national level.
  Finally, the legislation authorizes HCFA to create an Advisory 
Committee on Medicare Coding and Payment. As a result, when HCFA has to 
make coding and payment decisions, it will be prompt, permit public 
participation, and will guarantee Medicare beneficiaries access to the 
highest quality products and services. The panel would ensure that safe 
medical technologies are approved, covered, coded and paid by Medicare 
as expeditiously as possible.
  In addition to the above authorizations, the Medicare Patient Access 
to Technology Act proposes several refinements to the Administration's 
proposed outpatient prospective payment system (PPS). The legislation 
affects three changes to HCFA's implementation of the Balanced Budget 
Act (BBA) of 1997.
  The first change mandates HCFA to restructure the proposed ambulatory 
payment classification (APC) system to create groups of procedures that 
are more similar in cost and most closely related clinically. The 
current HCFA proposal would create unusual financial incentives that 
would clearly discourage the use of the most appropriate, cutting-edge 
technology. Furthermore by grouping very disparate technologies, 
hospitals will face serious underpayments for certain procedures. I 
believe that illogical categorization creates disincentives to use 
newer, but more expensive products and procedures that provide far 
superior patient care.
  The second change mandates that HCFA retain the current cost-based 
system for another four years to compile the cost studies and use data 
and conduct the analysis necessary to classify them in the appropriate 
APC. The development of these data sets are mandatory and without 
proper clarification. Therefore, these products could receive 
substantial underpayment, and, as a result, patient access to newer 
procedures and products could be limited.
  Third, the implantable medical technologies should be reimbursed 
under the new APCs along with other similar medical technologies. They 
should not be reimbursed through the durable medical technology fee 
schedule. By placing the implantables within the DME propective payment 
system, the fee schedule will lock implantables into defined categories 
that will limit their use and inhibit their access to seniors. By 
placing them into the proposed APCs with the other medical devices, 
they will be treated as other new, innovative medical technologies.
  Again, I am pleased to be joined by my Senate colleagues, Senators 
Nickles, Breaux, Grassley, Murkowski, and Bayh, in introducing this 
important piece of legislation. This bill supports both our Medicare 
beneficiaries and our technology, pharmaceutical, and biotechnical 
industries by continuing to promote life-enhancing innovations. I 
firmly believe that these significant improvements to our Medicare 
coding and payment systems will increase the access to modern medical 
innovation to Americans who need them most, our senior citizens.
  Mr. President, I urge my colleagues to join us in support of this 
important legislation.
                                 ______
                                 
      By Mr. REID (for himself, Mr. Grassley, Mr. Harkin, and Mr. 
        Cleland):
  S. 1628. A bill to amend title XVIII of the Social Security Act to 
increase the number of physicians that complete a fellowship in 
geriatric medicine and geriatric psychiatry, and for other purposes; to 
the Committee on Health, Education, Labor, and Pensions.


          medicare physician workforce improvement act of 1999

  S. 1630. A bill to amend title III of the Public Health Service Act 
to include each year of fellowship training in geriatric medicine or 
geriatric psychiatry as a year of obligated service under the National 
Health Corps Loan Repayment Program; to the Committee on Health; 
Education, Labor, and Pensions.


