<DOC> [DOCID: f:45631.wais] HEALTH CARE FRAUD IN NURSING HOMES--PART II ======================================================================= HEARING before the SUBCOMMITTEE ON HUMAN RESOURCES of the COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT HOUSE OF REPRESENTATIVES ONE HUNDRED FIFTH CONGRESS FIRST SESSION __________ JULY 10, 1997 __________ Serial No. 105-68 __________ Printed for the use of the Committee on Government Reform and Oversight U. S. GOVERNMENT PRINTING OFFICE 45-631 WASHINGTON : 1998 ____________________________________________________________________________ For Sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512-1800 Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001 COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT DAN BURTON, Indiana, Chairman BENJAMIN A. GILMAN, New York HENRY A. WAXMAN, California J. DENNIS HASTERT, Illinois TOM LANTOS, California CONSTANCE A. MORELLA, Maryland ROBERT E. WISE, Jr., West Virginia CHRISTOPHER SHAYS, Connecticut MAJOR R. OWENS, New York STEVEN SCHIFF, New Mexico EDOLPHUS TOWNS, New York CHRISTOPHER COX, California PAUL E. KANJORSKI, Pennsylvania ILEANA ROS-LEHTINEN, Florida GARY A. CONDIT, California JOHN M. McHUGH, New York CAROLYN B. MALONEY, New York STEPHEN HORN, California THOMAS M. BARRETT, Wisconsin JOHN L. MICA, Florida ELEANOR HOLMES NORTON, Washington, THOMAS M. DAVIS, Virginia DC DAVID M. McINTOSH, Indiana CHAKA FATTAH, Pennsylvania MARK E. SOUDER, Indiana ELIJAH E. CUMMINGS, Maryland JOE SCARBOROUGH, Florida DENNIS J. KUCINICH, Ohio JOHN B. SHADEGG, Arizona ROD R. BLAGOJEVICH, Illinois STEVEN C. LaTOURETTE, Ohio DANNY K. DAVIS, Illinois MARSHALL ``MARK'' SANFORD, South JOHN F. TIERNEY, Massachusetts Carolina JIM TURNER, Texas JOHN E. SUNUNU, New Hampshire THOMAS H. ALLEN, Maine PETE SESSIONS, Texas HAROLD E. FORD, Jr., Tennessee MICHAEL PAPPAS, New Jersey ------ VINCE SNOWBARGER, Kansas BERNARD SANDERS, Vermont BOB BARR, Georgia (Independent) ROB PORTMAN, Ohio Kevin Binger, Staff Director Daniel R. Moll, Deputy Staff Director William Moschella, Deputy Counsel and Parliamentarian Judith McCoy, Chief Clerk Phil Schiliro, Minority Staff Director ------ Subcommittee on Human Resources CHRISTOPHER SHAYS, Connecticut, Chairman VINCE SNOWBARGER, Kansas EDOLPHUS TOWNS, New York BENJAMIN A. GILMAN, New York DENNIS J. KUCINICH, Ohio DAVID M. McINTOSH, Indiana THOMAS H. ALLEN, Maine MARK E. SOUDER, Indiana TOM LANTOS, California MICHAEL PAPPAS, New Jersey BERNARD SANDERS, Vermont (Ind.) STEVEN SCHIFF, New Mexico THOMAS M. BARRETT, Wisconsin Ex Officio DAN BURTON, Indiana HENRY A. WAXMAN, California Lawrence J. Halloran, Staff Director and Counsel Marcia Sayer, Professional Staff Member R. Jared Carpenter, Clerk Cherri Branson, Minority Counsel C O N T E N T S ---------- Page Hearing held on July 10, 1997.................................... 1 Statement of: Buto, Kathy, Deputy Director, Center for Health Plans and Providers, Health Care Financing Administration, accompanied by Linda A. Ruiz, Director, Program Integrity Group, Health Care Financing Administration................ 8 Fish, Faith, long-term care ombudsman, New York; Pat Safford, California Advocates for Nursing Home Reform; and Tess Canja, Board of Directors, American Association of Retired Persons.................................................... 39 Letters, statements, etc., submitted for the record by: Buto, Kathy, Deputy Director, Center for Health Plans and Providers, Health Care Financing Administration, prepared statement of............................................... 11 Canja, Tess, Board of Directors, American Association of Retired Persons, prepared statement of..................... 94 Fish, Faith, long-term care ombudsman, New York, prepared statement of............................................... 43 Safford, Pat, California Advocates for Nursing Home Reform, prepared statement of...................................... 79 Shays, Hon. Christopher, a Representative in Congress from the State of Connecticut, prepared statement of............ 3 Towns, Hon. Edolphus, a Representative in Congress from the State of New York, prepared statement of................... 6 HEALTH CARE FRAUD IN NURSING HOMES--PART II ---------- THURSDAY, JULY 10, 1997 House of Representatives, Subcommittee on Human Resources, Committee on Government Reform and Oversight, Washington, DC. The subcommittee met, pursuant to notice, at 10:10 a.m., in room 2247, Rayburn House Office Building, Hon. Christopher Shays (chairman of the subcommittee) presiding. Present: Representatives Shays, Snowbarger, Pappas, Towns, Kucinich and Barrett. Staff present: Lawrence J. Halloran, staff director and counsel; Marcia Sayer, professional staff member; R. Jared Carpenter, clerk; Cherri Branson, minority counsel; and Ellen Rayner, minority chief clerk. Mr. Shays. I would like to call this hearing to order. I am sorry for the delay. We had a bit of computer problems. This is our second hearing on health care fraud in nursing homes. On April 16, State Medicaid officials, the Health and Human Services [HHS], Department's Inspector General and the General Accounting Office [GAO], described the absurdly complex system of eligibility and reimbursement rules that governs $45 billion of annual Federal long-term care expenditures. It is a system that invites exploitation. In the nursing home setting, patients are an accessible, almost captive audience. Overlapping eligibility for Medicaid and Medicare benefits creates opportunities for dual billing and cost shifting between programs. Unscrupulous providers know the chances of getting paid are very good, while the odds of getting caught are currently very low. As a result, Medicare, Medicaid and the beneficiaries who rely on both programs are vulnerable to fraud, abuse, and waste in the form of unnecessary services, excessive prices, fraudulent billings, and poorly coordinated care driven by financial, not medical, considerations. Today, we invite the Health Care Financing Administration, HCFA, and nursing home patient advocates to join our discussion of health care fraud in nursing homes and to suggest how vulnerable programs and vulnerable patients might be better protected. Some aspects of the program can, and should, be addressed administratively. We asked HCFA and the HHS agency that pays Medicare claims and approves State Medicaid payment rules to describe current efforts to screen nursing home claims more effectively. Working with the IG, State Medicaid Fraud Control Units, the Justice Department and State long-term care ombudsmen, HCFA proved in Operation Restore Trust that a coordinate effort can uproot some of the scams that have taken hold in the jurisdictional cracks and crevices of the Byzantine Federal long-term care system. Other solutions to nursing home fraud require legislative action. Last year, this subcommittee was instrumental in advocating many of the antifraud provisions enacted in the Health Insurance Portability and Accountability Act, the act known as the Kassebaum-Kennedy bill. New criminal sanctions now protect all health care payers, public and private. Dedicated funding is now available for the coordinated antifraud enforcement efforts we know to be effective against increasingly sophisticated schemes. Building on that foundation, Congress is considering additional steps to strengthen Medicare and Medicaid program safeguards. One promising proposal calls for consolidated billing by the nursing home for all Medicare and Medicaid services to a patient. Currently, basic long-term care charges are paid by Medicaid, while Medicare Part A and Medicare Part B can be billed separately for ancillary services to the same nursing home patient. Consolidating all these charges should make it much easier to detect double billing, overcharges and cost shifting between payers. It should also improve the coordination and the quality of care provided to nursing home residents. That is the bottom line to all our calculations about health care fraud in nursing homes: the quality of care. This is not a victimless crime. Every time a bill is rendered for an unnecessary or never-provided service, someone is denied needed care. Every time a coffee klatch is billed as group therapy, nursing home patients suffer an incalculable loss, the loss of dignity. Every time Medicaid doesn't know what Medicare is paying, or vice versa, nursing home care becomes disjointed, dictated as much by the source of payment as the needs of the patient. But many victims of fraud in nursing homes remain silent. Some cannot speak for themselves and must rely on family members or friends to protect them. Others, dependent and vulnerable, are reluctant to complain against those on whom they rely for the necessities of daily living. So we asked our witnesses today to put a human face on what might otherwise be considered merely an economic crime and to describe their efforts to give voice to the silent victims of nursing home fraud. This subcommittee is delighted to have this hearing today. We welcome our witnesses, and we welcome our guests as well. [The prepared statement of Hon. Christopher Shays follows:] [GRAPHIC] [TIFF OMITTED] 45631.001 [GRAPHIC] [TIFF OMITTED] 45631.002 Mr. Shays. At this time I would call on my partner in this effort, Ed Towns, the ranking member of this subcommittee, if he has a statement. Mr. Towns. Thank you very much, Mr. Chairman, for holding this hearing today, hearing on the questionable billing practices which surround dually eligible people. However, as we approach this subject, I am reminded of the words of Health and Human Services Inspector General June Gibbs Brown who testified before this subcommittee on March 18, 1987. In her testimony on fraud in medical equipment and supplies, she told this subcommittee that we must proceed cautiously to ensure that any measure to control the benefits do not harm those beneficiaries who truly need these services. I believe those words have special meaning today; and I would like to say, thank you, June Gibbs Brown. Those people who are called dually eligible are eligible for both Medicare and Medicaid. As the General Accounting Office found, compared to the overall Medicare population, dual-eligibles are much more likely to be female, living alone or in institutions, a member of a minority group and have long- term, chronic illnesses. They are poor--and I mean poor. Eighty percent of the dual-eligibles have annual incomes of less than $10,000. By definition, these are the people who are most in need of accessible and compassionate health care assistance. Yet this group of vulnerable beneficiaries is most likely to face access problems. As the Congress takes a second look at the billing procedures of skilled nursing care facilities and home health care services and as the States move toward managed care for Medicaid patients, this group of patients is most likely to fall through the cracks of any complicated system with unconnected coverage guidelines and confusing billing rules. Therefore, Mr. Chairman, may I suggest that as we receive testimony here today we keep in mind that those who are eligible for benefits from both programs are not people taking advantage of a vulnerable system, but vulnerable people accessing benefits which Congress has rightfully provided. Again, thank you for holding today's hearing, and I look forward to the testimony of the witnesses and taking this information and working with you to try and strengthen the system. I yield back. Mr. Shays. I thank the gentleman. [The prepared statement of Hon. Edolphus Towns follows:] [GRAPHIC] [TIFF OMITTED] 45631.003 Mr. Shays. At this time, I call on Mr. Kucinich. Mr. Kucinich. Thank you very much, Chairman Shays. This hearing is of vital importance to the American public. The abuses that seem inherent in the system always affect those who are least able to protect themselves; and, as the chairman said, there is a necessity to put a human face on these hearings. Because waste, fraud and abuse involving Medicare or Medicaid involves people who were supposed to receive services, didn't get those services, perhaps were billed more than the services should have cost. Any time that happens what it leads to is an overall attack on Medicare and Medicaid itself. Because these programs were set up by the Congress to help people who needed help and provide a health safety net for the people of this country; and anyone who is involved in waste, fraud and abuse in this program is helping to shred that safety net. So there is great relevance to these hearings, and I congratulate the chairman for his interest and efforts in this regard. There is anticipation now of structural changes in the Medicare program itself; and if we are successful in these hearings in pointing out the areas where we can correct waste, fraud and abuse, we can perhaps do much to rescue Medicare from many of the most serious changes which would be to the disadvantage of the beneficiaries. The Department of Justice, Mr. Chairman, has estimated that perhaps up to 10 percent of the $35 billion in Medicare assets and Medicaid assets paid to--according to GAO, Federal Medicare and--Federal and State Medicare programs paid nursing home providers more than $35 billion in 1995, and the Department of Justice estimates about 10 percent of that is lost to fraud and abuse. So this is a question that has enormous impact today; and, Mr. Chairman, as you know, in the future, with the change in demographics, we have a growth of the nursing home industry occurring. There will be an even greater number of people applying for nursing homes, greater demands on the system and, therefore, increased stress on the health care resources of this country. So as we go into these hearings, I am hopeful that it will help to point the way to remedying the deficiencies in the system which keep the system from realizing its full potential to serve those who need help the most. Thank you, Mr. Chairman. Mr. Shays. I thank the gentleman. At this time, we will call on our first of two panels. The first panel is one individual, Mrs. Kathy Buto, Deputy Director, Center for Health Plans and Providers, from the Health Care Financing Administration. You are going to be accompanied, in the sense that there may be responses to questions, by whom else? Ms. Buto. Linda Ruiz. Mr. Shays. Our custom is to swear in all witnesses, including Members of Congress. At this time, I would like you to stand and raise your right hand. [Witnesses sworn.] Mr. Shays. For the record, both witnesses have responded in the affirmative. Before we receive your testimony, I just want to take care of some housekeeping things. I ask unanimous consent that all members of the subcommittee be permitted to place an opening statement in the record and that the record remain open for 3 days for that purpose. Without objection, so ordered. I ask further unanimous consent that all witnesses be permitted to include their written statement in the record; and, without objection, so ordered. Let me say that we put the clock on for 5 minutes, but I am going to roll it over again. It is important that we receive your testimony, so you will have as much time as you need for your statement, especially since you are the only witness on this panel. So, welcome. You may proceed. STATEMENT OF KATHY BUTO, DEPUTY DIRECTOR, CENTER FOR HEALTH PLANS AND PROVIDERS, HEALTH CARE FINANCING ADMINISTRATION, ACCOMPANIED BY LINDA A. RUIZ, DIRECTOR, PROGRAM INTEGRITY GROUP, HEALTH CARE FINANCING ADMINISTRATION Ms. Buto. I actually will try to be brief, because I know there are a number of questions, and everyone has received my written testimony. Mr. Shays. Let me just say, though, I want to make sure that, for the record, you put in some of that verbally, so feel free. Ms. Buto. Mr. Chairman, members of the