Madam President, our vote today on H.R. 6331 carries real and immediate consequences for people who depend on Medicare. Action on this legislation is mandatory now because, 8 days ago, the temporary fix we passed at the end of last year…
Madam President, our vote today on H.R. 6331 carries real and immediate consequences for people who depend on Medicare. Action on this legislation is mandatory now because, 8 days ago, the temporary fix we passed at the end of last year expired. The cuts are in effect.
Next Tuesday, when the Centers for Medicare and Medicaid Services begins paying claims for services rendered after June 30, 2008, payments will be cut unless we pass this measure.
Because I return home every evening to my State, I interact frequently with Maryland providers. They cannot sustain a nearly 11- percent cut in their Medicare payments; they and many of their colleagues will stop accepting new Medicare patients unless we pass this bill.
The pending cuts are the result of a flawed system that pegs provider reimbursement to the growth of the Nation's GDP. It was created by the 1997 Balanced Budget Act as a way to rein in dramatic growth in Medicare spending on physician services. But this system, known as SGR, has not worked as intended. In fact, every year since 2001, Congress has had to act to prevent the cuts from going into effect. We know that the SGR formula must be repealed.
I have introduced legislation in past years to eliminate SGR and replace it with a system that reimburses based on the actual reasonable costs of providing care. The bill that was passed overwhelmingly by the House, H.R. 6331, provides another temporary fix through December 31, 2009. That is sufficient time for the next Congress, working with a new administration and the provider community, to develop a new mechanism.
But although ``doctor fix'' is the shorthand often used, this bill is far more than that, and our failure to pass it has repercussions far beyond physician offices. Another provision that expired on June 30 is the exceptions process for outpatient rehabilitation services. The 1997 Balanced Budget Act imposed dollar limits of $1,500 on Part B therapy services--one cap for physical and speech-language therapy, and another for occupational therapy. They are adjusted annually for inflation and are now at $1,810. I was a member of the Ways and Means Health Subcommittee at the time. Congress held no hearings on this issue to examine how the caps might affect patient care. The authors of the provision had no policy justification for imposing them, and the dollar amount was arbitrary. These caps were imposed for purely budgetary reasons. They were a crude budget-cutting measure designed to deliver savings--$1.7 billion over 5 years.
This misguided policy ignored clinical needs and it restricted care for the most frail patients--such as those who are recovering from stroke or hip fracture, and those with multiple injuries in a given year.
And because the dollar limits are not adjusted for cost variations across the country, seniors in high cost areas reach their caps even sooner.
The University of Maryland's Shock Trauma Center was the first such unit in the Nation. It is a world-renowned leader in caring for critically injured patients. They see patients with extensive fractures, severe burns, spinal cord and brain injuries, and other debilitating conditions. These patients require lengthy therapy sessions to restore basic functioning. They cannot be rehabilitated for $1,810 a year.
The therapy caps actually went into effect once before, on January 1, 1999, and they had serious consequences for beneficiaries. By April, many patients in skilled nursing facilities had exceeded the limits and were unable to receive necessary care. The administration recognized the danger of this provision, stating:
The limits will reduce the amount of therapy services paid
for by Medicare. The patients most affected are likely to be
those with diagnoses such as stroke and amputation, where the
number of therapy visits needed by a patient may exceed those
that can be reimbursed by Medicare under the statutory
limits.
That year, I joined the now-junior Senator from Nevada, John Ensign, to introduce a bill to repeal the caps. We had significant bipartisan support and at the end of 1999, Congress delayed implementation for 2 years. Since that time, Congress has acted several times to prevent the caps from taking effect.
In 2006, Congress created an exceptions process that would allow beneficiaries needing care above the statutory caps to receive those services. It was the right thing to do. This process has worked well. Medicare is saving money and patients are getting needed care. In February, the Centers for Medicare and Medicaid Services released a study concluding that:
The exception process that allows beneficiaries who need
therapy to get that therapy, even if the cost goes beyond the
cap, has worked to control cost growth. This study reveals
that from Calendar Year 2004 through 2006, although the total
number of therapy users continued to increase by 3.5 percent
the overall expenditures actually decreased by 4.7 percent.
