[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]





RESPONSE OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO THE NATION'S 
                         EMERGENCY CARE CRISIS

=======================================================================

                                HEARING

                               before the

                         COMMITTEE ON OVERSIGHT
                         AND GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 22, 2007

                               __________

                           Serial No. 110-25

                               __________

Printed for the use of the Committee on Oversight and Government Reform















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             COMMITTEE ON OVERSISGHT AND GOVERNMENT REFORM

                 HENRY A. WAXMAN, California, Chairman
TOM LANTOS, California               TOM DAVIS, Virginia
EDOLPHUS TOWNS, New York             DAN BURTON, Indiana
PAUL E. KANJORSKI, Pennsylvania      CHRISTOPHER SHAYS, Connecticut
CAROLYN B. MALONEY, New York         JOHN M. McHUGH, New York
ELIJAH E. CUMMINGS, Maryland         JOHN L. MICA, Florida
DENNIS J. KUCINICH, Ohio             MARK E. SOUDER, Indiana
DANNY K. DAVIS, Illinois             TODD RUSSELL PLATTS, Pennsylvania
JOHN F. TIERNEY, Massachusetts       CHRIS CANNON, Utah
WM. LACY CLAY, Missouri              JOHN J. DUNCAN, Jr., Tennessee
DIANE E. WATSON, California          MICHAEL R. TURNER, Ohio
STEPHEN F. LYNCH, Massachusetts      DARRELL E. ISSA, California
BRIAN HIGGINS, New York              KENNY MARCHANT, Texas
JOHN A. YARMUTH, Kentucky            LYNN A. WESTMORELAND, Georgia
BRUCE L. BRALEY, Iowa                PATRICK T. McHENRY, North Carolina
ELEANOR HOLMES NORTON, District of   VIRGINIA FOXX, North Carolina
    Columbia                         BRIAN P. BILBRAY, California
BETTY McCOLLUM, Minnesota            BILL SALI, Idaho
JIM COOPER, Tennessee                JIM JORDAN, Ohio
CHRIS VAN HOLLEN, Maryland
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
JOHN P. SARBANES, Maryland
PETER WELCH, Vermont

                     Phil Schiliro, Chief of Staff
                      Phil Barnett, Staff Director
                       Earley Green, Chief Clerk
                  David Marin, Minority Staff Director





















                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on June 22, 2007....................................     1
Statement of:
    Schwab, William, M.D., FACS, professor and chief of division 
      of trauma and surgical critical care, University of 
      Pennsylvania Medical Center, Philadelphia; Ramon Johnson, 
      M.D., FACEP, associate director, department of emergency 
      medicine, Mission Hospital Regional Medical Center, 
      director of pediatric emergency medicine, Children's 
      Hospital, Mission Viejo, CA; and Robert O'Connor, M.D., 
      MPH, professor and chairman, department of emergency 
      medicine, University of Virginia, Charlottesville, VA......    22
        Johnson, Ramon...........................................    31
        O'Connor, Robert.........................................    52
        Schwab, William..........................................    22
    Yeskey, Kevin, M.D., Director, Office of Preparedness and 
      Emergency Operations, Acting Deputy Assistant Secretary, 
      Office of the Assistant Secretary for Preparedness and 
      Response, Department of Health and Human Services; and 
      Walter Koroshetz, M.D., Deputy Director, National Institute 
      of Neurological Diseases and Stroke, National Institutes of 
      Health, Department of Health and Human Services............   110
        Koroshetz, Walter........................................   119
        Yeskey, Kevin............................................   110
Letters, statements, etc., submitted for the record by:
    Cummings, Hon. Elijah E., a Representative in Congress from 
      the State of Maryland:
        Letter dated June 14, 2007...............................    79
        Letter dated June 22, 2007...............................    81
        Prepared statement of....................................     5
    Davis, Hon. Tom, a Representative in Congress from the State 
      of Virginia, prepared statement of.........................    15
    Johnson, Ramon, M.D., FACEP, associate director, department 
      of emergency medicine, Mission Hospital Regional Medical 
      Center, director of pediatric emergency medicine, 
      Children's Hospital, Mission Viejo, CA, prepared statement 
      of.........................................................    33
    Koroshetz, Walter, M.D., Deputy Director, National Institute 
      of Neurological Diseases and Stroke, National Institutes of 
      Health, Department of Health and Human Services, prepared 
      statement of...............................................   121
    O'Connor, Robert, M.D., MPH, professor and chairman, 
      department of emergency medicine, University of Virginia, 
      Charlottesville, VA, prepared statement of.................    54
    Schwab, William, M.D., FACS, professor and chief of division 
      of trauma and surgical critical care, University of 
      Pennsylvania Medical Center, Philadelphia, prepared 
      statement of...............................................    26
    Watson, Hon. Diane E., a Representative in Congress from the 
      State of California, prepared statement of.................    18
    Yeskey, Kevin, M.D., Director, Office of Preparedness and 
      Emergency Operations, Acting Deputy Assistant Secretary, 
      Office of the Assistant Secretary for Preparedness and 
      Response, Department of Health and Human Services, prepared 
      statement of...............................................   113

































 
RESPONSE OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO THE NATION'S 
                         EMERGENCY CARE CRISIS

                              ----------                              


                         FRIDAY, JUNE 22, 2007

                          House of Representatives,
              Committee on Oversight and Government Reform,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:02 a.m., in 
room 2154, Rayburn House Office Building, Hon. Elijah E. 
Cummings (acting chairman of the committee) presiding.
    Present: Representatives Cummings, Davis of Virginia, 
Platts, Issa, and Jordan.
    Staff present: Phil Barnett, staff director and chief 
counsel; Karen Nelson, health policy director; Karen Lightfoot, 
communications director and senior policy advisor; Andy 
Schneider, chief health counsel; Molly Gulland, assistant 
communications director; Steve Cha, professional staff member; 
Earley Green, chief clerk; Teresa Coufal, deputy clerk; Caren 
Auchman, press assistant; Art Kellermann, fellow; David Marin, 
minority staff director; Larry Halloran, minority deputy staff 
director; Susie Schulte, minority senior professional staff 
member; Brian McNicoll, minority communications director; and 
Benjamin Chance, minority clerk.
    Mr. Cummings [presiding]. This committee will come to 
order. Today's hearing is regarding access to emergency care. 
Without objection, the Chair and Ranking Minority Member will 
have 5 minutes to make opening statements, followed by opening 
statements not to exceed 3 minutes by any other committee 
member who seeks recognition.
    I will remind the committee members that it is anticipated 
that we will be out of here by 12, so we are going to stick 
strictly to our rules.
    With that, I want to thank all of you for being here. Today 
we will examine the response of the Department of Health and 
Human Services to the Nation's emergency care crisis. In times 
of tragedy Americans rely on our emergency care system. Whether 
because of a car wreck, heart attack, stroke or pregnancy 
complication, Americans and their families show up at the 
doorstep of our Nation's emergency rooms seeking critical care 
every day.
    Emergency care is the great equalizer. It is the only form 
of health care guaranteed to every American, regardless of his 
or her ability to pay. But in this way it also provides a 
chilling snapshot of what is wrong with our Nation's health 
care system.
    We all want emergency care to work effectively for 
ourselves and for our loved ones. When it does work, and it 
usually does, by the way, lives are saved and lifelong 
disability is avoided. The many dedicated men and women who 
staff our Nation's ERs, trauma centers and ambulance services 
deserve our appreciation and our support.
    But when the system fails, it can have fatal consequences. 
Earlier this week, USA Today carried a front-page story on the 
health crisis in Houston, where ERs divert ambulances 20 
percent of the time. One doctor described a patient who died 
after being diverted from a Houston area hospital to one in 
Austin 1,600 miles away. He said, ``diversion kills you.''
    In my hometown of Baltimore, a city health department study 
documented that between 2002 and 2005 the total hours city 
hospitals were on red alert status, meaning that they had no 
cardiac-monitored beds for arriving ER patients, increased by 
36 percent; the length of time it took ambulances to offload 
patients in the ER increased by 45 percent; and the number of 
hours ambulances were diverted from over crowded ERs shot up by 
165 percent. Unfortunately, the emergency care crisis is not 
limited to Houston, and it is certainly not limited to 
Baltimore.
    Failures in the ER have led to an increase in preventable 
deaths from treatable conditions like heart disease. An article 
in this morning's edition of USA Today indicates that seven of 
our Nation's hospitals have worse heart attack death rates than 
the national average, while 35 have higher death rates for 
heart failure.
    The L.A. Times reported this past May that a 40-year-old 
woman collapsed on the waiting room floor of the ER at Martin 
Luther King-Harbor Hospital in Los Angeles while janitorial 
staff literally mopped the floor around her. Overburdened staff 
ignored her pleas for help, and her boyfriend, desperate for 
assistance, dialed 911 from the hospital. He was told to find a 
nearby nurse. His girlfriend died 45 minutes later.
    Last month, Newsweek.com described the critical challenges 
facing Grady Memorial Hospital in Atlanta. Grady Hospital 
supports one of the busiest ERs in the State and the only Level 
I trauma center in a metropolitan area of 5 million people. On 
any given day it is not unusual for eight Atlanta hospitals to 
be diverting patients at the same time. What will Atlanta do if 
Grady closes its ER?
    Even here in the District of Columbia it is not unusual for 
ambulances to be parked seven deep in front of one or more of 
the city's bigger ERs waiting to offload patients. Not to be 
too blunt, but these are the same ERs that Members of Congress 
and our families would turn to in an emergency.
    The fact of the matter is that we have a crisis in 
emergency care, and it is nationwide. This begs the question, 
with a national emergency and trauma care system as fragile as 
ours, how will we manage the real threats of a terrorist 
bombing, a natural disaster, or an outbreak of pandemic flu? 
Where is the surge capacity?
    The emergency room crisis is nothing new. More than 5 years 
ago, U.S. News and World Report published a cover story 
entitled, ``Crisis in the ER: Turnaways and delays Are a Recipe 
For Disaster.'' A copy is displayed on the easel before me.
    If you look closely, you will note, ironically, that the 
issue was published on September 10, 2001. Five weeks after 
September 11th, Chairman Waxman released a report detailing the 
national problem of ambulance diversions and the shortage of 
emergency care. His report identified over 20 States in which 
hospitals were turning away ambulances because of overcrowding 
and funding shortfalls. Subsequent reports reached similar 
conclusions. A 2003 report by the Centers for Disease Control 
and Prevention found that ER rooms in U.S. hospitals diverted 
more than 1,300 patients a day--1,300 patients a day--365 days 
per year. A 2003 GAO report documented ER crowding throughout 
the country.
    One year ago, the Institute of Medicine of the National 
Academy of Sciences released a three-volume report on the 
future of emergency care in the U.S. health system. This 
landmark study concluded that our Nation's emergency and trauma 
care system is at the breaking point.
    Last summer, Congress enacted the Pandemic and All Hazards 
Preparedness Act. This act assigned responsibility for leading 
all Federal public health and medical responses to public 
health emergencies to the Department of Health and Human 
Services. But despite this clear responsibility, and despite 
the billions of taxpayers' dollars that Congress has 
appropriated for biodefense and pandemic preparedness, HHS 
appears to be ignoring the mounting emergency care crisis.
    The Department has not made a serious effort to identify 
the scope of the problem and which communities are most 
affected. It has failed to require hospitals that participate 
in Medicare to report data on the extent of ER boarding and 
ambulance diversion. It has failed to use its purchasing power 
through the Medicare program to encourage hospitals to properly 
admit ill and injured patients to inpatient units rather than 
boarding them in ER hallways and forcing staff to divert 
inbound ambulances. It has done nothing to promote the 
regionalization of highly specialized trauma and emergency care 
services, a key recommendation of the IOM report.
    Worse yet, the Department has recently taken some actions 
that will make matters worse. It is undisputed that part of the 
emergency care crisis is a result of the historic underfunding 
of safety net hospitals, many of which serve as cornerstones of 
trauma and emergency care systems in their communities. 
However, rather than asking Congress for additional resources 
to assist these hospitals, the Department has attempted to 
bypass Congress by issuing rules that would cut hundreds of 
millions of dollars in supplemental Medicaid funding from these 
facilities.
    Ladies and gentlemen, this simply makes no sense. Last 
month the Congress enacted a 1-year moratorium that blocks the 
Department from implementing these funding reductions, but HHS 
has shown no signs of modifying its position.
    Today, we will hear from leading private-sector experts on 
emergency care, trauma care, and ambulance services. They will 
describe the emergency care crisis from the front lines. We 
will also hear from representatives of two agencies within HHS 
that have a particularly important role to play in addressing 
the crisis: the Office of the Assistant Secretary for 
Preparedness and Response, and the National Institutes of 
Health.
    I hope that the testimony we hear today will help provide 
our committee with an understanding of the emergency care 
crisis that confronts us all. Nearly 6 years have passed since 
the wakeup call of September 11th, and HHS has yet to tackle 
this problem. The time for action is long overdue.
    With that I yield to the distinguished ranking member of 
the full committee, Mr. Davis.
    [The prepared statement of Hon. Elijah E. Cummings 
follows:]


