Pete Stark

Mr. STARK

Mr. STARK. Mr. Speaker, it is with honor and profound respect that I rise today to salute Owen A. Marron, one of the most exemplary longtime leaders in the U.S. labor movement. Brother Marron was appointed to the Alameda County Central Labor Council in 1982 after a two-year stint in the U.S. Army and a long affiliation in the local United Steel Workers Union and SEIU. He rose up the ranks of leadership after his appointment to the Labor Council and was at the helm as Executive Secretary-Treasurer for the past decade. He was also elected vice president of the California Labor Federation. Brother Marron will be honored as Unionist of the Year on June 17, 1999 in Oakland, California. His numerous contributions and achievements will be applauded and well wishes will be extended as he retires. He will leave a legacy of commitment, strong leadership, unbending advocacy for affirmative action and for the rights of the disabled community, and tenacity in organizing and fighting for working people. Brother Marron's forty plus years in the labor movement will be long remembered and his leadership will be missed. I join his friends and colleagues in thanking him for his untiring efforts. Brother Owen Marron has indeed made a positive difference in the lives of many individuals.

Mr. STARK

Mr. STARK. Mr. Chairman, I rise in support of the Sanders-Stark- DeFazio amendment to freeze the Intelligence Budget at the 1998 level of spending. Without openness regarding the level of intelligence spending, there is no accountability. Without full accountability, I am not prepared to increase funds for intelligence. On Saturday, May 8, the U.S. bombed the Beijing embassy in Belgrade. The blame is being placed on the Central Intelligence Agency (CIA) for using an outdated map. Now, China is breaking off diplomatic ties with the U.S. on human rights and arms control. Many of my colleagues will attribute this fatal error--killing three Chinese journalists and wounding twenty other people--to shortfalls in intelligence spending on maps. However, in truth, this mistake was made by human error and the bombing should not be used as an excuse to spend more. There is no reason for the Intelligence Budget to be classified information. How can we justify a multi-billion blank check every year without disclosure of that amount to the American taxpayer? If this Congress is serious about saving Social Security and Medicare, we should not throw money into an unaccountable hole. Since almost all of the intelligence spending is hidden within the defense budget, we are misled about the real amount of intelligence spending through false line items in the defense budget. We must have budget integrity. The media, without compromising national security, routinely estimates the intelligence budget. When the government keeps this open secret clandestinely hidden, the American public grows increasingly cynical about their government. The Cold War is over. The specter of Communism no longer lurks on the horizon. While we face new challenges in this new age, the Intelligence community must share in the burden of fiscal accountability and discipline. I support the Sanders-Stark-DeFazio Amendment to freeze the Intelligence Authorization spending at the Fiscal Year 1998 level. Reports show that the U.S. spends more than twice the combined Intelligence budgets of our supposed hostile nations--North Korea, Iraq, Iran, Syria, Libya and Cuba. It is also more than the Intelligence budgets of the United Kingdom, Australia, Germany and Canada combined. Where has all of this secrecy gotten us? We bombed a Chinese Embassy in Belgrade, killing three and wounding others. We flew into a gondola in Italy, killing 20 unsuspecting civilians. And we destroyed a weapons and nerve facility in Iraq causing Gulf War illness in our military personnel serving in the Persian Gulf. The American taxpayer deserves to know what mistakes the CIA made and how they will be corrected. The Sanders-Stark-DeFazio Amendment calls for a CIA report on the accidents that have occurred over the past decade. I cannot, in good conscience, allow any type of spending increase when mistakes in U.S. Intelligence occur far too often and endanger innocent lives. For these tragedies, I urge my colleagues to support the Sanders- Stark-DeFazio amendment.

Mr. STARK

Mr. STARK. Mr. Speaker, I rise today to pay tribute to Fremont's Irvington High School. The California Department of Education has named Irvington as a 1999 Distinguished School--the most prestigious award they bestow. Consideration for this award does not come lightly. The California Department of Education uses a rigorous aggressive application model, which requires schools to be exemplary in their field. Irvington is a magnet school for the visual and performing arts, and currently 1,800 students are in attendance. Irvington High School should also be very proud of its cutting edge requirement that students complete 40 hours of service learning, or community service, in order to graduate. Programs such as these are what make Irvington stand out from the rest. I commend the faculty and students of Irvington High School for their dedication to excellence, and I congratulate them.

Mr. STARK

Mr. STARK. Mr. Chairman, I rise today in vehement opposition to the $12.9 billion supplemental appropriations for the military attack on Yugoslavia as well as the $11.7 billion substitute amendment. Last week, I voted against the bill to authorize the current NATO mission. In fact, the bill failed when two hundred thirteen members of this body also opposed the measure. Why is the majority leadership today requesting $13 billion for a mission they opposed just a week ago. It appears that the majority can't spend enough on a war they refuse to authorize. The majority is playing partisan politics with Kosovar and U.S. lives. I will not support a funding request for a mission that has no clear parameters and is laden with pork-barrel defense spending. The Administration asked for $6 billion in the emergency supplemental, not the $12.9 billion to be voted on today. This piece of legislation appropriates funds for some projects that clearly are not urgent in nature. Instead of giving NATO a war to justify it's purpose, we should be giving our elderly prescription drug benefits, our children better schools, and our workers a Social Security system they can count on when they retire. This bill will divert surplus funds attributable to Social Security in order to pay for military pay raises and retirement as well as military installations abroad that are completely unrelated to Operation Allied Force. Proponents who support this measure argue that the Pentagon in underfunded. they contend that we must improve our military readiness and quality of life for our military personnel. I disagree but the debate on the appropriate level of defense spending should come in the context of the normal appropriations process where spending caps cannot be broken. The emergency supplemental should not create an opportunity for ``Christmas at the Pentagon'' with more cruise missiles, laser guided bombs and other munitions added to our arsenal. Appropriating defense funds for the attack on Yugoslavia gives the President the authorization needed under the War Powers Act to continue the air strikes and allow him to use ground troops if necessary. However, if funds were withheld, the President would be required to remove the troops from their current mission by May 25, 1999. Unfortunately, those same Republicans who voted last week not to authorize the current air strike are essentially giving NATO carte blanche to carry out its air attack through the summer and beyond. If my colleagues really wanted to support the troops, they would help in the effort to end the NATO bombing. Thirty three thousand reserves have been called up for the Kosovo conflict. The Cold War is over. The U.S. and NATO must adapt their strategies to reflect this fact. They must learn to deal with regional conflicts and ethnic cleansing in an effective manner, including international diplomatic measures. I will not vote to spend billions of dollars for a mission that can be accomplished with a smaller price tag through diplomacy. I urge my colleagues to join me in opposing H.R.1664, Defense/Kosovo Supplemental Appropriations for FY 1999.