subcommittee, I am pleased to be here to discuss HCFA's fraud and abuse prevention initiatives. My testimony will focus on the type of fraud and abuse that occurs in nursing home settings. We must be increasingly vigilant in guarding against improper provider claims and billing, particularly as demand for services increase with the growth of the Medicare and Medicaid populations. We have some innovative ways to fight this type of fraud and abuse which I will describe and have described in detail in my written testimony, and I will touch on in my statement here. We have all heard the proverb ``an ounce of prevention is worth a pound of cure.'' This is especially pertinent in the area of physical well-being. By guaranteeing the initial accuracy of both claims and payments, we avoid having to, what we call pay and chase, and we can prevent opportunities for fraud and abuse. I think it is extremely important to note that some incorrectly billed claims can stem from confusion and misinformation about proper billing procedures, especially in the nursing home arena. For example, if there is a payer who is primary to Medicare, the Medicare contractor rejects the claim and submits to the appropriate primary payer. Where Medicare is primary, the contractor makes payment, then sends the paid claim to the supplemental insurer. For dually eligible Medicare and Medicaid beneficiaries, the Medicare contractor pays first and then sends the paid claims data to the Medicaid State agency as the payer of last resort. The policies regarding priority and precedence of payers is one source of payment confusion. HCFA uses many prepayment mechanisms, including our Medicare as secondary payer, or MSP activity, to determine not only the primary payer for benefits for a Medicare beneficiary, but to ensure that every bill is properly submitted. Using these methods to ensure proper billing, we can concentrate our resources on locating and eliminating areas of fraud and abuse, as I will describe. I would like to add, however, that we have heard many complaints that the Medicare/Medicaid payment methodologies are so complex that they invite error. This reflects the fact that current payment methods have evolved over 30 years into a variety of sophisticated methods covering a greater diversity of different kinds of services. Adding to this complexity, especially in the case of nursing home services, is the fact that both Medicare and Medicaid finance care, often for the same individuals. Because of the different but sometimes overlapping benefits of the two programs, there are opportunities for ``ping-ponging'' patients from nursing homes to hospitals and back. A typical instance is where the dual-eligible is transferred from a nursing facility to a hospital when there is an acute illness and then sent right back to the nursing home when the hospital determines that the admission is not needed. Although care could have been given in the nursing home, it was not provided because the opportunity to shift costs to Medicare for hospital costs is so great. The unfortunate results are a waste of Medicare and Medicaid dollars, as well as compromised quality of patient care. Let me stipulate some of our specific areas of concern. We are targeting fraud and abuse of Medicare and Medicaid at a critical time when America is spending about 15 percent of the gross domestic product on health care. In 1995, the bill for nursing home care financed by Medicare and Medicaid programs combined reached $44 billion, which represents about 55 percent of all spending for nursing home care. Especially in the area of nursing home care, there are numerous opportunities for fraud, as we have already noted. The nursing home population has a high percentage of patients who are incapable of monitoring their own bills and may not have family members to do this for them. This makes them easy prey for unscrupulous providers and suppliers. We are focusing on the following areas where there seems to be the greatest concentration of fraud and abuse. First, for the dual eligibles generally in 1995, I think, as others have noted, there were about 6 million dually eligible beneficiaries in Medicare and Medicaid, of which about one-quarter reside in nursing homes. Individuals who are dually eligible for both Medicare and Medicaid are a diverse and particularly vulnerable population. Most problems arise when their benefits are covered by both programs but under somewhat different coverage rules, creating opportunities for confusion, billing errors, misdirected or duplicate payments and, in the worse cases, outright fraud. Second is mental health services. A finding from the Inspector General's medical necessity review demonstrated that in 32 percent of Medicare records reviewed mental health services for nursing home residents had been ordered improperly or unnecessarily. Another area is medical supplies. Providers of medical supplies, such as those required for wound care, incontinence and orthotic equipment may unreasonably inflate prices for these supplies or may inaccurately describe the supplies in the bills in order to receive higher payment. Hospice services: The Inspector General has found that there is considerable financial incentive to enroll nursing home facilities patients in the hospice benefit since Medicare makes an additional payment for these beneficiaries, while few additional services are provided. Therapy services: Providers, we know, have been charging excessively more for Medicare therapy services provided under contract with nursing homes. Let me mention just a couple of our important fraud and abuse prevention initiatives. My written testimony really details these, and the chairman has already alluded to some of them. Operation Restore Trust, our Medicare Integrity Program, which is authorized under the Kassebaum-Kennedy provisions, and Medicare secondary payer initiative, which I have mentioned. The President's budget contains a number of proposals to reduce waste, fraud and abuse in the Medicare program. These include, first, provisions to require insurance companies to report the insurance status of beneficiaries to ensure that we pay right the first time; second, to implement home health prospective payment services in Medicare that incorporates all services provided in the nursing home; third, that we require the nursing facility to bill for all services that its residents receive, which is not now current law--we call that consolidated billing, as the chairman noted; and, fourth, to link home health payments to the location where care is actually provided rather than the billing location. We also propose to work with the medical community to develop objective criteria for determining the appropriate number of home health visits for specific conditions so that we can prevent excessive utilization in the area of home care. In March, the President presented additional legislative proposals titled the Medicare and Medicaid Fraud, Abuse and Waste Prevention Amendments of 1997. These amendments address areas of hospice benefit modifications, partial hospitalization benefits, which are mental health benefits, the provider enrollment process, rural health clinic benefit reforms, and other important areas. We are pleased that both the House and Senate reconciliation bills include many of the proposals put forth by the President. Neither bill, however, includes a provision that would authorize the development of a prospective payment system for rural health clinics services, nor do they include our proposal to clarify the partial hospitalization benefit, which is an area of rampant abuse. We hope these provisions are added in conference. In conclusion, HCFA is firmly committed to aggressively fighting health care fraud and abuse; and by collaborating with our counterparts in government, the industry nonprofit organizations and advocates, we can build a powerful team that will prevent our Medicare and Medicaid resources from being lost. We look forward to working with Members of Congress, including this committee, on legislation to enact the proposals I mentioned today. Thank you. Mr. Shays. Thank you very much. [The prepared statement of Ms. Buto follows:] [GRAPHIC] [TIFF OMITTED] 45631.004 [GRAPHIC] [TIFF OMITTED] 45631.005 [GRAPHIC] [TIFF OMITTED] 45631.006 [GRAPHIC] [TIFF OMITTED] 45631.007 [GRAPHIC] [TIFF OMITTED] 45631.008 [GRAPHIC] [TIFF OMITTED] 45631.009 [GRAPHIC] [TIFF OMITTED] 45631.010 [GRAPHIC] [TIFF OMITTED] 45631.011 [GRAPHIC] [TIFF OMITTED] 45631.012 [GRAPHIC] [TIFF OMITTED] 45631.013 [GRAPHIC] [TIFF OMITTED] 45631.014 Mr. Shays. Mr. Towns. Mr. Towns. Thank you very much, Mr. Chairman. Let me begin by thanking you for your testimony and saying to you that we do look forward to working with you to try and see what we can do to eliminate waste, fraud and abuse of any sort. Let me begin by saying, in your testimony, you discussed the billing confusion that results when someone is dually eligible. Can you tell me whether there is a way to eliminate the confusion without having the benefits delayed to those that are dually eligible? Ms. Buto. Yes. There are a number of different ways. The most tangible way that I can describe is a way that we have worked out and that Congress, we believe, is very much in favor of, which is a combined Medicare and Medicaid payment for the care of the dually eligible. This would be a combined, capitated payment. You may be familiar with the Program for the All-inclusive Care for the Elderly [PACE], for the frail elderly. This provides the right incentives to keep people out of institutions or provide them with the institutional care in a cost-effective way while also using the Medicare resources to cover their acute care, hospital-related, physician-related needs. This has been a very successful program. A number of the States are interested in this, and we look forward to expanding this kind of program. There is another programmed called the Social HMO Program, which is also under a demonstration in our agency, which is similar but doesn't target necessarily the frail elderly, but really tries again to combine those payments between Medicare and Medicaid to make the best use of the combined payment. That, too, seems to be a much more efficient way for some individuals to receive their care. Both of those are part of our legislative package. Mr. Towns. Let me make certain that I understand this hospice care. A patient must be terminal in order to go into this, like life expectancy of maybe 6 months or less, generally. Ms. Buto. Right. Mr. Towns. Is that what is really happening? Because when you talked about hospice you indicated that some of the services in some instances were eliminated, which means even though they are able to bill and get paid at a high level, the point is that maybe some people might be put into a hospice that should not go in there. I sort of get the feeling that that might be happening. Are you saying that? Or what are you really saying? That is the question. Ms. Buto. Let me just try to divide it into two things. One issue is are some people getting it who we do not think are really terminally ill. Hospice areas---- Mr. Towns. You are saying what I thought you were saying. Ms. Buto. There are some people getting it who are not terminally ill, and we think there are some people that are unscrupulous in certifying them. In Operation Restore Trust, we targeted hospice services because we saw a lot of growth in that area. There are a number of provisions we have in the budget proposals to begin to tighten and really recertify people every 30 days after the first two benefit periods, so that would really help us. Right now, the way the law is structured, there is a much more open- ended fourth benefit period. This would really help us tighten and recertify the eligibility. But the other issue, and the one I talked about in my testimony, is the issue of both Medicare and Medicaid paying for an individual whose home is the nursing home, but who is getting Medicare-covered hospice services. Right now, that hospice is getting a Medicaid payment for some services that Medicaid would cover, like the relief of pain, for example. Medicare's hospice payment also pays for that, so there is some overlap. The issue is, different States pay for different things, can we figure out what a reasonable payment is? We and the Inspector General are working on that issue to see if we can begin to audit how to pay more appropriately. But I think there is an issue of are we--that we have really raised as part of our reviews, which is, should we be paying or modifying proposals, both in Medicaid and Medicare? Mr. Towns. There has been a lot of talk about the Medicare Integrity Program. When is this going into effect? Ms. Buto. We have started the Medicare Integrity Program, which is an outgrowth of the Health Insurance Portability and Accountability Act, by whenever there is a contractor change-- -- For example, one of our large contractors in the West, Aetna, recently has decided to get out of the Medicare business. We have started to move toward what we call benefit integrity contract source. So when we have the opportunity that is what we are doing under current law. But we are working now on a statement of work to really compete for a whole separate set of fewer contractors whose entire purpose it is to focus on benefit integrity issues, and we expect that to go into place in 1998. Mr. Towns. Is there an incentive involved in this at all in terms of the contractor receiving an incentive payment for uncovering fraud and abuse? Ms. Buto. The incentive will be to get the business. But if I could just turn to my colleague who will be overseeing that, I will ask if she wants to elaborate. Mr. Shays. If you could identify yourself for the record. Ms. Ruiz. Certainly. My name is Linda Ruiz, Director of the Program Integrity Group. We hope to offer contractors some incentives. They will not be directly related--for example, recovering a certain percentage of money based on moneys that they might recover from a provider or anything that would provide some kind of reason for the contractor to unnecessarily hassle providers-- but we are looking for some legitimate ways to provide them with additional financial incentives to do the very best job for us they can. Mr. Towns. So you have not finalized what these incentives would be? Ms. Ruiz. No. We are experimenting. This is a tricky area. Mr. Towns. I agree with that. Let me just sort of ask one more question, Mr. Chairman, before I yield back. Mr. Shays. Sure. Mr. Towns. In your testimony, you described reforms to Medicare payments for durable medical equipment. Will you have a grandfather clause that will allow current equipment providers to participate in the programs without fulfilling the new requirements? Ms. Buto. I actually--some of the durable medical equipment provisions we are talking about--I am not sure whether this is what you are talking about or not--involve a bonding requirement. Is that what you are talking about? Mr. Towns. That is what I am talking about, yes. Ms. Buto. That we are, I believe, planning to do through regulation, but I don't know that we have--the legislative staffer is informing me that there will not be a grandfather requirement for the existing suppliers, that they will all need to be recertified, so there won't be some sort of an exemption for them. Mr. Towns. Will not be? Ms. Buto. Will not be. Mr. Towns. Mr. Chairman, I would like to talk about that a little more later on. Thank you very, very much. I yield back. Mr. Shays. There is always this number of 10 percent of health care is waste, fraud and abuse. We have indications from the Inspector General that, in certain areas, health care fraud could be 15 percent. There are some who think it is 20 percent. It is an