               geriatricians loan forgiveness act of 1999

  Mr. REID. Mr. President, I rise today to introduce two pieces of 
legislation that address our national shortage of geriatricians. I am 
pleased that Senators Grassley, Harkin and Cleland are joining me as 
original cosponsors.
  Our nation is growing older. Today, life expectancy is 79 years for 
women, and 73 years for men. While the population of the United States 
has tripled since 1900, the number of people age 65 or older has 
increased eleven times--to more than 33 million Americans. One-third of 
all health care costs can be attributed to this group. The fastest 
growing part of the Medicare population--those over 85--number more 
than three-and-a-half million. But, according to reports from the 
Institute of Medicine, the National Institute on Aging, and the Council 
on Graduate Medical Education, the number of doctors with special 
training to meet the needs of the oldest and frailest Americans is in 
critically short supply.
  I first became concerned about this problem when I read a report 
issued by the Alliance for Aging Research in May of 1996 entitled, 
``Will You Still Treat Me When I'm 65?'' The report concluded that 
there are only 6,784 primary-care physicians certified in geriatrics. 
This number represents less than one percent of the doctors in the 
United States. The report goes on to state that the United States 
should have at least 20,000 physicians with geriatric training to 
provide appropriate care for the current population, and as many as 
36,000 geriatricians by the year 2030 when there will be close to 70 
million older Americans.
  I first introduced legislation to address the national shortage of 
geriatricians during the 105th Congress. While I am encouraged that 
greater attention has been focused on this issue, little has been 
accomplished to improve the shortage of geriatricians. The two bills I 
am introducing today, the ``Medicare Physician Workforce Improvement 
Act'' and the ``Geriatrician Loan Forgiveness Act of 1999'' aim--in 
modest ways and at very modest cost--to encourage an increase in the 
number of the doctors Medicare clearly needs,

[[Page 22411]]

those with certified training in geriatrics.
  One provision of the ``Medicare Physician Workforce Improvement Act 
of 1999'' will allow the Secretary of Health and Human Services to 
double the payment made to teaching hospitals for geriatric fellows. 
This provision is limited to a maximum of 400 individuals in any 
calender year. This is intended to serve as an incentive to teaching 
hospitals to promote and recruit geriatric fellows.
  Another provision of the Medicare Physician Workforce Improvement Act 
would direct the Secretary of Health and Human Services to increase the 
number of certified geriatricians appropriately trained to provide the 
highest quality care to Medicare beneficiaries in the best and most 
sensible settings by establishing up to five geriatric medicine 
training consortia demonstration projects nationwide. In short, this 
would allow Medicare to pay for the training of doctors who serve 
geriatric patients in the settings where this care is so often 
delivered. Not only in hospitals, but also ambulatory care facilities, 
skilled nursing facilities, clinics and day treatment centers.
  The second bill I am offering today, ``The Geriatricians Loan 
Forgiveness Act of 1999,'' has but one simple provision. That is to 
forgive $20,000 of education debt incurred by medical students for each 
year of advanced training required to obtain a certificate of added 
qualifications in geriatric medicine or psychiatry. My bill would count 
their fellowship time as obligated service under the National Health 
Corps Loan Repayment Program.
  While almost all physicians care for Medicare patients, many are not 
familiar with the latest advances in aging research and medical 
management of the elderly. Too often, problems in older persons are 
misdiagnosed, overlooked or dismissed as the normal function of aging 
because doctors are not trained to recognize how diseases and 
impairments might appear differently in the elderly than in younger 
persons. As a result, patients suffer needlessly, and Medicare costs 
rise because of avoidable hospitalizations and nursing home admissions.
  A physician who takes special training in the care of the elderly 
becomes sensitive to the need to evaluate and address the patient's 
behaviors and moods, as well as her physical symptoms. This is 
especially important, as the rates of undiagnosed depression and 
suicide among the elderly are scandalous. By allowing doctors who 
pursue certification in geriatric medicine to become eligible for loan 
forgiveness, and by offering an incentive to teaching institutions to 
promote geriatric fellowships, my bills will provide a measure of 
incentive for top-notch physicians to pursue fellowship training in 
this vital area.
  Increasing the number of certified geriatricians will not be easy for 
a number of reasons. Geriatrics is the lowest paid medical specialty, 
because the extra time required for effective and compassionate 
treatment of the elderly is barely reimbursed by Medicare and other 
insurers. It takes a special individual to commit himself or herself to 
the work of helping older patients preserve vitality and functional 
abilities over time. Often the goal for a geriatrician is not to cure 
disorders, but to delay the onset of disability--that is, simply to 
help seniors live as well as possible. For these reasons, existing 
slots in geriatrics training programs sometimes go unfilled today. But 
while the work may be difficult and not well compensated, protecting 
quality of life for the elderly is extraordinarily important, and we 
need physicians whose training explicitly recognizes that.
  It is similarly difficult for teaching programs to build and remain 
committed to maintaining fellowship training in geriatric medicine, 
because geriatric faculty are scarce and the type of patients brought 
in by a training program often require extremely complex and high cost 
care. Simply, it is cheaper to train other specialties, and more 
lucrative in terms of graduate medical education payments to the 
hospital. In fact, there are only two departments of geriatrics at 
academic medical centers across the entire country.
  Another barrier to alleviating the shortage of geriatricians is the 
result of an unintended consequence of the Balanced Budget Act of 1997 
(BBA). A provision in this law established a hospital-specific cap on 
the number of residents based on the number of residents in the 
hospital in 1996. Because a lower number of geriatric residents existed 
prior to December 31, 1996, these programs are underrepresented in the 
cap baseline. The implementation of this cap has resulted in the 
reduction of, and in some cases, the elimination of geriatric training 
programs. This is one obstacle that should not be overlooked when 
Congress considers legislation to correct some of the unintended 
consequences of the BBA.
  When it comes to training the doctors we need, Medicare's current 
payment system is part of the problem, not part of the solution. The 
Medicare Payment Advisory Commission's (MEDPAC) August 1999 report to 
Congress entitled ``Rethinking Medicare's Payment Policies for Graduate 
Medical Education and Teaching Hospitals'' examines this very issue. 
According to the MEDPAC report:

