Medicare Physician Payment Equity Act of 2008

Mr. President, I am pleased today to introduce the Medicare Physician Payment Equity Act of 2008.

I stood before this body last December as we agreed to a short-term Medicare extension bill so that we would have the opportunity to address other

pressing priorities in a bipartisan Medicare package this year. One of the most significant issues I had hoped to address was the need to provide more equitable payment for physicians in Iowa and other rural states.

While the Medicare bill that Congress just enacted improves the situation for physicians in the near-term by averting the SGR payment cuts scheduled to occur during the next 18 months, it does little to remedy the unjustifiable geographic disparities in physician payment that exist. It is unfortunate that reforms to the geographic physician payment adjusters were not included in H.R. 6331. I have long supported more equitable treatment of physicians in rural areas, and I have pressed for reforms to the work and practice expense geographic adjustments in the Medicare physician fee schedule. However, much- needed reforms such as the establishment of a practice expense floor are not in the Medicare bill that Congress enacted last week.

The legislation I am introducing today is designed to remedy this problem by providing more equitable treatment for physicians in rural areas. The bill reduces inequitable disparities in physician payment resulting from the Geographic Practice Cost Indices or adjusters, known as GPCls, by establishing a 1.0 floor for physician practice expense adjustments as of 2009 and by providing a national 1.0 geographic index for physician work expense after the expiration of the existing 1.0 floor in 2010.

Although geographic adjustments are intended to reflect actual cost differences in a given area compared to a national average of 1.0, the existing, inaccurate formulas create significant disparities in physician reimbursement that penalize, rather than equalize, physician payment in Iowa and other rural states. These geographic disparities lead to rural states experiencing significant difficulties in recruiting and retaining physicians and other health care professionals because of their significantly lower reimbursement rates. This in turn leads to reduced beneficiary access to rural health care providers.

Here is a simple example that demonstrates the inequity of the current GPCI formulas. Iowa is widely recognized as providing some of the highest quality health care in the country, yet Iowa physicians receive some of the lowest Medicare reimbursement of any physicians in the country because of inequitable geographic adjustments. Medicare physician payment is equal in all 89 Medicare payment localities until the geographic adjusters, or GPCls, are applied. After the GPCI adjustments, however, Medicare reimbursement for some physician services in Iowa is at least 30 percent lower than payment for the same service in other parts of the country, and it is fundamentally unfair. Congress needs to reduce these unwarranted payment variations and realign Medicare incentives to reward physicians' quality instead of their geography.

Sadly, the inequitable geographic formulas which make these adjustments have merely exacerbated the problems of rural access to health care. Rural America today has far fewer physicians per capita than urban areas do. According to the National Rural Health Association, only about 10 percent of physicians practice in rural areas although nearly a quarter of the U.S. population lives there. Another grave concern is the lack of specialists in rural areas: only about 40 specialists exist per 100,000 in rural areas compared to more than three times as many--134 per 100,000--in urban areas. The evidence is clear that the existing geographic adjusters have been a dismal failure in promoting an adequate number of physicians in Iowa and other rural states. More severe physician shortages will occur in the future if we do not make essential changes to these formulas now.

The Medicare Physician Payment Equity Act revises the formulas used to determine geographic work and practice expense adjustments. The physician work formula currently used by the Centers for Medicare and Medicaid Services to estimate physician wages measures geographic differences in the earnings of six categories of professionals (lawyers, engineers, and others), rather than differences in physicians' earnings. In addition, the data that are used are based on outdated proxy data from the 2000 census. This bill recognizes that physician work for a service requires the same skill and training regardless of the geographic area, and should be similarly valued, and it establishes a national index of 1.0 for physician work beginning in 2010.

