To amend title XVIII of the Social Security Act to ensure Medicare beneficiary access to physicians, eliminate sweetheart deals for frontier States, and ensure equitable reimbursement under the Medicare program for all rural states.

SA 3569. Mr. GRASSLEY submitted an amendment intended to be proposed
by him to the bill H.R. 4872, to provide for reconciliation pursuant to
Title II of the concurrent resolution on the budget for fiscal year
2010 (S. Con. Res. 13); which was ordered to lie on the table; as
follows:

At the end of subtitle B of title I, insert the following:

SEC. __. REVISIONS TO THE PRACTICE EXPENSE GEOGRAPHIC
ADJUSTMENT UNDER THE MEDICARE PHYSICIAN FEE
SCHEDULE.

Effective as if included in the enactment of the Patient
Protection and Affordable Care Act, subparagraph (H) of
section 1848(e)(1) of the Social Security Act (42 U.S.C.
1395w-4(e)(1)), as added by section 3102(b) of the Patient
Protection and Affordable Care Act, is amended to read as
follows:
``(H) Practice expense geographic adjustment for 2010 and
subsequent years.--
``(i) For 2010.--Subject to clause (iii), for services
furnished during 2010, the employee wage and rent portions of
the practice expense geographic index described in
subparagraph (A)(i) shall reflect \1/2\ of the difference
between the relative costs of employee wages and rents in
each of the different fee schedule areas and the national
average of such employee wages and rents.
``(ii) For 2011.--Subject to clause (iii), for services
furnished during 2011, the employee wage and rent portions of
the practice expense geographic index described in
subparagraph (A)(i) shall reflect \1/4\ of the difference
between the relative costs of employee wages and rents in
each of the different fee schedule areas and the national
average of such employee wages and rents.
``(iii) Hold harmless.--The practice expense portion of the
geographic adjustment factor applied in a fee schedule area
for services furnished in 2010 or 2011 shall not, as a result
of the application of clause (i) or (ii), be reduced below
the practice expense portion of the geographic adjustment
factor under subparagraph (A)(i) (as calculated prior to the
application of such clause (i) or (ii), respectively) for
such area for such year.
``(iv) Analysis.--The Secretary shall analyze current
methods of establishing practice expense geographic
adjustments under subparagraph (A)(i) and evaluate data that
fairly and reliably establishes distinctions in the costs of
operating a medical practice in the different fee schedule
areas. Such analysis shall include an evaluation of the
following:

``(I) The feasibility of using actual data or reliable
survey data developed by medical organizations on the costs
of operating a medical practice, including office rents and
non-physician staff wages, in different fee schedule areas.
``(II) The office expense portion of the practice expense
geographic adjustment described in subparagraph (A)(i),
including the extent to which types of office expenses are
determined in local markets instead of national markets.
``(III) The weights assigned to each of the categories
within the practice expense geographic adjustment described
in subparagraph (A)(i).

In conducting such analysis, the Secretary shall not take
into account any data that is not actual or survey data.
``(v) Revision for 2012 and subsequent years.--As a result
of the analysis described in clause (iv), the Secretary
shall, not later than January 1, 2012, make appropriate
adjustments to the practice expense geographic adjustment
described in subparagraph (A)(i) to ensure accurate
geographic adjustments across fee schedule areas, including--

``(I) basing the office rents component and its weight on
occupancy costs only and making weighting changes in other
categories as appropriate;
``(II) ensuring that office expenses that do not vary from
region to region be included in the `other' office expense
category; and
``(III) considering a representative range of professional
and non-professional personnel employed in a medical office
based on the use of the American Community Survey data or
other reliable data for wage adjustments.

Such adjustments shall be made without regard to adjustments
made pursuant to clauses (i) and (ii) and shall be made in a
budget neutral manner.
``(vi) Special rule.--If the Secretary does not complete
the analysis described in clause (iv) and make any
adjustments the Secretary determines appropriate for 2012 or
a subsequent year under clause (v), the Secretary shall apply
clause (ii) for services furnished during 2012 or a
subsequent year in the same manner as such clause applied for
services furnished during 2011.''.

SEC. __. ELIMINATION OF SWEETHEART DEAL THAT INCREASES
MEDICARE REIMBURSEMENT JUST FOR FRONTIER
STATES.

Effective as if included in the enactment of the Patient
Protection and Affordable Care Act, section 10324 of such Act
(and the amendments made by such section) is repealed.
______