[Congressional Record (Bound Edition), Volume 146 (2000), Part 13]
[Senate]
[Pages 18849-18852]
[From the U.S. Government Publishing Office, www.gpo.gov]



                       HOME HEALTH CARE SERVICES

  Ms. COLLINS. Mr. President, Senate Republicans are committed to 
enacting legislation to preserve, strengthen, and save Medicare for 
current and future generations. It is also critical that Congress take 
action this year to address some of the unintended consequences of the 
Balanced Budget Act of 1997 which has been exacerbated by a host of 
ill-conceived regulatory requirements imposed by the Clinton 
administration. The combination of regulatory overkill and budget cuts 
is jeopardizing access to critical home health care services for 
millions of our Nation's seniors.
  If one thinks about it, health care has really come full circle. 
Patients are spending less time in the hospital, more and more 
procedures are being done on an outpatient basis, and recovery and care 
for patients with chronic diseases and conditions increasingly takes 
place at home. Moreover, the number of older Americans who are 
chronically ill or disabled in some way continues to grow each year.
  As a consequence, home health care has been an increasingly important 
part of our health care system, and I know the Senator from Kansas has 
been a very strong supporter of ensuring that these vital services are 
provided for our senior citizens. The kind of highly skilled and often 
technically complex services our Nation's home health care agencies 
provide have enabled millions of our most frail and vulnerable older 
citizens to avoid hospitals and nursing homes and receive care right 
where they want to be--in the comfort and security of their own homes.
  In 1996, however, home health care was the fastest growing component 
of Medicare spending. This understandably prompted consideration of 
some changes as part of the Balanced Budget Act that were intended to 
slow the growth in spending to make the program more cost-effective and 
efficient.
  Mr. ROBERTS. Mr. President, will the distinguished Senator from Maine 
yield for a question?
  Ms. COLLINS. I will be happy to yield.
  Mr. ROBERTS. First off, I thank the Senator so much for taking this 
time to draw attention to a very serious problem. I know the Senator 
from Maine is experiencing the same thing I am experiencing in Kansas 
and all Senators are experiencing when they go back home. Every 
hospital board--beleagured hospital boards--every hospital 
administrator, all of the rural health care delivery system--it is not 
only applicable to rural areas but all over--have been questioning me 
and our colleagues about when are we going to do something with regard 
to the Medicare reimbursement.
  The Senator has indicated--I underlined it in the Senator's remarks:

       It is also critical that Congress take action this year to 
     address some of the unintended consequences of the Balanced 
     Budget Act of 1997. . . .

  We should have done it this spring. The Senator from Maine and I 
talked about it. We should have done it last year. We did certainly 
provide that assistance. I wish we could have done that earlier. We are 
going to do that.
  Then the Senator also said:

       . . . [and also some problems] which have been exacerbated 
     by a host of ill-conceived regulatory requirements imposed by 
     the Clinton administration--

  And the folks at HCFA.
  That is a marvelous acronym, HCFA. I will tell you what, if that is 
not a four-letter word in the minds and eyes of people who have to 
provide health care services throughout our country, I do not know what 
is. Asking HCFA for help, if you are a hospital board or a hospital 
administrator, is like asking the Boston strangler for a neck massage. 
It just does not work.
  My question is this: as I recall, there was strong bipartisan support 
for these provisions, but haven't they produced cuts in home health 
care spending far beyond what Congress ever intended? It is my 
understanding--and I want people to understand this--home health care 
spending dropped $9.7 billion in fiscal year 1999, just about half of 
the 1997 amount; is that correct?