       Where Medicare does not pay for services generally 
     associated with a particular specialty, it may discourage 
     training. For example, although several studies have 
     indicated an inadequate supply of geriatricians, the number 
     of geriatric training slots exceeds the number of people who 
     choose to enter the specialty. This may reflect a lack of 
     payment for services such as palliative care and geriatric 
     assessment.

  Clearly, the incentives in Medicare's payment system are poorly 
aligned when training doctors specifically to care for the elderly is 
avoided. Again, my bill provides a modest incentive for hospitals to 
increase the number of training slots available.
  Medicare should be providing incentives to community-based programs 
to participate in the education of doctors, especially geriatricians, 
by directing graduate medical education payments appropriately to all 
facilities that incur the additional costs of providing training. My 
bill directs the Secretary to undertake up to five demonstration 
projects that will do just that.
  Many reports have highlighted the shortage of geriatricians we have 
today. The response to the problem needs to be a national one, and it 
would be most unwise to simply hope that the labor market will produce 
the kinds of doctors we will increasingly need. I am especially 
grateful to the American Geriatrics Society for its assistance in 
discussing ways to address the problem. I believe that the Medicare 
Physician Workforce Improvement Act and the Geriatrician Loan 
Forgiveness Acts are steps in the right direction, and I ask my 
colleagues to join me in supporting these bills.
  I ask unanimous consent that letters of support from the American 
Geriatrics Society and the Alliance for Aging Research be printed in 
the Record.
  There being no objection, the letters were ordered to be printed in 
the Record, as follows:

                                  American Geriatrics Society,

                                 New York, NY, September 17, 1999.
     Hon. Harry Reid,
     U.S. Senate,
     Washington, DC.
       Dear Senator Reid: The American Geriatrics Society (AGS), 
     an organization of over 6,000 geriatricians and other health 
     care professionals who are specially trained in the 
     management of care for frail, chronically ill older patients, 
     offers our strongest support to the Medicare Physician 
     Workforce Improvement Act of 1999 and the Geriatricians Loan 
     Forgiveness Act of 1999.
       The AGS is dedicateed to improving the health and well 
     being of all older adults. While we provide primary care and 
     supportive services to all patients, the focus of geriatric 
     practice is on the frailest and most vulnerable elderly. The 
     average age of a geriatrician's caseload exceeds 80, and our 
     patients often have multiple chronic illnesses. Given the 
     complexity of medical and social needs among our nation's 
     elderly, we are strongly commited to a multi-disciplinary 
     approach to providing compassionate and effective care to our 
     patients.
       As you know, America faces a critical shortage of 
     physicians with special training in geriatrics. Even as the 
     76 million persons of the baby boom generation reach 
     retirement age over the next 15 to 20 years, the number of 
     certified geriatricians is declining. In fact, the August 
     1999 MedPAC report noted the shortage in geriatricians, 
     despite the availability of training positions. The

