[Senate Hearing 109-970]
[From the U.S. Government Publishing Office]
S. Hrg. 109-970
RESPONSIBLE RESOURCE MANAGEMENT AT THE NATION'S HEALTH ACCESS AGENCY
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HEARING
before the
FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT
INFORMATION, AND INTERNATIONAL
SECURITY SUBCOMMITTEE
of the
COMMITTEE ON
HOMELAND SECURITY AND
GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
__________
JULY 27, 2006
__________
Available via http://www.access.gpo.gov/congress/senate
Printed for the use of the Committee on Homeland Security
and Governmental Affairs
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COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
SUSAN M. COLLINS, Maine, Chairman
TED STEVENS, Alaska JOSEPH I. LIEBERMAN, Connecticut
GEORGE V. VOINOVICH, Ohio CARL LEVIN, Michigan
NORM COLEMAN, Minnesota DANIEL K. AKAKA, Hawaii
TOM COBURN, Oklahoma THOMAS R. CARPER, Delaware
LINCOLN D. CHAFEE, Rhode Island MARK DAYTON, Minnesota
ROBERT F. BENNETT, Utah FRANK LAUTENBERG, New Jersey
PETE V. DOMENICI, New Mexico MARK PRYOR, Arkansas
JOHN W. WARNER, Virginia
Michael D. Bopp, Staff Director and Chief Counsel
Michael L. Alexander, Minority Staff Director
Trina Driessnack Tyrer, Chief Clerk
FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, AND INTERNATIONAL
SECURITY SUBCOMMITTEE
TOM COBURN, Oklahoma, Chairman
TED STEVENS, Alaska THOMAS CARPER, Delaware
GEORGE V. VOINOVICH, Ohio CARL LEVIN, Michigan
LINCOLN D. CHAFEE, Rhode Island DANIEL K. AKAKA, Hawaii
ROBERT F. BENNETT, Utah MARK DAYTON, Minnesota
PETE V. DOMENICI, New Mexico FRANK LAUTENBERG, New Jersey
JOHN W. WARNER, Virginia MARK PRYOR, Arkansas
Katy French, Staff Director
Sheila Murphy, Minority Staff Director
John Kilvington, Minority Deputy Staff Director
Liz Scranton, Chief Clerk
C O N T E N T S
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Opening statements:
Page
Senator Coburn............................................... 1
Senator Carper............................................... 11
WITNESSES
Thursday, July 27, 2006
Peter C. Van Dyck, M.D., M.P.H., Associate Administrator,
Maternal and Child Health Bureau, Health Resources and Services
Administration, U.S. Department of Health and Human Services... 5
Joyce Somsak, M.A., Associate Administrator, Healthcare Sercices
Bureau, Health Resources and Services Administration, U.S.
Department of Health and Human Services........................ 8
Alphabetical List of Witnesses
Somsak, Joyce, M.A.:
Testimony.................................................... 8
Prepared statement........................................... 36
Van Dyck, Peter C., M.D., M.P.H.:
Testimony.................................................... 5
Prepared statement........................................... 29
RESPONSIBLE RESOURCE MANAGEMENT AT THE NATION'S HEALTH ACCESS AGENCY
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THURSDAY, JULY 27, 2006
U.S. Senate,
Subcommittee on Federal Financial Management,
Government Information, and International Security,
of the Committee on Homeland Security
and Governmental Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 2:32 p.m., in
room SD-342, Dirksen Senate Office Building, Hon. Tom Coburn,
Chairman of the Subcommittee, presiding.
Present: Senators Coburn and Carper.
OPENING STATEMENT OF CHAIRMAN COBURN
Senator Coburn. The Subcommittee on Federal Financial
Management, Government Information, and International Security
will come to order.
I want to first thank all of our guests for being here and
the time they spent. I also want to tell you, regardless of
what comes through this Subcommittee hearing, we do appreciate
your service and your dedication to carrying out the charges
that you have been tasked with.
The title of our hearing is ``Responsible Resource
Management at the Nation's Health Access Agency.'' I will
apologize in advance. I do not think Senator Carper is going to
be able to make it. The Senate is not in formal session with
votes, but I will try to cover his areas of concern, as well,
in the hearing.
This, I believe, is our 43rd hearing on oversight since
April 12 of last year. I have a prepared statement that I will
place into the record, but I want to make a couple of points.
Six billion dollars goes through the Health Resources and
Services Administration (HRSA) a year and they have a vision
statement that is very broad. One of the things that we have
tried to do is to raise the awareness of metrics, measurement
of goals, and then evaluation of the metrics as to the goals of
whether or not we are accomplishing what we want and also using
that as a tool to help us decide where to direct monies in a
better way, where do we get the best dollar return in terms of
accomplishments at HRSA.
I am a big believer in the Performance Assessment Rating
Tool (PART) system. I know it has tremendous flaws, but it is
better than no system. One of the things that is quite evident
at HRSA is that the failure rate is about one in three programs
inside HRSA to either identify the goal or perform up to the
goal.
So the purpose of this hearing really is to talk about two
areas, but also just to raise the awareness that we are going
to be continuing to have hearings in areas in which I do not
think you would disagree is how do we get the best dollar
return for what our goals are, and also to give maybe some more
direction. We recognize we are not the Executive Branch, but we
do have the power of the purse and the authorization power to
try to redirect those.
This is all part of a larger goal, is how do we handle
health care in America? How do we make it affordable and
accessible, which you all are keyed into in terms of the
accessibility, and how do we do that to a degree where people
can afford it? Part of that problem is the bigger problem of
prevention, which HRSA is supposed to be associated with, as
well, and how do we change the format in America from treating
of disease to investing in health.
I know that you are both dedicated in those areas. The
question is do we have the performance measures and the
guidelines with which to assess the success or failure and the
objective measurements of whether or not we are successful or
failing in all the agencies, all the programs run by HRSA.
Just as an example, we had a hearing 4 months ago on the
Ryan White and it has taken 4 months to get the answer to
questions from HRSA. To me, 4 months to answer two or three
simple questions either means it is not a priority or you do
not have the capability or organizational skill to answer those
questions.
Also, we had a report from GAO, I believe it was, in terms
of the 340(b) program and what we know is we are wasting at
least $4 million a month because we are not getting the best
prices, which was some of the questions we asked, and that is a
recent GAO report.
So the point is not to be critical of individuals. Nobody
doubts your dedication or your desire to do what is in the best
interests of our country, but rather to have a real frank
discussion about what we can do better, how do we do it more
efficiently, and how do we measure what we are doing to see if
we are accomplishing the goals that were set out to us.
So I will put my full statement into the record.
[The prepared statement of Chairman Coburn follows:]
PREPARED STATEMENT OF SENATOR COBURN
We're here to talk about Responsible Resource Management at the
Nation's Health Access Agency--otherwise known as the Health Resources
and Services Administration (HRSA). In essence, we're here today for
nothing more than a routine health checkup.
As a practicing physician, I have often learned that sometimes you
treat symptoms in patients because they're a real problem. Other times,
those symptoms are really alerting you to a much bigger problem in the
patient. Today we're going to look closely at some programs that aren't
performing well. And while we expect these programs to make
improvements, they are only symptoms of a bigger problem at HRSA--a
universal lack of performance measures and therefore, a lack of
accountability to the taxpayers for how public funds are being used.
I recently held a hearing on President Bush's efforts to take a
multi-trillion dollar government and apply some sort of standardized
outcome evaluation on it--even if it's a crude instrument--known as the
Performance Assessment Rating Tool (or (PART). The PART is a tool to
review the strengths and weaknesses of government programs as agencies
go through the annual budget process. PART findings, as the agency
before us today knows, do influence funding and programmatic decisions.
As we found at that hearing, the Office of Management and Budget has
reviewed 793 programs, accounting for $1.47 trillion in taxpayer money.
Almost a third of these programs came up either totally ineffective or
are ``not demonstrating results.'' One-third of $1.5 trillion is $500
billion.
So, how do you manage a multi-trillion dollar Federal Government
with literally hundreds of agencies and departments? First, you ask
each agency: ``what are we trying to accomplish?'' You set measurable
goals that can be tied directly to the outcome you're trying to
achieve. And then you work diligently to achieve those benchmarks,
keeping good track of your money and your data along the way.
An agency's success will in large part depend on its mission being
realistic, measurable, and whether it has a role appropriate for the
Federal Government. HRSA is a $6 billion-a-year agency with the stated
goal to ``provide national leadership, program resources and services
needed to improve access to high quality, culturally competent health
care.'' What do you get when you have an unrealistic and unmeasurable
goal like this? You get seven out of 21 programs that have been
measured so far failing when it comes to rating program performance--
that's a third of the programs--and those are only the ones that have
been measured so far.