extraordinarily large number when we think of how much we spend. You have outlined areas, and I would like you to go into a little more depth with each one. You outlined dually eligible, you outlined mental health services, medical supplies, hospice, therapy services and prospective rural health care plans. You mentioned one other at the end. Do you remember what that was-- after rural--the two that you said that were not part of the proposal? Ms. Buto. Oh, we are hoping the conference agreement will pick up. One is prospective payment for rural health clinics, which we thought would have a lot of support but has not been picked up in either the House or Senate. The other is a proposal to address the issues involved with partial hospitalization. These are the mental health benefits that I will be glad to elaborate on, but this is the outpatient mental health services where we really need to have some authority to impose standards on providers, No. 1. No. 2, we have what we call right now Medicare-only providers. We think these should not be Medicare-only providers. They ought to be certified by States to provide services more broadly. We have seen a lot of abuse in the billing patterns here. Nursing home patients are quite vulnerable in this area where they are provided, in a sense, a social service. They think they have had a recreational activity. It is billed as a mental health visit. So that kind of behavior we need to get a handle on. We need to be able to screen providers, and that is called the partial hospitalization benefit. We will be glad to provide copies of the proposal to your staff. Mr. Shays. OK. I am having a hard time understanding, and I want to appreciate it, the challenge the administration faces and also Congress, as to why we can't deal with the dually eligible problem. What are the policy issues that work in conflict? My sense is that 6 million dually eligible Medicare, Medicare, one-fourth of those 6 million are in nursing homes. In our first hearing, it was very clear to me that you can rip off the system quite easily and not get caught. If you are caught, it is pay and chase. So why don't you talk to me first about dually eligible. Ms. Buto. OK. The dually eligible is an issue where we are dealing with people who are, as you can expect, certainly nursing home individuals who are the most vulnerable. Dually eligible are overrepresented by people over 85, for example. They are also overrepresented in the under-65 disabled population. Mr. Shays. Tell me, are they dually eligible because---- Ms. Buto. They are low-income Medicare beneficiaries. They cannot afford--for example, they meet the standards for either Medicare spend-down or the QMB provisions. Mr. Shays. Wouldn't anyone in Title 19 be potentially dually eligible? Ms. Buto. No, because so many of the--I think it is two- thirds of the Title 19 population is mothers and children right now. They would not be---- Mr. Shays. I am talking about in the nursing homes. Anyone under Title 19 in nursing homes would be dually eligible. Ms. Buto. If they meet the Medicare requirements of Social Security. They have basically paid into Social Security. They are entitled to Social Security Medicare. But, yes, the vast majority would be eligible for both programs. Mr. Shays. OK. So what makes it difficult to deal with this? On the surface, it seems like a no-brainer to me. There are two different programs. Admittedly, they have two different standards. So where is the problem? Mr. Towns, you know, rightfully cautioned that we don't want people to be caught--hurt in the process---- Ms. Buto. Yes. Mr. Shays [continuing]. Of our dealing with this issue, the patients. But describe to me why this isn't an easy issue to deal with. Ms. Buto. Medicare covers mainly acute care services. The skilled nursing services that we cover are supposed to be post- hospital, related to a hospital stay. There is a 3-day requirement and so on. Increasingly, the population, as Mr. Towns pointed out, is becoming more chronically ill. The demographics--people are living longer, they are more chronically ill, et cetera. So that post-hospital stay begins to, when they are in the nursing facility, turns into a chronic care management of some deterioration that occurred because they went in for a hip replacement or something else. Medicaid pays for the so-called custodial care. When people are poor and they go into nursing facilities--and you have heard of people using all of their assets. They may have not been Medicaid eligible, but the nursing home costs $35,000 to $50,000 a year. After a couple of years, they use up all of their assets. They are poor. They are on Medicaid. What they are doing at that point is not necessarily and usually not getting acute care followup, but they are there for a variety of other purposes having to do with their deterioration, such as Alzheimer's Disease or a variety of other conditions that make them eligible for nursing facility custodial care, which Medicare doesn't cover. Now, the problem comes in when you have an individual who is custodial, who may have dementia, may have some other things that really make up a long-term nursing home patient. They are living there, and they fall or they have some acute episode which, in a legitimate sense, takes them back to the hospital. Medicare pays because it is hospital care, because it is doctor care. It is all the acute services covered by Medicare. The problem comes in when the nursing facility sees that when somebody is ill, even though they could take care of the patient in the nursing home--they have the medication, they have the staff--but they would just as soon ship that patient off to a hospital, because it is now not their reimbursement issue. They have the financial incentive to, if you will, shift the patient. It is those cases where it really shouldn't be done, not the cases where someone really needs to be hospitalized--they have a heart attack or need a bypass operation--where we have this problem of making sure that we know what is going on. So that is one issue. The other issue is for the nursing home patient who doesn't get admitted to the hospital but is getting a new wheelchair, wound care services, things that Medicare Part B covers that the nursing home, because it doesn't have to bill us for those, can really wash its hands of. You can have unscrupulous providers getting the patient's billing number and billing Medicare for those supplies, those therapy services, et cetera; and the nursing home is pretty, you know, indifferent in the sense that they are not on the hook or accountable; and it really is less cost for them if those services are provided by Medicare. Mr. Shays. You are making an argument now why we need to deal with the problem. I am trying to understand why it is difficult to deal with the problem. Ms. Buto. I am sorry. OK, it is difficult because, in the case of Medicare, it has us working with 50 States and territories because each one of them has different rules for paying nursing homes. Some cover some things, some cover other things. We are experimenting with the State of Minnesota in a very comprehensive way to pay together and to share data so that we know what we are paying for. We also have begun to make our data available on who is eligible for what--at least let them know who the eligibles are--to States so that they can begin to, if you will, pay smarter when they pay Medicaid rates; and that has been difficult because of State rules of confidentiality of data and because again what they need and how they code things aren't necessarily compatible with ours. We are experimenting with the State of Maine right now and have been with the New England States to begin to share data, but we found that we don't describe services the same way. They code them differently, so it is hard to crosswalk those individuals. They may have different identifier numbers for people. Mr. Shays. As you have started to describe this problem, do you have someone in your office who focuses only on trying to resolve this issue? Ms. Buto. There are people in our data shop who are dedicated to this--not entirely, they do other things--but who are working with the States on this issue of compatibility of data. So, yes, on that. But we have people in other offices working on compatibility of policies, legislative proposals to make this work. We have an initiative that really talks about putting grants out to the States so that we can come up with common payment systems so we don't have both of us paying separately but we look to join our payment in ways that will get better care for the individuals. And that solicitation asking States to come forward with proposals that we can work with just went out. Mr. Shays. We have a vote, and I am just going to try to move it along so we don't keep you waiting for 20 minutes. We have a long list of areas, but we are still in the dually eligible. What I am hearing you say, the bottom line is that you have the Federal Medicare program. You--which is all Federal--you have Medicaid, which is 50-50 or 30-70, some mix of Federal and State or State/Federal. You have, obviously, different kinds of programs run differently in each State. We have heard that before and we know it is just dumb. I know it is administrative, but it is also legislative, but I must be missing something. There must be something more that makes it more difficult to deal with this issue. Is it a political problem? Who is saying, don't move forward? Or who is saying, if you do this you are going to hurt us, so don't do that? How would we be potentially hurting someone who is dually eligible? I just don't see it. It seems to me like it is our money, and we should---- Ms. Buto. Yes. There is an issue between the States and the Federal Government that I guess really is a political issue which is that, first and foremost, these are Medicare beneficiaries. Medicare pays primary, Medicaid pays secondary. The States feel, however, they are the most expensive beneficiaries; and they ought to have control over all of their health care costs. We don't agree, but the reason we have been able to work successfully with the States is that we have decided that the issue of who is in charge shouldn't be the issue, that we have to find a way to join the payments and jointly administer them. We can do that. I don't think it is impossible. It is just time consuming and complicated because of the different payment mechanisms, coding, all of the technical issues involved in joining payments and having proposals that the States are willing to come to the table with us, to come with a pay to jointly fund these services. Mr. Shays. Now, tell me what the negative impact is on us economically by our not dealing with dually eligible. What is happening? Give me some examples of what happens, where people, either through outright fraud or just through mistakes or inefficiencies, hurt us economically. Ms. Buto. What hurts us economically is having both programs sometimes paying for the same services and paying wastefully at times because, for example, the nursing home is not held accountable. Mr. Shays. Tell me why, if it is a health care service paid out of Medicare Part A, you know, Medicare Part A is hospital-- I am sorry. Ms. Buto. It is also skilled nursing. Mr. Shays. So there is--skilled nursing in Part A would be in a nursing home, correct? Ms. Buto. Right. Mr. Shays. So then tell me how a nursing home could possibly make a mistake without it being intentional to also bill Medicaid? Ms. Buto. Well, that is not--that is much less of a problem. When somebody is fully getting skilled nursing under Medicare, that is not the--the real problem comes when the person is really getting mainly Medicaid custodial nursing home care and then they bounce them back for a Part A hospital stay in Medicare or a Part B wound care service under Medicare. It is fragmented. Mr. Shays. So a person might be sent back to the hospital, but they are still billing for them being in the nursing home and they aren't? Ms. Buto. When they discharge from the nursing home, they are not billing for the nursing home care per se; but the most wasteful part is that they could have provided that care and were supposed to under the rules, which, by the way, are also the Medicare nursing home rules. Mr. Shays. And they also have hospitals in their--I am missing this part of it. If they are sending them out of the facility to the hospital, they are not their patient any more, period. Ms. Buto. Right. But the point is, sometimes they are sending people that don't need to be in the hospital. Mr. Shays. OK. Well, that is one thing, but I don't think that that is the biggest problem. We had lots of testimony last time that made it very clear that a number of nursing homes were double billing us, not that they were shifting them back to the hospital, which is inefficient and costly and wasteful, but not illegal. Ms. Buto. Yes. I think the double billing occurs on these supply issues as well as, in addition, on hospice care, where the nursing home really should be providing some of these hospice services maybe under the Medicaid rate. But the double billing really occurs in the medical equipment, in the therapy services where they are supposed to be providing those, and---- Mr. Shays. Let's talk about therapy services then. Ms. Buto [continuing]. Physical therapy, occupational therapy, speech therapy where we know of instances where the services--the therapy service providers are coming into the nursing home, basically getting services billed for Medicare beneficiaries who may or may not need them. The nursing home is not accountable. It doesn't, in a sense, take responsibility for whether those are needed services or not; and that is wasteful spending because we don't need to provide those services for individuals. Mr. Shays. I am going to have to recess. As soon as Mr. Barrett gets in, he will just convene and ask questions. Thank you. [Recess.] Mr. Shays. My best-laid plan. No one came in my place. Sorry. As I was going to vote, I was really thinking that I am not really satisfied yet with leaving dually eligible, because what I am hearing being said is that you have waste in that you are taking people out of nursing homes into hospitals when they could still be in the nursing home, admittedly at greater cost to the nursing home because they might require greater attention. But there is still nursing home responsibility. That clearly is wasteful. The only potential kind of fraud is--that I have heard is that you have a dual-billing when you have a nursing home that is part of the overall charge, would include certain therapy or services, but also is billing for those therapy services to Medicare. Ms. Buto. Right. Supplies that are provided by both programs. The other thing---- Mr. Shays. Tell me, for the record, some kind of supplies that we are talking about. Ms. Buto. Incontinence supplies, wound dressings. Mr. Shays. Those should be covered under the nursing care? Ms. Buto. Right, they really should be, because we actually have combined Medicare and Medicaid standards. Mr. Shays. Why would there ever be a bill then for that kind of service if it is in a nursing home? Why wouldn't you throw it out right away? Because the Medicare people don't know that the person is in a nursing home? Ms. Buto. Well, that is part of the issue; and that is one reason why we are improving our sort of information on where things are being billed, if you will, and one reason why the new contracts that focus on fraud and abuse as a result of the legislation will help us focus on the providers and the suppliers in that area and the beneficiaries and what everybody is getting. Mr. Shays. When you put a billing in for service, why wouldn't it say this person is in a nursing home? Why wouldn't we