Mr. STARK

Mr. STARK. Mr. Speaker, the Balanced Budget Act of 1997 made some long-overdue savings in Medicare and has resulted in extending the life of the Part A Trust Fund from about 2001 to 2015. As budget policy, it has been a success. There are some health policy problems, however. In the BBA, we capped most outpatient rehabilitation services at $1500 per patient per year for physical and speech-language therapy, and for occupational therapy. This was good budget policy, in that it provided an immediate limit to a sector that was growing at totally unacceptable rates that seemed to have little to do with the true need for rehabilitation services. It is terrible health policy, however, because in fact there are individuals who desperately need more than $1500 in therapy. I am introducing The Medicare Rehabilitation Benefit Equity Act today to provide exceptions from the $1500 cap for those who clearly need extra services. It will also require that we move to a diagnostic payment system that makes good health policy sense. Under my proposal, the $1500 dollar limitations on services will be replaced by a patient classification system effective January 1, 2002. While the BBA policy needs to be modified, some limitations on rehabilitation services were clearly necessary. Between 1990 and 1996 Medicare expenditures for outpatient rehabilitation therapy rose 18 percent annually, totaling $962 million in 1996. During that time, outpatient rehabilitation spending shifted substantially away from hospitals and toward rehabilitation agencies and comprehensive outpatient rehabilitation facilities (CORFs). Payments to agencies and CORFs rose at an average annual rate of 23 percent and 35 percent, respectively. Clearly, Congress had to act--and using a meat-ax approach--we did. It is time to revisit this issue and substitute some decent health policy for blunt budget policy. The Medicare Payment Advisory Commission recently examined the potential impact of the coverage limits and found that some patients were more likely to exceed the dollar limits than others. The Commission found that hip fracture patients had the highest median payments and stroke patients incurred the next highest payments. While Medicare spent, on average, about $700 per outpatient rehabilitation patient in 1996, half of all stroke patients exceeded the $1500 physical and speech therapy limit. In contrast, less than 20 percent of patients with back disorders exceeded the physical and speech therapy limit. In 1996 about one-third of patients treated in non-hospital settings (rehabilitation agencies and CORFs) incurred payments in exceed of $1500 for outpatient physical and speech therapy or $1500 for occupational therapy. Half of the patients affected by the limits exceeded them by $1,000 or more. My legislation will minimize the inequity and disruption of the BBA limits without substantially affecting the program savings. It allows for a system of exceptions identical to those proposed in legislation by Senator Grassley. It then requires the Department of Health and Human Services to develop and implement a new coverage and payment policy of outpatient physical and speech-language therapy services and outpatient occupational therapy services. Instead of uniform, but arbitrary, dollar limitations, the new policy would be based on classification of individuals by diagnostic category and severity of diagnosis, in both inpatient and outpatient settings. The Medicare Rehabilitation Benefit Equity Act also requires that the revised coverage policy of setting durational limits on outpatient physical and speech language therapy and occupational therapy services by diagnostic category be implemented in a budget-neutral manner. This change in payment is related to overall utilization, it will not change the use of fee schedules or affect the payment rates for providers of these services. The payment methodology will be designed to be budget neutral in relation to the exceptions policy created by this legislation. Current law provisions to adjust the annual coverage limits on outpatient rehabilitation therapy services by the medical economic index (MEI), beginning in 2002, are retained. The Medicare Rehabilitation Benefit Equity Act recognizes that the Department of Health and Human Services' Health Care Financing Administration currently lacks the data necessary to implement a coverage policy based on a patient classification system on January 1, 2000. It further recognizes that assuring services for Medicare beneficiaries in the year 2000 is HCFA's number one priority. For these reasons, a phased--and longer than desired--transition to a patient classification coverage policy is necessary. I urge my fellow Members of Congress to join me in support of the Medicare Rehabilitation Benefit Equity Act of 1999. Together we can ensure that implementation of the BBA dollar limits on outpatient rehabilitation services will not disproportionately affect our most vulnerable Medicare beneficiaries.

Mr. STARK

Mr. STARK. Mr. Speaker, several Members have touted the idea that Medicare should be turned over to the private sector. Although they say that privatization will save the program, their true motivation is to irreparably damage Medicare to the point that there is nothing left to salvage. In the words of former speaker Newt Gingrich, they want Medicare to ``wither on the vine.'' Republicans have always intended to destroy Medicare. While they have found new ways to disguise their message over the years, their intention remains the same: get government out of health care no matter what the cost. ``Privatization'' is just another one of their ploys. The truth is that the private sector cannot provide high quality health services to disabled and elderly Americans. Especially not at a lower cost. Medicare was originally created to fill in the gap of health insurance coverage for older Americans, and later the disabled. Before Medicare, the private sector either refused to provide insurance coverage to the elderly, or made the coverage so expensive that seniors could not afford to pay the premiums. Lack of health coverage meant having to pay for health care out of their limited retirement incomes. This left many elderly poverty stricken. Today the health coverage problem for older Americans is getting worse, not better. The fastest growing number of uninsured are people age 55-62, an even younger group than when Medicare was first established. Rather than extending coverage to this uninsurable group, Republicans insist on doing nothing, even though the President's Medicare early-buy proposal would have cost nothing. Why should we believe that private sector insurers will put their financial interests aside and compete to provide coverage for an older, sicker population when evidence suggests that they will not? Especially as costs for the chronically ill continue to rise. Republicans have also claimed that the private sector will save money for Medicare. This is simply not true. Over the past thirty years, Medicare's costs have mirrored those of FEHBP and the private sector, even though Medicare covers an older, sicker population. Recent evidence shows that private sector costs are now rising faster than Medicare's. Last fall Medicare+Choice plans abandoned 400,000 Medicare beneficiaries claiming that the Medicare rates were too low to cover this population. This suggest that health plans will charge ever more than we currently pay them, not less. Privatizing Medicare will not improve quality, either. Paul Ellwood, the ``father of managed care,'' recently stated that the private sector is incapable of improving quality or correcting for the extreme variation in health services across the country and that government intervention is necessary and inevitable. In his words, ``Market forces will never work to improve quality, nor will voluntary efforts by doctors and health plans. . . . Ultimately this thing is going to require government intervention.'' Why would we want to encourage more people to enroll in private health plans given the managed care abuses igniting the Patient's Bill of Rights debate? Medicare is the primary payer for the oldest elderly, chronically ill, disabled, and ESRD patients--all very complex and expensive groups to care for. Private managed care plans, which primarily control costs by restricting access to providers and services, simply do not meet the health care needs of everyone in this population. For the most part, Medicare+Choice plans have enrolled only the healthiest beneficiaries, while avoiding those most in need of care. There is no way of knowing whether or not private health plans are able to provide quality care to the sickest population. Medicare beneficiaries will have significant difficulties making decisions in a market-based system. This is potentially the most disastrous consequence of moving to a fully privatized Medicare program. Many Medicare beneficiaries are cognitively impaired. Thirty percent of Medicare beneficiaries currently enrolled in managed care plans have low health literacy. That is they have difficulty understanding simple health information such as appointment slips and prescription labels. Now we're discovered that health plans often fail to provide critical information to potential enrollees. How can we expect senior citizens and the disabled to participate as empowered consumers in a free-market health care system, especially without essential information? Medicare reform cannot be based solely on private sector involvement. More than 11 million Medicare beneficiaries--30% of the population-- live in areas where private health plans are not available, and because of the limited number of providers probably never will be available. A comprehensive, viable, nationally-based fee-for-service program must be maintained for people who either cannot afford to limit their access to services in private managed care plans, or who are incapable of participating in a free market environment. Unfortunately the debate surrounding privatizing Medicare is grounded in ideology, not fact. While I understand the need to improve and expand the choices available to Medicare beneficiaries--the Medicare+Choice program was created in recognition of this--we also have an obligation to preserve the promise of guaranteed, affordable health insurance for the people who need it most. The private sector is not a panacea for our problems. Historical experience proves that alternative solutions are necessary for our elderly and disabled citizens. Before we move to an entirely new system, we should attempt to improve the existing infrastructure, one that has served elderly and disabled citizens effectively for over thirty years.