When you're talking about healthcare, the results of inadequate
performance can mean the difference between life and death. We had a
hearing a few months ago on another HRSA program--the Ryan White CARE
Act--the Nation's safety net for people infected with HIV/AIDS. Due in
part to HRSA decisions, some patients are stuck indefinitely on
waitlists for drugs that could save their lives--some have even died on
the waitlists. GAO reported that the government is being overcharged
for those same life-saving drugs by unacceptable amounts. Backing up
this finding, the HHS Office of the Inspector General released a report
last week on HRSA's ``340B'' affordable drug pricing program. The
report found that 14 percent of purchases were made at prices that were
higher than they should have been--resulting in $3.9 million in
projected overpayments during just one month last year. HRSA has known
about the weaknesses in the 340B program but has never corrected the
problems. In this and other areas, HRSA has not been accountable.
Let's take another example. HRSA spends $6.2 million on its ``Stop
Bullying Now'' campaign, an initiative launched in early 2005 that
occupies quite a bit of ``real estate'' on HRSA's internet home page.
The recently updated web page includes a ``stop bullying now'' jingle,
12 games, 12 ``webisodes'' of short animated stories featuring
characters that ``just might remind you of people you know'' (and a
promise for new episodes every couple of weeks) as well as quirky
cartoon ``experts'' that answer questions about bullying. I don't doubt
that there are good intentions behind this program, that HRSA wants to
deter violence and stress in schools. But how does this program fit
into HRSA's goal of ``ensuring access to culturally competent health
care for all?'' HRSA's own website lists nearly 30 private groups
addressing the problem, and a host of other programs at HHS, including
violence prevention at the Centers for Disease Control and Prevention,
and mental health programs at the Substance Abuse and Mental Health
Administration, as well as the Departments of Justice and Education are
working towards the same goal. I wonder why this campaign even belongs
at HHS. Duplication and priorities that are out of whack are the
natural results of poorly conceived mission statements and a lack of
measurable objectives.
We could go on. But today we'll be examining two programs in
particular. First, Healthy Start--a program originally conceived to
reduce infant mortality. The program is currently going through the
PART process. Healthy Start was first intended in 1991 as a 5-year
pilot funded at $345.5 million, and today continues to receive large
sums of money--about $90 million--$100 million a year since 2000.
Healthy Start was designed to reduce infant mortality, but has
floundered in achieving results. It is a great shame for our Nation
that the United States ranks second worst among developed nations in
infant mortality rates.
The second program in the spotlight today is HRSA's National
Bioterrorism Hospital Preparedness program. The program received low
PART scores, and the Federal Government has poured over $2 billion into
this program since it was created in 2002 in the Public Health Security
and Bioterrorism Preparedness and Response Act in answer to the anthrax
attacks of the fall of 2001. It's also expected to receive another $474
million in 2007. The primary purpose of the program is to assist
communities to develop adequate surge capacity to handle a moderate
bioterrorism or natural health disaster. Building surge capacity is
hard, and expensive. In the case of a massive epidemic or a disaster
with catastrophic casualties, it's likely that no community would have
``adequate'' capacity, but there's a lot that can be done today to make
us as prepared as possible. However, with poor oversight, the taxpayers
have poured in billions of dollars to the program, but there remain
well-documented wide-spread deficiencies in the capacity,
communication, coordination, and training elements required for
preparedness and response in the efforts made so far. This is simply
unacceptable.
In addition, the Emergency System for Advance Registration of
Volunteer Healthcare Personnel (ESAR-VHP), as authorized in law in
2002, is a critical portion of the Hospital Preparedness program. The
law required the Secretary to directly develop and implement a
coordinated national database for the advance registration of health
professionals for Federal use in case of a nationally declared
emergency. Without this program, in a disaster situation, when
volunteer doctors and nurses show up and want to volunteer their
desperately needed services, they will not be able to do so. Despite
clear need, with the program authorized after 9/11 and addressed by the
2002 law, the Department has done stunningly little. Finally, even as a
program which does not match the requirements of the law, is still in
the design stage. Officials are simply passively sending funds to
States to develop their own systems--an approach rife with problems
that we'll address later today with our witnesses.
I want to thank our witnesses for being here today and for the time
they spent preparing testimony. I'd like to quote a man whose work I
admire--Hank McKinnell, Chairman and CEO of Pfizer Inc., who rightly
points out in his new book that ``the hopes and dreams of grandchildren
everywhere depend on us today--since the future they will inherit is
ours to create.''
Senator Coburn. I want to thank our guests for being here.
I would like to recognize Dr. Peter Van Dyck, who is both a
physician and has a master's in public health. He was appointed
Associate Administrator for Maternal and Child Health Bureau in
the U.S. Department of Health and Human Services, Health
Resources and Services Administration, in 1999. As Associate
Administrator for HRSA's Maternal and Child Health Bureau, Dr.
Van Dyck is responsible for a $836 million budget this year.
The Bureau is charged with promoting and improving the health
of mothers, children, and families, particularly those that are
poor who lack access to care. It administers the Maternal and
Child Health Services Block Grants Programs for the State, the
Healthy Start Initiative, and the Abstinence Education Program,
among other programs. Prior to that, he was Senior Medical
Advisor for 4 years to the Maternal and Child Health and HRSA
Directors. He is currently Executive Secretary of the
Secretary's Committee on Infant Mortality.
Joyce Somsak was appointed Associate Administrator of the
Healthcare Systems Bureau in the U.S. Department of Health and
Human Services, Health Resources and Services Administration on
February 28, 2005. My, that is a long title. As head of HRSA's
Health Care Systems Bureau, Ms. Somsak oversees $500 million in
programs and services under the National Bioterrorism and
Hospital Preparedness Program. The Bureau administers $471
million in fiscal year 2006 awards to the States to strengthen
the ability of hospitals and other health care facilities to
respond to bioterror attacks, infectious disease outbreaks, and
natural disasters that may cause mass casualties. The Bureau
also directs programs that oversees the procurement,
allocation, and transplantation of human organs, tissue and
bone marrow, manages the Vaccine Injury Compensation Program,
and administers grants to the States to improve health
insurance coverage for the uninsured. She served as Acting
Director for the Vaccine Injury Compensation Program, is
Director of HRSA's State Planning Grants Program, Acting
Director of the Division of Transplantation, and is a member of
the Department of Health and Human Services task force to
implement the new Medicare Part D drug benefit Medicare
Advantage legislation.
I would like to recognize you both in the order in which
your bios were read. You have no time limit on the amount of
time. It is just me and you, and so feel free to take off, Dr.
Van Dyck.
TESTIMONY OF PETER VAN DYCK, M.D., M.P.H.,\1\ ASSOCIATE
ADMINISTRATOR, MATERNAL AND CHILD HEALTH BUREAU, HEALTH
RESOURCES AND SERVICES ADMINISTRATION, U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Dr. Van Dyck. Thank you, Mr. Chairman, and Members of the
Subcommittee. I am Dr. Peter Van Dyck from the Health Resources
and Services Administration, the Director for the Maternal and
Child Health Bureau in the Department of Health and Human
Services. I want to thank you for the opportunity to testify
today concerning responsible resource management at HRSA, the
Nation's health access agency.
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\1\ The prepared statement of Dr. Van Dyck appears in the Appendix
on page 29.
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Today, I will concentrate my remarks on the Healthy Start
Program, one of the programs in the Maternal and Child Health
Bureau and one about which I am very proud to represent.
In the late 1980s, a national concern about persistently
high levels of infant mortality led to a number of efforts to
address this problem. Although infant mortality rates have
declined over time, the rate of decline had slowed by the
middle 1980s, and relative to other developed nations, the
United States' ranking had slipped. Even more alarming was the
racial disparity in infant mortality rates. Black infants in
the 1980s were more than twice as likely to die their first
year of life than white infants.
A White House study then recommended the development of a
major initiative to mobilize and coordinate the resources
available in selected communities and to demonstrate effective
approaches to reduce infant mortality. Concerned about this
persistent high rate of infant mortality, President George H.W.
Bush created the Healthy Start Initiative to fund 15 projects
in areas both urban and rural where the infant mortality rates
were 1.5 to 2.5 times the national average, and so the Healthy
Start Demonstration Program began as a demonstration program in
1991.
Each year in the United States, about four million women
give birth. Most have safe pregnancies and deliver healthy
infants, but some women give birth too early, they see their
babies die soon or after birth, or die themselves in pregnancy-
related deaths. These difficulties continue to occur in greater
numbers among women who are members of racial and ethnic
minority.
According to the most recent available data from CDC's
National Center for Health Statistics, the national infant
mortality rate in 2003 was 6.9 deaths per 1,000 live births and
the racial and ethnic breakdown was 14 deaths per 1,000 live
births for black infants, 5.9 per 1,000 for Hispanics, and 5.7
per 1,000 for whites.
Healthy Start began with a 5-year demonstration phase to
identify and develop community-based system approaches to
reducing infant mortality and improve the health and well-being
of women, infants, children, and their families. Since its
inception, Healthy Start has been located in HRSA. It was
originally funded under the authority of Section 301 of the
Public Health Services Act and most recently authorized as part
of the Children's Health Act of 2000.