[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    Mr. Davis of Virginia. Thank you very much. I want to thank 
Chairman Waxman for initiating this hearing. It is a very 
timely issue. We all know the value of a functioning emergency 
room. Millions of lives are saved annually only because 
emergency care is available.
    But across America, it is critical care services that are 
in critical condition. Last year, a study by the Institute of 
Medicine [IOM], concluded our hospital-based emergency medical 
system was at the breaking point. Emergency rooms are finding 
it impossible to meet growing and competing demands for trauma 
care, mandated safety net care for the uninsured, public health 
surveillance, and disaster readiness.
    The IOM panel found emergency care capacity suffering from 
an epidemic of crowding, with patients parked or boarding in 
hallways waiting to be admitted. Ambulances are routinely 
diverted to more distant facilities.
    While demand for EMS facilities grows, the number of 
facilities shrinks, and they find it increasingly difficult to 
retain on-call specialists to meet standards for timely care. 
The inevitable tragic result: preventable deaths as critically 
ill patients literally die from neglect in hallways and in 
ambulance spaces waiting for the lifesaving help that never 
comes.
    The simple truth is emergency care can and should be 
better, but it is the legal, financial and demographic trends 
that have converged to punish the success of hospital emergency 
departments transformed by Federal law into a de facto primary 
care provider for millions of under- and uninsured Americans. 
That unfunded mandate creates powerful incentives to close 
emergency rooms or limit admissions so that capacity to perform 
elective, fully reimbursed procedures will not be reduced.
    Low reimbursement rates and high malpractice premiums also 
work to keep needed specialists, neurosurgeons, orthopedic 
surgeons, and pediatricians, among others, from accepting 
emergency and trauma patients.
    The anemic state of emergency medical services means most 
hospital centers are already operating at or near capacity 
every day. A highway crash involving multiple casualties can 
overwhelm not just one, but all nearby hospitals because no one 
has information about the real-time availability of emergency 
beds in the region.
    Such a fragile, fragmented system holds virtually no surge 
capacity in the event of a natural disaster or terrorist 
attack. This committee has held several hearings on pandemic 
planning and preparedness. A constant concern that emerged from 
those hearings was the lack of surge capacity in our Nation's 
hospitals.
    We have made great strides in homeland security since 9/11, 
but our public health infrastructure, particularly emergency 
medical response capacity, is still not ready for prime time. 
When the influenza pandemic erupts, as many predict it will, 
more than half a million Americans could die, and over 2 
million could need to be hospitalized.
    How do we plan to move from the current inadequate 
emergency care structure to the coordinated, regionalized, 
scalable, and transparent system that we know that we need? 
What is the Federal role in building and sustaining affordable 
and efficient medical services? How can we link emergency care 
capacity into a national response network to meet the full 
range of critical care demands from the predictable to a 
pandemic?
    I look forward to a discussion with our witnesses today on 
these difficult questions. I am especially pleased to welcome 
Dr. Robert O'Connor, professor and chairman of the department 
of emergency medicine at the University of Virginia. He is 
widely regarded as one of our Nation's leading EMS physicians, 
and we are very grateful for his time and insights as we 
explore these urgent issues. Thank you.
    Mr. Cummings. Thank you, Mr. Davis.
    [The prepared statement of Hon. Tom Davis follows:]

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    
    Mr. Cummings. It is my understanding that Ms. Watson has an 
opening statement. Ms. Watson, you are recognized for 3 
minutes.
    Ms. Watson. Thank you, Mr. Chairman, for holding today's 
hearing. It is so relevant to constituents in my district in 
Los Angeles, the 33rd District.
    We are going through a very serious crisis in our emergency 
care system. A functional emergency and trauma care system is 
important for all communities to deal with and respond to 
disasters, and we must remember that these emergency care 
centers are not only for those patients who use them on a day-
to-day basis, but they are what our Nation will rely on if a 
natural disaster or a terrorist attack occurs.
    This sector of the health care system is one of the most 
important aspects of our homeland security. As pointed out in 
the majority memo on May 19, 2007, you heard about the 40-year-
old woman who collapsed on the waiting room floor at Martin 
Luther King Hospital, and her pleas for help were ignored, and 
she died 45 minutes later.
    This hospital serves a major portion of my constituency who 
has no insurance and who does not have access to any other 
means of health care. This incident was not the only one 
reported at the former King/Drew Hospital, and definitely not 
the only occurrence in many emergency rooms across the Nation. 
What are we showing the world by letting our citizens die in 
emergency rooms in the wealthiest Nation in the world?
    The three Federal departments, DOT, DHS and HHS, that are 
responsible for the oversight of emergency and trauma care must 
start working together to make the system work better. I am 
sure there is along list of oversight errors and omissions that 
point to the core of many of the problems we are discussing 
today. I hope that by addressing this issue, it is not too 
little and not too late.
    Hospitals in our Nation's urban areas have been plagued for 
years. They have been underfunded for so long that they cannot 
attract the type of doctors and nurses they need to run a high-
quality hospital, and, in turn, due to a poor reputation, you 
limit the number of talented health care professionals you 
attract, creating a downward spiral.
    Mr. Chairman, having hospitals such as King-Harbor in my 
community, even in the condition it is in, is better than not 
having a hospital at all. The risk of getting inadequate health 
care is outweighed by the potential loss from having to drive 
an extra 20 minutes to get care at any other hospital, leading 
to overcrowding at those other hospitals.
    So I am looking forward to hearing from the witnesses, and 
I hope that we can get some answers so that we can remove the 
many risks that accrue to our public.
    Thank you so much, Mr. Chairman.
    Mr. Cummings. Thank you, Ms. Watson.
    [The prepared statement of Hon. Diane E. Watson follows:]

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    
    Mr. Cummings. What we will do now, without objections, we 
will recess because we have two votes. We have about 5 minutes 
left for the first vote, and then another vote will come 
immediately thereafter. I anticipate that we should be back 
here at quarter of the hour. Until then, we will recess.
    Thank you, witnesses, for being patient with us. We will 
move this along as fast as we can. Thank you.
    [Recess.]
    Mr. Cummings. Thank you all for waiting. We will resume the 
hearing now.
    The committee will now receive testimony from the witnesses 
before us today. Our first panel consists of three 
distinguished experts in emergency and trauma care. Dr. William 
Schwab is professor and chief, division of traumatology and 
surgical critical care at the University of Pennsylvania 
Medical Center in Philadelphia. Dr. Ray Johnson is associate 
director of the department of emergency medicine, Mission 
Hospital Regional Medical Center, and director of pediatric 
emergency medicine, Children's Hospital, Mission Viejo. And Dr. 
Bob O'Connor is professor and chairman, department of emergency 
medicine, University of Virginia, Charlottesville.
    Gentlemen, would you please stand to be sworn in.
    [Witnesses sworn.]
    Mr. Cummings. I just remind you that we have your 
statements, your written statements, and we would just ask you 
to summarize within 5 minutes if you can. Then we will have 
questions.
    Dr. Schwab.

 STATEMENTS OF WILLIAM SCHWAB, M.D., FACS, PROFESSOR AND CHIEF 
OF DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE, UNIVERSITY OF 
PENNSYLVANIA MEDICAL CENTER, PHILADELPHIA; RAMON JOHNSON, M.D., 
 FACEP, ASSOCIATE DIRECTOR, DEPARTMENT OF EMERGENCY MEDICINE, 
MISSION HOSPITAL REGIONAL MEDICAL CENTER, DIRECTOR OF PEDIATRIC 
EMERGENCY MEDICINE, CHILDREN'S HOSPITAL, MISSION VIEJO, CA; AND 
ROBERT O'CONNOR, M.D., MPH, PROFESSOR AND CHAIRMAN, DEPARTMENT 
OF EMERGENCY MEDICINE, UNIVERSITY OF VIRGINIA, CHARLOTTESVILLE, 
                               VA

                  STATEMENT OF WILLIAM SCHWAB

    Dr. Schwab. Thank you, Congressman. I think rather than try 
to summarize, what I might do is start with a bit of a story, 
since it is a relatively recent story and something that is 
very pertinent to the IOM report.
    I sat for 2\1/2\ years as one of the 40 members of the IOM 
Commission and spent a considerable amount of time actually 
deliberating, analyzing, and trying to come up with solutions, 
both tactical and strategic, to look at this crisis in 
emergency care. But perhaps this story, more than anything, 
will make it real for you.
    Just 2 days ago I was not on call for emergencies. There is 
a group of nine of us at the University of Pennsylvania, 
surgeons that do all the emergency surgery and all the trauma 
care. We are a Level I trauma center, we are one of the city's 
safety net hospitals, and we are one of the hospitals that in a 
disaster for the greater Philadelphia area--a population of 
about 15 million people--would go into action.
    2:30 in the afternoon, just a normal day, I had a call from 
my fourth partner, also not on call, to go to the emergency 
department to run a fifth room. I walked down to the emergency 
department and walked through our unit, and in that emergency 
department there were people everywhere on stretchers. There 
were patients in chairs. The emergency physicians, our 
strongest colleagues and friends, were administering to people.
    And this wasn't a mass disaster, this was a fairly typical 
day with the exception that we had just been notified that, in 
fact, on Route 95 there was a significant crash, probably a few 
mortally wounded, and other people being brought in by 
helicopter and by ambulance.
    I went into our trauma bay, very similar to that in 
Nashville or that in Baltimore, and this three-bed unit had 
five people in it, two people on stretchers who were side by 
side with three other people. And as we started to take care of 
the patients coming in from this terrible wreck and this 
collision, we had 30 seconds' warning that the Philadelphia 
Fire Department was bringing in yet another person, and that 
was a trauma code. It was a young man who had received a 
gunshot wound. And in the middle of that mayhem, I opened his 
chest, and I started to pump his heart. I tried to resuscitate 
him.
    Now that is all part of our life in this business, but what 
is interesting is I looked up and I recognized that as I was 
doing that, about 40 feet away from me, watching me, were 
people brought in for routine care and other emergencies.
    What was most interesting about this is you might say that 
is just Philadelphia, it is a big city, and it is like any 
other city, Los Angeles, Washington, or Atlanta. But that 
morning I had been on the phone thanking someone at Strong 
Memorial Hospital in Rochester, NY, because last week my 
brother-in-law, 63-year-old retired teacher, an All-American 
football player in his prime who had lost his kidneys a few 
years ago to a terrible infection, and a renal dialysis patient 
for years, had just been transplanted. He was home, became ill, 
and went back to Strong Memorial. But he could not be admitted, 
because the emergency department had 40 or 50 people waiting to 
be admitted in Upstate New York, where I grew up, in beautiful 
downtown Rochester.
    I couldn't believe it. But having spent 2\1/2\ years on the 
IOM trying to find solutions for the government and for us to 
take on the emergency care crisis, you have to believe it. It 
is universal, it is a terrible problem, and it is a hidden 
problem. It has been swept underneath the rug continuously, and 
it may be being swept under the rug because people believe 
there is no good way to solve it, and the only way to solve it 
is throw money at it. I will tell you the IOM did not conclude 
that, and our recommendations came after some thousands of 
hours of deliberation and looking at things.
    I have to also tell you that as I walked through the 
emergency department, I saw teams of specialists down there, 
cardiology, neurology, but the one that really frightened me 
was an infectious disease specialist. This friend of mine in 
the infectious disease department is a virologist, a virus 
expert. And after I finished with the emergency thoracotomy, 
and I was walking out to do my paperwork, I thought of all the 
things I am afraid of. What I am afraid of the most is that 
virologist was seeing something, and it was a virus, and that 
it was sitting in the middle of our emergency department with 
all those hundreds of people.
    There is no way that simple solutions will fix this. This 
is going to take a concerted effort.
    I would like to end by saying that I am absolutely shocked 
that there hasn't been more done in the past year, even just 
simple communication about how we could help our government 
agencies and how we can partner as health care, medicine, and 
nursing to help fix this.
    We do need to look at better coordination from the 
government. We truly believe at the Institute of Medicine and 
in our committee, that it is spread out to too many agencies. 
There is no one agency that is responsible, there is no 
champion for emergency care. We believe that the whole system 
has to be looked at, and we believe that there has to be 
substantial thought, redesign, and reengineering--not of the 
system, but of things like why patients wind up in the 
emergency department when they could go to primary care.
    We felt that we needed to look at making hospitals and EMS 
systems accountable. We just weren't going to make 
recommendations to you from the Institute of Medicine that 
said, do this for us. We want to make the system accountable. 
And we looked for one of the best successes in medicine to fix 
it, and that is the trauma system.
    Trauma systems have been around for about 30 years. They 
actually come from the experience we had during Vietnam, and 
that military system was transformed and translated into 
civilian trauma care systems. Trauma systems are regionalized, 
they are accredited, they are credentialed, and they are 
accountable, because they report their results to the public 
and to the government. The Institute of Medicine in its 
interdisciplinary committee put this at the center of the 
committee report, to redesign emergency care based on regional 
systems that are accountable, and they report their outcomes. I 
think that is an important thing.
    Last, there were two things that came about during the 2\1/
2\ years that I served in the Institute of Medicine that I 
think you are aware of. One you are very aware of, and that is 
the inability of the health care system and specifically the 
emergency care system to respond with surge capacity for mass 
casualties and disasters. If on Wednesday afternoon we had 
another van or school bus crash, only the dedication and 
commitment of the nurses and physicians would have taken care 
of those patients, because we had no room.
    You know about that. You know about that because of some of 
the hearings that have taken place, that emergency care cannot 
respond. We don't have the capability to do it, we don't have 
the capacity to do it.
    The other one that I think is quite frightening, that the 
Institute of Medicine discovered, is the work force issues. If 
you look beyond the emergency department, there is a tremendous 
crisis developing on the surgical side to staff the in-house 
care that must take place after the emergency department care 
ends.
    One of the biggest things that we revealed is, in fact, 
after the emergency physicians resuscitate--many specialists 
including cardiologists, and surgeons, are called to render 
care and complete care within the hospital. The shortage of 
physicians and specifically surgeons that are responding to 
emergencies is concerning. And in the future, as we try to cope 
with caring for about 80 million boomers, the shortage of 
surgeons is a profound thing in this report that needs to be 
addressed.
    Thank you, Mr. Cummings.
    Mr. Cummings. Thank you very much.
    [The prepared statement of Dr. Schwab follows:]