Mr. STARK

Mr. STARK. Mr. Speaker, three weeks ago, I introduced H.R. 1392, the ``Centers of Excellence'' bill. H.R. 1392 would allow Medicare to provide incentives for beneficiaries to use certain high-volume, high- quality facilities. This initiative would both save lives, and save money for Medicare. It is a widely acknowledged fact that facilities that perform large numbers of complex procedures have lower mortality rates and fewer adverse outcomes. These facilities, known as ``Centers of Excellence,'' have become an important private sector tool for quality improvement and cost containment. An April 22 article in the Wall Street Journal highlighted an Ohio HMO with a Centers of Excellence program for heart procedures. After automatically removing facilities that performed fewer than 250 heart procedures per year from their list of preferred providers, the HMO conducted an extensive quality survey to determine the rating of the remaining facilities. This resulted in several more facilities being removed from the list, including some very reputable hospitals in the area. The Ohio experience showed that facilities with the best reputations for excellence did not necessarily have the best outcomes. Being removed from the Ohio HMO's preferred provider list was a strong competitive incentive for lower-quality facilities to improve their procedures. For one facility, the rate of heart attack following bypass surgery dropped from 2.8 percent in 1993 to 0.9 percent in 1997. A national ``Centers of Excellence'' program would likely have the same result, spurring facilities with a lower quality rating to improve their services and raising quality standards overall. Not only will H.R. 1392 improve quality, it will also lower costs for Medicare. Fewer complications after surgery mean less follow up care and fewer medical expenses. Targeting patient volume to certain facilities can also result in discounted prices. Although ``Centers of Excellence'' passed the House in 1997, political motivations have kept it from becoming law. quality health care should not be a pawn in the political chess game. We have a second chance to implement this important change for Medicare. I strongly urge my colleagues' support for H.R. 1392.

Mr. STARK

Mr. STARK. Mr. Speaker, I rise today to introduce ``The Medicare Critical Need GME Protection Act of 1999.'' This important legislation seeks to protect our nation against the depletion of health care professionals that are trained to appropriately treat costly and deadly illnesses. Under current law, the Medicare program provides reimbursement to hospitals for the direct costs of graduate medical education training. That reimbursement is designed to cover the direct training costs of residents in their initial residency training period. However, if a resident decides to proceed with further training in a specialty or subspecialty, a hospital's reimbursement is cut to half (50 percent) for that additional training. The rationale for this policy is strong. In general, we have an oversupply of specialty physicians in our country and a real need to increase the number of primary care providers. By reducing the reimbursement for specialty training, the Medicare program has promoted increases in primary care training rather than specialty positions. I agree with this policy. However, as is often the case, there are always exceptions to the rule. We do not want to hinder training of particular specialties or subspecialties if there is strong evidence that there is a serious shortage of those particular physicians. That is why I am introducing The Medicare Critical Need GME Protection Act. To provide an example of a current subspecialty facing serious shortages of professionals, we can look at nephrology. Between 1986 and 1995, the number of patients with End Stage Renal Disease (ESRD) has more than doubled. At present, more than 40 million Americans die from kidney failure or its complications each year. In 1998, the estimated cost to treat ESRD exceeded $12 billion. However, current data indicates that only 51.8 percent of today's nephrologists will still be in practice in the year 2010. Most primary care physicians are not trained to treat the complex multi-symptom medical problems typically seem in ESRD and are unfamiliar with particular medications and technology prescribed for such patients. The decreasing supply of nephrologists, coupled with an expanding population of renal patients, puts the health of our nation at risk. The Medicare Critical Need GME Protection Act provides a tool to help combat such shortages of qualified professionals. The bill would simply provide the Secretary of Health and Human Services with the flexibility to continue full-funding for a specialty or subspecialty training program if there is evidence that the program has a current shortage, or faces an imminent shortage, of physicians to meet the needs of our health care system. The Secretary would grant this exception only for a limited number of years. The Secretary would have complete control of the exception process. Programs would present evidence of the shortage and she could agree or disagree with the analysis. Nothing in this bill would require the Secretary to take any action whatsoever. The bill also includes protections for budget neutrality. If the Secretary approves a specialty or subspecialty training program for full-funding under this bill, the Secretary must adjust direct GME payments to ensure that no additional funds are spent. Again, The Medicare Critical Need GME Protection Act does nothing more than provide limited flexibility to the Secretary of Health and Human Services to ensure that we are training the health care professionals that meet our nation's needs. I would encourage my colleagues to join me in support of this important legislation. By giving the Secretary the flexibility to allocate funds to attract and train professionals in certain ``at risk'' fields of medicine, we will significantly improve patient care and lower long term health care costs.

Mr. STARK

Mr. STARK. Mr. Speaker, it gives me great pleasure to introduce the Rural Case Management Act of 1999, a common sense approach to delivering high-quality, coordinated health care in rural America. This is the third week, and the third bill, in my campaign to modernize and improve Medicare. Health care needs in rural areas are unique. Whereas many metropolitan areas suffer from an over-supply of providers, often there is only one provider serving a vast number of rural communities. One- size-fits-all solutions do not work for these opposite ends of the health care spectrum. Yet, Republicans continue to promote managed care as the solution for all problems and people. Most recently, they have asked taxpayers to subsidize private managed care companies in rural counties, despite the widely acknowledged reality that managed care cannot function in rural areas due to the lack of providers. Changes made in 1997 BBA result in outlandish over-payments to private managed care plans that serve rural markets. In some counties, health plans are being paid almost twice as much as it costs traditional fee-for-service Secretary to operate there. Putting more money into an idea that simply cannot work is ridiculous. It's like watering a garden that has no seeds. The Rural Case Management Act of 1999 would eliminate the waste established in the BBA by making payments directly to rural providers who coordinate care for their patients. This benefit would help coordinate care for the chronically ill, such as diabetes or HIV/AIDS patients, improve notification for preventive services, such as mammograms and flu shots, and provide follow-up care for people who need it. The choice to participate would be entirely voluntary: no one would be ``locked in'' to the web of a rural managed care plan that had limited providers and limited budgets. There is no evidence that managed care is better for consumers than fee-for-service Medicine. In fact, for the frail chronically ill, evidence suggests the contrary. If HMOs were established in rural communities, beneficiaries in the area might be forced to join in order to get any service from the few local doctors and the one local hospital. Then, if they needed expensive care at a specialty center, would their local providers be reluctant to refer them to that center for care, when the cost would come out of the small budget of the local, rural HMO? In light of the Patients Bill of Rights debate and the managed care horror stories I have shared with my colleagues in the past, I wonder if we should be subjecting rural America to monopolistic ``managed care'' unless much stronger consumer protections and quality measures are in place. Providers are also having a difficult time with managed care. In a recent Project Hope survey, providers reported very serious problems with HMO reimbursement, clinical review, and paperwork. We should not encourage the growth of a health system with this many problems. The most valuable thing managed care offers is coordinated follow-up care. This is an administrative function. Providers in areas without managed care can serve this function effectively. We can reap the benefits of managed care without throwing more money at an idea that simply will not work. The bill I am proposing would pay rural providers a special amount to provide the best thing that managed care has to offer: care management. Some Members believe that bringing managed care into rural areas would being prescription drug coverage to rural beneficiaries. This is not likely. Managed care needs competition in order to work. But there will never be competition in many rural areas. The problem is that rural areas do not have ``extra'' providers to compete against one other. Competition is also what results in extra benefits in Medicare managed care. Health plans vying for greater enrollment entice beneficiaries to their plan by providing extra benefits, such as prescription drug coverage and zero deductibles. Due to the lack of competition, these extra benefits will seldom be offered in rural areas. A recent GAO report noted that prescription drugs were the only extra benefit for which overall beneficiary access increased in 1999. However, access to prescription drugs actually decreased in lower payment (i.e., rural) areas. This decrease occurred despite the 23 percent payment increase in low-payment counties (compared to only 4 percent increase in all other counties). The GAO report proves that more money will not guarantee extra benefits in rural areas. We must find creative alternatives to solve the unique problems of health access in rural America. Managed care is not a silver bullet solution for delivering health care. In the best of worlds, managed care can offer coordinated health services for enrollees. The same function can be provided by providers who live in rural areas and have an established relationship with their patients. This bill eliminates the middle man by sending payments directly to providers in rural areas. Instead of spending money to create managed care plans in areas of provider shortages, this bill helps to improve the quality of care by putting the money where it is needed most. I strongly encourage members' support.