This suggests that the exceptions process in CY 2006 may
have satisfied to some extent the Congressional intent to
assure access to medically necessary services while
controlling the growth in expenditures.
The CMS study shows that the exceptions process works to control costs, yet still assures access for the more than 4.4 million beneficiaries who need additional care. The exceptions process allowed them to get the therapy they need to recover, function optimally, and live more productive lives. It allowed them to learn to cook, clean, and care for themselves after a stroke, to walk correctly and strongly after a hip replacement, and to speak and communicate after cancer surgery. But as of Tuesday, July 1, the process has expired. Section 141 of the bill we are voting on today continues the exceptions process through December 31, 2009.
This provision takes up just two lines of the bill. It is a small provision, but it has a major impact on seniors.
The story of Steve Kinsey and his patients illustrates why we must pass this bill without further delay.
Steve operates Hereford Physical Therapy in Baltimore County. He is anxious to know what the Senate will do this afternoon and so are the seniors he cares for. Steve's practice has about 9,500 patient visits each year, and one-fifth of them are covered by Medicare. He told me about two patients who are waiting for the Senate to act.
The first is a 72-year-old gentleman. He is a wheelchair-bound quadriplegic who needs physical therapy to keep up his strength. He qualified through the exceptions process, and so, although he exceeded the $1,810 cap in March, he has been able to receive therapy 2 days every other week to maintain his level of function.
The second patient is an 83-year-old woman who had a total knee replacement earlier this year. She received 20 visits and was under the cap, until a few weeks later when she fell and fractured her hip.
The cost of her care exceeded the cap 6 weeks ago, but after qualifying through the exceptions process, she has been able to continue treatment.
Because of the actions of a few Senators, as of Tuesday, July 1, these two Medicare beneficiaries can no longer receive care.
On July 1, CMS told providers: (1), that the exceptions process expired on June 30, 2008; (2), not to submit any claims with the code for exceptions because they will be automatically rejected; (3), that providers can check a CMS Web site to determine the amount of services their patients have received so far this year; and; (4), that patients who have reached the caps can go to an outpatient hospital department for care or pay out-of-pocket.
Because the exceptions process was in place for the first 6 months of this year, patients who have already gone beyond the cap--the patients most in need of care--must stop therapy or pay for it themselves. The average charge is about $80 for a 45-minute session. This is wrong.
If we do not reinstate the exceptions process as the bill before us would do, these individuals who need more care will be harmed. They received appropriate therapy under appropriate rules, but that does not matter: On July 1, they were effectively cut off from services that 8 days ago they were deemed eligible for. This is unfair and it is harmful.
Let's not forget that therapy services are also paid under the Medicare fee schedule, so the 10.6 percent cut will also apply to these services as well.
Now, as CMS stated, there is a last resort--to go to the outpatient department of a hospital for additional care. But Steve has learned that the two hospitals near his practice--GBMC and St. Joseph's--are turning away new patients because they don't have the capacity to see them.
Because of the shortage of therapists in Maryland and in other States, hospitals are already overloaded. So, Steve has 10 patients who are waiting at home for him to call and say they can come back in for therapy. They have no where else to go for treatment unless they pay out-of-pocket. They can't afford that.
Outpatient therapy services are paid under Medicare Part B. The people waiting for Steve's call are seniors who worked hard to qualify for Part A coverage and who are paying premiums for Part B. Working Americans--taxpayers--who do not yet qualify for Medicare, are paying to subsidize Part B premiums. The American people as a whole, not only providers and beneficiaries, should be outraged that a minority of the Senate is preventing us from moving forward on this legislation.
The 43 million seniors and persons with disabilities who rely on Medicare deserve a program that meets their health care needs. Our goal should be to ensure that Medicare provides comprehensive, affordable, quality care.