The practice expense formula used by CMS is inaccurate, outdated, and does not represent the actual office rent or employee wage costs for physicians in many areas. The office rent component uses Department of Housing and Urban Development residential apartment rental data from 2000 which does not accurately reflect physician office rent. The employee wage component comes from 2000 census data on clerical workers, nurses, and medical technicians which does not take into account any of the more highly compensated workers such as physician assistants, office administrators, and other specialists employed in physician practices today. The Medicare Physician Payment Equity Act provides for a more appropriate recognition of the geographic differences in employee wages and office rents by reducing the impact of this index to reflect more accurately the differences in physician practice costs, as of 2010. We must act now to help recruit and retain rural physicians to ensure that beneficiaries in Iowa and other rural areas will continue to have access to health care.

I urge my colleagues to support this legislation to address the growing problem of health care shortages in rural America by providing more equitable payment for physicians.

Mr. President, I ask unanimous consent that the text of the bill be printed in the Record.

Mr. President, I ask unanimous consent that the text of the bill be printed in the Record.

Mr. President, I am pleased today to introduce the Medicare Physician Payment Equity Act of 2008.

I stood before this body last December as we agreed to a short-term Medicare extension bill so that we would have the opportunity to address other

pressing priorities in a bipartisan Medicare package this year. One of the most significant issues I had hoped to address was the need to provide more equitable payment for physicians in Iowa and other rural states.

While the Medicare bill that Congress just enacted improves the situation for physicians in the near-term by averting the SGR payment cuts scheduled to occur during the next 18 months, it does little to remedy the unjustifiable geographic disparities in physician payment that exist. It is unfortunate that reforms to the geographic physician payment adjusters were not included in H.R. 6331. I have long supported more equitable treatment of physicians in rural areas, and I have pressed for reforms to the work and practice expense geographic adjustments in the Medicare physician fee schedule. However, much- needed reforms such as the establishment of a practice expense floor are not in the Medicare bill that Congress enacted last week.

The legislation I am introducing today is designed to remedy this problem by providing more equitable treatment for physicians in rural areas. The bill reduces inequitable disparities in physician payment resulting from the Geographic Practice Cost Indices or adjusters, known as GPCls, by establishing a 1.0 floor for physician practice expense adjustments as of 2009 and by providing a national 1.0 geographic index for physician work expense after the expiration of the existing 1.0 floor in 2010.

Although geographic adjustments are intended to reflect actual cost differences in a given area compared to a national average of 1.0, the existing, inaccurate formulas create significant disparities in physician reimbursement that penalize, rather than equalize, physician payment in Iowa and other rural states. These geographic disparities lead to rural states experiencing significant difficulties in recruiting and retaining physicians and other health care professionals because of their significantly lower reimbursement rates. This in turn leads to reduced beneficiary access to rural health care providers.

Here is a simple example that demonstrates the inequity of the current GPCI formulas. Iowa is widely recognized as providing some of the highest quality health care in the country, yet Iowa physicians receive some of the lowest Medicare reimbursement of any physicians in the country because of inequitable geographic adjustments. Medicare physician payment is equal in all 89 Medicare payment localities until the geographic adjusters, or GPCls, are applied. After the GPCI adjustments, however, Medicare reimbursement for some physician services in Iowa is at least 30 percent lower than payment for the same service in other parts of the country, and it is fundamentally unfair. Congress needs to reduce these unwarranted payment variations and realign Medicare incentives to reward physicians' quality instead of their geography.

Sadly, the inequitable geographic formulas which make these adjustments have merely exacerbated the problems of rural access to health care. Rural America today has far fewer physicians per capita than urban areas do. According to the National Rural Health Association, only about 10 percent of physicians practice in rural areas although nearly a quarter of the U.S. population lives there. Another grave concern is the lack of specialists in rural areas: only about 40 specialists exist per 100,000 in rural areas compared to more than three times as many--134 per 100,000--in urban areas. The evidence is clear that the existing geographic adjusters have been a dismal failure in promoting an adequate number of physicians in Iowa and other rural states. More severe physician shortages will occur in the future if we do not make essential changes to these formulas now.