[[Page 18850]]


  Ms. COLLINS. The Senator, as always, is entirely correct. I know how 
concerned he has been that inadequate reimbursements under Medicare, 
plus regulatory overkill by HCFA, are really jeopardizing the provision 
of care in our rural hospitals and our home health care agencies.
  In fact, we know the Balanced Budget Act is already producing--or 
expected to produce--four times the savings that we intended when the 
1997 Balanced Budget Act was passed. Moreover--and I know the Senator 
from Kansas shares my deep concern about this--looming on the horizon, 
believe it or not, is an additional 15-percent cutback in home health 
care reimbursements. That will put our already struggling home health 
agencies at risk. I know the Senator from Kansas shares my belief that 
it would, if allowed to go into effect, seriously jeopardize access to 
care for millions of our Nation's seniors.
  The effects of these home health care cuts have been particularly 
devastating to the State of Maine. In Maine, I would inform my 
colleague from Kansas, nearly 7,500 Maine seniors have lost access to 
home health care due to the cutbacks and the regulatory overkill by 
HCFA.
  Those 7,500 seniors did not get well. That is not why they lost their 
access to home health care. In fact, what has happened is some of them 
have been forced prematurely into nursing homes or they are at risk of 
increased hospitalization, which ironically costs the Medicare trust 
fund more money than if they were still receiving home health care. 
Some of them--and this is most tragic of all--are going without care 
altogether.
  Cuts of this magnitude, particularly for the home health agencies in 
your section of the country and mine, which were historically low cost 
to begin with, cannot be sustained without ultimately adversely 
affecting patient care.
  Mr. ROBERTS. Mr. President, will the Senator yield?
  Ms. COLLINS. I am happy to yield.
  Mr. ROBERTS. The same complaints are made in Kansas. The same 
complaints are made throughout the country. The home health care 
agencies in my State--in fact, since January of about 2 years ago, 68 
Medicare-certified agencies in Kansas have closed their doors, more 
than a 25-percent drop, more than a quarter drop.
  These were not the ``fly-by-night'' agencies that some in the Federal 
Government and others in regards to various inspections--and you have 
talked about that we have heard about so much--many of these agencies 
had been in existence for 20 years.
  The latest numbers from HCFA show that the total home health care 
visits are down by over 45 percent--almost half. The losers of this 
situation are not just numbers. It is just not accounting in regards 
to, say, HCFA. These are our Nation's seniors; in particular, those who 
are really sick. We are talking about the Medicare patients who are 
suffering through complex and chronic care needs who are already 
experiencing a lot of difficulty in the home care services they need.
  So the same thing is true in Kansas as the Senator has pointed out in 
Maine. I, obviously, think it is true in every State.
  Ms. COLLINS. The Senator has, as always, summarized the situation 
exactly right. The real losers are the sickest seniors because what is 
happening is, because they are more expensive to treat, our home health 
agencies are turning away some of the more expensive patients because 
they simply cannot afford to provide them care.
  I met recently with a group of very dedicated and highly skilled, 
compassionate home health nurses from the Visiting Nurse Service in 
Saco, ME. That is southern Maine's largest independent, not-for-profit 
home health agency. It performs more than 250,000 home visits per year.
  During my discussions with these nurses, I heard absolutely hard-
breaking stories of how recent cutbacks and regulatory restrictions 
have affected both the quality and the availability of home health 
services.
