Senator SPECTER [presiding]. Senator Harkin had asked me to resume the hearing, and I had to vote early to try to save your time, Mr. Secretary, so we shall proceed at this time, and Senator Cochran has been waiting, and we will turn to you now, Senator Cochran.

Senator COCHRAN. Thank you very much, Mr. Chairman.

Mr. Secretary, welcome to our committee again. I am grateful for the opportunity to be able to personally thank you for coming to Mississippi and making the commencement address at Jackson State University last year. You honored us with your presence, and we appreciate also the cooperation of your Department in helping to deal with some of the special concerns that we have in our State, one of which is trying to cope with the continuing problem of bringing health care services to small towns and rural communities. This continues to be a problem, and we appreciate your understanding of that.

And we hope that some policy can be developed and implemented to help these small town hospitals that are under such great pressures.

I know that we have seen some experimenting with conversions to alternative kinds of services. For instance, in Richton, MS, the hospital has built a long-term care wing onto the facility, and now they have moved into a conversion. So that hospital is not a traditional hospital as they knew, but it is providing some services that were not available in the community, and I do not know whether they are going to make a go of it or not financially and be able to sustain those services, but that is an example.

We have seen others experimenting with other kinds of services. I wonder what your reaction to that is. The plight of those towns and communities and what you may have in mind that we can go back and tell those who are trying to cope with this problem.

RURAL HEALTH CARE

Secretary SULLIVAN. Thank you, Senator Cochran. Thank you for your kind remarks. It was a great pleasure to not only visit Jackson State University, but several places in Mississippi to talk to the physicians and visit the Mount Bayou Medical Center in the rural part of the State.

We are very concerned about the issue of health care for citizens in rural areas, and there are several things that we have done to try and provide some support there.

First of all, through our National Health Service Corps program we give preference for the Health Corps personnel that we assignphysicians and others to both rural areas and inner cities. We anticipate with the proposed increase that we will have in the pipeline an increased number of health professionals for such areas.

Also, as part of our budget we propose a minority health initiative to train more minority physicians and other professional personnel. In a State like Mississippi where I think about 35 percent of the citizens are black, this would have a great impact in providing more health services.

In the hospital update that we proposed last year and which was approved by the Congress, we gave a greater update and the reim

bursement grade for rural hospitals and also for large urban hospitals-that is, hospitals with 500 beds or over-because we felt that those two kinds of hospitals were under great stress.

As part of our physician payment reform, that the Congress passed last year, we are emphasizing a bonus payment to physicians in primary care in rural areas to make it more attractive.

We changed the criteria for sole community hospital status, hospitals with that designation would be reimbursed at national rates, giving them a higher reimbursement rate and where the criteria had previously been that the hospital had to be 50 miles away from the next hospital, we changed that to 35 so that a number of hospitals that had not been eligible could participate.

The Office of Rural Health Policy works with rural hospitals to help them find ways for administrative efficiencies and other improvements-we have increased their budget from $3 million to $4 million.

Those are some of the things that we have done to try and address the problem. This is an issue that is going to be part of our review and debate as we examine the reports coming to us and submitting to the Domestic Policy Council as President Bush charged me in the State of the Union Address.

What all of these things represent now are measures to help make adjustments in the system and keep things going. I envision a more comprehensive approach as we look at options that will be forwarded to us from our various committees.

Senator COCHRAN. I appreciate very much your personal interest in this and your leadership trying to help deal with these problems that we see in the rural areas and the small towns of our Nation. One thing that I just wanted to bring up and get your reaction to is that the Public Health Service has come up with 21 steps, I think, that they suggest should be part of a national strategy to improve our preventive health effort.

As I see this increasing cost of health care problem, getting worse and not better, it seems to me that maybe what we ought to try is emphasizing preventive health care through suggestions such as the strategies developed by the U.S. Public Health Service.