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    Mr. Cummings. Dr. Johnson.

                 STATEMENT OF RAMON W. JOHNSON

    Dr. Johnson. Mr. Chairman, members of the committee. I want 
to first start by giving you an idea of my practice environment 
because I don't work in an inner city or a highly urbanized 
area. I work in a suburban emergency department that sees 
approximately 45,000 to 50,000 visits a year. We also function 
as a satellite children's facility, so approximately 40 percent 
of our volume are children.
    I want to tell you that even in our sleepy suburban 
community, which I believe is typical of almost every community 
of America outside of the urban setting, I am in an environment 
that continues to be understaffed. We are underfunded. We are 
overworked, overwhelmed, and overcrowded.
    I want to address each one of those things for you. First 
of all, let me give you a story. It was interesting listening 
to Dr. Schwab talk about his experience. My experience is a 
little bit more profound than that, because 1 day when I was 
working in the emergency department, a frantic mother brought 
in a child who was choking to death and was blue, and I did not 
have even a single bed available in my emergency department.
    I debated for a few seconds, should I just put the child on 
the floor in order to try and open the airway? I did not have a 
bed. Fortunately, because of the dedicated staff we work with 
in our emergency department, the nurses were able to scramble a 
patient out of a bed and pull the bed over to the middle of the 
emergency department hallway, where I pulled an apricot pit out 
of this child's trachea.
    It struck me then and there when I looked up, and you are 
kind of ``adrenalinized'' at that point--you look up and see 
about 30 people looking at you, most of them are patients, some 
of them sitting with their gowns that are kind of open in the 
back, so it makes for an interesting sight as well.
    I am here to tell you that even in my sleepy community of 
Mission Viejo, CA, a suburban area, there are days when I don't 
have adequate resources to take care of my patients.
    One of the big problems that we are facing, I think, in 
this country is an explosion in the volume of patients we are 
seeing. In my area, for example, we have had a tremendous 
growth in population because of construction, and I understand 
that we are not the only area of the country that is seeing 
that kind of explosion. But one of the problems that we are 
seeing is the lack of infrastructure to help support that 
explosion in population growth. So as a result, we are 
confronted with the issue of overwhelmed, overcrowded emergency 
departments every day.
    We also have a situation where we also have patients that 
are literally living in our emergency department for more than 
a day at a time. We have psychiatric patients sitting in our 
emergency department because we cannot get resources to them or 
there aren't beds in my immediate area to send those patients 
to.
    Most people have this misunderstanding about overcrowding 
in emergency departments. I would like to dispel that myth once 
and for all, here in this committee. Overcrowding in emergency 
departments is not due to patients who have minor problems 
coming into the emergency department. It is due to patients who 
are sick, sitting in beds in my emergency department, when 
there are no inpatient beds, no capacity in the hospital, to 
get them upstairs. So I can't get new, incoming patients back 
into my emergency department.
    That means that I have to contact my charge nurse and let 
her know when I don't have any beds any longer because they are 
full of inpatients in my department. I have to let her know 
that ambulances cannot come here. So that means, although we 
are a cardiac receiving center, we have a cath lab available 24 
hours a day to take the sickest cardiac patients in my 
community, I cannot get them into my hospital emergency 
department because I don't have a bed for them. So I have a 
hospital with tremendous capabilities, tremendous talent, 
tremendous dedication, and I cannot get these patients to my 
facility to take care of them.
    All I ask of you, all I ask of this committee and of the 
Federal Government, is to help me do what I do best, and that 
is save lives and take care of patients. I cannot do that 
unless we have the resources.
    I think the Institute of Medicine report laid it out very 
clearly. We are underfunded, we don't have adequate resources. 
We are talking about a surge capacity; there is no surge 
capacity left within our hospital environment. By the way, my 
hospital is located approximately 30 minutes north of a nuclear 
power plant, and I can guarantee you if there is anyplace that 
needs surge capacity, it is my facility. It just does not 
exist.
    Let me summarize by saying the American College of 
Emergency Physicians has over the last few years brought this 
to the attention of everyone we could possibly bring it to. We 
have had a rally on the lawn of the Capitol, had surveys that 
have been put together, and we have even introduced a bill, the 
Access to Emergency Medical Services Act of 2007.
    I know this is an oversight committee, but the fact of the 
matter is that we are making every effort to try and come to 
solutions that will help solve this problem. But, once again, 
my sleepy community town is, I think, average America. And if 
we are seeing the same problems that urban and suburban 
environments are seeing all over this country. We should all be 
very, very afraid of what is happening. We really need to do 
something, and do something quickly. Thank you.
    Mr. Cummings. Thank you very much, Dr. Johnson.
    [The prepared statement of Dr. Johnson follows:]

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    Mr. Cummings. Dr. O'Connor.

                STATEMENT OF ROBERT E. O'CONNOR

    Dr. O'Connor. Thank you very much, Mr. Chairman. I was 
struck by the opening comments that I heard several of you 
make, Congressman Davis, Congresswoman Watson, and Congressman 
Cummings. I agree with everything you said, and I am struck by 
the uniformity of recognition that our health care system, our 
emergency health care system, is in a state of disarray.
    I look back at my own career. I have been in practice for 
over 20 years. I have been involved in the medical direction of 
prehospital care for just about as long; the instruction of 
prehospital care providers perhaps longer. I wanted to try to 
tell what my views were about how we have gotten to the place 
we are at today.
    What I have seen throughout my career are tremendous 
strides in care. We take care of patients with myocardial 
infarction, heart attack right now, when we used to have no 
other treatment options other than to provide comfort measures 
only and not truly offer definitive care. We have made 
tremendous strides in trauma care, in stroke care, and the list 
goes on.
    However, we are hampered by our ability to provide that 
care. We have state-of-the-art technology, and yet we are 
practicing in a non-state-of-the-art environment where patients 
who are just hapless bystanders witness things that perhaps 
they should not see in a crowded emergency department 
environment.
    The conditions in an emergency department, we have the 
tools to provide the best care that we can. The environment is 
so crowded that it sometimes creates a major obstacle to that. 
I look back on my career with EMS and prehospital care, it was 
sparked by funding that goes back really into the 1970's, 
prompted by the National Academy of Sciences report, ``Trauma: 
The Neglected Disease of Modern Society.'' Over that time, the 
initial funding was at quite a high level. In 2007 dollars, it 
is about $1.5 billion. It was $300 million at the time. That 
has since dwindled. While a solution to the problem is not to 
throw money at it, I do think increased funding for EMS would 
be one possible solution.
    The second part is to look at some of the funding agencies 
that provide care for EMS and to see how best to spend that 
money. If you look at certain EMS programs, the rural EMS grant 
program exists to support training and equipment for smaller 
communities. That has since been eliminated. If you look at the 
Trauma Systems Planning grant, that has also been eliminated. 
The EMS for Children [EMS-C] program has to continually fight 
for funding year in and year out, and it is only through the 
focused effort of Members of Congress that this program has 
sustained funding from year to year.
    Regarding one of the recommendations from the Institute of 
Medicine report, it was to establish a lead Federal agency, I 
have some comments in my written testimony regarding that. 
There currently exists the Federal Interagency Committee for 
EMS, which is the ideal body, really, to look at how to 
establish a lead agency. I think it is essential that we have a 
lead agency in the Federal Government, one to champion EMS 
causes.
    If you go back to the fall of 2001, September 11th 
specifically, the public concern over our preparedness for 
terrorism, mass casualty events resulted in funding for police 
and fire and other agencies. EMS was notably absent from that 
funding pool. While I strongly believe that we need to have 
public safety--strong public safety resources such as police 
and fire--I also think that EMS is in a unique position where 
they work at the intersection of public safety plus public 
health. In fact, EMS is the integration of public safety with 
emergency health care.
    So in closing, I would like to thank everyone for your 
efforts. We in emergency care take pride in what we do. We, I 
believe, provide excellent care to patients. We are somewhat 
hampered by the resources we are given and the demands on our 
time and effort. If we are given the opportunity to and the 
resources to improve that care, we will welcome that 
opportunity. So thank you.
    [The prepared statement of Dr. O'Connor follows:]