Healthy Start was founded on the premise that communities
can best develop and implement the strategies necessary to
eliminate the factors contributing to infant mortality, low
birthweight, and other adverse perinatal outcomes among their
own residents, especially among populations at high risk.
Healthy Start communities form local coalitions of women, their
families, health care providers, businesses, various public and
private organizations, all working together to address
disparities in perinatal health. Every Healthy Start site is
guided by its consortium. Local residents are recruited, they
are trained and employed as case managers and outreach
providers.
HRSA provides the Healthy Start communities with national
leadership in planning, directing, coordinating, monitoring,
and evaluating the implementation of the various Healthy Start
programs throughout the country. Specifically, the national
program collects and analyzes information regarding the Healthy
Start projects, provides program policy direction, technical
assistance, and professional consultation on Healthy Start
activities. It obviously administers the grants and contracts
and serves as a focal point within the Department for Healthy
Start.
The program now reaches 96 communities in 37 States, the
District of Columbia, and Puerto Rico, and each of these
vulnerable communities receives funds but has suffered from
poor perinatal outcomes or an infant mortality rate in one or
more racial, ethnic, or geographically disparate populations
that is at least 1.5 times the national average.
While each Healthy Start project is unique as its community
setting, there are certain hallmarks of all Healthy Start
projects. Healthy Start was one of the pioneers in the use of
women living in the community as outreach workers and home
visitors. The approach achieves several things. It saves money,
pregnant women respond better to other community-based women
who have walked in their shoes, so to speak, and it has
provided real and meaningful jobs to hundreds of unemployed or
under-employed women in vulnerable communities.
Healthy Start communities do not stop helping to build
healthy families when a healthy baby is born. They stay with
the mother, the baby, the whole family for 2 years, monitoring
the baby's growth and development, ensuring the mother's health
and safety so that each new family is assured a Healthy Start.
These projects have been forward-thinking in their
recognition that there can be both physical and psychological
threats to a mother's health before, during, and after
pregnancy, and they are particularly focused on identifying and
treating perinatal depression. Part of what all Healthy Start
projects are funded to do is to help their communities build
and strengthen the medical, social, and psycho-social resources
available to the women and their families. These projects are
actively engaging mothers, babies, and families through these
crucially important first 2 years of the child's life. These
years are critical, as we know, because any difficulty in a
child's development can be uncovered and addressed early, and
the child's parents can be most readily engaged in positive
parenting techniques that will result in optimal development
and adjustment.
Just as important, Healthy Start programs begin with a
fundamental precept that it is important to make sure that the
mother has a medical home and that she is followed along with
her infant to improve her health through risk reduction and
health education. Good interconceptional care for women can
make a subsequent pregnancy less risky for both mothers and
babies.
Throughout the history of this program, it has been
monitored by an independent council known as the Secretary's
Advisory Committee on Infant Mortality, and the initial program
design included a rigorous national evaluation. This
evaluation, the first one for Healthy Start, was released in
2000. It used matched comparison communities, Healthy Start
communities to non-Healthy Start communities, and to the
original 15 Healthy Start program communities. The evaluation
revealed several statistically significant differences.
More than half of the Healthy Start communities had
improved adequacy of prenatal care. Four Healthy Start
communities had declines in the pre-term birth rate. Three had
reductions in the low birthweight rate. And two had declines in
the infant mortality rate in the first 5 years of greater than
50 percent. The evaluation also found that Healthy Start
projects were more effective in enrolling high-risk women into
prenatal care and that the community-based interventions which
Healthy Start uses may have longer-term impacts on future
health and well-being of women and their families that have not
yet been measured in the first years just surrounding that
individual birth.
A major result of the first national evaluation was that
using its findings, coupled with recommendations from the
Secretary's Advisory Committee, HRSA was able to reshape the
Healthy Start program to reflect what had been found to be most
effective in that first rigorous evaluation.
Committed to implementing evidence-based practices and
innovative community-driven interventions, Healthy Start works
with individual communities to build upon their own local
assets to improve the quality of health care for women and
infants at all service levels. At the service level, beginning
with direct outreach from community health workers to women at
high risk, Healthy Start projects ensure that the mothers and
infants have ongoing sources of primary and preventive health
care and that basic needs--housing needs, nutritional needs,
psycho-social needs, educational needs, and job skill
building--are met. Following risk assessments and screening for
perinatal depression, case management provides linkages with
needed services and health education for risk reduction and
prevention.
Getting women into prenatal care in the first trimester of
pregnancy, or as early as possible, is critical since we know
that prenatal care is critical to improving birth outcomes.
Healthy Start has made proven impacts on participants' access
to prenatal care. In 1998, participants' first trimester entry
into prenatal care was only at 42 percent. By 2003, 5 years
later, this number had risen to 71.4 percent, an increase of 73
percent across all Healthy Start sites in 5 years.
One of the first 15 sites, Washington, DC, reported for the
year 2000 its lowest infant mortality rate ever, and in that
same year, no babies born to Healthy Start clients died.
Central Harlem is another example of a Healthy Start success
story. The infant mortality rate there has dropped
significantly since its project began in 1991, when in 1991
there were 27.7 infant deaths per 1,000 live births. By 2003,
10 or 11 years later, the rate had dropped to 7.3, from 27.7 to
7.3 per 1,000 births, a 273 percent decline.
Other locations have had real success in reducing low
birthweight. In Baltimore, for example, the percentage of very
low birthweight babies is 2 percent among participants with
single births enrolled in Healthy Start. Ninety-nine percent of
those clients are African American. That 2 percent compares to
a 3.7 percent rate, almost twice, of very low birthweights
among African American women throughout the rest of the city
who are not in a Healthy Start site.
President Bush has asked for $101.5 million for Healthy
Start in his fiscal year 2007 budget, an amount equal to the
2006 appropriation.
I am proud to represent the Healthy Start program. Thank
you for this opportunity and I will be happy to respond to your
questions.
Senator Coburn. Thank you, Dr. Van Dyck. Ms. Somsak.
TESTIMONY OF JOYCE SOMSAK, M.A.,\1\ ASSOCIATE ADMINISTRATOR,
HEALTHCARE SYSTEMS BUREAU, HEALTH RESOURCES AND SERVICES
ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Ms. Somsak. Good afternoon, Dr. Coburn.
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\1\ The prepared statement of Ms. Somsak appears in the Appendix on
page 36.
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Senator Coburn. Good afternoon.
Ms. Somsak. Mr. Chairman, I am Joyce Somsak and I am the
Associate Administrator of the Healthcare Systems Bureau in the
Health Resources and Services Administration in the Department
of Health and Human Services.
Senator Coburn. Like I said, it is a long title.
Ms. Somsak. It is a long title. At least I was able to drop
``acting'' off of one of those.
Senator Coburn. That helps.
Ms. Somsak. Thank you for the opportunity to testify today
concerning responsible resource management at HRSA, which is
our Nation's health access agency. The specific program that I
have been asked to talk about today is the Bioterrorism
Hospital Preparedness Program.
HRSA recently announced the latest round of grants for this
program. This is the fifth consecutive year that we provided
funding for the program, which was created after the terrorist
attack of September 11.
Since then, the program has delivered over $2 billion to
hospitals and health care systems in all 50 States as well as
five territories, three freely associated States, and four
large metropolitan areas, New York City, Chicago, L.A. County,
and Washington, DC. This year, HRSA will be awarding $460
million to all these jurisdictions to strengthen the ability of
hospitals and other health care facilities to respond to
bioterror attacks and other public health emergencies.
Hospitals play a critical role in both identifying and
responding to any potential terror attack or infectious disease
outbreak.
During the first 4 years of the program, States used grant
funds to develop surge capacity to deal with mass casualty
events, such as expanding the number of hospital beds and
developing isolation capacity at hospitals. Other priorities
included identifying additional health care personnel who could
be called into action in the event of an emergency as well as
establishing hospital-based pharmaceutical caches for hospital
personnel and associated EMS.
Recipients also used the funds to increase coordination of
disease reporting among hospitals, local and State health
departments, and to improve coordination and communication
between public health laboratories and hospital-based
laboratories.
Jurisdictions were required to improve their ability to
provide mental health services, to strengthen trauma and burn
care, and to increase their supplies of personal protective
equipment and pharmaceuticals. Money could also be used to
support training, education, drills, and exercises.
This year, the program's focus is turning to efforts to
improve the capability of the local and regional health care
systems to manage mass casualty events and to integrate
preparedness activities across disciplines and agencies. The
goal is to ensure that each jurisdiction has a system in place
that will result in fewer deaths, long-term disabilities, and
required hospitalizations.