Of course, stopping smoking and dealing with the alcohol and drug abuse are things that have been mentioned, and there are others. Is there any way that you think we could help you by supporting efforts through appropriations of funds to implement that kind of strategy nationwide?

Secretary SULLIVAN. Well, Senator Cochran. I think you are referring to our Health 2000 goals, which focus on prevention. As those goals are enunciated, we want to give them as wide a dissemination as possible, through the mailing of brochures to the entire population, public announcements on radio, television, et cetera, as part of our effort to both improve the health of our citizens and to control costs through active participation by our citi

zens.

We have a broad significant educational effort to do that which must be ongoing-not simply a one-shot effort or a 1-month effort. We have known since the early 1960's that smoking resulted in lung cancer. The first Surgeon General's report on smoking was issued in the early sixties. As you know, it was only in the last 6 or

8 years that we have now begun to see changes in the health behavior of our population.

We need to reinforce that. What I am saying is, a health education effort must be an ongoing sustained effort and not simply an effort for 1 year, but really continued through many years.

HEALTH CARE FINANCING ADMINISTRATION

Senator CоCHRAN. I know that our Medicaid and Medicare Programs have the big challenge of trying to keep people happy in terms of reimbursements and timely response to inquiries and the like from health care providers.

Just this week I had a chance to meet with a group of providers from my State, and a common complaint I heard was the fact that there are delays and unnecessary delays and problems in dealing with the Health Care Financing Administration.

I know we have an opportunity to talk to them later today, as I understand it, and I will bring this up, but I just wanted to mention it as something I hope at your level there can be some emphasis placed on being more responsive to the hospitals and those who file their vouchers or forms for reimbursement.

There seems to be a tremendous amount of tension and dissatisfaction that is developing, at least in my State over this issue. Maybe it is the provider's fault, I do not know, but somebody needs to look into it, and I hope you will ask for a report on that and see how quickly they are making those checks out and sending them back.

They have the suspicion down home that they sent in their voucher and there is somebody up here that tells them to hold them and sit on them about 3 weeks before they process them, that that is a way of delaying payment and getting better budget numbers to send to OMB or somebody. That is a suspicion out there, and we need to deal with that.

Secretary SULLIVAN. Yes, Senator Cochran. We indeed are very concerned about that, the new HCFA Administration, Dr. Gail Wilensky, shares this concern. We are very pleased that she is on board. This is one of the areas that we have identified as needing attention.

We are required to make those payments, I believe, within 24 days of the receipt of the voucher. Until this year we actually were also mandated by the Congress to make the payments-between 14 and 24. The requirement for holding claims for 14 days prior to payment expired at the end of fiscal year 1989.

We are making efforts to make those payments sooner when we get our systems working.

Senator COCHRAN. Thank you very much.

Thank you, Mr. Chairman, for the time.

Senator SPECTER. Thank you, Senator Cochran.

Dr. Sullivan, I have just a few more questions that I would like to discuss with you. Senator Harkin has asked me to proceed, and I think this will wrap it up.

I have taken a look at the two facilities which you had described, checked with them, and I am aware of what has been undertaken with respect to Washington House, which was a Department of De

fense facility transferred to the city in 1985 that I had worked on. There is an additional homeless women's facility which was established in May 1988 as a smail, 20-bed facility, and this is really separate from the request which I had discussed with you last year and have been made a part of the Senate report accompanying the Labor, Health and Human Services, and Education appropriation bill on page 182 (S. Rept. 101-127) there is a reference to the committee having provided $9,090,000 for a homeless research demonstration project, and it enumerates a number of factors, including detoxification services and referenced on the same page problems in cities such as Philadelphia. So, I just want to round that out by saying this is different, and I would very much appreciate your attention to this one as soon as we can process the application.

Secretary SULLIVAN. I will give it my personal attention. We want to do everything we can to be sure that the response in our agency is as rapid as possible.

Senator SPECTER. I would appreciate that.

