[Congressional Record (Bound Edition), Volume 145 (1999), Part 6] [Extensions of Remarks] [Page 7988] [From the U.S. Government Publishing Office, www.gpo.gov]MEDICARE MODERNIZATION BILL NO. 3--RURAL CASE MANAGEMENT ACT OF 1999 ______ HON. FORTNEY PETE STARK of california in the house of representatives Thursday, April 29, 1999 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. ____________________