Progress has been made in getting the funds to local health
care systems. In the early stages of this program, there were
some difficulties in quickly expending the large infusion of
funds because State health departments were not set up quickly
to establish such large grant programs, and also the capacity
for the States to pass money on to the hospital systems did not
exist because this was a new activity.
States have cited three main reasons for initial delays.
Some State Governments were either reluctant or found it
difficult to quickly hire the necessary staff to operate the
programs. Due to procurement processes at the State level,
delays were encountered in trying to award contracts to
hospitals. And before disseminating funds to hospitals, they
were required to conduct a state-wide needs assessment of their
ability to respond to a bioterrorist event, infectious disease
outbreak, or other public health emergency. These three
barriers have diminished with time and States are now reporting
greater success at getting funds to their local health care
systems.
This program has built upon the needs assessments and
implementation plans developed by the State grantees during the
previous years and the updates of these plans from fiscal year
2003 to fiscal year 2005. Proposals are approved and funded in
accordance with preparedness priorities developed by the
States. Information on the improvements in the hospitals'
capacity to respond to public health emergencies in general and
to bioterrorism in particular is part of the progress reports
that are submitted by the States and other grantees.
Part of this program is the Emergency System for Advance
Registration of Volunteer Health Professionals, or as that
wonderful acronym we call ESAR-VHP----
Senator Carper. Can you say that one again?
Ms. Somsak. ESAR-VHP. That is one of our more interesting
acronyms. This program focuses on developing the personnel
component of medical surge and has provided grant funds to
States for the purpose of establishing a standardized volunteer
advance registration system that includes verified information
on volunteer health professional identity, license status,
certification, and privileges in hospitals and other health
care facilities. The establishment of these standardized State
systems will give each State the ability to quickly identify
and better utilize health professional volunteers in
emergencies and disasters and will lead to a virtual national
system that will allow the easy exchange of volunteers across
States and through the Federal Government, as necessary. The
value of these state-based registries was demonstrated in the
aftermath of Hurricanes Katrina and Rita, when 21 State
registries deployed over 8,300 health professionals to the
affected areas.
The National Bioterrorism Hospital Preparedness Program
focus this year will be to continue to enhance medical surge
capacity and capability as well as to develop a response
structure that allows the implementation of a complex health
and medical response through a single system. Since the
inception of the program in fiscal year 2002, the program has
established and awarded cooperative agreements to 62 States,
territories, and select cities. These agreements have been
essential for developing and coordinating health care emergency
response plans at the State, regional, and local level for the
management of mass casualty events that might otherwise
overwhelm the system.
Significant progress has been made by State awardees in
establishing the plans, developing partnerships, and assessing
crucial needs and how to address them. The majority of the
jurisdictions have in place or are finalizing a system to
receive and distribute pharmaceuticals made available from
Federal sources, such as antibiotics and smallpox vaccines.
States are putting mechanisms in place to address the gaps
in communications systems among hospital emergency departments
and outpatient facilities, emergency medical systems, and State
and local emergency management, public health, and law
enforcement agencies. They are also developing strategies to
implement MOUs and mutual aid agreements to foster intrastate
and interstate collaboration in meeting medical needs. These
include personnel, equipment, supplies, training, and
exercising.
You mentioned the PART program before. A PART review was
done very early in this program, in fiscal year 2004, and we
received a rating of ``results not demonstrated.'' The
assessment did indicate that the program had not demonstrated
results due to its relative newness and the difficulty in
measuring preparedness for events that do not regularly occur.
We developed some new measures that focus on medical surge
capacity. However, these again were developed early in the
program and the program has evolved since that time.
We are currently looking to go beyond capacity and work
toward capability. We believe the best measures of
effectiveness of the program will be in capability, not just
capacity. So we are in the process of developing new medical
surge capability measures. In January of this year, we had an
expert panel of awardees, hospitals, State hospital
associations, and the American Hospital Association, academia,
and others to develop the measures. We have measures now that
were cross-checked against others, such as CDC's performance
measures, our targeted national capabilities list, and JCAHO
standards. We have a national vetting process that is almost
complete and we expect these new measures to be final in the
next month. We think these new measures will be better in terms
of determining that our Nation's hospitals are prepared to
handle emergencies.
Health and Human Services Secretary Mike Leavitt recently
announced the funding for the preparedness program. His
statement in the announcement was, ``Improving our Nation's
response to health care emergencies is an important part of
securing America. All emergency incidents--whether naturally
occurring, accidental, or terrorist-induced--begin as local
matters, and with this program, States and communities will
build on the preparedness gains they have made over the past 4
years.''
Thank you for this opportunity to testify.
Senator Coburn. Thank you very much. Welcome, Senator
Carper.
OPENING STATEMENT OF SENATOR CARPER
Senator Carper. I have no opening statement. I am just
delighted that our witnesses are here. I am glad I can stop by
and join you for a while, and thank you for coming. I would
like to have a chance in a minute or two to ask a--well, not in
a minute or two, but later on, I will ask a couple of
questions. [Laughter.]
Senator Coburn. Thanks. We are just going to go through
some things.
Dr. Van Dyck, how many total women per year are impacted by
Healthy Start?
Dr. Van Dyck. Depending on the year, it is in the range of
16,000 to 18,000 to 20,000 babies born a year in the Healthy
Start program. There would be a few more women than that
because it takes 9 months to have a baby and you follow the
women whether or not they are successful at their pregnancy and
you follow them for a while after, so the number of pregnant
women would be somewhat more than the number of births.
Senator Coburn. So around 20,000 lives impacted plus
children, so you really have 40,000 lives, is that right?
Dr. Van Dyck. At least.
Senator Coburn. Yes.
Dr. Van Dyck. Correct, and again, we cannot forget if there
is a sibling that is 1 year old----
Senator Coburn. That is getting some impact.
Dr. Van Dyck [continuing]. And when that baby gets care and
immunizations.
Senator Coburn. Thank you.
Dr. Van Dyck. There may be another family member that gets
care. So we serve more than that.
Senator Coburn. Just some old housekeeping. I sent you a
letter--and you probably do not even recall this letter, I
never got an answer to it--in 2000 on the Ryan White and
Healthy Start on testing for HIV. What is Healthy Start and
Maternal Child's position now for neonatal testing of newborns
whose mother's status is not known?
Dr. Van Dyck. Healthy Start women, if appropriate, get
tested for HIV.
Senator Coburn. What about their children?
Dr. Van Dyck. The children will also, depending on the
local sites. It is recommended, but depending on the local
sites' particular policies.
Senator Coburn. So we do not condition any grants on a
totally curable and preventable disease at birth to test
infants whose mother's status is not known?
Dr. Van Dyck. The grants are not conditioned on that. There
are recommendations that are done.
Senator Coburn. And what percentage of this 20,000 are
there infants tested or their mother's status known?
Dr. Van Dyck. I do not know the answer to that.
Senator Coburn. You do agree with the medical practice. The
fact is if a child is treated early or treated during the
intrauterine----
Dr. Van Dyck. Absolutely.
Senator Coburn [continuing]. We can eliminate 90 percent of
it.
Dr. Van Dyck. Absolutely.
Senator Coburn. And a mother's status being known, even
though the child might not test positive, if they are positive,
breast feeding can lead--which is encouraged in Healthy Start--
can lead to infection in the infant.
Dr. Van Dyck. Absolutely, and we also know that a negative
test at the beginning of pregnancy does not mean a negative
test----
Senator Coburn. That is right.
Dr. Van Dyck [continuing]. Later on in pregnancy, either,
and these are highly recommended----
Senator Coburn. Interpartum testing is an important aspect
of pregnancy and delivery, and I was just wondering why we
would not require that as a part of these grants.
Dr. Van Dyck. That is a policy we would have to review.
Senator Coburn. Knowing that one out of every three people
who is infected with HIV in our country do not know it.
HRSA has had a PART evaluation, that is true, correct?
Dr. Van Dyck. Healthy Start?
Senator Coburn. Yes, Healthy Start and Maternal Child, is
that correct?
Dr. Van Dyck. The Maternal and Child Health Block Grant had
a PART review the first year, 5 years ago. Healthy Start just
has had a PART review and it is not posted or finished yet.
Senator Coburn. OK.
Dr. Van Dyck. We have completed the review.
Senator Coburn. I am fully supportive of the goals of
Healthy Start and Maternal Child, so as I question you, it is
not that I do not support the goals of the program and I want
you to bear that in mind. What are the metrics that you use in
Healthy Start for grants? In other words, what are the controls
and measurements and outcomes to know in the grants that we
are, in fact, for the amount of money, $5,000 per individual,
that is the best way to spend the money, and what percentage of
that $5,000 per individual actually gets to care, to treatment?
Dr. Van Dyck. First, the $5,000 per individual, that might
be per birth, but not per individual, if you will allow me----
Senator Coburn. But the per woman treatment. Let us use it
as per woman treatment.
Dr. Van Dyck. Per family unit.
Senator Coburn. OK.