require that every time a person is in a nursing home? When a bill is submitted, you acknowledge that that person is in the nursing home. Why would that be so difficult? It is silly for you to sit back. Ms. Ruiz. It is already on the bill. Mr. Shays. If it is on the bill, why would we pay for any of that kind of service? Why would Medicare pay that? Ms. Ruiz. We would not pay for something for DME, for example. Mr. Shays. DME is? Ms. Ruiz. Durable medical equipment, if the bill said the person was in a nursing home. However, lots of times that is not accurately reflected on the bill. Mr. Shays. Is that viewed as fraud or what? Ms. Ruiz. I think you would have to ask the IG. They would investigate whether it was intentional or not, but it frequently can be fraud. Mr. Shays. I don't want to, you know, swallow camels and strain out gnats here, but I want to just get a simpler idea of--I still don't have a sense of where the difficulty is in dually eligible. It seems to me that if you are in a nursing home, there are certain services you have no right to bill Medicare and that, if you did, it is just latent fraud. That is what it strikes me. Are our systems so broken down that somehow a nursing home can feign that they didn't know? I mean---- Ms. Buto. Well, let me just try to say that, because Medicaid, in the case of a nursing home patient who is there for the Medicaid stay, may pay for different items and services from one State to another, that nursing home should certainly know, and there should not be any confusion about that. But State rates are not necessarily always that clear. They will pay a rate to a nursing home. Their benefit package of what is covered for a nursing stay should be known. What we cover for a skilled nursing facility or other supplies should also be known, but we are finding that one of the problems is deliberate fraud on the one hand and some misunderstanding or confusion, especially as the States have been changing what they pay for, which they have been doing under Medicaid. So we need to do a better job of educating providers who really want to do the right thing so they understand when they are getting--when they ought not bill Medicare, if you will, or when they ought to just consider the charge covered by Medicaid. We are beginning to experiment in the home health area in both Connecticut and Massachusetts in doing that, but this is clearly another area. Let me see if I can address the dual-eligibility. I was trying to understand where I thought you were going. Mr. Towns. Would you identify---- Mr. Shays. It is silly for you to keep moving back and forth. Ms. Buto. My sense is what you are trying to understand is what is the most efficient way to pay for this service. It is one patient. Why can't we figure out how to pay appropriately? Why is there so much lack of coordination? You know, clearly there have been proposals to either block grant the nursing home benefit entirely to the States. That has been one set of proposals on the Medicaid side. On the Medicare side, from time to time we have thought about what if we covered all of the cost of care for Medicare individuals in nursing homes. Unfortunately for Medicare, especially right now, Part A and the trust funds is a big issue; and if we take on an additional cost, even if we could get the States to maintain their effort, it would show up as an increase, big increase, especially with the demographic shift over the next 10 to 20 years in the Part A trust fund in financing. So we are in that bad position where the States really don't want to take on the entire cost of care. They would like to control more of the care through managed care for people who are not in nursing homes and who are dually eligible, but they have not stepped up to the nursing home population except in a couple of States--Minnesota is one--to take on managing the Medicaid dollar in an efficient way under capitation. So part of the difficulty is we are looking for some comprehensive solutions and--in some sense--because of the nature of Medicaid, we need those to be voluntary on the part of individual States. We are not in a position right now to mandate that States have to turn their money over to us so we can manage it or, vice versa, that we would want to turn all Medicare dollars over to the States because their benefits are very different from ours. That is really the crux of the problem. I wanted to make sure you understood that the PACE program, although it has been a small demonstration, that it looks like Congress is going to enact legislation that will make it widely available as a Medicare benefit as a provider type. We think that is very good, because the States want that and so does the Medicare program. So that is one area that we can begin to get at nursing home fraud and abuse. Mr. Shays. OK. Let me recognize Mr. Barrett, and then I will come back. Mr. Towns, do you have more questions as well? Mr. Towns. I have one. You go ahead. Mr. Barrett. I actually have no questions at this time since I just came in. Mr. Shays. Mr. Towns. Mr. Towns. Yes, let me--do you believe that it would be appropriate for nursing homes that receive Federal funds be charged a fee to pay for their inspection audit as a condition of receiving Federal funds? Because I get the impression that you don't have these audits too often, and there is a reason for it--probably is the cost and all of that. Have you thought about that? Ms. Buto. You are talking about user fees for nursing home--I believe we have thought of that. Don't we--for surveys. Yes, sir, I believe that we have, in a number of areas, really gotten some initial authority to charge user fees for inspections and surveys. It would certainly help in terms of the frequency. But we do nursing home audits more regularly than we do some other provider audits. I think the complicated issue is, again, not just an audit of the Medicare costs, but of the joint spending and joint responsibility for Medicare and Medicaid. Until we get a way for all of the services provided to a person being billed to the nursing home under this consolidated billing arrangement, right now, some of those are suppliers or--you know, we have a bunch of different fragmented places to go to look at what is provided in that nursing home. That is why we feel we need this consolidated approach so that nursing home is accountable and we can go to that one place to look at the audit. Mr. Towns. When you say more frequent, I guess I need to have--what do you mean by more frequent? I am not sure I understand that part. I don't want to be pushy either. But I am thinking that not a lot of audits are taking place, and if you are not looking to see what happens--and probably there is a reason for it, because once you get involved in this you are talking about costs. Ms. Buto. I am sorry. I was confusing two things. The survey I was talking about was the health and safety and those kinds of things. But the audits--especially under the new contracts where we have integrity contractors whose whole purpose is to look in areas for patterns and we have, I guess, a contract or an agreement with the Los Alamos lab to develop some software for us so we can begin to detect better patterns of fraud and abuse in these kinds of providers. So we are definitely looking to improve the auditing and the frequency, and we are receptive to the notion of user fees to finance more of those audits. But I think a first step will be to have these benefit integrity contractors really begin to focus in on all of the providers in an area like nursing homes, to look for comprehensive patterns and to use this more sophisticated technology. Mr. Towns. Well, I am very concerned. Because I come from New York, and that is an area--you probably remember years ago in terms of the nursing home scandals, I want to make certain that we do not go back to this. That is a problem for me. You need to have some way to check to find out what is going on, and I think that we have to be a little bit more aggressive in looking. Ms. Buto. We agree. Mr. Towns. Because people are living longer, of course; and we need to make certain that, in their later years, that they are not being abused. Ms. Buto. The other thing I wanted to mention is that the Kassebaum-Kennedy legislation for the first time actually sets aside dedicated funding for these kinds of reviews. Before, it has always been the issue of how much we could spend on these kind of audits was subject to a budget process. This will use trust fund dollars to--over quite a long period of time we have dedicated funding for this purpose--to look at fraud and abuse and benefit integrity; and that is really a vast improvement over what existed before. Mr. Towns. Thank you very much, Mr. Chairman. I yield back. Mr. Shays. I thank you. Mr. Pappas. Mr. Pappas. Thank you, Mr. Chairman. My question centers around the coordination between Federal and State inspections. Is there uniformity amongst the 50 States? And what kind of coordination or sharing of information is there between your agency and any of the State agencies that do inspect? Ms. Buto. Let me start, and then I will ask Linda to chime in. The coordination varies. I think Operation Restore Trust was the beginning of real collaboration with the States as well as with the Justice Department and other investigative agencies. We have developed an investigative data base that we share with the States as well as with our Medicare contractors that gives us all a common understanding of the investigations and what is going on. But we expect that with this expansion of our Operation Restore Trust kinds of efforts to target high-risk providers and suppliers that we are going to be in an even better position to share information and work with States to get at these areas of abuse. Some States have started getting Medicare data from us and that has been--I mentioned earlier a task to make sure we are talking apples and apples when we talk about services. But the process has started. There are five or six States now that are working with us to join those data bases together so they can do a better job of seeing what Medicare is paying for and what they are paying for, and I think both that and the target investigations and the investigative data base all will help make that collaboration better. Linda, I am going to let you---- Ms. Ruiz. Ms. Buto has, I think, adequately described what we are doing in terms of law enforcement investigations. I just want to be sure that your question was not referring to initial or subsequent surveys for quality purposes in the nursing homes. Mr. Pappas. It is kind of both. Certainly one of the primary concerns that many people have is over specific incidents, but specific incidents could be prevented if there are adequate regular inspections. Again, this sharing of information and when it is appropriate--and sometimes it may not be conducive to any kind of positive application of information that may be passed from a State inspector to a Federal agency, but sometimes there is. The professionals themselves, I think, are best able to assess what is necessary information or helpful information. Ms. Buto. The other thing I just wanted to add--and I don't know if this is what you were going to say, Linda--but we are beginning to get data. We will start getting data on the quality of care being provided, the nature of services being provided to people in nursing homes that will enable both us and the States to, from a quality standpoint, make sure that we are not getting shoddy results or poor care for the money that is being paid out. Ms. Ruiz. I guess what I was going to say was we contract with the State survey and certification agencies to do the bulk of the surveys, and they always share the information coming out of those surveys with us. We do have some Federal surveyors. They do not do the bulk of the work. On occasion, they go in where there is a complaint made or there is some lack of resources on the part of the State to go in on an immediate basis. Sometimes they may go in to do sort of a check on what was already done. That information is always shared between the State and the Federal agency. Mr. Pappas. Is there any difference, generally speaking--I am looking for generalities--any difference between for-profit, not-for-profit or government owned and operated nursing home facilities? Ms. Buto. In terms of performance? We have seen a lot of growth in the for-profit area in terms of the numbers. But in terms of performance, we hold them all to the same standards; and for those that do not comply, there are a series of intermediate sanctions that apply; and they are treated all the same. I would be glad to take a look at the data, but I don't believe that we see any patterns of differences in the behavior or compliance. Mr. Pappas. One last question, is there anything that you think that we in the Congress could do to help you folks do what you are being expected to do? Ms. Buto. Yes, we have a long list of proposals that we would like to enact. Just in brief, in the nursing home area, I think nursing facility prospective payment and consolidated billing are really key to getting the payment accountability to where it should be. There are a series of different sanctions that we have asked for, some sanction authority. We particularly would like to get the Social Security numbers of, basically, the folks who own and operate these suppliers and providers so that we have some way of making sure they don't get out of one bad business and move to another State and get a different provider number. It is very hard to track them. We have asked for that, plus the employer identifier number. Both of those are very important to us. Mr. Towns. Will the gentleman yield? Mr. Pappas. Certainly. Mr. Towns. Do you have a Federal data base? Ms. Buto. Yes. Mr. Towns. You do? Ms. Buto. You mean generally on what we paid for? Mr. Towns. No, in terms of where you had--if a home had been cited for abuse, sanitary conditions or whatever it might be, that I would be able to plug into your data base to get information on a specific home, whether or not they have been cited for this or cited for that? Ms. Ruiz. We do have a data base that indicates certification citations. It is not available to the public, however. It is used by HCFA. Mr. Towns. Well, you know, I guess, just to personalize this thing for a moment, I was thinking that maybe we should have something like that in case my children want to put me in a nursing home. They would know whether or not the nursing home has been abusive or not. That, to me, seems to be information that one would need. Ms. Ruiz. I would believe that most States have that kind of information available to consumers, but we could check on that. Ms. Buto. Let me just mention, we did--and I believe it is still under development because it causes problems. We did try to develop, if you will, a nursing home report card kind of document at one time. The problem with it is that often by the time you develop the report card instrument the institution has corrected its problems. Often the problems are not health and safety problems. They may be technical issues of not having good documentation in one area, which they then are able to fix. So the issue of how you do those kinds of things is difficult. But I think we are looking for ways to make information better available to consumers so they can have some benchmark to figure out what facilities are doing. The one thing we can say is that where there are serious issues of health and safety or patient care, we do move against facilities either to terminate the provider contracts or to not allow--there are a series of sanctions that we can apply to not allow them to sign new people up, et cetera. So there are a variety of things we can do. It is