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    Mr. Cummings. I want to thank all of you for your 
testimony. We will go into questioning now, and we will stick 
by the strict 5-minute rule.
    I would like to ask a question of all three witnesses. 
Since back in 2002 the Congress has appropriated some $2.7 
billion to the Department of Health and Human Services to 
improve the ability of communities to respond to emergencies 
that cause mass casualties. According to an analysis prepared 
for this committee by the Congressional Research Service, 
critics have charged the program over the years with lacking 
sufficient focus to adequately direct funds in meaningful 
directions, and with failing to assure that emergency health 
care services will be available consistently across 
jurisdictions.
    Have the billions of dollars spent by the Department to 
enhance--that's HHS--to enhance surge capacity for bioterror 
attacks and other mass casualty events made any difference in 
your daily practice? Dr. Schwab, we will start with you.
    Dr. Schwab. Thank you, Mr. Chairman.
    It's an interesting thing, if you look at the IOM report 
and some of the data we looked at, of all those billions and 
billions of dollars. If I can track this back, only 4 percent 
ever went actually into the States to look at EMS or look at 
preparedness.
    In response to your question has any of this money affected 
myself or our trauma center or the emergency department, the 
answer is categorically no. I don't think we could track a dime 
into the actual practice at the bedside for making our 
patient's lives better.
    Dr. Johnson. I would have to also say no, Mr. Chairman. I 
sit on our advisory committee for HRSA funding for trauma 
preparedness in California, and I can tell you that while my 
hospital bought a tent, it doesn't help my day-to-day ability 
to take care of patients in the emergency department who are 
sitting there waiting for a bed upstairs.
    Mr. Cummings. Dr. O'Connor.
    Dr. O'Connor. Of the money you cited of the bioterrorism 
program, less than 5 percent has gone to EMS during that time 
period.
    Mr. Cummings. Dr. Schwab, you describe the situation has 
steadily worsened over many years. The crisis has been 
extensively documented in academic studies, the news media and 
even the Department's own reports. From your perspective what, 
if anything, has HHS done to address the problem?
    Dr. Schwab. I think one of the most important things that I 
think they have done is they have listened. I wish I could say 
they have reacted. On the other hand, I have been in this 
business now for 30 years. Twice during that 30 years I have 
seen Federal legislation that was directed specifically at 
emergency, EMS and trauma, and then within a few years I have 
seen actually that appropriation go away, which means that we 
had money, we used it effectively, it went away, and we can't 
make the sustained type of efforts.
    I was very heavily involved in the late 1980's and 1990's 
with HHS in designing the model trauma plan. That was 3 years' 
funding that was subsequently taken away through 
appropriations, and that whole effort failed, and honestly, all 
of our work really went up in smoke at that time.
    So I think there is a complexity here that in order for the 
government agencies to respond, they have to have money in 
order to do it.
    Mr. Cummings. A lot of people say that money is not 
necessarily always the answer. You hear that a lot up here. I 
have often argued that the most important thing is the 
effective and efficient use of money. And so I think that all 
of you have talked about money, and I am just wondering, what 
do you all see? If you could wave your magic wand and you had 
the money, what would be the most effective and efficient use 
of it? I will start with you, Dr. Johnson, then go back.
    Dr. Johnson. First, Mr. Chairman, I would like to say for 
at least my situation, unless my hospital wants to build more 
beds with that money, it doesn't really help my situation. More 
money doesn't help me personally in the emergency department.
    What it may do, though, is allow me to get my orthopedic 
surgeon to come in, because they won't come in to take care of 
patients who are underfunded. So it may entice them to come in 
and get my patients out of the emergency department a lot 
faster.
    So unless my hospital wants to build more beds, it doesn't 
really help me. I will say there is no question in my mind that 
there are many nurses, for example, who I can't hire for my 
institution because the cost of living where I live is too 
high, and the salaries are too low. So if I had that pot of 
money, the first thing I would do is buy myself about 10 more 
nurses to be on staff every day because that would certainly 
help me take care of my patients in a more efficient way.
    So, given that money, I would take care of that.
    Mr. Cummings. Dr. O'Conner.
    Dr. O'Conner. I think the best way to answer your question, 
the best way to spend money is to use it in a way where it is 
leveraged, where it amplifies the amount of money that we are 
spending. I think if you look at emergency care, systems of 
regionalization, a demonstration project in that area might be 
one such means to do that, to look at research so that findings 
in efficiency and effectiveness of care can be translated 
across the entire U.S. population, to look at a means of 
establishing best practices, whether it is through a 
demonstration program as well.
    But I would encourage, in terms of spending money--I mean, 
money, if there isn't enough, I think in terms of efficiently 
using it and safeguarding the taxpayers or the fiduciary 
responsibility--I think to look at the way to leverage the 
amount of money that is spent in terms of benefits to 
healthcare would be the way to go.
    Mr. Cummings. Dr. Schwab, I just want to go back to 
something earlier. You talked about the trauma system and how 
that might be helpful to what we are dealing with. Can you 
elaborate a little bit more on that?
    Dr. Schwab. Yes, thank you.
    Let me go back again, because I think it is important, 
because the staff has supplied you all with these references 
and our written comments constantly refer to the IOM report. 
The IOM Committee on the Future of Emergency Care worked for a 
year trying to find something that worked for a tactical 
solution, not a strategic solution. And my colleagues to my 
left actually have already given you some of the successes, but 
the real success in organizing regional care and delivering one 
form of emergency care to life-threatened patients was trauma, 
trauma systems. This has been a three-decade effort led by the 
American College of Surgeons but endorsed by enabling 
legislation in some 40 States to create regional centers in 
which all patients whose life and limbs are threatened are 
brought to those centers where emergency physicians and trauma 
surgeons are waiting. They are effective, they are efficacious, 
and they are cost-effective.
    And that is not me saying that or the IOM, but, in fact, 
the peer review literature. The most recent literature on that 
topic is in the New England Journal of Medicine. It was a 
national study. Some of the States were included in this study; 
some were not.
    In the entire national study population it asked the 
question, ``what advantage to the patient whose life is 
threatened does a trauma system give?'' And it was a 25 percent 
reduction in mortality.
    Now, we thought in the IOM that if we could use the trauma 
system model as a blueprint and apply those components, 
efficient and effective regionalized--not fragmented--care that 
is accountable, and apply it to the emergency care system 
overall, it would be a wonderful tactic to do. And going back 
to Dr. O'Conner's comments, there is a strong recommendation in 
the IOM to provide money immediately to set up pilot projects 
to study the impact of a regionalized emergency care system.
    So I think the tactical solution is there in print. It is 
proven in the field of emergency care, and I think it is 
doable. And if you asked me what I would do with the money, Mr. 
Chairman, I would take it and I would fund those projects, 
those pilot projects, but I would make them accountable for 
what they are doing; and I would require them to report what 
they've done--not just to our government agencies, but to you.
    Mr. Cummings. Let me ask one more question, and you all may 
answer this, too.
    CMS has proposed a rule that would cut hundreds of millions 
of Federal Medicaid dollars from securing supplemental payment 
to hospitals and provide significant amounts of uncompensated 
emergency and trauma care. The purpose of these payments is to 
help these hospitals offset the financial losses they incur by 
providing those services.
    Last month, Congress enacted a 1-year moratorium 
prohibiting CMS from implementing this rule. In this public 
notice about the rule, CMS officials say, ``we anticipate the 
rule's effect on actual patient services to be minimal.'' Do 
you agree with that?
    Dr. Schwab. I don't agree with that; and I have to tell 
you, this was a real shocker to all of us. This was a shocker 
to me; 40 to 50 percent of all the patients that my emergency 
medical colleagues and I touch have their reimbursement 
essentially administered under CMS. To in any way give those 
patients less ability to pay us to cover our costs, many times 
not even cover our costs, to me is absurd.
    What is interesting about this is that CMS should be 
standing up for the consumer, the patient. And this month in 
Consumer Reports the back page is entirely dedicated to the 
consumer in what it calls the greatest crisis in the most 
threatening part of healthcare, emergency care, and it tells a 
consumer how to get through an emergency department visit. For 
us to think that we are going to lose more funding is 
absolutely absurd at this time.
    Mr. Cummings. Dr. Johnson.
    Dr. Johnson. From what I understand, Mr. Chairman, it has 
been reported that hospitals lose more money on Medicare 
patients that come through the emergency department than some 
other groups of patients. Fifty percent of hospitals report 
being in the red when they admit patients through the ED that 
are covered by Medicare. So I do think that CMS, if it can 
increase funding for those patients, it would actually assist 
in getting those patients into the hospital more effectively.
    Mr. Cummings. Dr. O'Conner.
    Dr. O'Conner. In terms of speaking to the hospital impact 
of those cuts, as it stands now Medicare's share of transports 
is greater than the share of payments. Medicare patients 
represent 40 percent of the total transports, while comprising 
only 31 percent of the revenue; and to have that money further 
cut would increase that gap accordingly. Providers pay 
substantially below their average costs even to provide routine 
transport. In fact, one other aspect of this is that in 
general, pre-hospital care providers are reimbursed for 
transport only, not for the care or specific care that is 
provided. So I think those cuts would have a dramatic and 
deleterious impact.
    Mr. Cummings. Thank you.
    Mr. Davis.
    Mr. Davis of Virginia. Thank you. And thank you very much 
for what you do.
    My son had a broken jaw in a Swarthmore-Haverford game. He 
broke his jaw in a baseball game; and, of course, he had to 
wait to get a physician that would do it because of tort costs. 
But we took him to an emergency department, and I had my first 
experience with Pennsylvania's rules.
    Let me ask you, in terms of magnitude, I am going to get an 
order of magnitude here in terms of the problems and how we can 
solve it here. Tort laws play a role, there is no question 
about that, in emergency rooms, mandated emergency care. We are 
serving people in many cases who are either here illegally or 
are uninsured and can reimburse nothing who play a role in this 
and are squeezing out other people who can appropriately pay.
    We have certificates of need, limited beds, and try to 
allocate them in an appropriate fashion; and yet one of the 
problems I hear is that we don't have enough beds in some 
areas. But if they could get to appropriate certifications you 
could create more beds which would be able to alleviate moving 
people from emergency rooms to hospital beds.
    Federal reimbursability, which of course the private sector 
also pegs reimbursability now in some cases to Medicare, being 
very, very low, so even if you get a patient, the 
reimbursability of that doesn't always cover the cost. And when 
you add in the uninsured and everything else, it creates a huge 
problem; and the ability to attract and retain good people, 
whether doctors, where we still have a shortage, or nurses.
    As you rank all of these, all of them have a Federal 
component. What do we do? How important is each one or are some 
of them really red herrings or are they all important in terms 
of trying to get an understanding or our arms around this 
problem?
    I'll start with you, Dr. Schwab.
    Dr. Schwab. You are just picking on me because your son was 
playing in Pennsylvania. [Laughter.]
    Let me say this. They are excellent questions. Each on its 
own we could spend a fair amount of time, and I think you have 
to dissect and drill down and look at how it affects emergency 
care. I want to start with the first one you mentioned, if I 
could, sir, and that is tort reform.
    One of the things in the last 10 years, including the major 
crisis in Pennsylvania trauma centers just a few years ago that 
Governor Rendell handled beautifully for us, was blamed on 
malpractice. If one tries to ascribe that tort reform will 
solve the crisis in emergency care, I would say that it is not 
fair. That is a much bigger issue. However, where it affects us 
is that there is no consideration of our malpractice risk, our 
malpractice premiums, for delivering care to an emergency 
patient versus that patient in which you have established a 
doctor-patient relationship.
    And what is interesting about that, again, in the report, 
if you look at it, the majority of the patients are life 
threatened, many of which cannot speak for themselves, comas, 
hit in the head, having a heart attack or stroke. We can't get 
information about them. We have no information about them, yet 
we are required to treat within a matter of seconds.
    I knew nothing about this man whose chest I had to open. I 
didn't know his allergies. I didn't know his medicines. I 
didn't know anything. I didn't know if he had diabetes. I 
didn't know anything. But I had to do something, as do my 
colleagues sitting next to me.
    But what is interesting is my malpractice is exactly the 
same. I get no benefit for doing that. I get no recourse from 
that, and I am at extremely high risk if one goes ahead and 
tracks malpractice complaints into emergency care. They are 
very high.
    So I haven't answered your question comprehensively, but at 
least your first topic, what we say in the IOM report is that 
there needs to be a study done immediately to look at some way 
of relieving the physicians and nurses that are applying or 
giving emergency care. And by that, we defined and said we 
should define what an emergency episode is and in that episode 
we should go ahead and look at how the government may excuse us 
from some of the malpractice burden we carry if we truly are 
delivering life-saving care.
    Mr. Davis of Virginia. Everybody thinks reimbursements are 
low, and that drives a lot of this as well, the uninsured. I 
appreciate your answer.
    Dr. Johnson.
    Dr. Johnson. Some things CMS can do to help alleviate some 
of the problems. They are a very powerful organization because 
they hold the purse strings, and hospitals do whatever they can 
to try to get ahold of those funds. I think CMS can use its 
purchasing power to get hospitals to probably move patients 
upstairs by creating financial incentives to reduce crowding. 
If hospitals achieve high efficiency and get patients out of 
the ED in an efficient way, CMS can be rewarded by CMS for 
doing that; and if they are not, they can also raise a big 
stink, so to speak, to be penalized for not moving patients out 
of the ED.
    For example, we have observation codes that CMS could 
expand upon to provide additional funding. We can now put 
patients into areas of the hospital where we can observe them 
and not require full hospital admission. That actually might 
save money in the long run for the system.
    Finally, I do think you probably are aware that there are 
many different types of patients that hospitals can put into 
beds upstairs. Some of those are nice elective surgeries where 
it is certainly predictable how long they will be in the 
hospital and how much it is going to cost them, and it seems 
CMS is more than happy to pay a certain fee for those patients. 
But when you have an emergency department patient who is very 
ill, the hospital cannot collect enough money to cover their 
costs. So if CMS were to expand and prioritize emergency 
department patients over those nice elective, predictable 
patients, that actually might get patients into beds a lot more 
efficiently and open up emergency department beds.
    Mr. Davis of Virginia. Let me talk to you on the tort side, 
because Dr. Schwab makes a case. You probably know less about 
your patients than anybody else when they come in. You have to 
make life-saving decisions based on limited information, and if 
it is the wrong decision you are going to see it in court and 
you are going to have to revisit that decision. Is the standard 
pretty tough for emergency room? What has been your experience?
    Dr. Johnson. To be perfectly honest, there is a tremendous 
amount of defensive type of medicine that is practiced in the 
emergency department. There are many things that we do knowing 
full well that we are just covering the bases, so to speak, and 
probably not as important in the care of the patient. If I had 
some relief, some liability protection, I think that I could 
also practice in a more efficient way, absolutely.
    Mr. Davis of Virginia. Thank you.
    Dr. O'Conner.
    Dr. O'Conner. In terms of liability protection, many of the 
services are protected to the level of gross negligence. Maybe 
one such model is to look at emergency care in its total as a 
means to overcome this problem.
    In terms of your question, there are staffing issues; there 
are hospital issues.
    Mr. Davis of Virginia. Gross negligence is a much higher 
standard of negligence to show. It would give you some relief 
in not having to do some of these defensive mechanisms. Is 
there a consensus on that? That is an easier standard for you 
to operate under, at least.
    Dr. O'Conner. It is, yes. Also, I never would have thought 
that EMS pre-hospital work would be impacted by things such as 
nursing home placement, things on the other end of healthcare.
    In looking at the magazine cover that is now 6 years old, 
Crisis in the ER, and it really is a crisis in the healthcare 
system. I think our current admission and discharge process 
from the in-patient setting is broken. And it is reflected by 
the overcrowding stories that we have heard, it is reflected by 