[[Page 22412]]

     MedPAC report noted that the shortage is caused by faulty 
     system incentives, such as inadequate Medicare reimbursement 
     to geratricians. By providing modest incentives--which will 
     encourage teaching hospitals to increase the number of 
     training fellowships in geriatric medicine and psychiatry, 
     provide loan assistance to physicians who pursue such 
     training, and support development of innovative and flexible 
     models for training in geriatrics--your bills present very 
     positive steps toward reversing that trend.
       The AGS has been pleased to work closely with your office 
     to develop initiatives to preserve and improve the 
     availability of highest quality medical care for our oldest 
     and most vulnerable citizens. We believe that the ``Medicare 
     Physician Workforce Improvement Act'' and the ``Geriatricians 
     Loan Forgiveness Act'' represent a cost-effective approach to 
     training the physicians our nation increasingly will need. We 
     commend you for your leadership on an issue of such vital 
     importance to the Medicare program and our elderly citizens.
           Sincerely,
                                        Joseph G. Ouslander, M.D.,
     President.
                                  ____



                                  Alliance for Aging Research,

                               Washington, DC, September 23, 1999.
     Hon. Harry Reid,
     Hart Senate Office Building,
     Washington, DC.
       Dear Senator Reid: As the Executive Director for the 
     Alliance for Aging Research, an independent, not-for-profit 
     organization working to improve the health and independence 
     of older Americans, I am writing in support of the ``Medicare 
     Physician Workforce Improvement Act'' and the ``Geriatricians 
     Loan Forgiveness Act.''
       The Alliance has worked for many years to bring attention 
     to the critical need for more geriatricians, those physicians 
     who are trained to address the complex needs of older 
     patients. Best estimates suggest that there is a need for at 
     least 20,000 geriatricians at present and nearly 40,000 by 
     the year 2030 to care for the graying baby boomers. Not only 
     are we far short of current needs, with less than 7,000 
     geriatricians in practice, but far too few doctors in 
     training are choosing this field.
       The two bills you are introducing represent important first 
     steps in solving this problem.
       In addition to increasing the number of physicians trained 
     in geriatrics, we need to develop a strong cadre of academics 
     and researchers within our medical schools to help mainstream 
     geriatrics into both general practice and specialties. 
     Increasing the number of fellowship positions in geriatric 
     medicine will improve the situation.
       We must have this kind of support and commitment from the 
     federal government, along with private and corporate 
     philanthropy if we are to sufficiently provide care for our 
     aging population. The Alliance for Aging Research is 
     encouraged by your leadership and support in this area and we 
     look forward to working with you to bring these issues before 
     Congress.
           Best regards,
                                                     Daniel Perry,
                                               Executive Director.
                                 ______
                                 
      By Mr. SMITH of Oregon (for himself and Mr. Wyden):
  S. 1629. A bill to provide for the exchange of certain land in the 
State of Oregon; to the Committee on Energy and Natural Resources.