difficult to do the information in a way that is current and that is fair both to the people who are trying to figure out which nursing home and to the facilities as well. Mr. Towns. I don't want to put you in a spot. I am really a nice guy. But suppose we come forward with legislation. What do you think the reaction would be from the agency? Ms. Buto. Legislation to? Mr. Towns. Talk about a Federal data base that would have specific kinds of information in it where I could push the button to find out if that is where I would like to put my mother or father. Ms. Buto. I think the reaction would be--the first reaction would probably be, gee, that sounds like a great idea. The reaction of a lot of people would get very critical, though, if the data base was inaccurate or out of date; and I can imagine providers who felt they were unfairly identified. So I think the reaction is going to vary. Consumers who go to one that looks good in the data base and then it turns out there has been a recent complaint that they think is serious--so, I think the initial reaction is probably positive. It sounds like information consumers should have. But it is really going to depend on how accurate, how reliable and how valid that information is and whether people feel they can really rely on it. I think the credibility of the data base is critical to whether or not that going to be well- received down the road. Mr. Towns. Thank you very much. Mr. Chairman, I think we should talk. Mr. Shays. We talk a lot. This committee was responsible for Title II being inserted in the Kassebaum-Kennedy bill, and we were responsible because we had extraordinary cooperation from the administration. Much of what was included were suggestions by the administration. So I want to say for the record we have been grateful to work with your office. You have been very cooperative and very helpful, and I think we have made lots of progress. I am just aware of the fact that we are focused on so many things in Congress--balancing the budget, slowing the growth of Medicare--which, obviously, one way you do it is save money in fraud and waste and abuse. I am also aware that things don't happen because you have committees of jurisdiction that may be jealous if another committee gets involved. You have all of these things. I am really trying to sort out why you think it may take so long or why it is taking so long to move forward on some of these things. If I asked you what the most important thing to deal with dually eligible patients was, the most important reform, what would that be? Ms. Buto. I would have to say one thing as a caveat up front. There are distinctly different groups. The young disabled have a whole set of issues that are very different from the elderly in nursing homes, and so there are really different---- Mr. Shays. I think I know what the answer is that I would be looking for. I am curious, and then I would tell you what I would put down. Ms. Buto. I have to say from my personal experience from having looked at this area, for the dually eligible and especially for the elderly, the big issue---- Mr. Shays. The biggest reform we could put that would enable us not to be making double payments. Ms. Buto. OK. That is a different question. Some sort of combined payment approach---- Mr. Shays. Some kind of coordinated billing. Ms. Buto [continuing]. For nursing home patients. Mr. Shays. Let me not spend a lot of time on some of these issues. Let me focus on that one issue, and say what do we do-- what is going to be required to do it? Is it administrative or legislative or a combination of both? Just give me a sense much what it would take to do coordinated billing. Ms. Buto. It would take a willingness on the part of States to do it, No. 1. Mr. Shays. So we need their buy-in. Ms. Buto. No. 2, there is a real question as to how you actually combine the payment. Because nursing home patients range from hip fracture recovery to somebody who has got dementia and is totally dependent on the nursing home. How do you make those payments the right amount to make sure that they are getting decent quality of care without overpaying? So the issues of how you figure that out are not real simple, quite frankly. I guess the third thing would be to have an accountable nursing home so that the nursing home that is providing care should be accountable in a way that we can properly sanction them, that we can properly reduce payments where they are not-- -- Let's assume for a moment that they are combined payments, that we can figure that out. Then when you reduce payments you have to figure out who gets the savings. I assume we would have to figure a way of splitting Medicare and Medicaid savings so that States got some of the savings and the Federal Government got the rest. Mr. Shays. It strikes me that there is a lack of incentive. There is an incentive for Medicaid to basically send that patient to the hospital so it is Medicare, even though it may be more expensive; and there needs to be some way to have an incentive that we do the most cost-effective thing. Ms. Buto. Yes. There is one intermediate thing that we are trying that I think helps, which is Medicare case management of the nursing home patient. Medicare goes in and has somebody, a nurse or somebody, whose job it is to make sure that that tradeoff of care between what the nursing home is providing and what Medicare would provide is appropriate. That is a service we are looking at. Because there you have got an individual whose job it is to be the person's advocate and to worry about total dollars, not just one or the other. So that is a model we are taking a look at as well. Mr. Shays. I am having a little sensitivity on why it may be difficult to be a senior in a nursing home. Because I have needed to get my glasses fixed, my reading glasses that combine with long distance. Finally, it was going to take a week. I didn't want to buy a second pair, so I gave them my glasses. I have been frustrated this entire hearing trying to read and look up. But lots of what I want to be able to do is just read some of your testimony in which you outline extraordinary abuse-- your testimony is fine testimony--extraordinary abuse, much of it pointed out by the IG's office. But in one instance it says where you have a physician who billed $350,000 over a 2-year period for comprehensive examinations and never once examined the person. If a doctor or someone giving therapy comes to a nursing home, do they have to get the nursing home to sign off that they did what they said they did? Ms. Buto. I don't know the answer to that. We can get that for the record. Ms. Ruiz. The answer is no. There ought to be a record in the patient records of the visit. But there is no requirement that somebody responsible in the nursing home certify that the physician visited. Mr. Shays. I would think one way we could deal with this issue is that any time a service is provided in a nursing home, the nursing home has to agree that that service was provided. You walk in our building, you cannot bill for that unless it is certified by the nursing home that you did it. What would be the problem with doing that? I will be asking others, but what would you think would be the problem? Ms. Buto. I cannot think of one right off the bat. I think that that is a reasonable--it is kind of what we had in mind when we talked about consolidated billing. The nursing home in a sense has to sign off on everything that is provided and billed for. Mr. Shays. Why don't I conclude by having you tell me more about PACE and how that works. You are saying that you would be doing something like that under that program. Ms. Buto. Under PACE? Mr. Shays. Not under PACE. What was the program that you made reference to? The case management? Ms. Buto. I am sorry, case management. Mr. Shays. I confused you. You don't need to apologize. I apologize to you. Ms. Buto. I am beginning to feel like I need new glasses. The case management program I am talking about is one where we have already experimented. The earlier version we used, basically, nurse practitioners and nurses to manage a lot of the primary care and sort of under a capitated arrangement managed the services provided to nursing home patients. What we want to do, though--and that was pretty much limited to capitation of the Medicare service. We found that it had a lot of potential to limit unnecessary bouncing to the hospital or the outpatient department, et cetera, because the nurse practitioner was managing and making sure that the nursing home did its job and was paying appropriately, and we were paying that person to watch over the case. The other sort of variation on that that we are taking a look at is for people who are basically Medicaid nursing home patients--there is some possibility again for the nurse to manage the Medicare part but also the Medicaid services involved under a primary care kind of approach. We pay the nurse under Medicare, and they try to manage the whole set of services the patient is getting. It is less focused on just the Medicare service and more focused on the comprehensive care that is being provided. That has some real potential again to avoid the bouncing around that patients face, if somebody is managing the case, especially for a vulnerable person who is not able to fend for themselves. Mr. Shays. OK. Ms. Buto. So those are demonstrations again. We don't really have that kind of authority under Medicare now, and we need to know whether it is cost-effective and it works or whether it just adds cost to the system. But a number of people have suggested we look at that, and we think it is worth looking into. Mr. Shays. My regret is that we haven't taken full advantage of your testimony before the committee. I think what is going to happen is your continued dialog with this committee staff. But I would like some kind of sense of a time line of what we want to achieve and when we want to achieve it. I have this sense that we are having a pilot program here, we are having another program here, and it is a good-faith effort to try to get at this problem, with no sense that you would not come before us next year and we wouldn't be just having a continued dialog. I guess we will try to deal with this in our report on this issue. But I would love to see legislation that we would be pushing, I would love to see administrative changes that you would be doing, and I would love to see some kind of outline of some goals that we said we would achieve by this. It might help us provide maybe a sense of urgency to some parts of this. I don't know, I am just thinking out loud a bit, but I just have a feeling like we are just a lot of good people trying to do some good things, but we will be doing this forever unless we kind of put some time line and deadlines to this. Do you have deadlines? Ms. Buto. Well, yes we do. Mr. Shays. Can you give me an example of that? Ms. Buto. I guess I am aware of a couple of things--that it takes time, especially with this population. We put out in May basically a call to the States that said, we want to work with any State that wants to work with us around this population to come up with innovative ways to serve them better and-- especially nursing home patients--and to pay for the services jointly rather than to have this disaggregated payment system. We put that out in May, and the proposals are due this summer. That, we hope, will produce something that will come up with some approaches that we can use beyond the ones that we have already started. We think the States have some good ideas, and we have some good ideas, and we ought to try to do that. I know that that is going to produce something. We have three demonstration projects that will take us a long way in this area. One is Minnesota. There is a proposal now from six New England States including Connecticut, a concept paper to talk about serving the dual-eligibles in the six New England States. Mr. Shays. As one unit? Ms. Buto. No, each of the States will come in with its own proposals, although they have a number of common elements. The data collection will be common. There will be a number of things that the States want to do jointly. We are sharing data with all of them. That is very seriously probably coming to a head again this summer with specific proposals. Maine and Massachusetts are the two that are in the position to really go forward fastest. I think we are going to learn some important things there about how we can collaborate. We have some limited lessons in other areas; and, again, PACE has a permanent part of the Medicaid program as an option which it looks like it will be--as a result of the reconciliation process will be a major advance in Medicare. We have never had that dual-eligible option available, if you will. I don't think we are running in place or playing at the margins. I think there are some big things going on. I am also mindful of the fact that, after this Congress, HCFA will be--there is a tremendous amount work coming our way, and this is one of the things that we have already started. I expect we will continue, and PACE is part of that, but there will be a tremendous workload associated with the new reconciliation. Mr. Shays. I think that we will probably get to the next panel. Mr. Pappas. Is there anything that you want to say? Closing comments from both of you before we go to the next panel? Ms. Buto. The only thing I would like to say--I have said this before--I think that the dual-eligibles are both the hardest population to deal with and provide the most opportunity for us to do the right thing. They also represent-- since they are such a large share of spending both in Medicare and Medicaid, if we can responsibly address these issues I think we will go a long way toward ensuring a better future for Medicare and Medicaid. Mr. Shays. Ms. Ruiz. Ms. Ruiz. I have nothing. Thank you. Mr. Shays. Thank you both for being here. Mr. Shays. Our next panel: Ms. Faith Fish, a long-term care ombudsman from New York; Ms. Pat Safford, California Advocates for Nursing Home Reform; and Ms. Tess Canja, Board of Directors, American Association of Retired Persons. If all three of you would come forward and remain standing, we will swear you in. [Witnesses sworn.] Mr. Shays. If we could, we will go in the order I called you, beginning first with you, Ms. Fish, and then we will go to you, Ms. Safford, and then Ms. Canja. We welcome you here. If you would first present your testimony and make the comments you want to make, feel free to do that, and I will roll the clock. But the first pass is 5 minutes, and then I will give you a little bit more time if you need it. STATEMENTS OF FAITH FISH, LONG-TERM CARE OMBUDSMAN, NEW YORK; PAT SAFFORD, CALIFORNIA ADVOCATES FOR NURSING HOME REFORM; AND TESS CANJA, BOARD OF DIRECTORS, AMERICAN ASSOCIATION OF RETIRED PERSONS Ms. Fish. Thank you very much. Excuse me, much of my written testimony, as a matter of fact, will relate to specific questions that you did ask; and I also have incorporated some examples that I brought of actual cases that we worked on to give you an idea of what is happening in New York State and across the country. First, I thank you for giving me the opportunity to come here and to talk about the New York State long-term care ombudsman program and also the successful efforts of Operation Restore Trust. In New York State, I represent over 140,000 New York State long-term care residents. In the Nation, we are talking about-- -- Mr. Shays. How many did you say? Ms. Fish. 140,000 long-term care residents in nursing homes and adult homes. In the country, there are 1.6 million. Today they are not here to speak before you because of many reasons: They may be ill, reasons of finance, and also fear of retaliation for coming to speak with their voices. So I come here