The Medicare Physician Payment Equity Act revises the formulas used to determine geographic work and practice expense adjustments. The physician work formula currently used by the Centers for Medicare and Medicaid Services to estimate physician wages measures geographic differences in the earnings of six categories of professionals (lawyers, engineers, and others), rather than differences in physicians' earnings. In addition, the data that are used are based on outdated proxy data from the 2000 census. This bill recognizes that physician work for a service requires the same skill and training regardless of the geographic area, and should be similarly valued, and it establishes a national index of 1.0 for physician work beginning in 2010.

The practice expense formula used by CMS is inaccurate, outdated, and does not represent the actual office rent or employee wage costs for physicians in many areas. The office rent component uses Department of Housing and Urban Development residential apartment rental data from 2000 which does not accurately reflect physician office rent. The employee wage component comes from 2000 census data on clerical workers, nurses, and medical technicians which does not take into account any of the more highly compensated workers such as physician assistants, office administrators, and other specialists employed in physician practices today. The Medicare Physician Payment Equity Act provides for a more appropriate recognition of the geographic differences in employee wages and office rents by reducing the impact of this index to reflect more accurately the differences in physician practice costs, as of 2010. We must act now to help recruit and retain rural physicians to ensure that beneficiaries in Iowa and other rural areas will continue to have access to health care.

I urge my colleagues to support this legislation to address the growing problem of health care shortages in rural America by providing more equitable payment for physicians.

Mr. President, I ask unanimous consent that the text of the bill be printed in the Record.

Today I am introducing the Public Health Emergency Response Act. This bill authorizes a temporary health benefit during a public emergency for people in that area who don't have health insurance. The program makes it more likely that people who need healthcare services will get them and ensures that the doctors and nurses who treat them will be compensated.

Since 2000, the Secretary of Health and Human Services has had the authority to declare public health emergencies so that government can provide resources quickly to communities in need. That authority has been exercised very rarely--for 9-11; Hurricanes Wilma, Katrina, and Rita; and the recent flooding in the Midwest. These public health emergencies--both man-made and natural disasters--ruined neighborhoods, divided families, and weakened many spirits. But for every tragic emergency witnessed, we saw acts of remarkable selflessness and kindness.

One of the greatest examples of this generosity is in the efforts of local health care providers to meet the increased need for services. Whether it was the hurricanes that hit the Gulf Coast, the debris in downtown New York, or the waters in the Midwest, the need for medical services was immediate and in some cases dramatic. The demand for mental health services also rose in response to the psychological stress and trauma caused by the destruction of homes, the loss of jobs, the separation of families, and the death and devastation surrounding those in the areas hit by these tragic events.

Despite the trauma of a disaster or the pain from an injury incurred during a disaster, people who don't seek care not only leave themselves vulnerable to worsening health conditions, but they exacerbate the situation on the ground. For those uninsured people who do access medical care, the providers--typically those in areas immediately surrounding the disaster area--are often left without any compensation.

During Hurricane Katrina, the Harris County hospital district in Houston assumed responsibility for the health care of 23,000 evacuees living in the Reliant Astrodome. In Baton Rouge, hospitals struggled to meet the health care needs of a population that doubled in size after absorbing half a million evacuees. Health facilities and other public infrastructure were stretched beyond their capacity as they faced the multiple challenges of addressing the public health needs in the counties or parishes directly affected; delivering needed health care to the displaced; and ensuring the continued delivery of health care services to residents of the other areas.

Victims of public health emergencies should know that the government will assist them in their time of need. This is why I am introducing the Public Health Emergency Response Act.