The bill also includes important beneficiary improvements. In 1997, I worked in a bipartisan way to add to the Balanced Budget Act the first- ever package of preventive benefits to the traditional Medicare Program. That was 11 years ago. At that time, the members of the Ways and Means Committee recognized what medical professionals had long known--that prevention saves lives and reduces overall health care costs.
Preventive services such as mammograms and colonoscopies are vital tools in the fight against serious disease. The earlier that breast and colon cancer are detected, the greater the odds of survival. For example, when caught in the first stages, the 5-year survival rate for breast cancer is 98 percent. But if the cancer has spread, the survival rate drops to 26 percent. If colon cancer is detected in its first stage, the survival rate is 90 percent, but only 10 percent if found when it is most advanced.
Seniors are at particular risk for cancer. In fact, the single greatest risk factor for colorectal cancer is being over the age of 50--when more than 90 percent of cases are diagnosed.
Sixty percent of all new cancer diagnoses and 70 percent of all cancer-related deaths are in the 65 and older population. Cancer is the leading cause of death among Americans aged 60 to 79 and the second leading cause of death for those over age 80. So preventing cancer is essential to achieving improved health outcomes for seniors. Screenings are crucial in this fight.
In addition to improving survival rates, early detection can reduce Medicare's costs. Under Chairman Conrad's leadership on the Budget Committee, we have had fruitful debates about the long-term solvency of Medicare. A more aggressive focus on prevention will help produce a healthier Medicare Program.
Medicare will pay on average $300 for a colonoscopy, but if the patient is diagnosed after the colon cancer has metastasized, the costs of I care can exceed $58,000.
There is no question that these vital screenings can produce better and more cost-effective health care.
The 1997 law established place improved coverage for breast cancer screenings, examinations for cervical, prostate, and colorectal cancer, diabetes self-management training services and supplies, and bone mass measurement for osteoporosis. Since then, Congress has added screening for glaucoma, cardiovascular screening blood tests, ultrasound screening for aortic aneurysm, flu shots, and medical nutrition therapy services. In addition, in 2003, a Welcome to Medicare Physical examination was added as a one-time benefit for new Medicare enrollees available during the first 6 months of eligibility.
But we can only save lives and money if seniors actually use these benefits. Unfortunately, the participation rate for the Welcome to Medicare physical and some of the screenings is very low. I have spoken with primary care physicians across my State of Maryland about this. One problem is the requirement to satisfy the annual deductible and co pays for these services.
Most colonoscopies are done in hospital outpatient departments, where their copay is 25 percent or approximately $85. Our seniors have the highest out-of-pocket costs of any age group and they will forgo these services if cost is a barrier.
The other barrier to participation is the limited 6-month eligibility period for the one-time physical examination. By the time most seniors become aware of the benefit, the eligibility period has expired. In many other cases, it can take more than 6 months to schedule an appointment for the physical exam and by that time, the patients are no longer eligible for coverage.
I have introduced legislation to eliminate the copays and deductibles for preventive services and to extend the eligibility for the Welcome to Medicare physical from 6 months to 1 year. My bill would also eliminate the time consuming and inefficient requirement that Congress pass legislation each time a new screening is determined to be effective in detecting and preventing disease in the Medicare population.
It would empower the Secretary of Health and Human Services to add ``additional preventive services'' to the list of covered services. They must meet a three part test: (1) they must be reasonable and necessary for the prevention or early detection of an illness; (2) they must be recommended by the U.S. preventive Services Task Force, and (3) they must be appropriate for the Medicare beneficiary population.
H.R. 6331 incorporates several elements of my bill in the very first section. It will waive the deductible for the physical examination, extend the eligibility period from 6 months to 1 year, and allow the Secretary to expand the list of covered benefits.
This bill will also help low income seniors by raising asset test thresholds in the Medicare savings programs and targeting assistance to the seniors who most need it. It extends and improves assistance programs for seniors with incomes below $14,040 a year, including the QI program, which pays Part B premiums for low-income seniors who don't qualify for Medicaid.
