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would hurt both physicians and patients. As one rural Texas doctor told ASIM after the Texas carrier announced its new policy, many physicians call the carrier on behalf of patients who speak little English or are hard of hearing. They would no longer be able to afford to do so if such fee-per-call services are implemented.

ASIM also disputes HCFA's belief that many of these inquiries can be handled by recorded telephone messages. Physicians call carriers because they receive incorrect fee information specific to that individual physician. They want to know why a particular service was paid for last month but is being denied this month or why the carrier denied their hospital visit to Mrs. Jones who has chronic obstructive pulmonary disease, renal failure and anemia and required careful monitoring after a recent coronary artery bypass grafting. These questions do not lend themselves to, as Dr. Wilensky put it in her testimony, "computerized audio response units."

We are particularly concerned about how contractor funding affects the implementation of physician payment reform, which has already begun in anticipation of January 1, 1992. Changes in payment brought about by the geographic practice cost indices, relative value units for work and overhead, coding revisions and other elements of the fee schedule are certain to prompt many millions more inquiries to the carriers. Some of these questions could be alleviated through intensive provider education and training programs that HCFA has directed the carriers to undertake. However, the budget not only cuts by $1 million the professional relations category which funds those tasks but it pits the ongoing claims processing obligations of carriers against their other important beneficiary and physician services. If carriers do have to shift funds to contend with added demands resulting from payment reform, they are likely to shortchange claims processing and we will be back to the problem we faced this year. Blue Cross and Blue Shield Association of America is predicting 12 million more inquiries in 1992 than the 30 million projected by the Administration. Thus, some 33 million inquiries, many of which will concern changes resulting from payment reform, will go unanswered. Physician confidence in and support for payment reform specifically and the Medicare program in general would be seriously eroded.

ASIM urges this committee to give careful consideration to the needs of Medicare contractors because, ultimately, their operations affect the way physicians and beneficiaries view the Medicare program. Over the years, Congress has enacted laws requiring faster processing of claims, enhanced services to patients and physicians, expedited appeals procedures and other administrative requirements. These mandates are seriously undermined if carriers are not given the financial resources to carry them out. If indeed carriers come to view Medicare as a second-rate program, they will devote less time and attention to ensuring that it functions smoothly. This will adversely affect how the carriers treat physicians' Medicare claims and respond to patient inquiries, causing physicians and beneficiaries to view Medicare less favorably.

To summarize, Mr. Chairman and committee members, if these cuts in Medicare contractor funding are not averted, the likely effect will be (1) substantial delays in the appeal of improperly rejected claims, (2) increased out-of-pocket expenses to patients and increased physician financial liability for improperly denied claims while they seek reconsideration by the carrier, (3) an increase in the "hassle factor" as patients and physicians find it more difficult to reach the carrier to get answers to their individual questions, (4) the undermining of Congressional intent to improve the administration of Medicare, (5) erosion of physician confidence and trust in the federal government to implement physician payment reform property, (6) greater patient dissatisfaction with Medicare as their out-of-pocket expenses grow and it takes longer and longer to get information they need from Medicare, and (7) greater physician dissatisfaction with the program which may lead some physicians to limit their Medicare patient caseloads and exacerbate shortages of primary care physi

cians available to beneficiaries.


Senator BUMPERS. Let me say to all of you that it seems to me that each one of you have hit on something that is extremely important to Members of Congress, things that we talk about here increasingly.

Dr. Maloney, I am big on paperwork reduction. As a matter of fact, I am getting ready to introduce a bill again to further reduce paperwork. That is a big problem, isn't it?

Dr. MALONEY. It certainly is. It is growing like an avalanche.

Senator BUMPERS. Of course, I cannot read my bills. I just pay them. I do not know whether I am doing right or not. [Laughter.] I am not a Philadelphia lawyer, just a country lawyer, but I cannot decipher the bills I get from Medicare for the most part.

You make a very compelling case. As you know, the President is proposing an additional $20 billion cut in Medicare in addition to the $45 billion that he had already proposed. I can tell you categorically that is not going to happen. When we consider this rather mundane problem that you are talking about, compared to the bigger problems of the medical care in the country, it does not seem like very much.

Dr. MALONEY. There is a thinking that this is a cut to the provider, but it is, indeed, a cut to the beneficiary because physicians are acting as patient advocates many times when there are language barriers or other explanations which must be given to justify the coverage of the service. Ultimately they are approved, but this is going to lead now to 9 months. And there is going to be terrible frustration if that cannot be addressed.

Senator BUMPERS. Ms. Best, periodically we get these reports about poor training and the labs where wrong diagnoses have been made, wrong conclusions reached and so on. And you come here this morning and you tell us that you have a critical shortage of good laboratory technicians. The President has not proposed any funding to train clinical laboratory personnel or other allied health professionals.

I have been sitting up with my good friend, Senator Pryor, who is down at George Washington Hospital with a heart attack. I do not go to hospitals often, just when I have a close friend there or something, but I always try to be a keen observer about how things are going. And you keep hearing horror stories about different things. I must say I am impressed with how well those places run. It looks like chaos, but underneath the chaos, there is some organization to it. But when you get these tests and you go into the hospital and they take your blood and they test you for everything under the shining Sun, you are really at the mercy oftentimes of how well trained that clinical pathologist was.

So, you certainly make a very good point. When you start talking about scholarships and stipends for lab personnel, if they agree to work in underserved hospitals, you really get my attention.