The Public Health Emergency Response Act would make it easier for uninsured victims to seek treatment and would provide coverage to the health care professionals who are treating them. The bill would establish a temporary emergency health benefit for people who are uninsured. The benefit could be triggered only when the Secretary of Health and Human Services declared a public health emergency and chose to activate the benefit. The benefit would last for up to 90 days, and the Secretary could extend it once for another 90 days. Rather than put additional stress on our public health programs like Medicare, Medicaid or SCHIP, the funding mechanism for the benefit is the Public Health Emergency Fund, a no-year fund established in 1983. Funds for emergency victims' health coverage would be determined by Congressional appropriations. The bill will help save lives and ensure a functioning health care system for whatever lies ahead.

Most recently, we saw the entire Midwest reeling from weeks of flooding and tornadoes--from Minnesota to Kansas and everywhere in between--Wisconsin, Iowa, Missouri, and, of course, Illinois. The damage has been heartbreaking. We know from the great flood that devastated the Midwest in 1993 and from Hurricanes Katrina and Rita that the losses from this chain of weather-related disasters will be more than our states and citizens alone can bare. We also know that, in times of crisis, Americans have always come together to help those in need.

The Public Health Emergency Response Act carries on this tradition. The bill allows Federal government to prepare for the next emergency. We do not know what the next public health emergency will look like. It may be a bioterrorist attack, a hurricane, or pandemic flu. We should act now to create the framework for emergency health coverage and reimbursement.

Mr. President, I ask unanimous consent that the text of the bill and a letter of support be printed in the Record.

Mr. President, in 1831, the great chronicler of early America, Alexis de Tocqueville, explored the Great Lakes. As he passed through Lake Huron, he observed of the empty, undeveloped expanse: ``This lake without sails, this shore which does not yet show any trace of the passage of man, this eternal forest which borders it; all that, I assure you, is not grand in poetry only; it's the most extraordinary spectacle that I have seen in my life.''

Nearly 2 centuries later, the Great Lakes remain one of the most extraordinary spectacles in the world. The sheer size of the Great Lakes is impressed upon anyone who has stood on their shores, or who has seen the outline of the Michigan mitten, which the Great Lakes make one of the most distinctive shapes and recognizable shapes on maps or satellite photographs of the earth. Beyond their awe-inspiring appearance and enormity, the Great Lakes help fuel an economic engine that stretches from Minnesota to New York, producing some of our nations most celebrated and relied-upon goods and agricultural products.

This morning, my colleagues and I are introducing a joint resolution to ratify an historic agreement to manage Great Lakes water, the Great Lakes Water Resources Compact. While the existing Water Resources Development Act law provides sufficient protection and authority to prevent diversions, the Great Lakes Compact will provide an effective means for Great Lakes states jointly to safeguard water for future generations. The compact will ban new diversions from the Basin with certain limited exceptions, and those exceptions would be regulated. Further, the compact keeps the authority to govern our water in the hands of the Great Lake States.

The compact states that ``the protection of the integrity of the Great Lakes Ecosystem shall be the overarching principle for reviewing proposals.'' For the first time, water conservation goals will be developed to deal with any water diversion proposals.

Beyond that, the compact would specifically address withdrawals and diversions of both ground and surface water. This would represent an improvement over existing law because there are differing opinions on whether the current law addresses ground water diversions.

Additionally, because the compact would provide a scientific method for determining whether to allow a proposal to divert water from the Great Lakes, it makes our efforts to protect the lakes more clearly compliant with international trade agreements.

This agreement has been in the making for close to decade, following the mistaken issuance of a permit for bulk water diversion by the Province of Ontario. In the 2000 WRDA, Congress directed the governors to negotiate a water management policy, and in 2005, the eight Great Lakes Governors and two Canadian Premiers came to an agreement.

I have heard that some people believe that there is a water bottle ``loophole.'' The compact prohibits water in a container larger than 5.7 gallons to be diverted outside the Great Lakes basin. Though the compact would not prohibit water withdrawals in containers less than 5.7 gallons, individual states would retain their authority to regulate bottled water in any size container.