ambulances that have to be diverted, thereby creating a problem 
in a second hospital that they divert to. Ambulance diversions 
are particularly problematic because they tend to cause a rapid 
downward spiral of the entire system in the region.
    So I think, in answer to your question, it is not a simple 
thing to answer. I think that, as a first step, we may want to 
try to understand the problem a little bit better.
    Mr. Cummings. Mr. Yarmuth.
    Mr. Yarmuth. Thank you, Mr. Chairman.
    I want to get at that topic a little more extensively. I am 
trying to get my arms around--and I know it is hard to 
generalize across the entire country in all sorts of different 
communities--to what extent this is a total patient capacity 
problem and, therefore, more of a method of dispersion problem, 
as opposed to just an emergency room capacity problem. Dr. 
Schwab, do you want to start?
    Dr. Schwab. Thank you.
    Let me just say the difficulty here is--if I can just have 
you think about a large geopolitical area. So you have a 
metropolitan service area, suburban area and a rural area. 
There are a certain number of hospital EMS units, emergency 
departments that render care for their citizens. There is no 
doubt that there is a disbursement or a fragmentation problem. 
And again in the report, we identified that and said one of the 
things that could really help deficiencies is if we design this 
regional emergency care system that includes all components of 
that care system, from the rural ambulance care up in the 
mountains versus the ones in the city, all talking 
electronically and in real time so that we can take people to 
where there are open beds. Thus the term regionalization.
    But then there is also a problem in that we have to look at 
how those hospitals that are getting patients--and especially 
if the patient needs specialized care, cardiac, neurologic, 
trauma obstetrical or pediatric--that those centers that 
function as the regional emergency care centers are in fact 
enabled through proper funding and proper resources to maximize 
their efficiency and be able to move patients through.
    Dr. O'Conner just mentioned he never thought that the 
nursing home would affect the EMS. I can tell you every day we 
have now continuously dedicated very high-level nursing and 
administrators who are helping to get people out to skilled 
nursing facilities, rehabilitation so we can take more people 
in. It is all connected, Congressman.
    But I think what you have to look at is, again, how you 
might design this regionalized system which would help us 
disperse people better, but not lose sight that not all 
hospitals can deliver all types of care.
    Mr. Yarmuth. To what extent--and maybe Dr. O'Conner can 
address this--to what extent do you believe that the 
competitive aspect of institutions exacerbates this problem?
    I know in my community we have several very highly 
competitive hospital entities who most not-for-profit now, but 
we know that means in the healthcare business mostly 
nontaxpaying don't make profits. I am curious as to whether you 
have done an analysis of how big a problem that is in this 
context.
    Dr. O'Conner. I can give you some examples.
    Locally, we established a--again I won't name the locale--
pre-hospital, 12-lead program to identify patients with heart 
attack, with acute myocardial infarction in the pre-hospital 
setting, so they can go to a place where they can receive 
angioplasty if necessary. But we found tremendous resistance 
from some of the smaller hospitals which perceived a potential 
competitive disadvantage of taking care of all patients, 
including heart attack patients.
    I went back to them with data that showed how many patients 
this involved. It was a small number and I pointed out they 
were the type of patients that were being transferred out 
anyway. And the hospitals understood this, so they were more 
accepting.
    We started the program, and it has been very successful. I 
say this because if you can educate the administration of these 
other hospitals, they will realize that it is not really a 
competitive disadvantage. In fact, what you are doing is saving 
a secondary transfer or taking patients who are too sick for 
that hospital or require services that cannot be rendered by 
that hospital to a more appropriate facility.
    Mr. Yarmuth. One quick question, and anybody can answer.
    We talked about this regional approach, and I understand 
that would be very important here. To your knowledge, is any 
region or any community in the country doing a good job at 
this? Are there any models we can look at to try to roll out 
across the country?
    Dr. Schwab. Well, I don't want to play to your chairman, 
but the model that occurs in the State of Maryland is an 
excellent model to look at. As far as trauma systems go, the 
model in San Diego. And as far as models in emergency medical 
services [EMS] coordination, the greater Pittsburgh regional 
area is well-known.
    To go back to the question, how would you use your money, 
what we need to do is formally study those systems and see what 
the best practices are, again, for efficacy, efficiency, and 
effectiveness, and make sure that that is not just our feeling 
but in fact we can prove that to the country and to our 
citizens.
    Mr. Cummings. Thank you very much.
    Mr. Issa.
    Mr. Issa. Thank you, Mr. Chairman.
    Dr. Johnson, welcome. I apologize that I no longer 
represent Mission Viejo, but redistricting was not kind to me 
in my loss of Orange County.
    Governor Schwarzenegger has proposed in your home State, in 
our home State, a broad, sweeping universal coverage initiative 
that requires that employers either take fiscal responsibility 
for their employees or pay a 4 percent fee that would go into a 
pool to help fund those activities which are necessary as a 
result of their failure. And emergency rooms, obviously, become 
the first choice of people who have no formal health coverage.
    In Orange County if, in fact, we were able to accomplish 
that through private means to ensure that every individual had 
either State coverage, if they were unemployed or indigent in 
some other way, or company coverage, back door, front door, 
depending whether or not an employer provided that care or paid 
the 4 percent, how much would that change what you see at the 
emergency room in yours and neighboring hospitals?
    Dr. Johnson. That is an excellent question. Let me answer 
that by saying, since 1993, the number of patients visiting the 
emergency department has arisen to 115 million visits a year, 
and most of those visits are patients who are insured. They are 
insured. So it is not a question of not having funding and 
going to the emergency department because it is a place of last 
resort. It is a question of not having access to primary care 
capabilities within the community; and, as a result, the 
emergency department becomes the facility where they are forced 
to go because they can't get in to see their physician. Or, 
worse, they go to see their physician who decides you must go 
to the emergency department. In that regard, whether there is a 
universal coverage in California or not, it probably would not 
change the situtation in our particular environment of Mission 
Viejo.
    Mr. Issa. So how do we reverse that? I realize it is a 
wealthy community in the center of the greater LA, Orange 
County, San Diego megalopolis. So if it can be fixed, and a 
suburban well-to-do neighborhood would seem to be the easiest 
place to fix it, how do we make those changes to get people to 
the front door of an urgent care center or to the front door of 
routine medical treatment through a normal relationship and not 
at your emergency room door?
    Dr. Johnson. Well, once again, given the reality that most 
of the patients who actually come to the emergency department 
are absolutely sick and actually need to be there, we actually 
see a very small volume of patients who have minor problems 
that really do not need to be in the emergency department. 
Unless we are willing to build another hospital in Mission 
Viejo, CA, we are not going to solve the problem.
    Mr. Issa. When you say ``sick,'' do you mean life-
threatening, immediate injury, or----
    Dr. Johnson. Life-threatening admission.
    Mr. Issa. And what percentage did you say that was?
    Dr. Johnson. Between 20 and 30 percent of the patients who 
present to the emergency department there of Mission Viejo 
require admission.
    Mr. Issa. Twenty percent.
    Dr. Johnson. Twenty to thirty percent.
    Mr. Issa. What about the 80 percent?
    Dr. Johnson. I would say the remaining 70 percent, at least 
half of those patients require being seen in the emergency 
department and probably receive care within 2 hours.
    Mr. Issa. What did we do in our society that created this 
huge rise?
    Dr. Johnson. Lack of primary care access is driving a lot 
of it. I think patients are waiting until they are sick before 
they seek healthcare.
    Mr. Issa. So they are insured, well-to-do, in a suburban 
neighborhood; and they are not going to primary care because 
there is no access.
    Dr. Johnson. Correct. If you call your physician and say 
you need an appointment to be seen because I have a cough and 
they say I will see you 3 weeks from now, that doesn't work. 
Then you wait a week until you have pneumonia and then go to 
the emergency department.
    Mr. Issa. I guess I will ask one more time, because this is 
an area I want to shed light on. It is your neighborhood that I 
missed. Because if anything can be fixed, it can be fixed in 
southern Orange County because means are there. You are saying 
we need more doctors so doctors don't say come in 3 weeks. What 
really will change that? Do we need urgent care? Do we need 
community clinics? Tell me what we need in one of the richest 
geographic areas in the country that we don't have and why.
    Dr. Johnson. There is no doubt the entire healthcare system 
is broken. I think all those things are possible solutions. I 
do think we can expand our emergency department capabilities to 
add more observation capability, for example, and keep patients 
out of the inpatient service but require some prolonged level 
of care, perhaps in between the inpatient service and the ER.
    Mr. Issa. The day before yesterday I was with Michael 
Moore, the maker of ``Sicko;'' and the group I was with, I was 
the only person that wanted to preserve the private care 
system. Everybody else in that room, from Mr. Conyers on down, 
they wanted to have a single-payer, government-driven system. 
And I have to ask you, do you know of a single-payer, 
government-led system that would fix this? And what is that 
model, if one exists?
    Dr. Johnson. I think any model that we create in the United 
States of America will be unique to this particular country. I 
don't think we can look to other models to be the only model 
that is available. I think we will have to try to find our own 
model that will work for most of our citizens.
    Mr. Issa. Anybody else want to weigh in on that?
    Dr. Schwab. If you'll think of Philadelphia as Orange 
County.
    Mr. Issa. I love Philadelphia. You had a great convention 
for us there, and I was there just a few weeks ago. Except for 
the heat, the humidity, if you are on the 19th floor and you 
look out, it does look like San Diego.
    Dr. Schwab. In short, I don't think one solution fits all.
    I will go back again to the IOM report. We looked at this. 
And specifically what we said with no doubt, including one of 
our recommendations, is we have to increase access to primary 
care in all aspects of the population. Because, according to 
the analysis, if you look at those 114 million ED visits, a 
huge percentage of those, maybe not where Dr. Johnson 
practices, are for non-life-threatening emergency chronic care 
conditions for people who can find care in no other area. And 
in Philadelphia, in our hospital, that is a huge part of our 
emergency medical faculties' burden.
    Mr. Issa. Thank you, Mr. Chairman, for the indulgence.
    Mr. Cummings. No problem.
    Let me just say this. As I listen to the testimony, it is 
frightening. When you think about an area like, for example, 
where you operate Dr. Johnson, to have the kind of problems 
that you just stated is amazing. Then I guess it quadruples in 
an area where you are from, Dr. Schwab. Is that a fair 
statement?
    Dr. Schwab. Yes, it is.
    Mr. Cummings. Mr. Cooper.
    Mr. Cooper. Thank you, Mr. Chairman.
    John Maynard Keynes once said that we are all the slaves of 
some defunct economist. I would like to suggest that we may be 
somewhat the slaves of the major Federal intervention in this 
area in the last several decades, the EMTALA law. When you see 
graphs like the ones we have been presented with where patient 
demand is going up, up, up and the number of emergency rooms 
and emergency capacity is going down, down, down, there is a 
fundamental problem. Because any regular economic system when 
demand goes up, supply goes up. So, thinking strategically for 
a moment, I think that what we really need here is a 
recognition of the role that money plays.
    Mr. Issa questioned why in a rich community there is a 
shortage of primary care. Well, it is pretty well-known, at 
least at the elite medical schools, no one wants to be a 
primary care doctor, because being a primary care doctor pays 
much less than being a specialist and the work is often more 
difficult and carries other risks.
    You get what you pay for, and you don't get what you don't 
pay for. You also don't get what you mandate without funding. 
And if we had a third panel of hospital administrators, the 
people who actually allocate resources between the grass roots 
and 60,000 feet, I think most of them will tell you, whether a 
nonprofit or for-profit hospital, that the ER business is a 
very bad business to be in.
    That is why new-fangled hospitals, specialty hospitals 
oftentimes don't even include an ER. And that is why, in a 
celebrated case that I am surprised hasn't been mentioned, in a 
Texas specialty hospital they had to call 911 from the hospital 
because they had no emergency capacity within the hospital.
    So it seems to me that if you look at programs like 
Medicare or Medicaid, the truth is they really don't pay enough 
for the services received, and they haven't for years. And 
everybody knows that, but we don't do anything about it. And a 
couple billion dollars here or there isn't going to solve the 
problem because the problem is so immense, you know, these 
specialty problems, because bioterrorism or things like that 
are fashionable at the moment, they are little more than Band-
Aids for the needs that you have.
    When the government wants to tackle the problem, it can. 
None of you are old enough to remember the old Hill-Burton 
hospitals that were built pretty much nationwide after World 
War II because we needed more hospital capacity.
    Well, today, we need more ER capacity. And especially that 
surge capacity that many of you have alluded to is extremely 
expensive. Because, by definition, surge capacity is not used a 
good bit of the time; and you have to pay for all these 
resources to be on hand when they are not used.
    But think of this analogy. With fire protection, it costs 
you more the farther you live from a good fire department. We 
may be reaching the time where health insurance will cost you 
more the farther you live, the less able your local ER is. 
Because I think Dr. Schwab mentioned a 25 percent risk or 
increase in mortality if you don't receive proper emergency 
care.
    Dr. Schwab. Proper trauma care.
    Mr. Cooper. So these are serious issues that will take far 
more than this committee's resources to deal with.
    I would like to suggest that fundamentally it is an 
economic problem; and yet physicians, others who are not 
trained to think in those terms--but solving them I think will 
take an economic solution.
    So I have used up my time, Mr. Chairman, but it is more of 
a statement than a question, anyway.
    Mr. Cummings. You actually have about a minute, because the 
timer malfunctioned.
    Mr. Cooper. Timer malfunction. Well, I would welcome any 
response that you all have. I just say it is more of a 
statement than a question.
    Dr. O'Conner. If I may very briefly, I think your comments 
are right on target. We are in many ways--I am very comfortable 
with EMTALA, because I treat any patient who comes in. I have 
to say that is the way I like it. I look at the curves in the 
reports.
    Mr. Cooper. EMTALA has two parts, the requirement that you 
see everyone and then also no pay for some.
    Dr. O'Conner. Yes. I was going to say when EMTALA was first 
enacted, I was talking to a leader in the health insurance 
field who said I am not paying for a medical exam. There is no 
reason I have to. That has, of course, softened somewhat. I was 
struck by that stance.
    I think if you look at the number of visits in emergency 
care, in many ways, we are victims of our own success. A 
patient can get a very elaborate work-up in a very brief period 
of time. A similar work-up as an outpatient would take days to 
weeks. So I think that is part of the explanation for demand. 
Even if we had something along the lines of universal health 
coverage, demand would still be quite high. That would be my 
opinion.
    Mr. Cummings. Mr. Murphy.
    Mr. Murphy. Thank you very much, Mr. Chairman.
    Thank you all for being here today.
    I spent 4 years as the chairman of the Public Health 
Committee in the State of Connecticut; and part of the reason 
that I sought a seat here in Congress was that it was pretty 
apparent that this wasn't going to be a 50-State strategy, that 
there needed to be a central solution to the issue of 
overcrowding in the ER.
    I want to ask the three of you sort of an unfairly simple 
question. It strikes me, as we are talking about potential 
solutions here, that there are sort of three areas in which you 
can focus your efforts.
    First, you can focus your efforts on trying to prevent 
people from getting to the ER in the first place, either 
through greater access to primary care or through trying to 
broaden those who have insurance.
    Second, you can focus on the ER itself, greater resources 
there, greater coordination between sites.
    And, third, as Dr. Johnson noted, you can expand the 
ability to move patients out of the ER. You can broaden and 
expand the capability of hospital inpatient services, i.e., 
sort of open up the potential to move patients out more 
quickly.
    I guess it would be helpful for me at the very least to get 
a sense of how you might prioritize those three approaches. If 
we had to focus in one place first, second and third, 
preventing people from getting there, making the process itself 
in the ER more efficient or, third, trying to open up capacity 
to get people out of the ER, how might you recommend us 
approaching that? Or is there a fourth that I am missing?
    Dr. Johnson. I would certainly recommend the final 
recommendation which would be to open the capacity by ending 
the boarding of admitted patients in the emergency department. 