                          oregon land exchange

 Mr. SMITH of Oregon. Mr. President, I rise before the Senate 
today to introduce legislation which would facilitate two exchanges of 
public and private lands in my home State of Oregon: the Triangle Land 
Exchange and the Northeast Oregon Assembled Land Exchange (NOALE). In 
terms of acreage, approximately 54,000 acres of BLM and Forest Service 
land is proposed to be traded for nearly 50,000 acres currently held by 
private landowners in northeast Oregon. As a result of 4\1/2\ years of 
delays with administrative process, there is enormous support from my 
constituents for a legislative resolution to the exchange.
  Both the government and the public have deeply rooted interests in 
this exchange. Federal agencies are seeking to acquire sensitive river 
corridors which will improve the efficiency of their protection efforts 
for threatened and endangered fish. Currently, many of these selected 
lands are intermingled with private parcels and make resource 
management difficult for the agencies. As you know, the improvement of 
fish-bearing streams and riparian areas is critical to the survival of 
many struggling species of fish in the Northwest.
  Communities and landowners will also benefit from these exchanges. 
Each and every aspect, from the consolidation of ownership patterns to 
the release of previously inaccessible timber stands, will boost local 
economies and enhance the ability of the private sector to manage its 
own lands.
  In addition, these land exchanges have received the strong collective 
support of several Oregon Indian tribes; conservation groups such as 
the Oregon Natural Desert Association, Oregon Trout and the Sierra 
Club; the Governor and scores of concerned citizens at large.
  While these exchanges hold enormous benefit for all interested 
parties and for Oregon's natural resources, it is apparent that the 
only sure means of completing them is through legislation. Mr. 
President, I am hopeful that the Senate will take this opportunity and 
support my colleague from Oregon and me in the swift passage of 
legislation to facilitate the Triangle and Northeast Oregon Assembled 
Land Exchanges.
                                 ______
                                 

                             By Mr. CONRAD:

  S. 1631. A bill to provide for the payment of the graduate medical 
education of certain interns and residents under title XVIII of the 
Social Security Act; to the Committee on Finance.


    graduate medical education fair technical amendment act of 1999

 Mr. CONRAD. Mr. President, today I am pleased to introduce the 
Graduate Medical Education Fair Technical Amendment Act of 1999. This 
legislation will take important steps to sustain and improve the 
availability of medical professionals in communities in my State.
  Mr. President, as you know, the Balanced Budget Act of 1997 (BBA) 
included many measures to control rising health care spending, 
including provisions that reduced the level of resources for graduate 
medical education. In particular, the BBA set a limit on the amount of 
medical residents for which teaching hospitals can receive 
reimbursement. This cap was set according to the number of medical 
residents on staff as of December 31, 1996. While this reimbursement 
limit has helped to contribute to the overall savings generated by the 
BBA, I am concerned that it has unfairly limited the ability of certain 
programs to adequately train future health care providers.
  Over the last few years, we have heard much discussion about the 
issue of physician oversupply. As you may know, various experts suggest 
that the true problem regarding physician supply is an unequal 
distribution of physicians across the country. In my State of North 
Dakota, for example, more than 85 percent of the counties are in health 
professional shortage areas. There certainly isn't a physician 
oversupply in my state--we are grateful for the health care providers 
serving our communities and we are grateful to have facilities with the 
capability to train medical residents.
  Recently, it came to my attention that one of the teaching hospitals 
in my State had committed to training an increased level of medical 
residents. This situation arose because another facility in my State 
was no longer able to offer these residents an adequate training 
experience. The facility's decision to take on the new residents was 
important--while we cannot guarantee that physicians trained in my 
State will pursue permanent practice in the State, we know that 
providers are more likely to serve where they are trained. And it is 
important to note that the University of North Dakota produces a higher 
percentage of graduates who practice in rural settings than any medical 
school in the Nation.
  The facility took on these residents assuming that they would receive 
adequate Medicare graduate medical education reimbursement to train 
these individuals. Unfortunately, retroactively set BBA limits capped 
the allowable reimbursement level just prior to the time the residents 
in question came on board. Thus, the facility was already committed to 
training these residents but the funds they depended on to do so were 
no longer available. The result of this situation is that the entire 
graduate medical residency program is suffering and I am concerned tat 
this could result in reduced services for beneficiaries.