Dr. Van Dyck. Just to not understate it. We have a number
of performance measures that have been used for a number of
years. The first is to reduce the infant mortality rate among
the Healthy Start program participants, and our long-term goal
for 2013 is to reduce it to 4.28 infant deaths. To give you an
idea, and we have been following this since the beginning of
the program, in 1991 to 1993 when the program first began in
those 15 communities, the rate averaged around 20. In 2000, it
was 13.9. In 2003, it was 11. In 2004, it was 7.65.
Senator Coburn. So each one of these grantees have to
return all this data to you?
Dr. Van Dyck. Yes, sir.
Senator Coburn. It is a component of the grant?
Dr. Van Dyck. That is a requirement, and that is infant
mortality. So not only do they have to return it, but we
aggregate--we review each Healthy Start project against these
performance measures----
Senator Coburn. So what----
Dr. Van Dyck [continuing]. So aggregate it, as well.
Senator Coburn. So what happens if somebody is not
performing right now?
Dr. Van Dyck. Well, we work with them and we will send out
technical assistance and we will review the grant again and we
will review what they are doing.
Senator Coburn. And so who has lost a grant?
Dr. Van Dyck. No one has lost a grant that I can remember,
and I can check on this, from poor performance.
Senator Coburn. But that does not mean there has not been
poor performance.
Dr. Van Dyck. It does not mean there has not been
performance that needs improvement. But the Healthy Start sites
have improved.
Senator Coburn. A key finding from the 2000 mathematical
review of Healthy Start found that even after the program had
been around for several years and ``despite considerable
investment, programs were unsuccessful in developing a
management information system that would allow for the ongoing
tracking of service receipt by clients. Client-level data were
of poor quality and were of limited use for program monitoring
and for evaluation purposes.'' What has changed since then?
That is the first part of my question.
And the second is the independent review that is ongoing
now, and I understand the close-knitness of holding this close
to the vest because of a history of people who let things out
to hurt you in the past that were not necessarily in a balanced
perspective, but since the early one, there have been two
reports released in 2000 that came out of the early report. I
understand there is currently another full independent review
being conducted by Apt Associates at a cost of around $4
million for a full 3-year phased study that is in the final
clearance at HRSA. You all denied us the ability to see that,
which will necessitate us after we see it having another
hearing. Can you update us on this particular review? Why was a
report needed? When is it expected to be released, and what is
it expected to contain?
Dr. Van Dyck. This Healthy Start evaluation by Apt
Associates is a 4-year study. The first 2 years are to get a
better idea about what are the features of the Healthy Start
projects across communities, what results have the projects
achieved, and are there intermediate outcomes that would be
helpful. Is there an association, then, between what elements
the Healthy Start programs include in their programs and
outcomes, and then how does that all fit together in improved
outcomes.
There are two phases to the program. The first phase is
what has just been completed and the document is in clearance,
and that is an analysis of all 90-plus Healthy Start sites, how
they serve people, what the elements are in their service
package. That is in clearance currently as we speak and should
be, I would hope, cleared within the next several weeks.
The second phase of the project is on the outcomes, and
that is a smaller project designed to look at eight to ten
particular Healthy Start sites against the findings in the
first half of the evaluation to really tie together the
practices, features, and elements that the Healthy Start site
has implemented against the outcomes to see if there is a
relationship between those elements and the outcomes, but in
addition, to see if there is any evidence that particular
elements have a greater impact on the outcome than others, and
we suspect that may be the case. So this would allow us to
tailor the programs much more succinctly.
Some preliminary results, just to give you an idea of the
type of results that are in this first piece of the outcome, or
the evaluation, are that 100 percent of the Healthy Start
projects have elements that include health education and
training to their participants. Ninety-nine percent of the
Healthy Start projects have identified strategies for
addressing the disparities in their particular population.
Again, these are features of the program, and 97 percent of
them have implemented these strategies. That gives you a flavor
for the types of findings, the description of the elements and
the number of Healthy Start sites that have those elements
within them.
Senator Coburn. What about the earlier review where they
were talking about the data being of poor quality and limited
use to do any program analysis?
Dr. Van Dyck. The Healthy Start program began in 1991 and
there was a real attempt made in the first 15 projects and in
those early years to develop a data system for those projects
which was uniform across the projects and would collect
information such as I described that would allow you to measure
outcomes. It was not very successful and it was changed to
rather let us tell the Healthy Start sites what data we want to
reach which outcomes and let them develop the system that best
meets those needs for them, because many of them tie into
universities----
Senator Coburn. I cannot be critical of that. That is a
good approach to doing it.
Dr. Van Dyck. And so now we do have good data and almost
all Healthy Start sites have a data system that can allow us
access to individual data.
Senator Coburn. If you were just divorcing yourself away
from the importance of what Healthy Start is about and the
maternal-child function and you sit and say, the $5,000, that
does not count prenatal care. That does not count delivery
costs. That is the cost. The question I have for you is how do
we get more benefit? Instead of having 96 sites, how do we have
180 sites with the same amount of money accomplishing the same
thing? In other words, how much money is spent on administering
Healthy Start versus actually making the difference and how do
we lessen that so we get this greater coverage with the same
amount of money?
Dr. Van Dyck. The Healthy Start legislation has limits on
both evaluation and administration. Healthy Start law says we
may spend up to 1 percent of the budget on evaluation. We spend
a little less than that, but these are important national
independent evaluations which are the elements that get us a
decent PART score. I think I can assure you that our PART score
will be quite positive.
Senator Coburn. Right. That is what we want.
Dr. Van Dyck. But OMB requires an independent evaluation
and that is what this pays for. So up to 1 percent of the money
each year can be used for an independent evaluation. No more
than 5 percent can be used for technical assistance,
administrative kinds of costs, and so we stay under that 5
percent. So we have somewhere between 94 and 95 percent being
spent on programs.
Senator Coburn. OK. Per family unit that you are impacting,
we are spending $5,000 to impact in terms of postnatal care,
pediatric care, parental training, diet, prenatal nutrition----
Dr. Van Dyck. Right.
Senator Coburn [continuing]. All those things. We are
spending $5,000 per unit. The question I would ask is, how do
we get that cost lower so we cover more people?
Dr. Van Dyck. Well, there are probably several ways. One is
to look at the results of the evaluations to see which of these
elements make a difference and which are nice but may not make
as big a difference and focus more on those.
Senator Coburn. Let me tell you some personal experience.
Dr. Van Dyck. Yes.
Senator Coburn. As you know, I am still delivering children
on weekends, and routinely when I am in my office, I will get a
call from somebody from Oklahoma State University and some
Medicaid patient that I am caring for, they are in their home
visiting them. They have driven to their home to visit them and
they are telling me something that I have already told the
patient that I already know the patient is compliant with, but
to meet their marker they have to call the physician. That
makes no sense to me. Now, I do not know if that is in the
rigors of that particular grant program that is a requirement
for them to do, but, in fact, if you are given really good
prenatal care, which I like to think that the group that I was
formerly associated with did, nutrition is a lot of the
teaching--what medicines to avoid, what you can take without
talking to us first. Parenting skills is a part of what you
talk about. Signs of illness in newborn children, teaching that
not just to the mother but to other family members that might
be there.
I guess my question is I am somewhat amazed that we are not
treating more with the same amount of money, that it is costing
$5,000, or 94 percent of $5,000 to do this. And my question to
you is in terms of having metrics to measure, can we design a
metric system where you can take this program and instead of
approaching 20,000 family units, you can approach 40,000?
There are a couple of reasons why I am asking it, and it is
not to be critical of what you are doing. It is hard what you
are trying to do. If somebody said you were king tomorrow and
you could make everybody do it, you could do it a lot cheaper,
I understand that, and you would not have to go through
different universities and all these other different things.
But this program is not going to get increased in terms of
dollars. We are on the downward trend of shrinking every
program we have just to be able to pay for the major programs
that are out there and pay the interest.
So my question really goes and my charge to you is set up
the metrics in a way where we can become much more efficient
with the program, so we get two families for $5,000. And in
terms of infant mortality, what will that mean? If you are
lowering it 30 or 40 percent in these areas, then you are going
to lower it 30 or 40 percent in other areas if we do that, and
so the overall accomplishment of the goal will be that--I will
stop now because I know Senator Carper has some other time
constraints and I will come back.
Dr. Van Dyck. May I respond, please?
Senator Coburn. You bet.
Dr. Van Dyck. Yes. So I agree. The evaluation is one way to
determine which elements are most efficient and effective. But
we also do other things. We have community well baby clinics,
where there may be 10 mothers together with their newborn
babies getting a well baby visit or a well baby educational
session, making that much more efficient. We use community
workers or doulas extensively to bring women in to keep their
appointments, to make sure that they come when they are
scheduled and the time is not wasted and that they do
everything that is necessary at that visit--seeing the
dietician or the nutritionist or the social worker or the
psychologist and physician or the nurse, so they do not have to
come back on the interim, or get their lab work at the same
time.