Mr. STARK

Mr. STARK. I thank the gentleman for yielding time to me, and I applaud the efforts of the gentleman from California (Mr. Campbell) for his resolution that forced this debate today. Without his efforts, we would continue to have U.S. military might, troops and weapons of war with no congressional deliberation whatsoever. I support his resolution, House Resolution 82, because the administration policy is not defined, it is not clear, it is not viable with its use of force. Indeed, it is hardly existent. Members have heard people talk about why we are not in other parts of the world, and excuse it blithely. I cannot. We cannot ignore all these other conflicts, but that does not give us an excuse, when we had no policy then, to begin killing people when we have no policy now. This resolution is of the highest priority because we must exercise our obligation under the War Powers Act to debate the use of military force, particularly so in light of the absence of any comprehensive policy on the part of our administration. Unfortunately, we are not allowed enough debate. We are going to talk about spending $13 billion, approving the committal of ground troops, which we all know is beginning while the debate goes on, and I support this resolution authorizing House Resolution 82 of the gentleman from California (Mr. Campbell) because the use of force is not working and will not work here. NATO has made matters worse, not better. The administration chose force as the most probable outcome by our expectations and deliberations in Rambouillet. The administration left no room for further negotiation or diplomatic efforts. They chose war. I do not. Our children, by the way, learn firsthand from our adult behavior. The Colorado deaths are no coincidence. They are the natural consequence of what our children see the national leaders in their adult role models perform. When the President held a press conference at the school to talk about conflict resolution, as he was talking, NATO-based troops were dropping bombs and explaining away civilian deaths as collateral damage. These civilians died because of our inability to resolve this crisis. The Campbell resolution provides that the troops should be withdrawn. I support this as a first step, not a last step, to bring peace in Kosovo.

Mr. STARK

Mr. STARK. Mr. Speaker, I rise today and ask my colleagues to join me in a commitment to the preservation of our environment as we celebrate Earth Day 1999. We have made great strides in the conservation of our dwindling wilderness resources. I would like to thank Forest Service Chief Michael Dombeck for his decision to halt new road construction in roadless forest areas across the United States, and for his continued leadership in the preservation of these irreplaceable resources. As someone who cares about protecting our environment, it has been frustrating to watch my colleagues in the majority pepper appropriations bills with language which would never pass Congress on its own merits. These special interest riders historically benefit only a few wealthy landowners and private interests; they do nothing for the good of our environment. I ask my colleagues to join me and vote against any bill that will do damage to our environment. Our policies should help us to leave a legacy of clean air and water to our children and teach them the value of leaving that legacy to their children. I would sincerely hope that my colleagues share in my concern. Otherwise, they will take their place in history as the party that allowed the destruction of our nation's greatest resources. Let's work together to ensure an environment in which our children can thrive.

Mr. STARK

Mr. STARK. Mr. Speaker, I rise today to introduce a House Resolution supporting the establishment of the fourth Friday in April as ``Children's Memorial Day.'' We are all saddened by the tragic shootings at Columbine High School in Littleton, Colorado. Unfortunately, violent acts against children are occurring with increasing frequency--destroying innocent lives and devastating families and communities. In the United States each day, five infants and children die from abuse and neglect, and seven teens are murdered. In fact, more children lose their lives to criminal violence in the United States than in any of the 26 industrialized nations of the world. This is unacceptable. In Alameda County, California, which I represent, the County Board with the hard work and strong dedication of Alameda County Supervisor Gail Steele, adopted in 1996 the Children's Memorial Flag Project and established a National Children's Memorial Day on the fourth Friday in the month of April to remember all of the children who have died by violence in our country. The Child Welfare League of America has adopted Alameda County's Children's Memorial Flag and promotes it nationally. This year we anticipate 20 State Capitol Buildings will fly the flag at half-mast, with 13 others memorializing these children by other means this Friday, April 23rd. We have lost far too many children in violent, preventable deaths, through gun violence, fire, automobile accidents, suicide, and physical abuse and neglect. From this moment forward, let us approach our work in Congress with renewed resolve. It is our responsibility and the responsibility of adults everywhere to protect children and to ensure that they have a full opportunity to become healthy and productive adults. Even one child lost is one child too many. I urge my colleagues to cosponsor this resolution and to honor the memory of children lost to violence in this country. Let us condemn acts of violence committed against the children of our communities and pledge to safeguard the welfare of the children in our nation.

Mr. STARK

Mr. STARK. Mr. Speaker, I am pleased to introduce the Patient Empowerment Act of 1999, the second in a series of Medicare modernization bills designed to improve program administration and the quality of health care for Medicare beneficiaries. Mr. Speaker, Medicare beneficiaries currently have little or no control over their health care decisions. Instead of choosing the most appropriate course of treatment for their particular circumstance, some patients are being told what they should do based on an oversupply of hospital resources or physician specialists in their area. Many diseases have several treatment options available. In most cases, there is no evidence to suggest that one course of treatment is better than another. Dr. John Wennberg, one of the world's most renowned health policy researchers, talks about this issue in the 1998 Dartmouth Atlas: ``The greater the per capita supply of hospital resources, the greater will be their per capita use, and the greater the per capita expenditures.'' The Atlas provides overwhelming statistical proof that in the economics of health care, supply often drives demand. Dr. Wennberg estimates that if Medicare spending for all hospital referral regions with higher rates were brought down to the level of spending in the Minneapolis region (considered a very high quality of care region), Medicare's financial problems would be solved. Many costly hospital stays could be averted entirely if Medicare beneficiaries were fully informed about their treatment alternatives. Not surprisingly, when presented with the range of available options, patients will often choose less invasive treatments. For example, treatment of benign prostatic hyperplasia, a common condition affecting the majority of men over the age of 65, ranges from surgical removal to watchful waiting. Each of the options raises a number of trade-offs: while surgery is the most effective way to deal with symptoms, undergoing surgery presents certain risks. In Wennberg's analysis, most men with mild symptoms choose watchful waiting when educated about the full range of options, and watchful waiting is clearly the least expensive of all the options. Patients have long deferred their medical decisions to their physicians. But medical care is becoming increasingly complex, and improvements in health technology have led to a multitude of available treatments. The treatment they choose should reflect the personal values and lifestyles of the patient and their family. Therefore, I am introducing a demonstration bill to give patients more power over their health decisions. The findings from these demonstrations could lead to ways to greatly reduce the cost of the Medicare program, without jeopardizing health outcomes. I strongly urge members to support this legislation.