And I want to say something nice about the President. Ronald Reagan tried to kill the National Health Service Corps every year he was President, and to George Bush's credit, he has resurrected it in a really good way and a big way. We hope to award up to 500 scholarships this fall to people who will go back into underserved areas. One of my strong interests here is to serve the Delta area, both sides of the Mississippi from the southern tip of Illinois to New Orleans. And I can tell you the doctors who go into these National Health Service Corps programs and agree to go back and serve in those areas really have my admiration.

Did you see the Court decision against a young woman who went through the National Health Service Corps and then declared bankruptcy so she wouldn't have to complete her service or pay back her scholarship? Her actual debt was about $150,000. And the court awarded a judgment against her for over $600,000. Right on.

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We entered into a contract with her, a binding contract, paid for her medical education, and then to try to pull off a scam like that is absolutely unforgivable.

But we have areas in eastern Arkansas if it were not for the National Health Service Corps, we would have no medical care. So, I applaud the President for that, and obviously, yours is just a small request, but essentially to do the same thing, and I applaud you for being concerned about it.

Dr. Jones, you are looking at the young, dynamic Governor of Arkansas 20 years ago who started the family practice division at the med center.

Dr. JONES. Yes, sir; I am aware of that, Mr. Chairman. Senator BUMPERS. We also started the AHEC program, and we modeled it after North Carolina's program. And so, I am a strong proponent of family practice. We have a great residency program in Arkansas.

And to you, Mr. Kelehan, I could not agree more with your proposals. I have to tell you that because about 73 percent of the people over 65 in this country vote, you all get about what you want. [Laughter.]

I tell my Democratic colleagues that one of the problems we face is a large majority of the people that we try to help do not vote. They do not feel it makes any difference one way or the other, and it makes it difficult.

We have reduced poverty among the elderly in this country from 25 percent in 1950 to 12 percent today. And a lot of that is because of the political clout the AARP and other elderly groups have, and I applaud you for it. Winston Churchill said the way you treat your elderly, the way you treat the condition of your libraries and the condition of your prisons are the real marks of a civilization. I agree with that.

Mr. KELEHAN. Thank you, Mr. Chairman.

Senator BUMPERS. Thank you all very much.


Senator BUMPERS. Let me call four more witnesses now: Dr. David Satcher, president of Meharry Medical College, Association of Minority Health Professions Schools; Michael K. Gemmell, executive director, Association of Schools of Public Health; Donald R. Cohodes, vice president, Federal Programs, Blue Cross & Blue Shield Association; and Kati Haycock, vice president of the Children's Defense Fund.

Dr. Satcher.

Dr. SATCHER. Thank you, Mr. Chairman. I am David Satcher. I am president of Meharry Medical College and president of the Association of Minority Health Professions Schools, and I appreciate this opportunity to present this testimony. I am going to summarize my testimony and submit the full document for the record.

Senator BUMPERS. Thank you very much.

Dr. SATCHER. I think you remember that there are eight institutions in our association. We represent three schools of pharmacy, three schools of medicine, a school of dentistry, and a school of veterinary medicine. And these institutions have educated a large per

centage of minority physicians, dentists, pharmacists, and veterinarians who practice ir this country.

And I guess if I were to summarize our mission, there are two major components to it. One, we are concerned about increasing access to the health professions for minorities and other disadvantaged persons, and we are concerned about increasing access for health care to underserved and disadvantaged communities.

And I just want to make the point that I think today in this country there is an urgency about that mission. I think we have a real problem in terms of access to health professional careers, and that is most dramatically reflected in the fact that so many students now leave health professionals schools with debt burdens that make it very difficult for them to pursue the careers in the areas that they would like to. I participated a few weeks ago in the American Medical Student Association meeting in Kansas City, and I can tell you that among those students throughout this country, there is a real concern about the growing debt burden.

So, I just want to echo your point about the National Health Service Corps and the critical role which that has played for so many low income and minority students in the past. In the absence of that program in the late 1980's many of these students either were turned away from the health professions or experienced the kind of debt burdens that is making it very difficult for them.

And getting back to that article in the Washington Post yesterday, one of the interesting things for me in that article was that 83 percent of the students who have received National Health Service Corps scholarships have, in fact, served in underserved communities. I think we forget that a lot of people do-because there are a few people like the young lady in that case yesterday who have not carried out their obligation, but the overwhelming majority have and have made a significant difference in access to health care in rural and inner city communities in this country.

So, we are concerned that the National Health Service Corps continue to grow. We do not think the President's budget growth is adequate. We would like to see at least $60 million put in National Health Service Corps scholarships. And again, since we realize the problem with the budget, it is important to emphasize what I think is the urgency in this country today of access to health care for the poor and the fact that providers in underserved communities are really struggling.

I will mention just a few other programs.

The AHEC program, which you are very familiar with, we are very concerned that there is zero in the President's budget for AHEC programs for 1992. Last year it was $19 million, and we feel that there should be at least $23 million in this upcoming budget. Again, the AHEC program is critical for many communities throughout this country. There are 1,500 designated underserved communities in this country, and the AHEC program gives us an opportunity to have our students and residents experience practice in these communities while they are still students and residents, while they are being tutored by faculty members who serve as role models. I really think it would be a serious mistake to allow that program to be inadequately funded. So, we urge you to support that program.

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The health profession student loans like the National Health Service Corps in a sense is important. Last year there were $2.9 million. The President has requested $15 million, and we support that. We think that it is important to continue to expand the low interest loans.


And again, title III is another program that is consistent with what we are trying to do in getting more minority and low income students into the health professions. Why is this important? There are many reasons. One is these students, when they graduate, are twice as likely to serve in underserved communities as other students.

Thank you.

Senator BUMPERS. Thank you, Doctor. [The statement follows:]

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