As this Congress continues to make progress toward passing a comprehensive mental health parity bill, this bill provides mental health parity for Medicare beneficiaries, moving their copayments from 50 percent to 20 percent gradually over 6 years. Depression, bipolar disorder, and other mental illnesses are prevalent among seniors, and yet fewer than half receive the treatment they need. This provision will help them get that treatment.
It will also ensure that a category of drugs called ``benzodiazepines'' are covered by Medicare Part D. When Part D took effect on January 1, 2006, millions
of beneficiaries found that the medicines they took were not covered by the new law. A little-known provision in the bill actually excluded from coverage an entire class of drugs called benzodiazepines. These are anti-anxiety medicines used to manage several conditions, including acute anxiety, seizures, and muscle spasms. The category includes Xanax, Valium, and Ativan. Most are available as generics.
The current-law exclusion has led to health complications for beneficiaries, unnecessary complexity for pharmacists, and additional red tape for the States. Beneficiaries who are not eligible for Medicaid have had to shoulder the entire cost of these drugs or substitute other less effective drugs. In 2005, I first introduced legislation that would add benzodiazepines to the categories of prescription drugs covered by Medicare Part D and Medicare Advantage plans.
This provision is essential for our seniors; without it, dual eligibles would have to rely on continued Medicaid coverage for benzodiazepines. Medicare beneficiaries who are not eligible for Medicaid will have to continue to pay out-of-pocket for them. For those who cannot afford the expense, their doctors would have to use alternative medicines that may be less effective, more toxic, and more addictive. This is a significant improvement for our seniors who are enrolled in Part D and for the fiscal health of our States.
This bill will also help our community pharmacies. I have heard from pharmacies throughout Maryland who cannot receive prompt reimbursement from private plans. This bill requires plans to pay them within 14 days of receiving a clean claim. It also requires plans to update their price lists weekly so that pharmacies have accurate data about what they should be reimbursed.
H.R. 6331 is paid for by small reforms to the Medicare Advantage program, in particular to private fee-for-service plans. The nonpartisan Medicare Payment Advisory Commission, MedPAC, has recommended that we equalize payments between Medicare Advantage and traditional Medicare.
As we discuss the solvency of the Medicare Program, we must take note that private health plans are not saving the Federal Government money. In fact, they are costing us money. I was a member of the Ways and Means Committee when health plans approached us with an offer.
If the Federal Government would pay them 95 percent of what we were spending on the traditional Medicare Program, they would create efficiencies through managed care--efficiencies that they said were lacking in traditional Medicare--that would save the Federal Government billions of dollars each year. They promised to provide enhanced coverage, meaning extra benefits as well as all the services covered by traditional Medicare, for 95 percent of the cost of fee for service. Congress gave them a chance to do just that.
Instead, what we saw across the country was cherry-picking of younger, healthier seniors. Each time Congress indicated that it would roll back their overpayments to a more reasonable level, they responded by pulling out of markets. In Maryland, the number of plans declined over a 3-year period from eight to one, abandoning thousands of seniors. Since 2003, when payments were substantially increased, the number of plans has steadily increased as well, but at too high a cost to beneficiaries, taxpayers, and the future of the Medicare Program.
Right now, these plans are paid up to 19 percent more than the amount that we would pay if these seniors were in fee-for-service Medicare. Over 10 years, we are overpaying them by more than $150 billion.
That is enough money to fund significant valuable improvements in the overall Medicare Program, or to permanently repeal the sustainable growth rate formula. It is time, for the health of the Medicare Program, to pay these plans appropriately. This bill would make small adjustments to these overpayments as well as prohibit the abusive marketing practices, such as cold calling, door-to-door sales, and offering incentives such as free meals, which have led to many seniors being enrolled in private plans without their knowledge or consent.
Mr. President, this is a balanced and responsible bill that addresses immediate reimbursement concerns while setting the foundation for a higher quality, more cost-effective Medicare Program.
The time to act is now. With the support of just one more Senator, we can pass an urgently needed bill and restore the promise of improved access, adequate reimbursement, low-income assistance, and additional needed benefits to the seniors who depend on Medicare. I urge my colleagues to support this legislation,
Medical Home Demonstration