Mr. STARK

Mr. STARK. Mr. Speaker, my colleagues and I are proud to introduce the ``Partial Hospitalization Services Integrity Act of 1999'' that will enact much-needed reforms to Medicare's partial hospitalization benefit. Partial hospitalization is an important component of Medicare. In- patient hospitalization for psychiatric treatment is expensive and disruptive to the person's life. Therefore, Congress created partial hospitalization as a cost-effective alternative for treating seniors with acute psychological disorders. The program allows them to live at home and receive intensive treatment. Unfortunately, many dishonest individuals have abused the partial hospitalization program and defrauded the government of millions of dollars. On October 5, 1998, the Department of Health and Human Services Office of Inspector General issued a report that exposed egregious waste, fraud, and abuse by many partial hospitalization providers. The report quickly gained national attention. Later that evening, NBC News featured the report in their ``Fleecing of America'' segment. The results of that audit represent a clear case of greed and fraud committed by dishonest mental health care providers. For example, the total program costs increased by approximately 482 percent between 1993 and 1997, from $15 to $349 million per year! More distressing is the fact that much of this was squandered on unreasonable and unnecessary services, given to people who were not eligible, and provided by organization that were not certified to provide the services. The bill that I am introducing will correct the conditions that lead to the abuse of the program. The Partial Hospitalization Services Integrity Act of 1999 clarifies the current definition of the organizations that can provide partial hospitalization services and includes clear civil monetary penalties for fraudulent claims. The legislation represents a broad consensus of interested parties that include the Administration, representatives of qualified partial hospitalization providers, and patient advocates. It is time to act quickly and decisively to preserve a valuable service and to stop the waste, fraud, and abuse perpetrated by unscrupulous operators.

Mr. STARK

Mr. STARK. Mr. Speaker, on Monday, April 19, the Washington Post ran a story about the failure of Medicare beneficiaries to get adequate preventive care. The article was based on a recent study by Dr. John Wennberg of the Dartmouth Medical School. Dr. Wennberg found that the level of retinal eye exams for Medicare beneficiaries with diabetes--so very important for helping prevent blindness in diabetics--was abysmally low. Only 43-45 percent of Medicare beneficiaries with diabetes received this critical service. One reason this important test is not provided more frequently is that, unfortunately, Medicare does not cover this service or pay doctors to do it. We should. Today, I am introducing legislation to rectify this omission and add this service to the list of preventive care benefits covered by Medicare--the ``Medicare Diabetic Eye Exam Act of 1999.'' Diabetes affects over 16 million Americans, and over 150,000 die from diabetes and its complications each year. Individuals of African, Asian, and American Indian descent are particularly vulnerable to this disease. Most of the morbidity and mortality of diabetes is due to the complications associated with the disease, including blindness, kidney failure, nerve damage, and cardiovascular disease. Diabetic retinopathy is the leading cause of blindness in the United States. Studies show that many of the complications of diabetes can be slowed or even prevented by better management of the disease, including regular eye examinations. Studies show that a periodic dilated eye exam is cost-effective in reducing the burden of diabetic retinopathy and blindness. The Diabetes Quality Improvement Project (DQIP) is an effort to recommend a set of diabetes-specific performance and outcome measures that health plans and providers can use in treating patients with diabetes. DQIP began under the sponsorship of the American Diabetes Association, Foundation for Accountability, Health Care Financing Administration, National Committee for Quality Assurance, and joined by the American Academy of Family Physicians, American College of Physicians, and Veterans Administration. HCFA is asking Medicare+Choice plans to use the DQIP measures this year in improving their care of diabetic Medicare beneficiaries enrolled in the plans. One of the measures contained in DQIP is retinal eye exams. DQIP recognizes that the dilated eye exam may not be necessary for everyone every year, and has developed a risk stratification scheme to guide plans and providers in determining frequency of providing the test. It is inexcusable that Medicare does not provide coverage and payment for this test that is so critical in preventing blindness. If we expect Medicare+Choice plans to provide this test, we should also provide payment for it. And we should provide payment for it in traditional fee-for-service Medicare, as well. Following is a copy of my bill. I urge that we add this provision to whatever Medicare bill is enacted by this Congress.

Mr. STARK

Mr. STARK. Mr. Speaker, today, Representatives Henry Waxman, John Dingell, myself and others are introducing the Access to Rx Medications in Medicare Act of 1999. Senators Edward Kennedy (D-Mass.) and Jay Rockefeller (D-W. Va.) are introducing the bill in the Senate. It provides a basic, affordable Part B benefit of $1,700 per year that will cover 80% of pharmaceutical costs for all seniors and eligible disabled individuals with more than $200 in annual drug costs. The bill also helps all Medicare beneficiaries by covering 100% of their costs above $3,000 in annual out-of-pocket prescription drug expenditures. The benefit is to be administered by private-sector entities such as pharmacy benefit managers (PBMs), insurers, or networks or wholesale and retail pharmacies, which would competitively bid for Medicare's business. Entities contracting with HHS to provide the drug benefit would be required to meet certain standards, including establishing an adequate formulary and an exceptions process to the formulary, as well as a 24-hour counseling program for enrollees, an education program for medical providers on appropriate prescribing and dispensation of covered drugs, and drug utilization review. To stabilize employer-sponsored retiree health coverage, we're proposing to subsidize employer's coverage by paying companies a capitated amount that would otherwise be paid to a private entity--but only if that coverage is at least as good as what Medicare is offering. In return, employers would have to agree to pay the cost of their retirees' Medicare Part B prescription drug premium for at least a year. Clearly, adding a prescription drug benefit to Medicare is not an inexpensive proposition. But the price of leaving pharmaceutical medications out of the programs' benefits package and instead paying for unnecessary hospitalizations for those who just `try to do without' is also high. The Food and Drug Administration estimated that the cost of hospitalizations caused by inappropriate use of prescription medicines was $20 billion annually higher in 1995. There are several financing options that I hope will be considered as the Medicare prescription drug debate advances. One is to assess tobacco companies for what they cost the program to treat smoke-related illnesses. A second is to support a strategy of recouping Medicare expenditures on tobacco-related diseases through suits against Big Tobacco. A third is to consider dedicating a portion of projected budgetary surpluses to paying for Medicare drug coverage. Debate about the financing options for a Medicare drug benefit will inevitably be contentious. But there is no better time to join this debate than today--when the program's solvency has been extended until 2015 even without an infusion of money from budgetary surpluses. With an infusion, the solvency timeline stretches far into the future--until 2027. It is time to turn our attention to meeting the needs of the growing number of senior citizens who are being rapidly priced out of drug coverage. Adding a prescription drug benefit is an investment--one of the most important we can make--in the health of tens of millions of our citizens. I recently sent out a survey to seniors in my district to assess the prices they pay for a range of specific prescription medications. Their responses were both revealing and sad. Asked what percentage of her monthly $547 income is dedicated to prescription drugs, one elderly women suffering from osteoporosis replied very simply: ``I cannot afford them.'' Queried about how this makes her feel, she said: ``I just try to cope.'' Another of my constituents, who has asthma, wrote: ``During the winter and spring my asthma is particularly bad and I have to use my inhaler quite often; and I sometimes am not able to purchase another, and I limit my use.'' Asked whether she has ever had to choose between paying for items like food or electricity because of the high cost of prescription drugs, she said: ``Yes, and I felt frightened.'' People who are sick need pharmaceutical treatment. Many who aren't take pharmaceuticals to stave off illness. In my case, taking Zocor lowers my blood cholesterol and helps reduce my risk of winding up in the hospital for costly bypass surgery. There are millions more elderly Americans with similar stories in congressional districts across the country. There are people who suffer from lack of medically appropriate access to pharmaceutical treatment. I submit that for a health plan in the year 2000 not to offer pharmaceutical care is preposterous. In today's era of unprecedented prosperity, who would say ``No'' to legislation providing prescription drug coverage to the one group that would benefit most--our nation's seniors? In the 105th Congress, we invested in children's health when we enacted the State Childrens' Health Insurance Program. Now we must fix the huge hole in Medicare's benefit package. If we don't a bolder future Congress will.