  Let me tell my colleague of just one example the nurses related to 
me. Consider this case. It involves an elderly Maine woman who suffered 
from advanced Alzheimer's disease, pneumonia, and hypertension, among 
many other illnesses. She was bedbound, verbally nonresponsive, and had 
a series of serious health issues, including serious infections.
  This woman had been receiving home health care for approximately 2 
years, and that had allowed her condition to stabilize through the care 
and coordination of a skilled nurse. Unfortunately, the care provided 
to this patient abruptly came to an end when HCFA'S intermediary sent 
out a notice denying further home health care for this woman.
  That is an example of the kinds of regulatory problems that the 
Senator was talking about.
  Let's look at what happened in this case.
  The fact is, it produced a tragedy. Less than 3 months later, this 
woman died. She died as a result of a wound on her foot that went 
untreated. Undoubtedly, the home health nurse would have caught that 
problem before it got out of control.
  That is just one of the heart-wrenching stories that I have heard not 
only during that visit but in discussions with patients and health care 
providers throughout my State.
  Mr. ROBERTS. Will the Senator yield?
  Ms. COLLINS. I am happy to yield.
  Mr. ROBERTS. The home health care agencies in my State, as I have 
indicated, also complain about their exacerbating financial problems. 
That is a very fancy word to say it has been made a whole lot worse by 
a host of the new regulatory requirements imposed by HCFA, including 
the implementation of another marvelous acronym called OASIS. The 
thought occurs to me, if there is an ``oasis'' that is proposed by 
HCFA--we all remember the ``Survivor'' show that was so popular--there 
would be no survivors in regards to this OASIS, I can tell you.
  OASIS stands for the new outcome and assessment information data 
set--new outcome and assessment information data set--new requirements 
for surety bonds, new requirements for sequential billing, new 
requirements for overpayment recoupment, new requirements on a 15-
minute reporting requirement. And all of this adds up.
  I just concluded a 40-county tour in my State. I will go on another 
65-county tour. At every stop was a hospital administrator. They said: 
I don't know who reads this stuff. I think they must weigh it somewhere 
in Kansas City--which is the regional center.
  I am not trying to deprive from the purpose and the intent and 
responsibility that HHS and HCFA and OASIS have here, but it just seems 
to me that just about the time you have one requirement promulgated--
there is another fancy word--then it is changed, and it is changed 
overnight. This is the kind of thing that a small rural hospital, or 
any hospital, just cannot put up with, with that very tight margin. We 
are down to the morrow of the bone.
  Naturally, we are going to put in some money in regards to Medicare 
reimbursement, but this regulatory overkill is something that just has 
to stop.
  Ms. COLLINS. The Senator is entirely correct. I could not agree with 
his point more.
  What I heard from the home health nurses is not only do all these 
excessive regulatory requirements and paperwork cost a lot of money to 
the agency, but they detract from the time that otherwise would be 
spent caring for patients. Instead of focusing on patients, they have 
to complete paperwork. Indeed, at that visit in Saco, ME, that I 
mentioned, the nurses--to illustrate the OASIS paperwork which the 
distinguished Senator from Kansas has just talked about--put it up all 
over the room. It covered the walls of the entire room. That was just 
one OASIS questionnaire.
  Last year, I chaired a subcommittee hearing of the Permanent 
Subcommittee on Investigations. We heard about the problems that 
excessive regulation was imposing. We heard about the cash-flow 
problems that agencies across the country are experiencing.