By ending boarding and opening beds in the emergency room, all 
of a sudden you solve the problem of ambulance diversion. You 
basically allow patients to be seen in the ED. If they have no 
access to primary care, we are more than happy to take care of 
them there. Most emergency departments have figured out that if 
patients have minor problems they can wait in the waiting room 
for who knows how long or be seen in another area where minor 
care cases can be seen efficiently. But once you at least have 
bed capacity in the emergency department you can do what you 
are there to do, which is to save lives; and getting those 
boarded patients out should be the No. 1 priority, I believe.
    Dr. O'Conner. I would agree that the third priority is the 
key of increased capacity. Because, without it, it doesn't 
allow for improved efficiencies within the department.
    I think a lot of the inefficiencies that occur in the 
emergency department now are directly attributable to patient 
boarding hours, where staff will take care of patients who are 
normally in the inpatient setting.
    As far as keeping patients who don't belong there out, I 
think just by waiting times and the crowding issue, we sort of 
do that already. We have looked locally at some of our EMS 
transports, and patients with seemingly minor complaints such 
as a headache ``self-triage'' with higher acuity if they call 
EMS. Or if they come to the emergency department, as opposed to 
an urgent outpatient clinic, they tend to be sicker, tend to 
have a more serious illness than if not.
    Mr. Murphy. Let me ask one last question, and that is the 
issue of psych patients. One of the greatest capacity issues 
for inpatient beds in Connecticut is our lack of inpatient 
psych beds, adult psych beds in particular. How much of a 
problem right now is the lack of capacity on the back end to 
get psych patients, both juvenile and adult, out of the ER and 
into a more community based system of care or an inpatient 
system of care?
    Dr. Johnson. A single word: Huge. In my department, for 
example, one to two patients a day that come into my department 
are psychiatric patients. Even after we have done all the 
medical screening, they can potentially sit in my emergency 
department for a period of time from hours to literally up to 
24 hours and supposedly get admitted into my hospital if there 
is bed capacity. But they have actually lived in my emergency 
department for a couple of days before we can get psychiatric 
personnel to come out and evaluate them to find a bed to place 
them in.
    Sometimes there may not be a bed to place them; and, as a 
result, they will have to stay in the emergency room if they 
are a true high risk before we can actually stabilize them or 
have an evaluation of them to be seen or to be sent home or to 
another institution.
    So psych patients are a huge problem. I would love to talk 
to you after the hearing on ways we might be able to solve 
that, but this is a huge problem confronting emergency rooms 
all over the country now.
    Mr. Cummings. Thank you.
    Let me ask a question quick. If you had to relate our 
emergency systems using hospital terms like ``intensive care'' 
or ``a critical condition''--you know the various terms you all 
use--how would you all describe it?
    Dr. Schwab. I would say it is life-threatening or 
resuscitating on a day-to-day basis, and it is going to die if 
we don't fix it. I don't know if that is hospital terms or not.
    Mr. Cummings. It sounds pretty hospital terms to me, but it 
sounds almost like funeral home terms, too.
    Dr. Schwab. Let me just go on and say I meant what I said 
before. If it wasn't for the dedication of the nurses, the 
paramedics and the physicians that struggle with this on a day-
to-day basis, this system would have broken already; and that 
was the conclusion the Institute of Medicine's report.
    Mr. Cummings. Dr. Johnson.
    Dr. Johnson. Mr. Chairman, I believe that you are looking 
at the proverbial canary in the mine right now. You are looking 
at him face to face. Because I am here to tell you that when I 
take my last breath in that emergency department it will be 
when the system completely falls apart, and I am on my last 
breath right now. So we are the canaries, the emergency 
physicians and the nurses and the personnel. I have had some of 
my best nurses leave my department, which is I believe one of 
the best departments in California, to go to other areas of the 
hospital like the cath lab where they can get paid the same 
salary for half the work.
    Dr. O'Conner. In terms of what is acceptable to the staff, 
situations that used to be considered bad days, tough days at 
work are now routine; and the threshold to which some of the 
days rise is appalling.
    Mr. Cummings. Mr. Sarbanes.
    Mr. Sarbanes. Thank you, Mr. Chairman.
    I had the privilege for almost 20 years to represent as my 
prime clientele community hospitals in Maryland and the region, 
probably 25, 30 hospitals over the course of that time. So this 
problem is one that I am very familiar with from all sides, and 
it is almost impossible to overstate it. You are trying your 
best here to do it in ways that will get our attention, which I 
think you have, but hopefully a broader attention.
    Dr. Schwab, you said ``the patient may die'' when asked to 
assess this system using those kinds of terms; and, Dr. 
Johnson, you said that the system--you are holding on before 
the system completely falls apart. What does that look like? 
What does this system look like when it dies, when it 
completely falls apart? What is the prospect down the road that 
we can look back later to the testimony in this hearing and 
say, well, this is not a surprise to anybody. I mean, we 
predicted this would happen.
    This is the fundamental human problem of if A, then B, and 
if B, then C, but for some reason we can't get it together to 
have a minimal amount of foresight. So what does it look like 
when the system dies?
    Dr. Schwab. Let me tell you about my Wednesday afternoon, 
which is a pretty typical day. What you probably don't know is 
that we are the most frequently closed trauma center in the 
State of Pennsylvania. We are closed nine times more than any 
other trauma center in the State because of volume. So I see 
this doomsday picture you are asking me to give. I see it 
momentarily.
    Because what happens is we close, ambulances are diverted, 
ambulances go to other centers, some are not trauma centers, 
there are no surgeons waiting. And ultimately what happens, I 
think, if we can ever prove it and would dare to prove it, is 
patients die. If the emergency system falls apart, rather than 
that being episodic throughout a day, it is going to be 
continuous; and it will be some kind of terrible movie that I 
don't want to ever think about.
    But it is happening now in our largest cities and even some 
of our suburban areas. It happens. People are diverted. And 
there is now an excellent study to show that people, other 
patients don't do well with diversion. They die while they are 
being diverted.
    There are also now studies, one of which is now coming out 
of the University of Pennsylvania, which shows that if 
simultaneously on an overload condition everybody is busy, you 
are doing major trauma cases and yet another cardiac code comes 
in, there is data to show that those patients don't do as well 
either. Why? Because everybody is busy.
    Think of O'Hare International Airport on Friday afternoon, 
a terrible thunderstorm and all flights are canceled, what it 
is like. It is mayhem.
    Mr. Sarbanes. You conjure up an image in my mind where, 
ultimately, diversion is straight to the morgue. That you are 
going from one hospital to one hospital to one hospital and you 
can't get in; and eventually, you know, you just pass it by and 
you go straight to the morgue. That is what I am hearing here.
    Dr. Johnson. In your scenario, what would probably happen 
is that a patient would stay in the ambulance until they 
reached a point where they would die, and then the ambulance 
would have the ability to upgrade the patient to a ``code'' 
status and go to the nearest facility, regardless what the 
status would be, whether they are open or closed. So patients 
eventually do have a finite period of time which they can ride 
around in the ambulance.
    I will tell you what will happen in your scenario. It will 
be a very slow, incremental collapse of the system, beginning 
with the loss of subspecialty capability. So neurosurgeons, 
orthopedic surgeons, hand specialists, they will eventually be 
gone from those facilities. And what would happen is you would 
lose them in your rural areas, for those who have that 
specialty backup already, and then you will lose them from your 
suburban areas and consolidate them in fewer and fewer 
facilities, leaving more and more facilities without any 
subspecialty backup. Which means if you come in with something 
other than what I can handle as an emergency physician, if you 
require plastic surgery or if you need a hole drilled into your 
skull to relieve pressure from blood building inside your head, 
that would not happen and you would, of course, then die in my 
facility because I would not be able to transfer you anywhere 
and I would not have the specialty backup in order to take care 
of you.
    So that is how it would happen. The lack of subspecialty 
services would mean that patients would die at the institutions 
they were at.
    We would foresee increasing ambulance diversion to the 
point where you would have some facilities that would have 
ambulance diversions continually. I know in my area there is a 
rule in the Los Angeles area that if you are on diversion for 
so many hours you have to be off an hour before you can go back 
on. So it would be on diversion, off diversion, on diversion, 
off division.
    Mr. Sarbanes. You are describing an emergency diversion 
system, not an emergency care system. I appreciate you being 
candid about this. Let's talk about a solution.
    I am out of time. Thank you, Mr. Chairman.
    Mr. Cummings. Thank you, Mr. Sarbanes.
    There are a lot of people dying, aren't there? I am basing 
it on what you all just said. There are people dying that don't 
have to die.
    Dr. Schwab. That's correct.
    Dr. Johnson. Yes.
    Mr. Cummings. Ms. Norton.
    Ms. Norton. Thank you, Mr. Chairman.
    This is an important hearing. I am here not only as a 
member of this committee but as a member of Homeland Security 
Committee. I am here also as a representative of a big city in 
the post-9/11 period, one might say of a big city in the post-
9/11 period where you have to think about EMS. And there is a 
lot of thinking about it, but I don't think enough thinking 
about what the Federal Government's responsibility is to EMS 
ambulance services.
    Taking a point you make, Dr. O'Conner, in your testimony 
about the funding of EMS ambulance services. Looking to more 
than 30 years ago, 1973, this was a clear priority because we 
funded $300 million to advance EMS services nationwide, is that 
correct?
    Dr. O'Conner. Yes. That was in 1973.
    Ms. Norton. Now, in real terms, you show a kind of 
priority. In real terms 1973, that amount of money would be 
$1.5 billion today.
    Now, let's look at what you are coping with now. The block 
grant program, the whole thing has been block granted. That 
happened in 1981. What we are seeing is the devolution of this 
whole mission. As I understand it, the block grant program 
provides these EMS services to only 16 States and only $8 
million. We are talking now the equivalent of $1.5 billion 30 
years ago. $8 million out of $9 million that we appropriated, 
but only $8 million of it for EMS services.
    Now, as I understand it, the Bush administration wants to 
eliminate the block grant altogether. Now that would mean the 
$8 million would be gone, would it not?
    Dr. O'Conner. Yes, it would.
    Ms. Norton. In 2006, the committee notes that the Bush 
administration zeroed out the small community ambulance 
development and trauma EMS programs that was once run by HHS. 
We are awfully concerned here about isolated rural communities, 
and without community ambulance service I don't need to tell 
experts like yourselves what the effect of that would be. Now 
the only HHS program that I could find that still supports EMS 
services at the Federal level is the EMS for children, called 
the EMSC program, is that not correct?
    Dr. Johnson. That is correct.
    Ms. Norton. Now the signature issue for this administration 
is homeland security. We are talking about emergency services. 
This gets to be very serious. In the last three budgets, we 
could not find--what we did find was the administration had 
proposed to zero out even EMSC programs, is that not correct?
    Dr. Johnson. That's correct.
    Ms. Norton. We talk about a nonexistent program. Can you 
explain how over 30 years we have gone from a priority for EMS 
services through the Federal Government to essentially the 
decline and fall of such services? I mean, how could that 
happen? Have States been clear about the importance of these 
services?
    In post-9/11, Dr. O'Conner, you are from Virginia, close to 
where we had the worse trauma, second only, of course, to New 
York, how could this disconnect continue to get to this point?
    Dr. O'Conner. There has been a slow decline over 30 years. 
The initial money started up what we now know as pre-hospital 
care and EMS. That was largely successful. In fact, it was 
money that most would argue was extremely well spent. It 
allowed the establishment of State EMS offices and really 
created the medical care that we know today as pre-hospital EMS 
care.
    What has happened since then is there has been a transition 
of funding to different areas that has resulted in it becoming 
a very easy target to zero out EMS programs. I would just hope 
that the administration would reconsider some of these 
decisions.
    Ms. Norton. So if it wanted to eliminate something and you 
were receiving the money, was this considered more a State 
issue and not a Federal issue, do you think, so the money could 
be stolen from here as opposed to other places?
    Dr. O'Conner. I think some of it has to do with the 
fragmentation of EMS. There is not a single go-to lead agency 
that can oversee where the money goes.
    Ms. Norton. Would folding it into the block grant--was that 
the beginning of the end of the program?
    Dr. O'Conner. In retrospect, yes. I didn't know that at the 
time.
    Ms. Norton. Do you think that this program should be a 
stand-alone program?
    Dr. O'Conner. I think that all of emergency care would fair 
better as a stand-alone program. This is not just about EMS. It 
is about everything we do in unscheduled care for emergency 
problems. I think if the sum total of emergency care were a 
stand-alone agency, it would help for sure.
    Dr. Schwab. If you are asking me about EMS alone, I think, 
once again, my comments have always been to look at the 
emergency care system comprehensively, a lead agency or a 
coordinating body with the authority of responsibility and 
continuous appropriations to help us solve these problems.
    Ms. Norton. And you think EMS would receive the proper 
priority within emergency care?
    Dr. Schwab. I absolutely do. In the IOM report, we actually 
call for that. One of the three reports is about emergency 
medical services, and we need to fund them adequately to do 
their job.
    Mr. Cummings. The gentlelady's time is up.
    Let me say as we summarize and we move onto our next panel, 
the gentlelady, when she opened her questioning, she talked 
about homeland security. And I was just curious, if we had a 
Madrid-level bombing today in D.C., for example, what would 
happen? Would we be able to take care of folks?
    Dr. Schwab. America has always been good, Congressman, at 
rising to the occasion, no matter what it was. So would we be 
able to take care of them? The answer would be, we would. The 
question is, who would suffer? Because we have to put all of 
our resources taking care of those that are involved with that 
type of bombing. Where would we divert our ambulances, where 
would the children go, and where would the routine myocardial 
infarction, heart attack, stroke victim go while we were 
overwhelmed with that?
    Mr. Cummings. So there is no capacity, really, no extra 
capacity.
    Dr. Schwab. There is no extra capacity. That is very clear. 
It is frightening because, because of our emergency departments 
being overloaded with routine patients and trauma patients and 
whatnot, it occurs on a day-to-day basis already. So adding on 
a disaster like that would just overwhelm the system.
    Mr. Cummings. Dr. Johnson.
    Dr. Johnson. I would echo that as well, Mr. Chairman. I 
think that in the beginning when the Federal Government created 
moneys to be used for bioterrorism protection, what it didn't 
do was figure out if we would be much more at risk of a routine 
bombing. As we started down the road of buying tents and 
preparing for pandemic flu, we have yet to deal with the day-
to-day environment of not having enough trauma surgeons, not 
having enough resources in our everyday emergency department 
that is already overwhelmed.
    Dr. O'Conner. At this time of day in every emergency 
department in the United States there is no capacity, so a 
Madrid-level bombing would completely overwhelm the system.
    Mr. Cummings. Thank you all very much. Your testimony has 
been chilling. It is very, very helpful. Thank you very much.
    We'll call our next set of witnesses: Dr. Kevin Yeskey and 
Dr. Walter Koroshetz.
    As you all come forward, I just want the committee to know 
the committee also invited Dr. Leslie Norwalk, the Acting 
Administrator of the Center for Medicare and Medicaid Services 
for EMS to testify on behalf of her agency. She has declined to 
appear citing schedule conflicts. She also has declined to send 
any other CMS official to represent her agency.
    This is highly unfortunate and, frankly, inexplicable and 
inexcusable. The programs administered by CMS play a major role 
in the financing of our healthcare system, including medical 
care and emergency care. Indeed, all patients admitted to a 
hospital through the ER, over three-fifths are covered by 
Medicare or Medicaid. Because lack of adequate financing is one 
of the factors contributing to the Nation's emergency care 
prices, the testimony of CMS is critical to a full assessment 
of the Department of Human Health and Human Services' response 
to the emergency care crisis.
    Our staff was informed that Ms. Norwalk's schedule did not 
permit her to attend. However, CMS has 4,328 full-time 
employees. It is difficult for us to understand why she could 
not be with us today. So the Office of the Assistant Secretary 
for Preparedness and Response, which is represented here today, 
has only 222 full-time equivalent employees. This is just 5 
percent of CMS's staff capacity.
    Chairman Waxman shared these concerns with Ms. Norwalk in a 
letter sent earlier this week. I ask unanimous consent a copy 
of that letter be included in the record at this point. Without 
objection, so ordered.
    [The information referred to follows:]