So there are many elements like this that I think we really
do, and as far as the metric, we do have an efficiency measure
which has been in effect since 2002 which is the number of
persons served with constant funding. In 2002, it was 289,000.
In 2004, the baseline was 367,000. And our target for 2008 is
410,000.
Senator Coburn. So you are growing the number of
population.
Dr. Van Dyck. So this is a metric for Healthy Start of
efficiency that we worked out with OMB to try to show that we
can serve progressively more people to a point with the same
number of dollars.
Senator Coburn. One final comment before I turn it over.
There is the case management technique that is being used in
North Carolina on Medicaid parents. There is case management
for the severely disabled, where they have an advisor that
helps them manage it and it is not through the program, it is
independent. Have you all looked at that to say, maybe we could
do this better by just assigning case managers and Medicaid to
accomplish the same goal?
Dr. Van Dyck. All these women have case managers or care
coordinators and they work in making the plan for that woman
and making sure her visits are efficient and timely and go get
her if she is not there. And so we do use case managers, and in
fact, some of them might be modeled after the Baby Love Program
in North Carolina, which is the EPSDT program for case managers
through EPSDT.
Senator Coburn. All right, thank you. Senator Carper.
Senator Carper. Thanks, Mr. Chairman. I want to just follow
up, if I could. Ms., is it Somsak?
Senator Coburn. It is a Delaware name. I wanted you to know
that. [Laughter.]
Senator Carper. I wanted to ask Dr. Van Dyck a couple more
questions, if I could, and if time allows it, I would like to
come back to you for a question.
Dr. Van Dyck, you were just giving some responses to our
Chairman with respect to the number of folks served. Would you
just repeat those again?
Dr. Van Dyck. In 2002, it was 289,000, rounded. In 2004,
367,000. So when I said earlier that the number of babies born
does not truly reflect the number of clients seen in the
program, this gives an indication of that. There are family
members, other siblings, fathers who are all involved in this
process, and there are many women that may come and end up not
pregnant who still have been seen and evaluated. So, it is a
significant impact.
Senator Carper. And the level of funding between 2002 and
2004, how does one compare it with the other?
Dr. Van Dyck. Funding in 2002 was $99 million, and the
funding in 2006 is $101.5 million.
Senator Carper. So it is basically flat?
Dr. Van Dyck. So it is basically flat.
Senator Carper. The quality of the service--you are
providing service for more people. Are you providing comparable
service? How do you evaluate the success of the care that you
are giving, the service you are providing, the quality of the
service that you are providing for all those people?
Dr. Van Dyck. Quality is extremely important to us and we
think if we lower the infant mortality rate, we decrease the
low birthweight rate, and I might add that Healthy Start has
decreased the low birthweight percent in Healthy Start clients
really significantly.
Senator Carper. How so?
Dr. Van Dyck. In 1998, it was 12.1 percent of all babies
born in Healthy Start were low birthweight, and in 2004, it was
9.3 percent.
Senator Carper. Say those numbers and dates again.
Dr. Van Dyck. In 1998, the low birthweight was 12.1
percent. And in 2004, it was 9.3 percent.
Senator Coburn. Would you care if I interject?
Senator Carper. No, go ahead.
Dr. Van Dyck. In the Nation, the low birthweight percent
has increased for the last 15 years. We are not being
successful in the Nation of reducing it, yet in Healthy Start,
we are.
Senator Coburn. Those statistics are only important if you
ferret out pre-term delivery, because the only way you measure
low birthweight infants is to look at term infants who are low
birthweight versus pre-term infants, and what are the numbers
on those?
Dr. Van Dyck. These are----
Senator Coburn. That is where you know whether you are
making a difference.
Dr. Van Dyck. I do not have that in front of me.
Senator Coburn. But you will admit, it is important. Pre-
term delivery----
Dr. Van Dyck. It is important for pre-term birth and low
birthweight----
Senator Coburn. You bet, and I understand all the
ramifications, but if you----
Dr. Van Dyck. And they run together----
Senator Coburn [continuing]. Combine the statistics
together, you cannot measure what you are really doing. We want
to eliminate pre-term deliveries, which are much greater risk
for children than a term infant that is low birthweight.
Dr. Van Dyck. Correct.
Senator Coburn. And so what we want to try to do is if we
had to pick which one do we want to excel in, it is pre-term
deliveries.
Dr. Van Dyck. Right.
Senator Coburn. I will not go into all the reasons for
that, but there are a lot of reasons in our society today why
we have that.
Dr. Van Dyck. And that is true, and we have also decreased
the pre-term delivery rate, and that has also gone up
nationally.
Senator Carper. In the State of Delaware, 15 or so years
ago, there was a time that Mike Castle was our Governor--the
fellow who served with our Chairman in the House for a while--
but Delaware had maybe the highest rate of infant mortality in
the country. In his administration, he went to work on it. I
succeeded him as governor. We worked on it again. We have a new
Governor who is mindful of this, but we are seeing our infant
mortality numbers, which had dropped, beginning to rise again
and they are now at levels that are alarming in our little
State.
If you look at, and you mentioned the incidence of low
birthweight babies being born, we have a lot of those for our
State, and in a State with a fairly high level of income. We
are not a poor State by any stretch of the imagination.
We used to have a Healthy Start program in Delaware and I
think it went away, I want to say maybe in 2004. Is that
correct?
Dr. Van Dyck. Two-thousand-and-one.
Senator Carper. Two-thousand-and-one. I know the State has
been interested, and especially as we have seen our incidence
of low birthweight babies rise and as we have seen infant
mortality again having dropped to turn around and head back up,
there is a significant interest in the State of Delaware having
a Healthy Start program again. Could you give us some guidance
as to how we ought to proceed to get a program again in our
State?
Dr. Van Dyck. Healthy Start has a competitive grant cycle.
That cycle was competitive this last year, and so these grants
are awarded for a period of, I believe, 4 years. So there will
be another competition coming up in about 3 to 4 years, unless
we get more money. Then we can have a new competition.
Otherwise, these are the grants that will be in effect for the
next several years.
Senator Carper. All right. Can you give us some guidance? I
do not know how often it is that States or programs are in
existence and they are not funded or States reapply and they
are not approved. What are the common reasons why States that
might have a program do not continue to have a program, why
they go away?
Dr. Van Dyck. There is a lot of competition for the Healthy
Start grants, as you might imagine.
Senator Carper. You said there is a lot of competition.
Give me some idea of what----
Dr. Van Dyck. There may be two to three times as many
applications as can be funded with the money.
Senator Carper. OK.
Dr. Van Dyck. One reason might be that the site has
improved enough, lowered their infant death rate enough that
they become ineligible for the grant and allow us to put
somebody else into the competition or award a grant in an area
that has worse, or less good, numbers.
Another might be--and again, these are reviewed by an
independent review process--may be that the consortium that is
built with the community folks does not meet the requirements.
It could be that the partners that have been assembled to
deliver the care and to provide this seamless network of care
for the pregnant woman and her baby does not provide enough of
that network. It could be that the grant just is not written
well enough for the grants committee to get the essence of
local communities' needs. It can be any of those or all of
them.
Senator Carper. In our State, it sounds like in order for
us to get back into the game, we have to be ready 3 years from
now?
Dr. Van Dyck. Yes.
Senator Carper. OK.
Dr. Van Dyck. And we can offer technical assistance to make
sure that there is an understanding about the guidance and all
the rest.
Senator Coburn. Is there a reason that this was not a
staggered grant process?
Dr. Van Dyck. Well, the money became available at one
time----
Senator Coburn. So you started on----
Dr. Van Dyck [continuing]. And in order to spend the money,
you have to start to spend the money----
Senator Coburn. I have got you.
Dr. Van Dyck [continuing]. Because the money becomes
available.
Senator Carper. The last question I have, if I could, I
missed your testimony and let me just ask for just one or two
points you really want us to take away from here in terms of
what you think are important. Then I am going to ask the same
question of Ms. Somsak.
Dr. Van Dyck. Well, there is a real need with an infant
death rate in the Nation that is twice in African Americans
what it is in whites--actually, more than twice--a Hispanic
rate that is higher, and pockets of people who have
significantly higher infant mortality and low birthweight or
pre-term birth rates and lack of prenatal care, there are those
significant areas that Healthy Start seems to be able to make
an improvement in when they get a grant and they can stay with
it for 4 or 5 years.
We just need to make that need known, because there are
other areas that do not get funding, as you have suggested,
where we could make a difference in the infant mortality rate.
Healthy Start has proven successful. We are getting more
efficient. We are decreasing numbers and we are doing
independent evaluations and making them public. We could always
move faster, but we think we are on the right track.
Senator Carper. Good. Thanks very much.
Ms. Somsak, just briefly, if you could just summarize one
or two major points that you want us to take away.