Mr. STARK

Mr. STARK. Madam Speaker, I am confused by this. It does tend to imbalance things. I am not so sure that if they had a two-thirds majority to cut taxes along with the two-thirds majority to raise it that I would not go along with them. I am not so sure that if they had a two-thirds majority to increase defense spending, I would not go along with them. I am not so sure if they had a two-thirds majority to cut payments to children, to cut Medicare, to cut benefits for the poor and the disabled that I would not go along with them. Because those right-wing, radical Republicans, with their majority, have been doing just that. They have been cutting money for education. They have been cutting money for health care. They have been cutting money for the impoverished. And all they want to do is give a big tax cut to the 2 or 3 percent richest people in the country for which they do not have the votes. And so they are stacking the deck. It is wrong. It is a way, in the case of Medicare, to see that we disband Medicare, to let it wither on the vine, as their former Speaker, a couple of iterations ago, decided to do. So what they cannot do within their own party with a simple majority they are trying to do by obfuscation and indirection and misuses of the Constitution, create an unbalanced situation where a small radical group of right-wing reactionaries can begin to control the spending in this country to disadvantage the majority. This constitutional amendment, if it ever came up, it certainly has gone through no committee hearings, it is reported out of the Republican leadership without any hearings, without any markup, and if it were ever to see the light of day, it would proceed to destroy the Medicare system, it would destroy Social Security, and eventually, I suppose, reach that goal of these radical right-wing Republicans, and that is to destroy Federal Government as we know it today.

Mr. STARK

Mr. STARK. Mr. Speaker, I rise today to call for the use of modern statistical methods in order to assure an accurate census in the year 2000. Without this, the undercount of the urban and rural poor and minorities will persist. H.R. 472, the Local Census Quality Check Act, would prevent the use of statistical methods by requiring the use of a postcensus local review as part of each decennial census. Representative Dan Miller's bill would require the Census Bureau to review the count of local addresses a second time--nine weeks after the census field work is done. This new requirement will consume so much time that the Census Bureau will be unable to carry out its plans to use modern statistical methods. The 2000 census will suffer from the same flaws as the 1990 census--millions of people missed and millions of others counted twice. Mr. Speaker, an accurate count is essential to California. The population in the 13th district of California was undercounted by 11,857 for the years 1991-1999. This translated into nearly $32 million in lost federal funds. In addition to formula funds, hospitals and community clinics which provide vital services in our communities use census data to determine where to build and whom to serve. Without an accurate count, our citizens will again be denied essential services. This legislation is opposed by the National Association for the Advancement of Colored People, the National Asian and Pacific Legal Foundation, and the National Association of Latino Elected and Appointed Officials, and for good reason. The 1990 Census missed 8.4 million people, miscounting children, the poor, and people of color. The requirements in H.R. 472 would further undermine the accuracy of the next census, and would compromise our constitutional assurance of ``one American, one vote.'' It is critical that we put partisan policies aside and work to ensure an accurate census in 2000--for poor and minority Americans in California and throughout the nation.

Mr. STARK

Mr. STARK. Mr. Speaker, for the past 14 years, hospitals have been up-coding their Medicare bills. Each year, the ``complexity'' of the cases that hospitals treat is said to increase. Like grade creep in a school, the way patients' illnesses are graded in a hospital gradually creeps upwards, and the taxpayer and Medicare pay more and more. Last year, for the first time, the ``complexity'' of the cases declined. As the following memo makes clear, this has something to do with the Administration's fight against waste, fraud, and abuse in Medicare and in the well-publicized case against Columbia-HCA. Taxpayers and Medicare beneficiaries should congratulate HCFA, the HHS Inspector General, and Justice for their efforts. Vigilance against fraud is a major reason that the life of the Medicare hospital trust fund has just been extended from 2008 to 2015. Date: November 19, 1998 From: Office of the Actuary Subject: Analysis of PPS Hospital Case-Mix Change between 1997 and 1998 The prospective payment system, PPS, uses diagnosis related groups, DRG's, as the basis of payment. Each DRG is assigned a relative weight which is used in the payment formula. Average case-mix is the discharge-weighted mean of all the DRG relative weights. We have monitored changes in case-mix since the beginning of PPS in FY 1984. From FY 1983 through FY 1997, case-mix increased every year. FY 1998 is the first year we have measured a decrease in case-mix. Based on information available through October 1998, we have measured a change in PPS hospital case-mix in FY 1998 of -0.74 percent. When we receive further updates for FY 1998, we estimate that the final measure of the FY 1998 case-mix increase will be in the neighborhood of -0.5 percent. Since FY 1998 is the first year that case-mix has decreased under PPS, I have undertaken a study of the reasons for this decrease. My study found the following: As is usually the case, some DRG's contributed to an increase in case-mix while others contributed to a decrease. The new DRG's for back and neck procedures increased case- mix 0.05 percent. The redefinition of DRG 116 in combination with DRG 112 increased case-mix 0.59 percent. The change in coding of pneumonia cases decreased case-mix 0.23 percent. DRG's in complex-noncomplex pairs decreased case-mix 0.82 percent. Non-pair DRG's decreased case-mix 0.27 percent. While assessing cause-and-effect is always difficult, I believe that some of the decrease in case-mix is likely to be attributable to certain efforts to combat fraud and abuse. The Department of Justice investigation of the Hospital Corporation of America, subsequent indictments, and the possibility of triple damages may have prompted hospitals to code diagnoses less aggressively--resulting in fewer complex cases. Similarly, the inspector general's investigation of pneumonia cases may have caused the significant shift of admissions from the more expensive respiratory infections DRG's to the simple pneumonia DRG's. HIPAA provides continuing funding for fraud investigations, which may have a continuing impact on increases in case-mix.