to speak on behalf of them. Now what is the role of the ombudsman? What do we do? The ombudsman is there to support and protect the residents. We are there to ensure that they get quality care and that--we talk about quality of life, something that you have all been talking about in your opening statements. In New York State, we have over 550 volunteers that are trained--duly trained and authorized to go into nursing homes. Upon certification, what happens is ombudsmen are actually assigned to a facility. When you are assigned to a facility, you are there somewhere between 4 to 6 hours a week. Mr. Shays. These are volunteers you said? Ms. Fish. Right. These are volunteers that are trained, and they are trained in the 36-hour training certification program. When they are trained, they go in 4 to 6 hours a week. Now this is very different than regulatory agencies that go in once every 18 months or upon situations of neglect and abuse. So we feel that our constant presence there does a couple of things. One is, we are able to deal on the spot with complaints and resolution of complaints. But, second, it is also a prevention. When you are there on a regular basis what tends to happen is abuses do not tend to occur as much. Let me give you an example--a short example of a case that one of our ombudsmen wrote up. It is a very, very short summary. In this particular nursing home, approximately 2 months ago a resident developed a small sore on his toe. Due to the lack of aggressiveness in treatment, medical treatment, the resident now has blackened legs to the knees and a giant hole in one hip and one developing in the other. The resident went from ambulating freely and independently to a bedridden person with severe pain. Despite constant reporting of pain and sore sizes and growth, we feel nursing was very lacking in seeking prompt care and didn't aggressively contact the doctor. The above resident is scheduled for a bilateral amputation. A good quality of life, pain free, could have been accomplished if treatment was sought sooner. That is one example. Now, the ombudsmen, as I said before, are the only advocates that are in nursing and adult homes on a regular basis. This is one of the reasons why we became and were sought after as partners in Operation Restore Trust. In May 1995, we became very involved with this. But I know you know all about Operation Restore Trust, so I am not going to go into any of the details about that. But I want to tell you specifically about the model that we have in New York State, because I think it speaks or addresses some of the issues that you asked before. Under the leadership and the guidance of Governor George Pataki, a State work group was developed; and this State work group was a coordinated effort with the Attorney General's office, the State Department of Health, the State Department of Social Services, and the Division of Criminal Justice, with the State Office for Aging ombudsman program heading it up. The purpose was to bring all of these agencies together. One interesting thing that we found--you talked about what are some of the barriers of people coordinating these efforts--is we found that people weren't talking. They simply weren't talking to each other. So let me tell you some of the things that we did that have been used as an example for the rest of the country, and they are using some of the things that we have done in New York State. We approached it with three steps. We approached it with education and outreach. We decided that--how do you best find out about fraud and abuse? You best find out about fraud and abuse by actually educating people and teaching them what to look for. That is one thing. So we went out and we trained all of our ombudsman volunteers to, in fact, go out and look for certain things. We taught them certain red flags to look for. Then we looked at systemic changes. Well, if you find a complaint and you resolved it, what about the systems that we are talking about? What about the dual payments that we are talking about? Well, during one of our meetings, the State work group met with the Federal work group. When they both came together the Department of Social Services, Medicaid Division, started talking to the people in Medicare. What happened is that they said--we never really talked before--Medicaid people said, how about if we start sending you some of the things that we think are dual payments? They did, and now we have a system that is being used in New York State where the people in Medicaid are talking to the people in Medicare, and in one quarter they found over $1.1 million in dual payments, dual billings that are taking place. Something as simple as talking, getting together, communicating. So that is one of the answers that I would give to you is communication, people sitting down and working it out. That is one of the things. Mr. Shays. I just want to be clear. Who is talking? Ms. Fish. OK. The State work group, which consisted of the State agencies I talked about--the State Department of Social Services; State Department of Health, OK, with HCFA, the Administration on Aging; and the Office of Inspector General. Those are the three Federal partners. I am sorry. I forgot to mention that. That was the systemic part of it, looking at those services. Now the third part was complaint handling, and I was happy to hear about talk about quality care. While making the system more efficient is important, we also want to make the system responsive, so I want to talk about the cases. When we first became involved in Operation Restore Trust, I was not a believer. I could not understand how an ombudsman volunteer could go in and start becoming an investigator until I came home. I came home, and we began to find a number of cases after we trained our volunteers, cases like this: A podiatrist wanted to make molds on every resident's feet and make custom shoes, whether the resident could walk or not. Many were in wheelchairs. A family complained to the ombudsman about being billed for hundreds of dollars of bandages 1 month. Bandages for a scratch on this person's leg was $300, and the resident was responsible for paying $127 of this. One of the other things you talked about, therapists. We found that when we went into nursing homes that there would be group therapy. Instead of giving the individual therapy that Medicare and Medicaid were being billed for and that the residents should be getting, they had what they called ``wave therapy.'' Wave therapy is when a therapist walks into a room with a group of people, they wave, and they walk out and bill individually. That is called wave therapy. We found an example of an administrator, after we trained our ombudsman--an ombudsman goes in and sits on a residents council; and the administrator comes in and says, look at the explanation of benefits that the person was supposed to have received. It is too confusing to nursing home residents. They don't understand. So what we are going to do is we are going to keep them. And the ombudsman said, you can't do that. First of all, there is a copayment; and that person has a right to see that. Second, there is an ombudsman in there to discuss it with them. Third, it is a violation of a patient's rights to keep their mail. So what happened was that the residents now have the ability--continue to have the ability to review the explanation of medical benefits. Another case, where a family member comes in and finds their mother crying hysterically. The ombudsman walks in, and the person reaches out and hands the ombudsman a sheet of paper, an explanation of medical benefits, and said, my granddaughter just opened this. I am so ashamed. I am so embarrassed. The explanation of medical benefits read that Medicare was being billed for this person for alcohol rehabilitation. This woman was never an alcoholic and was not a drinker, but her granddaughter opened this up and began to say--it was just humiliating, absolutely humiliating to the person. Mr. Shays. Let me get to our next witness soon, so if you would kind of conclude. You have given us some very good examples, so I am grateful to you. Ms. Fish. OK. I will conclude with one last statement. I urge to you support and expand on Operation Restore Trust. The momentum has to continue in this case. My last statement is this: Ombudsmen deal with many frustrations while working with agencies and families. Sometimes I wonder why volunteer ombudsmen wish to continue trying to overcome the obstacles they face. Then I speak to a volunteer and hear a story about a resident that he or she has helped, and every one in this room will remember a face of someone who needed help or a story that touches our hearts. Most ombudsman residents cannot be here today to talk with you, but they silently watch and wait for your help. My testimony today is on behalf of over a million voices asking not to be forgotten. I would be glad to answer any questions when the time comes; and I thank you very much. [The prepared statement of Ms. Fish follows:] [GRAPHIC] [TIFF OMITTED] 45631.015 [GRAPHIC] [TIFF OMITTED] 45631.016 [GRAPHIC] [TIFF OMITTED] 45631.017 [GRAPHIC] [TIFF OMITTED] 45631.018 [GRAPHIC] [TIFF OMITTED] 45631.019 [GRAPHIC] [TIFF OMITTED] 45631.020 [GRAPHIC] [TIFF OMITTED] 45631.021 [GRAPHIC] [TIFF OMITTED] 45631.022 [GRAPHIC] [TIFF OMITTED] 45631.023 [GRAPHIC] [TIFF OMITTED] 45631.024 [GRAPHIC] [TIFF OMITTED] 45631.025 [GRAPHIC] [TIFF OMITTED] 45631.026 [GRAPHIC] [TIFF OMITTED] 45631.027 [GRAPHIC] [TIFF OMITTED] 45631.028 [GRAPHIC] [TIFF OMITTED] 45631.029 [GRAPHIC] [TIFF OMITTED] 45631.030 [GRAPHIC] [TIFF OMITTED] 45631.031 [GRAPHIC] [TIFF OMITTED] 45631.032 [GRAPHIC] [TIFF OMITTED] 45631.033 [GRAPHIC] [TIFF OMITTED] 45631.034 [GRAPHIC] [TIFF OMITTED] 45631.035 [GRAPHIC] [TIFF OMITTED] 45631.036 [GRAPHIC] [TIFF OMITTED] 45631.037 [GRAPHIC] [TIFF OMITTED] 45631.038 [GRAPHIC] [TIFF OMITTED] 45631.039 [GRAPHIC] [TIFF OMITTED] 45631.040 [GRAPHIC] [TIFF OMITTED] 45631.041 [GRAPHIC] [TIFF OMITTED] 45631.042 [GRAPHIC] [TIFF OMITTED] 45631.043 [GRAPHIC] [TIFF OMITTED] 45631.044 [GRAPHIC] [TIFF OMITTED] 45631.045 [GRAPHIC] [TIFF OMITTED] 45631.046 Mr. Shays. Let me ask you, before we go to Ms. Safford, are the ombudsmen not paid just in New York? Ms. Fish. The ombudsman program is different in every State, and in New York State they are all volunteers. They are not paid. In some States, they are paid a small stipend; and in other States they are just paid mileage to get to and from. Mr. Shays. I have been in public office 20 years, and I did not know they were volunteers. I am amazed. Ms. Fish. Most States are trying to get more volunteers. There are 7,000 volunteer ombudsmen in the United States, and you could have 21,000 with additional funding. There are people out there who are more than willing to give their time. Mr. Shays. That is amazing to me. It certainly qualifies for a point of light. Mr. Shays. Ms. Safford. Ms. Safford. Mr. Chairman, subcommittee members, I would like to thank you for the opportunity to testify today about health care fraud in California. California Advocates for Nursing Home Reform was founded in 1983---- Mr. Shays. I am going to have you lower the mic just slightly. I think that would be good. Ms. Safford [continuing]. Founded in 1983 by Pat McGinnis. She was determined to create an organization independent of Federal funding or funding from the industry, of course, so we are mainly a membership organization. We do get some fees for-- as far as buying our materials and quite a bit of foundation grants. Only recently we have accepted a Federal grant to provide pension counseling for California consumers. We have a program of community education, outreach and advocacy; and it is our goal to provide consumers with up-to- date information to help them make choices about nursing home placement. To that end, we have information compiled from the Department of Health Services in California as well as from HCFA on all 1,450 nursing homes in California. We have this data available to any consumer who calls on our 800 line. We also now have it on the Internet so people--we have a web page so people can call up that information. We also put out--we have legal services, the legal services in California. We provide support service as far as nursing home patient rights. We provide assistance with legal and financial issues. We have organized family councils throughout the State, and we have community workshops as well as putting out an annual report card. The report card on the facilities in California lists the bottom 50, the ones with the most violations; and it also lists those with the best records. To keep apples and apples being compared, we make sure that the ones on the ``best'' list also accept Medi-Cal. Because it is easy to provide great care when you charge people exorbitant fees. It is quite another thing to stay within the budget. We have some very good nursing homes in that category, too. The data base helps us in a number of ways. In addition to providing consumers with information, it helps us to compile information about the nursing homes, about the ownership, too. We worked hard over the years to try to change the enforcement system in California, which, by the way, was put in place in 1974 with a lot of input from the industry. It has an awful lot of safeguards for them, and it really has not worked in California. To that end, we had a bill, AB 1133, which had made it through the State assembly and was on its way to the Health Committee in the Senate; and just last week Governor Wilson managed to make an end run and kill it. What we know from talking to those people is that they are as frustrated as we are about trying to get some changes made and trying to get the nursing homes to be responsible and try to correct problems; but, for now, effectively it killed the bill this year. It did, however, make us more determined to have more reform and a bigger bill for next year. In 1996, California got a large share of the Medicare and Medicaid pie. We call it Medi-Cal in California. We have--over $4 billion income came to California nursing homes. Seventy- five percent of that is directly from the taxpayers through Medi-Cal, Medicare or through the Department of Mental Health Services. So the majority is tax dollars, and the problem is there is really no accountability for it. We started a number of years ago studying costs. Our first report came from OSPHD, Office of Statewide Health Planning and Development. They come out yearly with a report, usually about a year and a half late, of all the costs for every nursing home. But the problem with this is that it is self-reported, and the auditing they do is simply to see if the numbers add up and if they filled out every category. Starting last year, we have ordered all of the audits that have been done by the State Department of Health Services. They have an audit and investigation division. Unfortunately, they only audit 15 percent of the nursing homes a year; but what we found there was pretty startling, at least to me anyway. With a one-in-seven chance of ever being audited--and they never audit chains as a whole--the chances of getting caught are almost nil. In addition to that, even if the audits find some horrendous overcharge, it doesn't automatically get turned over to an investigation division because the audits division of DHS mainly concentrates on beneficiary fraud. They are not looking at provider fraud particularly. They are looking at people who applied for Medi-Cal who shouldn't have, who filled out the application paper and had assets. That is their focus instead of focusing on the provider fraud, the bigger area. I have brought these along. One Inglewood facility claimed $109,000 in expenses for home health care, and they don't provide it. This is very common. One