[[Page 18851]]

  One nurse from Maine, who runs a home health agency, terms HCFA's 
approach as being one of ``implement and suspend.'' In other words, 
HCFA requires these agencies to go through all these regulatory hoops 
to fill out all this paperwork and then says: Never mind. This really 
isn't what we meant.
  Meanwhile, tremendous cost and energy has gone into complying with 
these burdensome regulations.
  Mr. ROBERTS. Will the Senator yield again, please?
  Ms. COLLINS. I am happy to yield.
  Mr. ROBERTS. This OASIS business, in regard to all the complaints we 
have heard, as I have indicated--I think I ought to go into that a 
little bit more than explaining what the acronym is. OASIS is a system 
of records containing data on the physical, mental, and functional 
status of Medicare and Medicaid patients receiving care from home 
health agencies.
  HCFA tried to implement OASIS as a tool to help the agency improve 
the quality of care and form the basis for a new home health care 
prospective payment system. The problem is--and my colleague chaired 
the subcommittee and asked all the very pertinent questions--the 
collection of data is so burdensome and expensive for agencies, it 
invades the personal privacy of the patients. It must be collected for 
non-Medicare patients as well as those served by Medicare.
  Just yesterday, I learned that the whole OASIS information system in 
Kansas is not working; the computer system has failed. Agencies across 
the State are having a lot of difficulty in transmitting any kind of 
data. This burden is being felt by agencies all over the country. The 
question I have for the Senator is, Does she have any idea how long it 
takes? She has already spoken about this to some degree. Can we put a 
timeframe on it? Can we get more specific as to how long it takes for 
nurses to collect this information for HCFA? What does it cost in terms 
of nurse time?
  Ms. COLLINS. I inform the Senator from Kansas that the testimony at 
my hearing indicated that it generally takes a nurse as long as 2 hours 
to complete these forms with one patient. The patients do not welcome 
this intrusive questionnaire in any way.
  Mr. ROBERTS. I certainly agree with that. Will the Senator yield for 
another question?
  Ms. COLLINS. I am happy to yield.
  Mr. ROBERTS. The OASIS document includes an 18-page initial 
assessment that must be completed by a registered nurse and a 13-page 
followup assessment that is required every 60 days. This reminds me of 
a situation quite a few years ago, when the Department came out with a 
requirement that all Medicare patients would have to be reviewed by a 
doctor every 24 hours. At the time I said I was for that, stunning all 
of the health care folks in my district. I was in the House of 
Representatives then. I said: Surely, if they are going to require a 
24-hour reporting requirement by a doctor, they will furnish us the 
doctor. There was sort of a method to the madness.
  At any rate, as I have indicated, there is an 18-page initial 
assessment that must be completed by a registered nurse. A 13-page 
followup assessment is required every 60 days. This is on top of 
assessments already required by the State. That is very important. It 
isn't as if there is no regulatory function to safeguard the interests 
of the patients and the taxpayer. The paperwork burden is immense. I am 
curious about what is included in this assessment. Is the Senator aware 
of the nature of the questions?
  Ms. COLLINS. Mr. President, this is one of the problems. The Senator 
from Kansas has put his finger right on it. OASIS collects information 
not only about the patient's medical condition or history, but about 
living arrangements, medications, sensory status--I am not even sure 
what that means--and emotional status as well. That raises a host of 
problems.
  Mr. ROBERTS. Emotional status? I see that patients must answer 
questions about their feelings. Have they ever been depressed? Have 