Mr. STARK

Mr. STARK. Mr. Speaker, I rise today in strong support of H.R. 912, The Medical Use of Marijuana Act, introduced by Representative Barney Frank. This bill would move marijuana from Schedule I of the Controlled Substances Act to Schedule II of the Act, allowing physicians to prescribe marijuana to patients with a clear medical need for the drug. Institute of Medicine studies have shown that components of marijuana relieve symptoms associated with terrible diseases such as AIDS, cancer, glaucoma, and epilepsy. The New England Journal of Medicine also supports the medical use of marijuana in relieving the symptoms linked with these illnesses. As an appetite stimulant, marijuana can help prevent the weight loss associated with cancer and AIDS. It can alleviate the nausea and vomiting associated with cancer chemotherapy. Marijuana has also been proven to provide some relief to patients with glaucoma and epilepsy. Additionally, marijuana can provide pain relief to millions of patients suffering from conditions ranging from post- surgery pain to chronic muscle spasms. Often the alternative pain relief options for these conditions have serious side effects such as liver and kidney damage, stomach bleeding, and ulcers. Marijuana has never been shown to cause death or serious illnesses such as these. Opposition to medical marijuana use has often focused on the belief that legalizing the drug for medical use will lead to an increase in its recreational use. I do not condone recreational use of marijuana, nor does H.R. 912 seek to increase illicit use. This bill is simply meant to treat marijuana as we treat drugs such as morphine. It would only be available to those with a doctor's prescription. A recent Institute of Medicine report entitled ``Medicine and Health Flash,'' concluded that there is no convincing data to support the believe that the medical use of marijuana will lead to an increase in its illicit use. The point of making marijuana a Schedule II drug is so that it can be regulated as closely as other prescription drug with the potential for abuse. As we have learned in the failing, ``War on Drugs,'' treating marijuana as an illicit drug in all circumstances not only fails to curb its recreational use, it eliminates a potential treatment for some of the most painful and terrible diseases. Treating marijuana as a prescription drug will give doctors more alternatives for alleviating the pain and suffering of their patients. H.R. 912 would allow for the use and possession of marijuana by those who have been prescribed the drug by a physician. Passage of this bill will succeed in opening the door to increased research into the ways marijuana can be of a medicinal value. We must not eliminate the drug as a potential tool for alleviating the suffering of millions of Americans. I urge my colleagues to support the Medical Use of Marijuana Act.

Mr. STARK

Mr. STARK. Mr. Speaker, today I am introducing the first in a series of bills to modernize Medicare for the future: the ``Centers of Excellence Act of 1999.'' Not only will this legislation save Medicare money, it will save the lives of many of its beneficiaries. Centers of Excellence has already been proven to decrease mortality and lower cost. Centers of Excellence originated as a demonstration project in the early 1990's to evaluate the effect of volume on quality and mortality for coronary artery bypass graft (CABG) surgery. The Department of Health and Human Services selected facilities on the basis of their outstanding experience, outcomes, and efficiency in performing these procedures. They found that hospitals that do large volumes of a certain type of procedure tend to have better outcomes and quality. The demonstration resulted in an 8 percent average annual decline in mortality and saved Medicare an average of 14 percent on CABG procedures. This year, CBO has scored the Centers of Excellence proposal as saving $300 million over five years and $600 million over ten years. Since the early 1990's, numerous reports have come out documenting higher quality care and lower mortality in facilities that perform a large volume of cancer treatments, cardiac surgeries, and transplants, among others. These conditions often require highly specialized care that should only be provided by the highest-rated facilities. Centers of Excellence is currently being used in the private sector to improve quality and decrease cost. Many private sector employers are requiring higher quality standards from their health plans. Not only are these employer groups able to improve quality through Centers of Excellence, they are also able to negotiate deeper discounts with high-volume facilities. Medicare should be given the authority to contract with certain hospitals for quality and volume--both to save money and to deliver better health care. Centers of Excellence has already been approved by the House in the past. The bill we are introducing passed the House in the 1997 Budget Reconciliation bill (H.R. 2015). H.R. 2015 would have made the Centers of Excellence program a permanent part of Medicare by authorizing the Secretary to pay selected facilities a single rate for all services, potentially including post-acute services associated with a surgical procedure or hospital admission related to a medical condition. As with the CABG demonstration, selected facilities would have to meet special quality standards and would be required to implement a quality improvement plan. The amendment was dropped in conference because of resistance from the Senate. Some Senators from States where no hospitals were designated as Centers of Excellence felt that the program tended to cast into doubt the quality or excellence of non-designated hospitals. Mr. Speaker, the name of this program is not important--what is important is that it can save money and by encouraging beneficiaries to use hospitals that have high volume, quality outcomes, it can save lives. Like Lake Wobegon, where all the children are above average, it is human nature for all Members of Congress to want their local hospitals to be above average. But not all hospitals are above average--and this is a serious matter. In fact, it is a matter of life and death. Indeed, good health policy in this nation would prohibit hospitals from doing sophisticated procedures if they do not have sufficient experience. This principle is applied to liver transplants, for example, and ought to be applied to other complex procedures as well. We may all have pride in our local hospitals, but the fact is: some of them are killing people because they do not do enough of certain types of procedures and therefore are not skilled in those procedures. I regret that this important provision has been subjected to pork- barreling by previous Congresses. I hope that this body will see that it is included in the next Medicare bill that moves through Congress. Some members of the now defunct Medicare Commission are proposing radical and unnecessary changes to Medicare. Before we cut back benefits and ask beneficiaries to pay more, we should explore every possible cost saving in the system. This bill is a step in the right direction: it saves money and improves the quality of care provided to seniors and the disabled. The 1999 Trustees report projects that the Part A trust fund will remain viable until 2015, one of the longest periods of solvency ever projected in the history of the program. Simple changes, such as the Centers of Excellence proposal, are all that are needed to improve Medicare for its beneficiaries. As further explanation of why this legislation makes great sense, I am including below ``Extracts from the November, 1995 Research Report'' on the Centers of Excellence Demonstration. Centers of Excellence Demonstration Extracts from November 1995 Research Report Rationale for the Demonstration: Physicians operate under different payment incentives than hospitals, so hospital managers have difficulties implementing more efficient practice patterns. A global fee that includes physician services aligns incentives and encourages physicians to use institutional resources in a more cost effective manner. Design of the Demonstration: Under the demonstration, Medicare paid each of the hospitals a single global rate for each discharge in DRGs 106 and 107, bypass with and without catheterization. This rate included all inpatient and physician services. The standard Medicare hospital passthroughs were also included, i.e., capital and direct medical education, on a prorated basis. Any related readmissions were also included in the rate. Pre- and post-discharge physician services were excluded except for the standard inclusions in the surgeon's global fee. All four hospitals agreed to forego any outlier payments for particularly expensive cases. The hospitals and physicians were free to divide up the payment any way they chose. Medicare Savings under the Demonstration: From the start of the demonstration in May 1991 through December 1993, the Medicare program saved $15.3 million on bypass patients treated in the four original demonstration hospitals. The average discount amounted to roughly 14 percent on the $111 million in expected spending on bypass patients, including a 90-day post-discharge period. Ninety percent of the savings came from HCFA-negotiated discounts on the Part A and B inpatient expected payments. Eight percent came from lower-than-expected spending on post- discharge care. Beneficiary Savings under the Demonstration: Beneficiaries (and their insurers) saved another $2.3 million in Part B coinsurance payments. Total Savings under the Demonstration: Total Medicare savings estimated to have been $17.6 million in the 2.5 year period.