Ms. Somsak. Sure. I think the goal of the program, of the
Healthcare Preparedness Program, is to improve the health care
deliver at the hospital level, at the primary, the health care
level where patients are likely to be seen. We need to do that,
to be able to have them respond in emergency situations where
there is a terrorist attack or an influenza outbreak. That
capacity has to exist at the hospital level. That is where our
funds go for the preparation.
The first few years of the program, we have worked on
increasing the medical surge capability, the infrastructure,
creating the equipment, creating the capacity to increase beds
on short notice, training the personnel to be able to respond.
Now we are moving towards, in the next few years, moving from
just a focus on increasing capacity to making sure there is
demonstrated capability. So that is the thing we have to be
able to really assure, not just that you have the capacity, but
when there is an emergency, can you activate the personnel you
need? Can you demonstrate this in emergencies?
And we have seen it, not in drills, but we have seen it in
a situation where there has been a chlorine tanker overturned,
in South Carolina, and we have seen it in some workers who were
crop dusted. They were really concerned. They were
decontaminated in a facility. We have seen it with Hurricane
Katrina, where we were able to mobilize personnel from across
States in an emergency situation. So this is the kind of thing
that this program really does, and it does it at a hospital
level. It works in coordination with State and local health
departments, but it is unique in terms of the hospital-level
capacity that it works on.
Senator Carper. Good. Thanks, and thank you both.
Senator Coburn. And we will leave the record open so you
can ask additional questions if you want.
Senator Carper. Thank you.
Dr. Van Dyck. The number of pregnancies remained about the
same.
Senator Coburn. So the expansion has not been in pregnant
women, but in their family members, in those numbers?
Dr. Van Dyck. It has been in the people surrounding the
pregnant woman. And we think that is an important element in
improving the care of that particular pregnant woman.
Senator Coburn. Well, I would not disagree. Is it more
important than enrolling more pregnant women, though? That is
the question to ask, not the other one.
I also note in the President's budget justification, which
I assume you were involved in, that your targets are static,
both in terms of first trimester prenatal care and low
birthweight, and my question is why? I mean, you are making
some progress. You have gone from 10.5 to 9.3 percent, but you
keep a target that is 10.5 percent. Why wouldn't we want to go
to 8 percent as a target? Why wouldn't we want 95 percent of
all the women getting first trimester prenatal care? It is page
370 of the President's justification, and you can answer that
later, if you would rather.
Dr. Van Dyck. I do not have the same pages you have. We do
have additional performance measures other than the infant
mortality, one being entrance into prenatal care, and our
target for 2007 is 70 percent. Our target for 2008 is 75
percent. And so in our performance measurement system, we do
have an increase in target. The actual number in 2002 was 69.
In 2003, it was 71.
Senator Coburn. And in 2004, 73. In 2005, 75. In 2006, 75.
In 2007, 75. That is what you submitted in the budget
justifications to Congress.
Dr. Van Dyck. Right. So in 2008----
Senator Coburn. Next, on low birthweight babies, it is 10.5
percent from 2002 to 2007, and you are below that again. The
question is, why is the target not lower? If we are going to
use metrics and the input we have just had, your testimony that
says, in fact, this is one of the things that really changes
outcomes, and we know it changes perinatal death rates, why
would we not up the target?
Dr. Van Dyck. Well, there may be an overlap between when
that was written and when the data came in for the performance
measure----
Senator Coburn. Fair enough.
Dr. Van Dyck [continuing]. And you point out something we
will review, because our metric for the performance measures,
which are our real measurement, are increasing, or decreasing.
Senator Coburn. OK. Fair enough. The one thing that has
bothered me, this last year, you gave out three new grants and
we had something like 233 applications. The only thing that
bothered me in what you said is your PART score is going to be
good now. It was not in the past, and yet----
Dr. Van Dyck. No, I did not say it was not in the past. We
have not been PART-ed before. This is the first----
Senator Coburn. Well, your independent reviews from 2000--
let us put it that way, the fact is nobody has lost a grant for
poor performance, and if that is the case, then somebody has to
question the evaluation of grants. If somebody who already has
a grant and they are not performing well and you have 233
applications of which you are only going to be able to give
three or four new grants to, there has got to be somebody in
that group, after this has been going since 1988, ramped up in
1991 to 1995, is that correct?
Dr. Van Dyck. Correct.
Senator Coburn. You really did not get ramped up until
1995, correct?
Dr. Van Dyck. During that----
Senator Coburn. We cannot really judge you before 1995.
Dr. Van Dyck. That would probably be a fair statement----
Senator Coburn. OK.
Dr. Van Dyck [continuing]. Although we have tried to judge
that period.
Senator Coburn. I understand. I am not critical of that. I
am just saying from 1995 to 2006, not one of those grantees had
such poor performance and not one of those applications showed
a better need that one of the grantees lost their grant and
somebody new got it.
Dr. Van Dyck. No, I did not say that. I said I did not
remember for sure if anybody lost for poor performance. There
are--and I can check that. The other thing is whether somebody
did not get a grant who previously had a grant because they
could not successfully compete or the numbers in the grant did
not show enough success. There have been grantees who have not
been successful subsequently. You heard that case happening in
Delaware.
Senator Coburn. Yes.
Dr. Van Dyck. So there are instances where people----
Senator Coburn. Have lost their grant?
Dr. Van Dyck [continuing]. Where they have lost their
grant, yes.
Senator Coburn. All right, fair enough.
Dr. Van Dyck. So there are two ways to look at that. One is
for poor performance. The other is in a grant competition, they
may not compete as well as somebody else, then, and we can give
you those numbers.
Senator Coburn. You are in good shape.
Dr. Van Dyck. Thank you for the opportunity, Dr. Coburn.
Senator Coburn. Thank you, and thanks for your
pleasantness. And as I told you, if there is any area that you
want to qualify when we get through that you think our
assumptions are wrong or inappropriate or inaccurate, please
bring them up.
Ms. Somsak, you have a tough job. We will never have the
surge capacity we need, right? I mean, there is no way we can
afford to put surge capacity, if we were to have a major
catastrophic event, that we could have enough ICU beds and
ventilators. So where do you draw the line? How do you do that,
and how do you give us the best for the limited amount of money
that we can go in this direction?
Ms. Somsak. I think there are two ways that States are
approaching it that gives us a way to deal with capacity. The
individual States are working to establish, with the State
associations and State plans, to come up with ways to handle
the surge capacity. So within a State, we have a lot of, say,
how you would do it. Like in New York City, they are working
with not just hospital by hospital plans, but multiple
hospitals working together, and I think that is the first way
you are going to get it, is within a State that the hospitals
work together so that every hospital is not getting every
capacity, that you work together to establish and respond.
The other way you are getting it is across State lines, and
this is really key. Particularly, for example, in the New
England region, that whole series of States have come together
to develop their surge capacity because they do not believe
individually in their own States they would be able to deal
with it, particularly if there is one major incident in one
State and not another. So that is the second way we are seeing
it, is that regional plans are being worked on to do it, and we
are really encouraging that and we are seeing that across the
country, particularly where you have a low population of
adjacent States and things like that, that you are really going
to have to have other people come to their help.
The third way is just in terms of the regional compacts,
where you could have States that have compacts with other
States to respond to their needs. So even though they do not
plan regionally necessarily, they have compacts so they can
respond to another State's needs. It is a lot easier,
obviously, in terms of personnel, medical personnel, to be able
to respond to another State in terms of capacity, but that is
going on now and we saw it in Katrina, with many of the States
stepping forward to help Louisiana and Texas.
Senator Coburn. So there has been $2 billion spent in
grants on surge capacity.
Ms. Somsak. Yes.
Senator Coburn. Where was it spent?
Ms. Somsak. A lot of it has been on equipment.
Senator Coburn. How much of the $2 billion was spent on
equipment and capacity?
Ms. Somsak. Well, overall, the requirement is that 85
percent of the money has to go to the hospitals to be spent on
the requirements of the grant itself.
Senator Coburn. Has it?
Ms. Somsak. Of the 85 percent, I would have to find out the
figures on how much actually was spent on the medical equipment
component versus pharmaceuticals and storage.
Senator Coburn. Pharmaceuticals, stockpiling, and things
like that. But my question is do you have at your fingertips
the measurement tools to know, out of the $2 billion, the 85
percent of that--how much of that has actually gone to
capacity, pharmaceutical stockpiles, ventilators, and beds
versus how much went for those creating the program to get
those? What is the percentage? Do you have that at your
fingertips as a manager, and do you have the ability to measure
that through the grant process, and if so, what are the
results, and is every grant recipient spending that money
appropriately and do you know that?
Ms. Somsak. The States are required to give us yearly
reports on their progress in meeting their plans and the State
plans go to what capacity they are going to be building at the
hospital level. So the State is required to report on where
they are building the capacity for hospital beds or
decontamination units. We have targets in their grants that
they are supposed to meet and then they have to report against
those grant targets and tell us where they are in meeting the
goals in terms of surge capacity, in terms of decontamination
units and things like that.