I believe that the Great Lakes Compact is beneficial and will provide greater protections for the Great Lakes than the status quo. However, as is explicitly stated in this joint resolution, the Great Lakes Water Compact does not imply that it is necessary for Congress to pass the compact in order for the Lakes to be protected from diversions. WRDA gives each Great Lakes governor veto power over certain types of diversions by any Great Lakes state. While this authority is clear, additional safeguards and standards will be helpful in the years ahead.

Tocqueville further observed during his journey in Lake Huron, ``Nature has done everything here. A fertile soil, and outlets like to which there are no others in the world.'' Nature has, indeed, given us so much in the Great Lakes. We need to take this important step to pass the Great Lakes Water Compact so as to make sure that we conserve this precious resource as best we can, ensuring sensible use now so that future generations can benefit from the Great Lakes as we do. I support passage, and I urge my colleagues to support it as well.

Mr. President, I ask unanimous consent that text of the Joint resolution be printed in the Record.

Mr. President, as Chairman of the Committee on Indian Affairs, I have overseen five hearings this Congress that confirm a longstanding and life threatening public safety crisis on many of our Nation's American Indian reservations.

One of the primary causes for violent crime is the disjointed system of justice in Indian country that is broken at its core. The current system limits the authority of Tribes to fight crime, and requires tribal communities to rely completely on the United States to investigate and prosecute violent crimes occurring on reservations.

This is a system that the United States created. With this responsibility, comes a legal obligation to provide for the public safety on Indian lands. Unfortunately, we are not meeting our obligation.

Between 2004 and 2007, the United States has declined to pursue an average of 62 percent of reservation criminal cases referred for prosecution. This means that 75 percent of adult and child sex crimes and 50 percent of homicides on Indian lands went unpunished in those four years.

This is an inherent flaw in the system. The system vests the prosecution of reservation crimes in the federal courts which are often located hundreds of miles away from the crime scene, the evidence, and the witnesses needed to prosecute these difficult cases.

The results of this system include an epidemic of domestic and sexual violence against American Indian and Alaska Native women. The Department of Justice reports that 34 percent of Native women will be raped in their lifetimes. This past February, the Centers for Disease Control and Prevention reported that 39 percent of Native women will be subject to domestic violence. These rates are more than twice the national average.

This broken system of justice has also drawn the unwanted attention of criminals to Indian lands. In recent years, reservations have been targeted as safe havens for criminal activity. One Federal prosecutor said that Indian lands are being used as pipelines by drug organizations to funnel their poison to tribal and nearby communities. These drugs eventually reach larger metropolitan areas.

To address this crisis, I am pleased to announce the introduction of the Tribal Law and Order Act of 2008 with the support of my colleagues Committee Vice Chairwoman Murkowski, and Senators Biden, Domenici, Baucus, Bingaman, Lieberman, Kyl, Johnson, Smith, Cantwell, Thune, and Tester.

This bill seeks to take initial steps at mending this broken system by arming tribal justice officials with tools to protect their communities.

The bill would expand on a program to enable tribal police to enforce violations of Federal laws on Indian lands.

The bill would also provide police greater access to vital criminal history information.

Further, the bill would enable tribal courts to sentence offenders up to 3 years in prison for violations of tribal law, an increase from the current limit of 1 year.

Title I of the bill would provide for greater consultation and coordination between federal law enforcement officials, tribal leaders, and community members. Increased communication and coordination at all levels of government responsible for crime on Indian lands is vital to combating this public safety emergency.

To increase coordination of prosecutions, the bill would require U.S. Attorneys to file declination reports and maintain data when refusing to pursue a case. Maintaining consistent data on declinations will enable Congress to direct funding where the additional resources are needed.

This bill was developed over the past 18 months in consultation with tribal leaders, tribal, federal and state law enforcement officials, and many others.

I want to again thank my colleagues for their support of this legislation, and urge the Senate to act to meet our public safety obligations to all tribal communities.

Mr. President, I ask unanimous consent that the text of the bill be printed in the Record.