they ever had trouble sleeping? Have they ever attempted suicide? In 
some cases, that might be necessary, but do we really think we need a 
nurse to bother a physical therapy patient for this information so that 
he or she can send the answers over computer to someplace in 
Baltimore--hopefully Kansas City, but probably in Baltimore?
  Does the Senator from Maine have any idea how patients have reacted 
to this survey? Talk about emotional distress, if somebody were to ask 
me in a hospital what I felt or how would I feel, do I feel depressed, 
I think they would learn pretty doggone quick.
  Ms. COLLINS. That has been the experience of the nurses in Maine, 
that the patients believe this is unnecessarily intrusive. We are not 
talking about patients, in these cases, who are receiving home health 
because of emotional problems. Obviously, those questions might be 
appropriate in some cases, but they are clearly not in these cases.
  What the nurses explained to me is that the patients say: What does 
this have to do with what you are treating me for? The nurses expressed 
concern that this ``exercise of Olympian endurance'' inevitably elicits 
a negative response from their patients. That is a problem because that 
patient-nurse relationship is very important. It is a relationship that 
respects the confidentiality and the privacy of patients, or it should.
  Unfortunately, the OASIS information mandated by HCFA immediately 
erects a barrier that is often difficult to overcome. There is one 
example I want to share with my colleague from Kansas, one 76-year-old 
Medicare patient about whom I was told was being treated for a wound to 
his left shoulder. The wound care and teaching provided by the home 
health nurse took approximately 30 minutes. Completing the OASIS form 
took an hour and a half. The patient understandably asked: What does 
all this have to do with my shoulder? A very common response.
  Mr. ROBERTS. Will the Senator yield for another question?
  Ms. COLLINS. I am happy to yield.
  Mr. ROBERTS. I agree with my colleague. That is too much to ask. That 
is ridiculous. I also point out that the time filling out the forms 
would be much better used actually caring for the patients. There is an 
hour and a half that the nurse could have been doing that.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. ROBERTS. Mr. President, I ask unanimous consent for an additional 
10 minutes.
  Mr. WELLSTONE. Mr. President, I will not object, but with the 
indulgence of my colleagues, I ask unanimous consent to then be allowed 
to speak for 15 minutes of the Democrats' time?
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. ROBERTS. I thank my colleague from Minnesota. I will try to keep 
my remarks certainly more brief and more pertinent.
  The point I was trying to make--I know that the same is true with 
regard to Texas--the Senator from Texas is here--and also Minnesota and 
Maine--is the time to travel great distances, many miles. Our health 
care providers spend an awful lot of time traveling from one patient's 
home to another. What happens is that the first patient may be located 
many miles away from the next patient. It requires the home health care 
nurse to work virtually nonstop to meet the deadlines required for the 
submission of the data to HCFA, which interferes with the personal care 
and the travel time. This is like 24-hour duty that is exacerbated by 
all of the data requirements.
  Ms. COLLINS. Will the Senator yield on that point?
  Mr. ROBERTS. Yes.
  Ms. COLLINS. The Senator has spent a lot of time understanding OASIS. 
One of the complaints I have heard is that OASIS even requires, in some 
cases, the collection of data for non-Medicare patients; is that 
correct?
  Mr. ROBERTS. I tell my distinguished friend that unfortunately that 
is correct. Any Medicare-approved home health agency must comply with 
all Medicare conditions of participation, including the collection of 
OASIS. This means that patients who