Senator Coburn. But you do not have a metric yourself,
other than self-reporting, that says you know where the money
is spent? In other words, have you audited one of the grants?
Ms. Somsak. They are financially accountable for what they
spend.
Senator Coburn. I know, but have you all audited the
grants? Have you audited Oklahoma's money that they have gotten
under this grant program to see that what they are saying is
actually where the money went?
Ms. Somsak. I do not know about Oklahoma's.
Senator Coburn. Has anybody been audited to see that the
money that has actually been spent, the $2 billion, actually
went for what they said it went for?
Ms. Somsak. Even if they have not been audited to date,
they will be audited under the financial because all the
grants, any long-term grant has to be audited. There is an
audit process that they have to go to. But I cannot tell you at
this point whether that has occurred because a lot of the
grants are only 3 years.
Senator Coburn. OK. Is there any requirement in the grant
process that X-percentage of the money has to be spent on
actual capacity, actual ventilators, actual pharmaceutical
storage, actual units? In other words, if they have 85 percent
of $200,000----
Ms. Somsak. Yes.
Senator Coburn [continuing]. Is there a requirement that
you cannot consume it in consultants, planning, and
conferences, but you have got to consume it in actually buying
the goods?
Ms. Somsak. I do not know at this point, and I will get
that information for you, as to what the restrictions are about
the money that actually goes to the hospitals. I will tell you
that the hospitals are spending more money, far beyond what we
give them through the State, because hospital needs are great.
So the hospitals are actually investing beyond in terms of
preparing themselves for emergencies, and particularly major
hospitals.
Senator Coburn. Let me tell you why I asked this question.
Ms. Somsak. OK.
Senator Coburn. HHS's own website, a report responding to
the IG identified challenges. It established the bioterrorism
preparedness as management challenge number three. It describes
issues with both CDC and also surge capacity. One major issue
that they outlined in that, the grantees failing to comply with
financial accounting and reporting requirements in HRSA and CDC
grant programs. Now, you have testified that they are required
to do that, and here is the IG of your own agency saying they
are not doing it.
Ms. Somsak. Yes.
Senator Coburn. So are they doing it or are they not doing
it?
Ms. Somsak. I am not familiar with the IG report, but what
year was the IG report? Which one are we talking about?
Senator Coburn. It is the one they filed this year on their
challenge number three for HHS.
Ms. Somsak. OK.
Senator Coburn. OIG has issued 15 audit reports in 2003 on
State and city monitoring of grantees receiving these, citing
some States and major cities lacked any appropriate monitoring
mechanism.
Ms. Somsak. OK.
Senator Coburn. So again, my job is not to beat you up on
this. I am telling you what I am looking for.
Ms. Somsak. OK.
Senator Coburn. I am looking for, if they are supposed to
report and they are not reporting, why are they getting the
money? That is the question I have for you, and your own IG
says they are not. So if they are not, then they either
immediately have to start or they should not be getting
additional money.
Ms. Somsak. OK.
Senator Coburn. And again, the whole purpose of that is for
you, as an administrator, to make sure the money is going where
you say it is going, and that is what we want it to do. This is
a big deal for us. Senator Richard Burr is so concerned about
are we going to be able to respond, and we are 5 years out and
we are $2 billion down the road, and if you have grantees that
are not responding and not reporting according to the
requirements of the grant, my question for you is why are they
still getting the money?
Ms. Somsak. Well, we have reduced--we have put holds on a
number of grants to States where the State has failed to make
progress towards it. We have also reduced funding for a number
of States that have failed to make progress. There are a number
of other States beyond those that we have worked with to
increase the performance level. But there are problems with
some of the States, but we have actually withheld funds or put
holds on their funds where they have not made adequate progress
until they have demonstrated additional progress.
Senator Coburn. But you would agree, as a management
technique, as a director of this program, that if there are
requirements in the grant and they do not think you are going
to hold them to the grant requirements, then not just in terms
of financial accounting, they may not respond in other areas.
So the reason I asked you about metrics first is do you have
that at your fingertips so that you know, and what I would like
to see is you all to bring that up to date. That is our whole
problem. It is not just HHS. We have not given you all the
management tools you need to make measurements to evaluate
whether or not you are having the performance that you want.
There are things in the legislation, there are things in the
management, but to actually say, how do I know this money is
getting the best deal?
The other thing--just to clarify, that was challenge number
three, HHS strategic challenge number three in their audit
report for 2005. That is where that came from.
The other thing is all States, every State got some of
these grant monies, right?
Ms. Somsak. Last year----
Senator Coburn. All hospitals got a small amount of money
instead of a few designated surge centers?
Ms. Somsak. Not all hospitals in the State received money,
but a large number of hospitals received money depending on the
State's plan, working with the hospital association and the
other hospitals.
Senator Coburn. But are there hospitals that have received
this money that will not be strategic surge centers?
Ms. Somsak. Well, in terms of what the State's plan is, the
problem is that no one can indicate where the event is going to
occur and what is going to happen. I think the other issue is
that it is not just bioterrorism. It is also other activities.
Senator Coburn. Sure.
Ms. Somsak. So, for example, with the flu, there is no real
indication that you may have the capacity across a large number
of geographic areas to be able to handle that issue. Just being
in a large metropolitan area may not help you. And so when the
States are looking in terms of planning for where the capacity
should be, the feeling is that just concentrating in a few
areas is not adequate.
And, for example, with the hurricane, what was the impact
of the hurricane? As people moved out of the metropolitan area
into what they called the ring area, and that is one of the
strategies, too, is that what would happen in an emergency is
people would not stay in the area. They would move out. So when
people put together a plan, it is one plan--if you just say,
well, we should just concentrate the money in one area, then if
that area is attacked, then where is the capacity for the
people that move out of that area? So I think that what the
States are trying to do is come up with multiple scenarios in
terms of planning for multiple, not just bioterrorism or a
natural event.
Senator Coburn. OK. I admitted to you at first that you
have a tough job, and I think it is a true statement, we do not
have the amount of money to have the preparedness that we would
like to have. There is no way we are ever going to have surge
capacity everywhere. So the question then becomes, how do we
prioritize this? I would question allowing the hospital
associations to make that determination rather than strategic
thinkers here looking at the numbers from CDC's health
statistics and centers.
Is it strategic if every hospital, let us say in Oklahoma,
gets a small amount of money, but much more to the bigger ones
when, in fact, a hospital that is in Salisaw, Oklahoma, is 60
miles from a 300-bed hospital in Muskogee, in other words, in
terms of surge capacity, and they have two ventilators at most
now. Are we going to put 10 ventilators there in excess or are
we going to put 50 in excess in a larger regional center that
has a larger population to draw on?
So I guess the point I am making is I am not critical of
what you are doing. I just want to make sure the word
``strategic'' is there and that we are not trying to please
States on a political basis of everybody getting some money. It
is kind of the rest of the grants at Homeland Security. If you
give it to every State--we ought to do it based on risk, and
your job is to try to figure out what that risk is. I know that
is not easy. As a matter of fact, you will be criticized no
matter what you do in this if we have an event. Everybody will
say, no matter which way you would have gone, you are going to
get criticism because you have an unattainable goal of truly
creating surge capacity.
Then when we have the PART score that is coming out for
you, what I would do is ask that you all come back. Maybe we
can just have a meeting in my office and go through what the
results are on that so that we do not have to do it so
formally.
Our goal is to hold you accountable, to make you better.
There is no question on your motivation. Please understand
that. But the biggest problem we have in the Federal Government
is how do we squeeze more benefit out of the same amount of
money, because we are in a pinch. In 2016, 81 percent of the
dollars of this budget of this country, no matter whether we
raise taxes or not, are going to be consumed by Medicare,
Medicaid, Social Security, and interest. That means 18, 19
percent is left for defense, HHS, and everything else. So we
need to have the metrics with which you can make the best
decisions to take care of the most people and to supply the
greatest amount.
I want to thank you for being here. Do either of you want
to say anything in closing, a change of opinion or critical of
the attitude or whatever? I want to give you an opportunity to
do that. Ms. Somsak, you have got a smile. There is a question
on whether or not you want to say it or not.
Ms. Somsak. No. I think when Senator Carper was here, I
kind of summarized what I would like to point out, is that it
is critical that we do prepare the hospitals and the primary
health care. In other words, when the incident occurs, that is
the people at the ground level that are going to be dealing
with this situation. But it is important to make sure that we
have the capacity, strategic capacity to say, and that people
have the capability to be able to respond to an actual thing.
We can plan all we want, but it is really important for the
States to be able to demonstrate that they can actually respond
to an incident.
Senator Coburn. You bet. All right. Thank you all very
much.
The hearing is adjourned.
[Whereupon, at 3:51 p.m., the Subcommittee was adjourned.]
A P P E N D I X
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