[[Page 22413]]

  The legislation I introduce today will correct the unintended 
consequence of the BBA by allowing a technical adjustment to medical 
resident caps in certain situations. I am confident this legislation 
will help ensure we have adequate resources to meet our health care 
needs well into the future. I urge my colleagues to support this 
important effort.
                                 ______
                                 
      By Mr. LIEBERMAN (for himself, Mr. Dodd, Mr. Schumer, and Mr. 
        Moynihan):
  S. 1632. A bill to extend the authorization of appropriations for 
activities at Long Island Sound; to the Committee on Environment and 
Public Works.


            reauthorization of the long island sound office

 Mr. LIEBERMAN. Mr. President, I rise today to introduce a 
reauthorization bill of critical importance to the future of 
Connecticut's most valuable natural resource, the Long Island Sound. 
This bill, which I offer with my colleagues Mr. Dodd, Mr. Schumer, and 
Mr. Moynihan, reauthorizes the Long Island Sound Office through the 
year 2005, and increases the grant authorization amount to $10 million.
  The Long Island Sound is among the most complex estuaries in the 
National Estuary Program, both in terms of the physical features and 
scientific understanding of the estuary system, and in the context of 
ecosystem management. Unlike most estuaries, Long Island Sound has two 
connections to the sea. Rather than having a major source of fresh 
water at its head, flowing into a bay that empties into the ocean, Long 
Island Sound is open at both ends, flowing to the Atlantic Ocean to the 
east and to New York Harbor to the west. Most of its fresh water comes 
from a series of south-flowing rivers, including the Connecticut River, 
the Housatonic, and the Thames, whose drainages reach as far north as 
Canada. The Sound's 16,000 square mile drainage basin also includes 
portions of New York City and Westchester, Nassau, and Suffolk Counties 
in New York State. The Sound combines this multiple inflow/outflow 
system with a diverse and complex shoreline, and an uneven bottom 
topography. Taken together, they produce unique and complex patterns of 
tide and currents.
  The interaction between the Sound and the local human population is 
also complex. The Sound is located in the midst of the most densely 
populated region of the United States. In total, more than 8 million 
people live in the Long Island Sound watershed and millions more flock 
yearly to the Sound for recreation. The Sound provides many other 
valuable uses, such as cargo shipping, ferry transportation and power 
generation. It is largely because the Sound serves such a concentrated 
population that the economic benefits of preserving and restoring the 
Sound are so substantial. More than $5.5 billion is generated annually 
in the regional economy from water quality-dependent activities such as 
boating, commercial and sport fishing, swimming, and beach going.
  In 1994, the Long Island Sound Management Conference, sponsored by 
the EPA, the New York State Department of Environmental Conservation, 
and the Connecticut Department of Environmental Protection, completed a 
$15 million Comprehensive Conservation and Management Plan (CCMP). That 
plan was adopted by the Governors of New York and Connecticut and the 
EPA Administrator.
  The EPA Long Island Sound Office coordinates the implementation of 
the plan among the many program partners, consistent with the Long 
Island Sound Improvement Act of 1990. The office is small, staffed by 
two EPA employees, whose salaries are covered by EPA's base budget, and 
a Senior Environmental Employment Program secretary. In addition, the 
office supports two outreach positions, with one in each state. It 
avoids duplicating existing efforts and programs, instead focusing on 
better coordination of federal and state funds, educating and involving 
the public in the Sound cleanup and protection, and providing grants to 
support implementation of the Long Island Sound restoration effort. By 
coordinating the activities of numerous stakeholders involved in the 
Sound's management program, in addition to serving as an educational 
and informational interface with the public, the Long Island Sound 
office provides an integral local outreach and meeting point.
  While the quality of the Sound has improved dramatically over the 
years, there is still much work to be done. Implementation of the CCMP 
will help restore fish populations that have been impacted by hypoxia, 
will improve and restore degraded wetlands, and will begin to address 
the toxic mercury pollution that has lead to health advisories for fish 
consumption in many of the Sound's waters. Specific near term goals of 
the office include reducing nitrogen loadings which degrade water 
quality by depleting the Sound of oxygen, supporting local watershed 
protection efforts to reduce nonpoint source pollution, monitoring and 
expanding scientific understanding of the Sound, and educating the 
public and regional stakeholders about the sound and cleanup 
activities. Federal, State, and private funds have been well-spent over 
the years to research the conditions in the Sound and to identify 
conservation needs. We are now moving to apply critical funding toward 
implementing these projects, directly improving the water quality and 
habitat of the Long Island Sound.
  Overall, recent federal funding of the program and the office are 
small relative to state commitments. New York State has approved $200 
million for Long Island Sound as part of a $1.75 billion bound act. 
Connecticut has awarded more than $200 million in the past three years 
to support upgrades at sewage treatment plants and is a national leader 
on wetlands restoration. The Long Island Sound Office now faces a 
daunting task, orchestrating a multi-billion dollar effort to implement 
efforts to reduce nitrogen loadings that degrade the waters of the 
Sound. The modest increase in the authorization levels, and the 
reauthorization of the Long Island Sound Office, therefore represent 
timely, important contributions to the cooperative regional effort to 
restore the waters of the Long Island Sound.
                                 ______
                                 