[[Page 18852]]

do not participate in Medicare are still subject to the Medicare 
assessment. That is exactly correct.
  Last year, HCFA amended this regulation to say that these agencies 
don't have to transmit the data on non-Medicare patients for the time 
being. However, the agency still must spend the time making the 
assessment. So it is sort of a Catch-22. I am certainly sympathetic to 
the concerns raised by my constituents that these new regulations and 
spending cuts will harm, again, the senior. But aren't these policy 
changes necessary to achieve the Medicare saving goals established by 
the Balanced Budget Act, I ask my colleague?
  Ms. COLLINS. As the Senator's rhetorical question implies, these are 
not necessary. The fact is that it now appears the savings goals set 
for home health have not only been met but far exceeded.
  According to CBO, spending for home health care fell by 35 percent in 
1999, and CBO cites the larger-than-anticipated drop in the use of home 
health services as the primary reason that total Medicare spending 
actually dropped, overall Medicare spending, by 1 percent last year. 
The CBO now projects that the post Balanced Budget Act reductions in 
home health care will be approximately $69 billion. That is over four 
times the $16 billion Congress expected to save. It is a clear 
indication that the cutbacks have been far deeper and far more wide 
reaching than Congress ever intended.
  Mr. ROBERTS. Will my distinguished colleague yield for another 
question?
  Ms. COLLINS. I am happy to yield.
  Mr. ROBERTS. My colleague referred to--and I referred to it in my 
opening comments--the additional 15-percent cut across the board in 
these payments to go into effect on October 1, 2001. With regard to 
what she has just related to the Senate, given the savings that have 
already been achieved, the question is obvious, is this additional cut 
necessary?
  I tell my colleagues and all those interested in this particular 
issue that last year we had to come up with an emergency bill. Nobody 
likes to do that.
  We would prefer it to go through authorization and appropriations. 
Nobody likes to be faced with an emergency bill. This year is the same 
way. We are wrestling with that in terms of the budget caps we should 
live with. We are trying to figure that out. Here we are willing to 
provide more emergency money and we turn around and go through another 
15-percent cut. It seems to me that is not conducive to what we are 
about with regard to consistency. What effect would that have with 
regard to home health care agencies?
  Ms. COLLINS. A further 15-percent cut would be devastating. It would 
sound the death knell for those low-cost, nonprofit agencies in our 
States, which are currently struggling to hang on. It would further 
reduce our seniors' access to critical home care services. As we have 
discussed, we don't need to do it. We already have more than achieved 
the savings goals that were put forth in 1997.
  Mr. ROBERTS. If the Senator will yield for an additional question, 
what are we going to do to help remedy this serious problem? I know the 
Senator has legislation, but would she summarize what she thinks is the 
answer to that.
  Ms. COLLINS. The Senator from Kansas has been a strong supporter 
along with my colleagues, Senators Bond and Ashcroft from Missouri, as 
well as many colleagues, in cosponsoring legislation introduced to 
eliminate the automatic 15-percent reduction in Medicare payments that 
would otherwise occur. It would provide a measure of financial relief 
for those home health agencies that already are cost-efficient and 
doing a good job. That is what we need to do--to pass that legislation 
before we adjourn.
  Mr. ROBERTS. If I may ask one additional question, what kind of 
support do we have in the Senate? I think the magic number is 55. I 
would like for the Senator to tell our colleagues.
  Ms. COLLINS. I am pleased to confirm to the Senator from Kansas that 
my legislation has strong support not only from the Senator from Kansas 
but many of our colleagues. It has 55 Senate cosponsors, including 32 
Republicans and 23 Democrats, showing that this is a nationwide 
problem. It also has strong backing of many consumer and patient 
groups, including the American Diabetes Association, American Nurses 
Association, National Council on Aging, and the American Hospital 
Association. All of these groups have come together because they know 
that an additional 15-percent cutback would be absolutely devastating 
to American seniors and people with disabilities.
  So if we allow this to go into effect, any of our other efforts to 
strengthen Medicare and home health, to help improve that benefit will 
really be meaningless.
  Mr. ROBERTS. I have one final question. First, I thank the Senator 
from Maine for all her leadership and her hard work in this effort, for 
tapping not so gently on the shoulders of the leadership and, in a 
bipartisan way, attracting all sorts of support for this bill. I 
believe it is possible for Congress to bring this much needed relief to 
the home health care industry, as well as to the small rural hospitals 
and the teaching hospitals that are feeling the pinch of all these 
regulatory and legislative changes made in the last few years--with 
every good intent.
  But this is the law of unintended consequences personified. We must 
work quickly. Time is of the essence for many of our home health 
agencies and hospitals, especially the small rural providers. I don't 
want to have to go out again on a 105-county listening tour in Kansas 
and have people come and say; Senator Roberts, thank you so much for 
your past help on a whole litany of things we have gone through 
regarding the home health care delivery system, only to find out that 
their doors may close.
  I will continue to work with my colleague from Maine to pass 
legislation before Congress adjourns this year. We have a good team and 
we have good support. We cannot go home without providing help. I thank 
the distinguished Senator for her leadership in heading up a home 
health care posse for fairness and justice.
  Ms. COLLINS. I thank the Senator from Kansas for his kind comments 
and his strong support and leadership. He clearly understands the 
issues involved. Time is of the essence. I appreciate the opportunity 
to discuss this issue this morning.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Louisiana.
  Ms. LANDRIEU. Mr. President, I ask unanimous consent that after my 5 
minutes of remarks Senator Wellstone and Senator Harkin be recognized.
  Mr. GRAMM. Mr. President, does that reserve my 20 minutes?
  The PRESIDING OFFICER. The Senator's 20 minutes is not affected by 
this request.
  Ms. LANDRIEU. Is it the understanding of the Senator from Texas that 
after I speak Senator Harkin and Senator Wellstone will speak 
immediately after me? I am under the impression that we have about 20 
or 30 minutes on our side.
  The PRESIDING OFFICER. The total is 25 minutes.
  Mr. GRAMM. As I understand the schedule of the Senate, I think there 
would be no problem, as long as it didn't exceed 30 minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Ms. LANDRIEU. Mr. President, I thank the Senator from Texas. I will 
be very brief, and then Senator Wellstone will need about 10 minutes.
  I thank my colleagues from Maine and Kansas for taking time to speak 
on the floor about such an important issue as health care. As we wrap 
up this session, I am very hopeful, in a bipartisan way, we can address 
specifically many of the questions that were raised in terms of the 
tough situation facing our home health care agencies and hospitals, our 
rural health clinics. It is something this Congress must address in the 
last few weeks. I thank them for their leadership.




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