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    
    Mr. Cummings. This afternoon the committee will send a 
letter to Ms. Norwalk posing a set of questions regarding her 
agency's response to the emergency care crisis. We look forward 
to complete and truthful responses to these questions by the 
close of business on Friday, June 29th. I ask unanimous consent 
that those responses be included in the record as well. No 
objection, so ordered.
    [The information referred to follows:]

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    Mr. Cummings. Thank you very much, doctors. Would you 
please stand.
    [Witnesses sworn.]
    Mr. Cummings. We will first hear from Dr. Kevin Yeskey, the 
Director of the Office of Preparedness and Emergency Operations 
and Acting Deputy Assistant Secretary in the Office of the 
Assistant Secretary for Preparedness and Response at HHS.

     STATEMENTS OF KEVIN YESKEY, M.D., DIRECTOR, OFFICE OF 
PREPAREDNESS AND EMERGENCY OPERATIONS, ACTING DEPUTY ASSISTANT 
 SECRETARY, OFFICE OF THE ASSISTANT SECRETARY FOR PREPAREDNESS 
  AND RESPONSE, DEPARTMENT OF HEALTH AND HUMAN SERVICES; AND 
WALTER KOROSHETZ, M.D., DEPUTY DIRECTOR, NATIONAL INSTITUTE OF 
   NEUROLOGICAL DISEASES AND STROKE, NATIONAL INSTITUTES OF 
        HEALTH, DEPARTMENT OF HEALTH AND HUMAN SERVICES