You had commented that there had been a delay on appropriations, and I had questioned that and I was told that it is a general practice to await the appropriations process. I ask you to review that, as to whether it is necessary to await the final appropriation, where you have a project as important as this one.

But, at any rate, we are on track now, so I would appreciate your attention to it.

DRUG REHABILITATION

Dr. Sullivan, last year I had brought up the subject with you which I had raised with your predecessor, Dr. Bowen, the year before, regarding what rehabilitation works on the drug issue. When Dr. Bowen was here in 1988, there had been a comment that they did not really have much to rely upon in the way of experience as to what was successful.

As I had expressed to you last year, this is a concern I have had for more than two decades since the founding of drug rehabilitation centers that I helped with in Pennsylvania in 1968. I am interested to know, and you might want to submit this in writing since time is short, and it is past noon, as to what progress has been made on the identification of treatments which work.

You had submitted a written answer for the record last year, and there had been some preliminary information, but there were more projects to be evaluated, and I would be very much interested to follow this up not only with a written answer now, but with continuing responses so we can evaluate just what we are accomplishing by way of finding out what does work.

Secretary SULLIVAN. We will be pleased to submit that to you. I am pleased that with the increased funding for demand reduction activities will provide significant increased funding for research on new types of therapy.

[The information follows:]

METHODS OF TREATMENT

I share your concern in determining what methods of treatment are effective. Dr. Charles Schuster, Director of the National Institute on Drug Abuse, will provide the committee with a report on treatment method effectiveness. In August, 1989, a tech

nical review was sponsored by NIDA on "Improving Drug Abuse Treatment". A full report of what was discussed at the technical review will also be included in Dr. Schuster's report to the Committee.

MENTAL HEALTH

Senator SPECTER. Well, there had been that direction in the 1988 legislation giving your Department a new responsibility. If we can document programs which work on rehabilitation, I think that the Congress would be very interested in increasing funding.

Dr. Sullivan, the next point that I want to take up with you briefly is the issue of mental health, and I do not know that there is a whole lot to be said about it except that we really need to search for additional funding. I ask your assistance on that as Senator Harkin and I and others try to find more money for that very important line.

There is a lot of sentiment in Congress for increased funding because there have been so many breakthroughs and it seems so productive to utilize those funds at this time.

Secretary SULLIVAN. Senator Specter, I share your concern. I was pleased that Congress passed the resolution to declare 1990 the decade of the brain. We have proposed in our budget $99 million for research in schizophrenia. We believe that much remains to be done. We look forward to working with you as we expand our research and our understanding of mental disorders such as Alzheimer's disease.

Senator SPECTER. Very good. We will look forward to doing that. The next topic that I want to just touch on is this issue of crack babies. I recently visited St. Francis Hospital in Pittsburgh, where there has been a grant of some $1 million, and there is very important research being undertaken on women who are addicts are giving birth, Thomas Jefferson Hospital, where there is a special pediatric AIDS program and St. Christopher's Hospital in Philadelphia. Again, we are balancing many needs for funding, and we are trying to find answers through limited funds for pilot projects, and I just wanted to mention that we will be following up with you on this matter of expanding on present efforts.

Secretary SULLIVAN. Thank you.

GAUCHER'S DISEASE

Senator SPECTER. Now, the final subject I want to talk to you about-and there are many, many like these, but I had a contact on a special problem relating to a disease known as Gaucher's disease. And the President of the Gaucher's Foundation, Mr. Michael Epstein met with Dr. Mray Goldstein, Director of the National Institute on Neurological Disorders and Stroke and Dr. Ross Brady, head of the Gaucher's disease intramural research program at NINDS.

What this boils down to is that they need additional enzyme for clinical treatment to determine the appropriate dosage, as I understand it, for a treatment of Gaucher's disease, which affects some 15,000 to 20,000 children nationwide.

It comes down to a need to find $2.5 million to buy the enzyme, and among the many, many requests which have crossed my desk,