facility claimed half a million dollars for lease and rental expense. They own the facility. This is clearly a subsidiary company, and that is what they do. They pay rent to themselves, and this goes around and around. Often they will take both lease expense and the mortgage interest, so they are taking doubly. This is fairly easy to spot in a cost report. But when it is spotted, it doesn't automatically go to investigations. It is just essentially they set the rate. The only purpose of the audit division is to set the daily reimbursement rate. No other reason. I have a few other examples, one where the owner's airplane expense was listed as patient care. That was disallowed, obviously. Anyway, for-profit chains routinely form subsidiary groups. They are related corporations. The State is aware of some of these but not all of them. There is a morass out there. We had a project about 3 years ago called Who Owns Nursing Homes. You may or may not be aware that violations with the nursing home stay with the facility. They don't stay with the owner or the licensee. They essentially don't stay with the persons responsible for the violations. That is why when the lady from HCFA was talking about the report card, why we have to be so careful. We have to try to identify the current owner. Who was responsible when these violations occurred? What consistently happens in California is if you get into too much trouble and the State or Federal Government is breathing down your neck you simply sell out to someone else, move somewhere else, obtain a new corporate name and continue on and take that new facility and drive it into the ground. That is why it is really important to try to identify the owners and the chains and to take a look at these costs State- wide, not just one individual facility. Because if they are improperly taking costs in one facility, you can be sure they are doing it, you know, right across the board. Right now, the California Attorney General's Bureau of Medi-Cal Fraud and Patient Abuse is responsible for investigating Medi-Cal fraud. There has been very little activity in this area, by the way. I tried to get statistics this week about how many cases. They didn't have any. I know a year ago they started a patient abuse in nursing home--I mean, they have one unit just for that; and the report they issued about a month ago showed they had 10 convictions last year. I know this is 10 more than we ever had before, but this is minuscule compared to what goes on every day in the nursing homes in California where we have 125,000 residents. In 1996, the California Department of Health Services issued what they call a WFM citation. It is welfare falsification of medical records. Every single one of these cases reported treatments and therapies and services that were not provided. So the Department of Health Services doesn't turn that over to a fraud unit, but they issue a citation for fraudulent recordkeeping. Medicare was billed for many of these. Medicare is billed for doctor visits. They are called gang visits; and even if they do visit the facility, they visit the chart, not the patient. They sit there and take a group of them. Particularly it is the medical director of the facility. They will get everyone's chart; and even if you look at them, they say the same thing month after month after month. We have cases where someone deteriorated to the point where they died; but their chart looks just fine, very stable. Essentially, they are not looking at the patient. It is also difficult for consumers to spot fraud. As she was saying, they often do not get the explanation of benefits. In our family council meetings, we try to have the people to bring their bills. It is very easy to spot. Many are billed for things they never receive. Some of the cases that we saw--a Nevada company was billing for psychotherapy services for one facility. No one had gotten those services. This is probably where they were then given a diagnosis of mental illness which they didn't have. Lotion was being billed at $150 a month from another company; $75 for discharge instructions when it was a mimeographed sheet of paper saying what to do when you get out of the hospital. Another $10 for talcum powder. This is not unusual. A bill I brought in with me was a complaint I received just before I left was $40 for 4 ounces of baby lotion, and that was being billed throughout the chain. Mr. Shays. What was that? Ms. Safford. $40 for a 4 ounce bottle of baby lotion. Pretty expensive. Anyway, we have a number of recommendations. We have tried to beef up protections, but one of the main problems we have is fear of retaliation. In a group in San Mateo County I met with 2 weeks ago, people said they wanted to do things, but they were afraid to complain because administrators could identify who was complaining by who they investigated. If the State came in to look at a patient, there is retaliation going on. In California, there is a $1,000 fine for retaliation; but it is difficult to prove and hardly ever is cited. If your mother now has to wait for an hour for a call bell, how can you prove it is because you complained? It is hard to get consumers to come forward and family members to come forward. We need stronger ownership disclosure and conflict of interest. These subsidiary companies, they should report every way that they are getting income. In some places, they are charging us for outside x-ray equipment that is being used. It is their own x-ray equipment. This is not outsiders coming in. It should be a lower rate. Mr. Shays. You need to conclude your comments. Ms. Safford. Finally, we believe that there should be a Federal ownership data base to coordinate ownership throughout the country so that when these bad operators go from California to Nevada to New York we will be able to provide those regulatory agencies with their background. We are not able to do that right now. [The prepared statement of Ms. Safford follows:] [GRAPHIC] [TIFF OMITTED] 45631.047 [GRAPHIC] [TIFF OMITTED] 45631.048 [GRAPHIC] [TIFF OMITTED] 45631.049 [GRAPHIC] [TIFF OMITTED] 45631.050 [GRAPHIC] [TIFF OMITTED] 45631.051 [GRAPHIC] [TIFF OMITTED] 45631.052 [GRAPHIC] [TIFF OMITTED] 45631.053 [GRAPHIC] [TIFF OMITTED] 45631.054 [GRAPHIC] [TIFF OMITTED] 45631.055 [GRAPHIC] [TIFF OMITTED] 45631.056 [GRAPHIC] [TIFF OMITTED] 45631.057 [GRAPHIC] [TIFF OMITTED] 45631.058 Mr. Shays. And your organization again is? Ms. Safford. California Advocates for Nursing Home Reform, otherwise known as CANHR. Mr. Shays. How are you funded? Ms. Safford. Mostly through membership and by foundation grants. We sell publications, generally for cost. We are lucky if we make our costs. For instance, we have all of the facilities by county. We charge $2 for the list for every facility in the county and their record for the last few years. It costs about 78 cents to send it out. Mr. Shays. Are you an ombudsman in California? Ms. Safford. No. I was for 4 years an ombudsman in upper California and handled over 100 cases of abuse. I was disgusted at what I found about the system and how it doesn't work for the patients and decided I wanted to work in a more direct way to try and change some of these abuses. Mr. Shays. It raises an interesting question of whether we can do what you all are doing in some measure, to have the ombudsmen be people who are really well-versed in bills. Ms. Safford. In California, we have some staff--generally, each district may have one or one-and-a-half staff members, very understaffed. The rest are all volunteers. One of the problems that we found is that we need two different types of ombudsmen. I was in Tehama County, the only ombudsman in that county. But we need one person that goes out and is the eyes and ears for the office. The second is one that has some investigatory skills. Also, we found that the problem in the ombudsman program in California, as it is with the Department of Health Services over all, is that money talks and the industry is very powerful. This is a billion-dollar industry. So they stop reforms often before they get started. Mr. Shays. I am having some dentist bills, and the bills sometime come in 6 months after because they go to the insurance company. So I thought I would pay the bill if I have it. So, finally, I asked them to give me all the billing that I have had, because it struck me that I was paying a lot. I can tell you I cannot decipher one line of that bill, not one line. So I am going to have a visit with my dentist. But it is awkward, because he is a friend. Yet I am finding it is just a good experience for me to have to go through that, because I have a sense of what it must be like for people. Mr. Shays. Ms. Canja. Ms. Canja. Thank you. Good morning. I am Tess Canja from Port Charlotte, FL, and vice president of AARP. I was asked to testify today about the results of a survey that we conducted recently on public attitudes toward health care fraud. I appreciate that opportunity and commend you for holding this hearing and for your genuine interest in finding ways to make inroads against fraud and abuse in nursing homes. Based on the results of our survey, AARP believes that older Americans and their families want to help correct the problems of fraud in all areas of the health care system, including nursing homes. The stumbling blocks for consumers are in identifying fraud and in knowing what actions to take. Of course, consumers can't do the job alone. They need to feel confident that Congress and the Health Care Financing Administration are doing their part to protect consumers and to spend taxpayer dollars wisely. Our survey also reveals a widely held misconception that stopping health care fraud can solve all of the financial problems of our health care system. However, we know that stopping fraud alone cannot keep the Medicare program solvent or repair the problems with the Medicaid program, but it is an essential first step. Fraud and abuse, especially in nursing homes, directly affect consumers in two basic ways--in their pocketbooks and in the quality of the care they receive. Indeed, fraud and abuse affect all Americans by increasing the cost of the Medicaid and Medicare programs. The most serious impact is on consumers who depend on these programs for their health and long-term care. AARP's health care fraud survey sheds light on how the public views fraud and its impact on health care costs and the delivery of quality care. Here is what the survey found. Americans believe that health care fraud is a major, widespread and growing issue. Interestingly, when asked who is responsible for health care fraud, respondents mentioned doctors, consumers or patients and insurance companies, those people they are most familiar with. Respondents were unaware of any efforts to reduce fraud, but the survey underscores that Americans are optimistic that something can be done about it. Almost all respondents agreed that it is their personal responsibility to report suspected health care fraud. Eighty- five percent indicate they would be more inclined to report fraud if only they knew more about it; and, in addition, 70 percent of respondents indicated they would not be more likely to report suspected fraudulent behavior if a reward or monetary incentive was offered. Finally, a solid two-thirds approved spending more public and nonpublic funds to fight health care fraud. The results of this survey demonstrate that the American public believes there is a significant problem with fraud and abuse in our health care system. The results also clearly underscore the need to provide the public with more information about how to recognize and report fraud and about ongoing efforts to fight it. Clearly, there is a need and a desire for greater public education on health care fraud. If consumers were aware of the types of fraud being perpetrated, if they knew what to look for when reviewing their claims and if they knew whom to call when they suspect fraud, their chance of being unwitting participants in a scam would be greatly reduced. Equally as important, they would become valuable partners in the fight to reduce health care fraud. AARP believes there are several simple things that consumers can do to prevent fraud: One, protect your Medicare card the same way you protect your credit card. Two, Medicare does not make house calls. Beware of anyone who contacts you claiming to be from the Medicare program. Three, be cautious of any offer of free medical services or supplies. The standards set by government to hold providers accountable and the coordinated enforcement efforts of Federal, State and local authorities are essential to reducing fraud and abuse in nursing homes as well as in the rest of the health care system. However, these efforts cannot be successful unless Congress provides adequate financial resources and continues to develop legislative policies that support enforcement efforts. Moreover, nursing home owners and operators themselves are important players in the fight against fraud. It is incumbent on them to take more responsibility for their actions and for the actions of other providers in their facilities to follow their own code of ethics and to set standards for their industry. Thank you for the opportunity to testify. [Note.--The AARP survey entitled, ``America Speaks Out On Health Care Fraud,'' can be found in subcommittee files, or obtained from AARP by calling (202) 434-2277.] [The prepared statement of Ms. Canja follows:] [GRAPHIC] [TIFF OMITTED] 45631.059 [GRAPHIC] [TIFF OMITTED] 45631.060 [GRAPHIC] [TIFF OMITTED] 45631.061 [GRAPHIC] [TIFF OMITTED] 45631.062 [GRAPHIC] [TIFF OMITTED] 45631.063 [GRAPHIC] [TIFF OMITTED] 45631.064 [GRAPHIC] [TIFF OMITTED] 45631.065 [GRAPHIC] [TIFF OMITTED] 45631.066 [GRAPHIC] [TIFF OMITTED] 45631.067 [GRAPHIC] [TIFF OMITTED] 45631.068 [GRAPHIC] [TIFF OMITTED] 45631.069 Mr. Shays. Thank you, all three of you. Your testimony is very helpful and valuable because it may get us to think outside the box a little bit. We tried last year--we, in this case, the majority party-- tried to, in our Medicare reform bill, provide a bounty provision; and we weren't able to set a number. But I remember one time I spoke before a group at AARP, and a woman came and gave me a stack of envelopes. They were Medicare bills. She said, they all came in 1 week, she said, over like a 2- to 3-day period. She wanted to know why they couldn't have all been in one envelope. I was trying to look through these envelopes, but there were something like 30 of them. This is just this bill of the $40 for the lotion. I mean, you know, fortunately, it is registered down as baby L-T-N. Ms. Safford. Lotion. Mr. Shays. Yes, but they could have put a code number. They could have just put some code, and you wouldn't have known. Ms. Safford. Did you also notice the $400 for gauze for 1 month? Mr. Shays. The dressing is $402. Ms. Safford. Yes, for 179 little gauze bandages. Mr. Shays. But what you could do very quickly is, it seems to me, you could have the beneficiary, if they have a bill that they think is wrong, that they get to keep 10 percent of it. Ms. Safford. That would be great. Mr. Shays. Or even more. But it could be 10 percent. We would get 90 percent. Because in most cases we wouldn't catch it. Ms. Safford. Just 90 percent more than we would get otherwise. Mr. Shays. Yes. But the bottom line is, on the $402, they would get $40. Ms. Safford. I have one other quick comment. We found a real strong correlation in California between those operators that have the most cases of violations and fraud. They seem to go together. They cut their costs by cutting back on staff and services and activities, by not providing what they are contracted to do. So I would like to see some way to put these two together, because they are joined. Mr. Shays. What I want to ask, though, is