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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.
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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) 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.
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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, 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
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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,
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