      By Ms. SNOWE:
  S.J. Res. 34. A joint resolution congratulating and commending the 
Veterans of Foreign Wars; to the Committee on the Judiciary.


                        VFW DAY JOINT RESOLUTION

 Ms. SNOWE. Mr. President, I rise today to introduce 
legislation honoring the centennial of the Veterans of Foreign Wars 
(VFW) of the United States, which will occur on the 29th of this month.
  Earlier this year, the Senate passed my legislation designating 
September 29, 1999, as ``National VFW Day.'' I would like to express my 
sincere appreciation to my colleagues for joining me in honoring the 
more than 2 million members of the VFW, and urge the approval of this 
legislation, which congratulates all members of the VFW on the occasion 
of the organization's centennial. Similar legislation passed the House 
on June 29 and awaits approval by the Senate. I hope that we can pass 
this legislation before September 29 in order to pay tribute to these 
brave protectors of liberty.
  As I indicated, September 29, 1999, marks the centennial of the VFW. 
As veterans of the Spanish-American War and the Philippine Insurrection 
of 1899 and the China Relief Expedition of 1900 returned home, they 
drew together in order to preserve the ties of comradeship forged in 
service to their country.
  They began by forming local groups to secure rights and benefits for 
the service they rendered to our country. In Columbus, OH, veterans 
founded the American Veterans of Foreign Service. In Denver, CO, 
veterans started the Colorado Society of the Army of the Phillippines. 
In 1901, the Philippine War Veterans organization was started by the 
Philippine Veterans in Altoona and Pittsburgh, PA. In 1913, these 
varied organizations with a common mission joined forces as the 
Veterans of Foreign Wars of the United States. I am truly honored to 
salute this proud organization.
  The joint resolution I am introducing today recognizes the unselfish 
service

[[Page 22414]]

VFW members have rendered over the last 100 years to the Armed Forces, 
to our communities, and other veterans. It also highlights the historic 
significance of this important day in the lives of so many veterans, 
and calls upon the President to issue a proclamation recognizing the 
anniversary of the VFW and the contributions made by the VFW to our 
Nation.
  I have nothing but the utmost respect for those who have served their 
country. With this legislation, we say ``thank you'' the men and women 
and their families who have served this country with courage, honor and 
distinction. They answered the call to duty when their country needed 
them, and this is but a small token of our appreciation.
  The centennial of the founding of the VFW will present all Americans 
with an opportunity to honor and pay tribute to the VFW and to all 
veterans. I thank my colleagues for joining me in a strong show of 
support and an expression of thanks to the VFW and all 
veterans.

                          ____________________