what is the downside of paying a beneficiary a certain sum? Because the interesting thing about my dentist bill is, I can tell you this, that if I didn't pay it, I wouldn't care. That is a horrible thing. I wouldn't have noticed. I have to pay it. My insurance doesn't cover it. I mean, it covers like 10 cents on the dollar, so it matters to me. But to someone who has Medicare, Medigap, Medicaid, it is simply not going to really show up, other than the fact they just, as American citizens, become outraged. If they have to pay a portion of it, they would become more concerned. But if they were given a bounty, what would be the negative on that? Ms. Safford. Retaliation. For nursing home residents, money isn't the issue. The issue is, if you reported that it was fraud or misbilling and you were afraid that your vulnerable relative in a nursing home is going to suffer for it, you wouldn't say a word. That is the downside. Ms. Canja. Our survey showed that that really doesn't help, that people didn't feel that they would be more inclined to report it if they had a bounty. The other side is, my mother was in a nursing home for 2\1/ 2\ years, so I have some experience with some of this. I thought I detected fraud; but, you know, there is small amounts, like the doctor that didn't see her. Well, 10 percent would have been $4. The podiatrist that cut her nails and gave this inflated bill, that would have been $6, $7, $8. Mr. Shays. Was the bill paid? Ms. Canja. The bills were paid by Medicare. They were paid. Mr. Shays. So maybe we give them 50 percent. Ms. Canja. No, would I have? Yes, I did report one of them. Would I have done it for the money and what would the administrative cost have been to give me the $6 and the $8 and the $4? I don't know. I am just answering your question. Mr. Shays. I am not trying to have you answer the way I want. I want you to answer the way you feel. Ms. Canja. Yes. I don't know. But if there were larger amounts of money--I am wondering if they were mainly small, accumulative kinds of things that add up to a lot of money in the aggregate. Mr. Shays. Ms. Fish. Ms. Fish. Yes. I think it would be an incentive. But we have done with our volunteers an enormous amount of education and outreach, teaching them to read the bills, teaching them to talk with the residents. We have found that when the residents have found out that they were victimized, just the thought that they were victimized, it didn't even have to do with the fact of the money, that they had to pay it or didn't pay it, but that they were outraged, and the families and residents are now beginning to come forward. Resident councils as a group are being educated on how to read these bills. So, to me, the answer is, yes, I think it could be an incentive; but I think the real focus has to be on getting out to the public, the way we have been doing, on reaching out and educating not only ombudsmen, but now we are going into senior centers. You have right now existing all the tools you need to do exactly what you need to do. You have the ombudsman program, which has a whole cadre of volunteers throughout the country. You have organizations like the National Citizens Coalition for Nursing Home Reform right here in Washington, which is a base organization, which has distribution to all the nursing home residents across the country, to do education and outreach. You would be amazed at the outrage that you would hear out in the public. People would say, I am not going to take it any more, and they are going to mean it. They really are going to mean it. In New York State, we have found in the first year, as a result of our coordinated efforts in getting the word out to the community, we have identified over $25 million in overpayments, overbillings, with people coming forward. Mr. Shays. The fact that it would inhibit you is just the personal relationship you have with the people who have submitted the bills. They are your friends, they are caring for you, and questioning them would be kind of difficult, I would think. It is difficult for me. I would think it would clearly be difficult for someone in a nursing home. Ms. Safford. Is there a way to take it out of that personal range or even worrying about retaliation and have like an automatic review, you know, like just so many--that you actually have a readout? Right now, Medicare just gets a summary bill. They don't even handle these charges. They would spot in a minute something is wrong with $40 worth of baby lotion, but they are not. They are just getting a package. But isn't there some way in the billing system that we could use to help find these problems? It seems to me that that would be a start. Mr. Shays. OK. Mr. Towns. Mr. Towns. Thank you very much, Mr. Chairman. You have been extremely helpful in so many ways. Let me begin with you, Ms. Canja. Do you believe that patients who are called dual eligibles--you have been listening to the discussion that we have had this morning--are more vulnerable than those who receive Medicare or private insurance coverage? Do you feel they are more vulnerable? Ms. Canja. I would have to speak from my personal experience, because my mother was in both of those situations. I did feel she was more vulnerable when she was a dual- eligible, just because she was more dependent on other resources. I am not aware that because she was dual-eligible that there was fraud involved. I am not aware in her situation that she received a lower level of care, although I know of many situations where that did happen. Mr. Towns. Thank you. Feel free to talk. We are really trying to come up with some ways to--there is a problem out there, and I think we all are saying that, and I think that we want to make certain that we get as much information as possible to be able to fix the problem. I think that, as Members of Congress, you are there on the firing line, and you have been out there working in this area and have some very valuable information, and that is what we are really looking for. So feel free to share that, because we want to be helpful in every way. Yes. Ms. Safford. We have found that there is a big impact on the people who have both Medicaid and Medicare. I will tell you a typical call I get at least twice a week. They say, oh, all of a sudden you are told you don't need skilled nursing anymore. You have been in here 2\1/2\ weeks. I say, are you now qualified for Medicare? Invariably, they say, yes. The facility says, sorry, you don't need care anymore; get out. That is what happens to those people in California. It is not proper, it is not legal, but it happens. So I think they suffer. Mr. Towns. Ms. Fish, it appears that the ombudsman in your program have an extremely important oversight responsibility. There is no question about that. Since you operate with volunteers, is there some concern about the turnover rate? Consistency in this business is very, very important. Ms. Fish. Turnover, yes. There is definitely burnout, because this type of work you are dealing constantly with a very serious problem. But we have volunteers who have been volunteers for 10, 15 years because of their dedication. We hand-select volunteers, and they are usually people who have some background in this work, and they are very committed. I would say that probably there is at least a 10 percent turnover every year, 10 to 20 percent turnover every year, but I don't think any more than that right now. It depends on the type of support the State is giving the volunteer program, I think. Mr. Towns. You mentioned communication or coordination--I am not sure which one it was--but I remember hearing communication or coordination of the various agencies that are providing services and have responsibility for oversight. What is your office's relationship with State and local prosecution in terms of police authorities and when you file a complaint? What happens there? You didn't talk about that. Ms. Fish. Right. When the Governor convened the first State work group, we brought on board the Attorney General's Office, but we also worked with the Office of Inspector General. We developed a system where, when an ombudsman saw a red flag in one of the facilities, saw something happening, a therapist not giving treatment, whatever, we would then make the referral directly to the Office of Inspector General and HCFA and also the State Attorney General's Office. If it was Medicaid, the State Attorney General's Office handled it. If it was Medicare, HCFA and the Office of Inspector General would handle it. Then they would get back to us, and we would get back to the complainant. But that is basically how it worked. We were very involved with all of the law enforcement. We continue to be. Mr. Towns. Ms. Safford indicated instances of physical abuse of residents. Have you found any such instances in New York? Ms. Fish. Of physical abuse? Mr. Towns. Yes. Ms. Fish. Oh, yes. I can't right now give you the number, but I can tell you last year our figures. We have reported over 5,000 cases. That is reported. We know that could be tripled if people would, you know, the ombudsman actually did the paperwork. But out of our work, the majority of cases is resident care, and within that category is patient abuse and neglect. I mean, there is still a question. That case I gave you is the first example. I wish I could say it wasn't really typical, but it does happen. It happens frequently. Mr. Towns. Let me just ask you one other question, also, picking up on Ms. Safford's testimony, about an extensive data base established by her group which includes important information about complaints and penalties imposed on nursing home facilities. Can you tell me whether your office keeps a similar data base? Ms. Fish. We keep a data base of all of our cases that we get in regards to that. We have a reporting system, an ombudsman reporting system, but we also take a look at the data that our health department has. But, no, we really don't have. Does that respond to your question? Mr. Towns. Yes. Sometimes my staff will say to me that you are barking up the wrong tree. I just think that if you have information, then it helps in a lot of ways. If people know that this information is coming in a very coordinated fashion, they would even behave differently in terms of being responsible for providing service. Ms. Fish. You are right. As a matter of fact, you had said something earlier, and I wanted to address that question, when you talked about how do you know where the quality nursing homes are. Is there a listing, if I wanted to look at a data base or whatever? I can tell you that in other States--and we are going to start doing this in New York State. In other States, what they have done is they have taken the survey reports and in their annual report they list the top 10 nursing homes in terms of compliance. You know, they have been complying, but they also list the top 10 worst in terms of compliance. You will be amazed at how many people want to get on the top 10 list; and that automatically will start having facilities raise their standards to not just minimum standards, not just compliance. What we are talking about is a good nursing home goes above minimum standards. They say, we don't just need to be in compliance. We need to provide quality care to people. We go above that standard. Ms. Canja. I did want to comment. I can tell you in Florida that nursing homes are rated and that their compliance record has to be posted for residents and families to see. Ms. Fish. We do have in New York State, too. They do have to post it in the nursing home. Ms. Safford. The last survey has to be available. We have about 2,000 calls a month. We tell them to go to the facility and ask for that survey, take a look at it. Mr. Shays. It wouldn't be on the Internet? Ms. Safford. No, no, the survey of each individual facility. You know, all 1,450 have to make them available. Mr. Shays. Why wouldn't there be one central source that someone could just turn to? Ms. Safford. It would be 25, 30 pages for each facility. We put it on the Internet. The State doesn't. Mr. Shays. That is what I say. It is on the Internet, though? Ms. Safford. The survey results? Mr. Shays. Yours. Ms. Safford. In Department of Health Services? Ours are, yes--I am sorry--but the results from the Department of Health services are not. They are just in each facility. Ms. Fish. But the interesting think about that is that in New York State, I think it is, there is a one-page compliance report that is supposed to be posted; but unless you know you would never know to go over to the administrator and say, can I see the entire report. You have to be informed to know that. That is part of what the ombudsman does, is to inform them. Mr. Towns. Last quick question. Ms. Safford, Operation Restore Trust, has it made any difference in California? Ms. Safford. Well, I was just talking with Ms. Buto earlier. I will give you an example. When I get calls that involve Medicare fraud--I have several pending right now--it has to go to the carrier. An insurance carrier investigates it. One case in point. A man in Orange County, who is very motivated to get this investigated, has made 10 calls, but Mutual of Omaha is the carrier. They have not been able to make contact. Ms. Buto said that is going to change. They are going to have new investigators. But, right now, it is a real problem to get the consumer, who does want to complain, to get the person together with an investigator. That has been our experience. Mr. Shays. I just have one question before our vote, and I am not looking for a long answer. Just give me a few key characteristics of a good nursing home. Ms. Fish. Well, OK. I will go back to a statement I made earlier. To me, in my experience, 31 years experience, my definition of a good nursing home is not--when you are looking at regulations and you want to make sure you are compliant to each and every regulation when the survey agency comes, that is one thing. It doesn't necessarily mean you are a good facility. A good facility rises above that. A good facility says, how are we going to go above the minimum, the very, very, very minimum qualifications? How are we going to do that? And there are many facilities who do that in New York State and all over. Mr. Shays. Ms. Safford. Ms. Safford. Looking to patient care, No. 1, as a mandate for your operation and profit being--coming in second is a key to us. When you are looking at the net profit first, patient care generally suffers. You can see that again and again. So it is what your focus is. Are you looking at providing care or looking at making big bucks? Ms. Canja. I would say all of that. If a nursing home goes in with a real concern for the dignity of their patients, a lot of other things fall in place. Mr. Shays. You opened the door for us to just see and to understand more about ombudsmen and what they do. It is just an extraordinary thing in this country I think; and it is very moving to think that there are so many people who are willing to, in fact, volunteer and commit to being somewhere at a certain time and doing it on a weekly basis. I really am surprised that I wasn't more aware of this. So we will be doing a little more work here in seeing how we can use the ombudsmen more effectively in dealing with waste, fraud and abuse as well as quality care. Thank you very much. This hearing is adjourned. [Whereupon, at 12:45 p.m., the subcommittee was adjourned.] [Additional information submitted for the hearing record follows:] [GRAPHIC] [TIFF OMITTED] 45631.070 [GRAPHIC] [TIFF OMITTED] 45631.071 [GRAPHIC] [TIFF OMITTED] 45631.072 [GRAPHIC] [TIFF OMITTED] 45631.073 [GRAPHIC] [TIFF OMITTED] 45631.074 [GRAPHIC] [TIFF OMITTED] 45631.075 [GRAPHIC] [TIFF OMITTED] 45631.076 [GRAPHIC] [TIFF OMITTED] 45631.077 [GRAPHIC] [TIFF OMITTED] 45631.078