Mr. STARK

Mr. STARK. Mr. Speaker, I join my colleagues to mourn the loss of Immigration and Naturalization Service attorney Joyce Chiang. Ms. Chiang was a bright young woman who was of uncompromising service to my staff on issues concerning immigration law. My staff spoke highly of Ms. Chiang, who was a knowledgeable representative of the agency, who confidently and concisely explained the intricacies of the 1996 immigration law. My district office was fortunate to benefit Ms. Chiang's expertise on implementation of the new law, as she fulfilled her trial-attorney training in the San Francisco INS office. I am saddened by the questions concerning her death as we mourn the loss of this bright young woman and fine public servant.

Mr. STARK

Mr. STARK. Mr. Speaker, I am today introducing legislation to reduce the ability of Medicare HMO's to use financial incentives to encourage doctors to deny care. Instead of letting HMO's just use the stick of payment denial, my bill encourages managed care plans to use the carrot of bonuses to improve health outcomes and provide more preventive care. As a result of legislation I first passed nearly 15 years ago, the Secretary of HHS has the authority to limit the amount that an HMO can place a doctor at financial risk if he or she orders tests for a patient, refers to specialists, or otherwise provides extra care. Using this authority, the Secretary has limited the amount that a doctor can be liable for such extra care to 25 percent of compensation. I have always thought that ``25 percent'' regulation provided too much power to HMO's to pressure doctors to deny care. Would you fly on an airline which withheld up to 25 percent of their mechanics' pay if they spent too much time checking out the airplane? No? Well, we allow HMO's to pay doctors that way. My bill reduces the 25 percent amount to no more than 10 percent over a 3-year period. In recent years, there have been a number of studies and reports that suggest the 25 percent figure is too high. Other reports have suggested that we encourage the payment of HMO doctors for quality of care, for the extent they provide preventive care services, and on how well their patients like the care they receive. These seem like commonsense ideas. They are ideas basic to any service type industry. But unfortunately, it looks like we need legislation to move HCFA and the industry in this direction. I hope my legislation can be considered as we debate managed care reform proposals, both for Medicare patients and for the general public. Following are some examples of how the current payment incentives may be bad for our nation's health--and how they can be improved. In 1998, 57 percent of primary care physicians in managed- care organizations in California reported feeling pressured to limit referrals. . . . From 1943 to 1985, the duration of the average visit to a physician's office fell from 26 to 17 minutes. Among family practitioners, the average visit in 1985 lasted 14 minutes. Whether or not there have been large reductions in the time physicians spend with patients, 75 percent of primary care physicians in managed-care practices in California reported pressure to see more patients per day.--From ``The American Health Care System,'' by Thomas Bodenheimer, in The New England Journal of Medicine, February 18, 1999. In all capitation agreements, the amount of overall financial risk or gain based on ``withholds'' and bonuses should be small and should be structured to avoid unusually intense conflicts of interest in individual clinical decisions. . . . In a survey of managers of health maintenance organizations, nearly half believed that physicians' decisions regarding the ordering of tests, referrals to specialists, and elective hospitalizations could be noticeably affected at individual risk levels ranging from 5 to 15 percent of income [note, the HCFA regulation is 25 percent]. In keeping with these views, and in the absence of empirical data, it seems reasonable to consider an aggregate risk of more than 20 percent for an individual physician--or even a group of physicians--as unacceptably high. Moreover, physicians should not be at risk of losing more money than is being withheld. Bonuses and distributions from withheld surpluses should be paid out in percentages of the targets achieved, in installments, or in other ways to avoid the possibility that the entire payment will depend on the health care costs of a few patients at the end of the contract year.--``Ethical Guidelines for Physician Compensation Based on Capitation,'' from The New England Journal of Medicine, September 3, 1998. Our results suggest that the goal of providing high-quality care may be better approached by the use of limited financial incentives based on the quality of care and patients' satisfaction than incentives that reward physicians for restricting access to specialty care or for squeezing in a greater number of visits per day. Policies that emphasize the former approach may enhance satisfaction with the U.S. health care system on the part of both patients and their physicians.--``Primary Care Physicians' Experience of Financial Incentives in Managed-Care Systems,'' by Grumbach, et. al., in The New England Journal of Medicine, November 19, 1998. . . . HMO managers believed that the impact of withhold accounts, bonus payments, and risk pools are subject to thresholds below which little or no effect is expected. For example, more than 90 percent of respondents reported no noticeable effect on the ordering behavior of physicians at risk as individuals if the level of withheld funds is below 5 percent of total HMO payment. Conversely, most respondents (nearly four-fifths) believed that there would be a noticeable effect when withholding represents 5-30 percent of total HMO payment. . . .''--``HMO Managers' Views On Financial Incentives And Quality,'' by Hillman, et. al., in Health Affairs, Winter 1991.

Mr. STARK

Mr. STARK. Mr. Speaker, recently, one or more companies (for example, Total Health Care Consulting, Inc.) have been writing doctors throughout the United States offering to rent office space from them at $21 a square foot but in some cases in an amount equal to $64 per square foot for the time the space is in use) and this space would be used to house rehab therapists. In some cases, these services are described as satellites of uninspected comprehensive outpatient rehab facilities (CORFs). The incentive for gross over-utilization of services in these kinds of deals is enormous. Implicit in the deal is, ``doctor, you can make a lot of money by renting spare office space to me, but I will have to keep busy . . . through referrals of your patients for rehab and physical therapy.'' I forwarded several of these contracts to the HHS Inspector General on the grounds that they violate various laws designed to prevent financial incentives to over-utilize Medicare services. I include in the Record at this point a response to my letter from the HHS IG. I want to thank the many good doctors who were troubled by this scheme and called my attention to it. As in all things, if someone offers you a sweetheart deal that it too good to be true, it either isn't true, or it is cutting a legal corner. Department of Health & Human Services, Office of Inspector General, Washington, DC, March 30, 1999. Re rental of physician office space. Hon. Pete Stark, House of Representatives, Washington, DC. Dear Mr. Stark: We are writing in response to your letter of March 24, 1999, regarding a contract and other materials describing an arrangement where a physician will allow his office to be used as a ``site'' for a new comprehensive outpatient rehabilitation facility in exchange for what appears to be inflated rental fees linked to expected referrals. We have received reports of similar activities from across the country. We share your concern that this activity raises serious questions under the Federal fraud and abuse laws, in particular the anti-kickback statute (42 U.S.C. Sec. 1320- 7b(b)) and we have forwarded your letter and accompanying materials to our Office of Investigations. If you have further questions, please feel free to have your staff contact Helen Albert, Director of External Affairs, at (202) 260-8610. Sincerely, D. McCarty Thornton, Counsel to the Inspector General.

Mr. STARK

Mr. STARK. Mr. Chairman, I yield 2 minutes to the distinguished gentlewoman from New York (Mrs. Maloney), a member of the Joint Economic Committee.