                   STATEMENT OF KEVIN YESKEY

    Dr. Yeskey. Thank you, Mr. Chairman, members of the 
committee, for the invitation to speak to you today on such an 
important topic, one in which the Office of the Assistant 
Secretary of Preparedness and Response is extremely interested 
and engaged.
    I am Kevin Yeskey, a Board-certified emergency medicine 
physician, a former U.S. Public Health Service Officer and the 
Director of the Office of Preparedness and Emergency Operations 
within the Office of the Assistant Secretary for Preparedness 
and Response at the Department of Health and Human Services.
    The Office of the Assistant Secretary for Preparedness and 
Response is relatively new, being created by the Pandemic and 
All-Hazards Preparedness Act passed in December 2006 
establishing a lead Federal official for public health and 
medical preparedness and response within HHS. The Assistant 
Secretary for Preparedness and Response [ASPR], serves as the 
principal advisor to the Secretary of Health and Human Services 
on matters related to Federal public health and medical 
preparedness and response activities to national disasters.
    Additionally, the responsibility of the ASPR include: one, 
leading the Federal public health and medical response to acts 
of terrorism, natural disasters, and other public health and 
medical emergencies; two, developing and implementing national 
policies and plans related to public health and medical 
preparedness and response; three, overseeing the advanced 
research and development and procurement of qualified medical 
countermeasures; four, providing leadership in international 
programs, initiatives and policies that deal with public health 
and medical emergency preparedness and response.
    In short, the ASPR is responsible for ensuring a one-
department approach to public health and medical preparedness 
and response, and leading and coordinating the relevant 
activities of the HHS operating divisions. As a result of many 
changes, including the passage of the Pandemic and All-Hazards 
Preparedness Act, the Office of the Assistant Secretary for 
Preparedness and Response is forward-leaning and results-
driven. In just a short time since the enactment of the 
Pandemic Act, it has created the Biomedical Advanced Research 
and Development Authority; has completed the transfer of two 
programs, the National Disaster Medical System from the 
Department of Homeland Security and the Hospital Preparedness 
Program from the Health Resources and Services Administration; 
and has announced a National Biodefense Science Board. Again, 
all this has been completed since January 2007.
    We are also committed to the use of evidence-based 
processes and scientifically founded benchmarks and objective 
standards called for in the law under the National Health 
Security Strategy. By utilizing this approach, OASPR will 
assure consistency in the preparedness efforts across our 
Nation, ensure greater accountability of local, State and 
Federal entities, and provide for a foundation for improved 
coordination.
    The IOM ``Future of Emergency Care'' report represents an 
objective assessment of the status of our Nation's overall 
emergency care, as we have already heard. Recognizing the 
importance of these reports, HHS convened an internal work 
group to examine the 22 recommendations that were specifically 
directed at HHS.
    We evaluated the initiatives, and the working group 
suggested a strategy to address those concerns. The working 
group was comprised of senior-level representatives from the 
relevant operating divisions and staff divisions of the 
Department, to include the National Institutes of Health, the 
Centers for Disease Control and Prevention, the Center for 
Medicare and Medicaid Services, the Food and Drug 
Administration, the Agency for Health Care Research and 
Quality, the Health Resources Services Administration, the 
Assistant Secretary for Health, and the ASPR.
    The working group met regularly in 2006 and 2007, and the 
ASPR and I were briefed about the working group's progress. In 
evaluating the recommendations, the working group concluded 
there were three consistent items. One was the creation of a 
lead agency for emergency care within HHS to encourage efforts 
directed at daily emergency care issues, while also supporting 
the Federal Interagency Committee on Emergency Medical 
Services. The second was a unity of effort within HHS to 
promote clinical and systems-based research; and, finally, to 
further promote greater regionalized approaches to delivering 
daily emergency care.
    The Institute of Medicine also held regional workshops to 
discuss these findings and recommendations and to encourage an 
open dialog with involved parties. The final capstone workshop 
conducted here in the National Capital included the 
participation of the ASPR.
    As already noted, we have undertaken initial steps to 
better understand the IOM report recommendations, and we have 
initiated steps within HHS to implement them. ASPR is also 
creating an administrative element within the Office of the 
Assistant Secretary for Preparedness and Response that will 
promote coordination and unity of effort across the 
Department's emergency care activities.
    In closing, OASPR will continue to provide leadership in 
this area, fostering a departmentwide approach to the Nation's 
emergency care issues.
    Again, thank you for the invitation to speak today.
    Mr. Cummings. Thank you very much, doctor.
    [The prepared statement of Dr. Yeskey follows:]

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    Mr. Cummings. Dr. Koroshetz.

                STATEMENT OF WALTER J. KOROSHETZ

    Dr. Koroshetz. Thanks very much. It is a pleasure to talk 
to you about the NIH efforts in emergency research.
    The emergency conditions that threaten patients with risk 
of their life and risk of their quality of health are 
exceedingly important to the NIH, and much of our effort goes 
into trying to find better treatment for these patients, and I 
would ask you to think about our efforts in terms of a pyramid 
where at the bottom we have the basic research issues that then 
go up higher into the translational research issues where what 
we discover from the basic can be applied to disease process. 
And at the final top of that pyramid is the effort to get this 
out to patients and actually try on patients to see if it 
really helps them.
    I would say that this has been the motive of research at 
NIH, and it has actually, I think, led to significant 
improvements in the care of emergency patients. I would say 
that at the current time the difficulties you heard in the 
first panel, they are impediments not only to patient care, but 
also to research on this high end of the pyramid where it is 
much more difficult now to be able to translate these new 
discoveries into better care in that environment where people 
are so hard pressed. It's very hard to ask them to do research 
on top of taking care of patients.
    So I would just emphasize what you heard this morning is 
affecting the research in emergency care as well as the patient 
care.
    In response to the IOM report, the NIH put together a 
Trans-NIH Emergency Medicine Task Force comprised of 
representatives from over 23 institutes. We are now involved in 
doing a targeted internal review of our research portfolios and 
trying to get at the key questions that need to be addressed to 
improve emergency care of patients, what are the real big 
questions that need to be answered.
    Doctors also met with leaders of emergency medicine and 
asked them to come up with the same type of analysis, what are 
the big questions that need to be solved in this area to 
improve patient care. Because it is very multidisciplinary, 
these problems--some of which are very high-level neurologic 
problems, cardiac problems. It requires coordination throughout 
the NIH, and after the NIH there has been a much greater 
emphasis on doing this kind of coordination through the Office 
of Portfolio Analysis and Strategic Initiatives. So I think we 
can come up with a trans-NIH approach to these problems that 
arise from our internal review and from discussions with the 
outside experts. As mentioned before, the NIH has participated 
with the major groups at HHS.
    In terms of just a couple of examples of what came out of 
our institute, the Neurologic Institute, lots of things that 
are real emergencies that need to be taken care of quickly like 
strokes, head injury, and we have, for instance, set up 
networks of emergency physicians to try to do trials and get 
new treatments in the emergency scenario out to patients 
quickly. We have stroke centers throughout the country where 
emergency medicine has to be the lead organization. We are 
trying to train emergency physicians in these centers to become 
experts in stroke care delivery.
    And even in the Washington area, the NIH Intramural Program 
has gone into emergency rooms in different hospitals and 
offered stroke and imaging expertise in the emergency setting. 
The NHLBI has had similar efforts with the Resuscitation 
Outcomes Consortium, the Heart Attack Alert Program, and NIGMS 
with research and training programs in trauma.
    So, in summary, I think that the NIH is very successful at 
coming up with new discoveries that will impact the care of 
emergency patients. Our bottleneck may be at the point of 
testing in the environment, which, as you heard today, is 
somewhat chaotic, and we are certainly interested in working 
with the Department and the Assistant Secretary of Preparedness 
and Response to improve delivery.
    Mr. Cummings. Thank you very much.
    [The prepared statement of Dr. Koroshetz follows:]

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    
    Mr. Cummings. Mr. Sarbanes.
    Mr. Sarbanes. Thank you, Mr. Chairman.
    Dr. Yeskey, I am interested in knowing more about this $2.7 
billion of resources that has been committed since 2002 to the 
Hospital Preparedness Program, and I guess what is remarkable 
is the testimony we heard from the prior panel was pretty 
uniform in saying they don't really see much evidence of impact 
from expenditures to that program.
    That is consistent with my own experience when I worked 
with community hospitals post-9/11, and certainly post-2002 
when these dollars became available, where, for the most part, 
absent the occasional grant opportunity, they were not able to 
perceive any kind of coordinated effort to improve disaster 
preparedness at their level.
    And I understand the program is now within your 
jurisdiction or oversight, and I wonder if you could speak to 
why it is that so much money has been spent on this, and yet in 
the field, the practitioners who are on the front lines don't 
have a perception that it has made any kind of a measurable 
impact on improvement.
    Dr. Yeskey. The program, in its transfer coming over, needs 
to be enhanced in its ability to assess the impact that it has 
had. We know we can do a better job of assessing both the 
weaknesses of the program thus far, as well as some of the 
successes, and there have been some successes. The program 
initially was set up to provide hospital preparedness for the 
bioterrorist scenarios rather than the day-to-day surge 
capacity issues that we heard about today.
    But there have been successes. Hospitals have developed 
command-and-control systems that enable them to integrate 
better into a community's response plans with EMS, law 
enforcement. They have developed interoperable communications 
so they can help in a systems way route patients in an event so 
they have a better way of getting the patients to the care they 
need. Those are just a few examples of that.
    I think we need to look a little bit harder at how we can 
improve how moneys are being spent using more effective 
performance measures, being able to describe what exactly we 
want hospitals to do and to measure that. The money we give in 
a hospital preparedness program goes to the States. It doesn't 
go directly to the hospitals, it goes to the States, and they 
distribute that money to their hospitals and health care 
facilities rather than going to the hospitals directly.
    We do have this year, in this upcoming grant program, a 
competitive piece as directed by the Pandemic and All-Hazards 
Preparedness Act where money can go for the development of 
regional coalitions of hospitals, and that money will go 
directly to those coalitions rather than to the State; however, 
those coalitions need to be integrated into an overall state 
plan. And we hear that from the States from time to time, that 
they want to make sure that they understand what their 
coalitions are doing so fits into the overall State 
preparedness plan.
    Mr. Sarbanes. So it sounds from the get-go they needed more 
accountability as the money was being passed down the line, 
which ultimately that accountability comes back to those who 
are originating the grants and the money that is flowing. So 
that is the Federal Government's responsibility, if it is going 
to dispense $3 billion, to make sure as it is meted out, it is 
being done in a judicious way.
    Let me ask you really quickly before time runs out, we 
heard a lot of testimony about what some viewed as a tactical 
response to the emergency care situation. I view, perhaps, it 
as being strategic as well, and that is to set up these 
regional networks of response, emergency care, and I was glad 
of the mention of what has been accomplished in Maryland, which 
I think is a model with the MIEMS model and Maryland Shock 
Trauma Institute and so forth.
    I assume you see great possibilities in that approach, and 
that many of these dollars would be directed toward trying to 
facilitate that kind of thinking and modeling.
    Dr. Yeskey. We support regional--coalitions. Regional 
models of emergency care.
    Mr. Sarbanes. Thank you, Mr. Chairman.
    Mr. Cummings. Thank you very much, Mr. Sarbanes.
    Dr. Koroshetz, in the IOM report on emergency care, the 
committee recommended, ``The Secretary of the Department of 
Health and Human Services should conduct a study to examine the 
gaps in opportunities in emergency and trauma care research and 
recommend a strategy for the optimal organization funding of 
the research effort.''
    I am very glad to learn from your testimony this morning 
that the Department has organized a Trans-NIH Emergency 
Medicine Task Force. When can we expect the task force's 
recommendations?
    Dr. Koroshetz. My understanding is that we are currently in 
the process of doing the internal review and the fingerprinting 
of the research that is going on now, and that should be done 
by the end of this year, along with the consultation with the 
outside groups about where they see the gaps matching up with 
our assessment. And so we think the beginning of next year we 
would have the final report.
    Mr. Cummings. Now, let me tell you this, that Mr. Waxman 
and this committee, we are going to hold you to that, so when 
you get back to your shop, and there is something different, 
would you let us know that? And I hope staff will make that a 
part of our questions, because one of the things that we are 
trying to do is that we found a lot of times is we will get 
answers, people tell us they are going to do things, and the 
next thing you know, time passes by and it is 2 years later, a 
whole new group of Congressmen, a whole new committee, and it 
sort of slips under the rug. This is something that we cannot 
afford to let happen. So we are going to hold you to that.
    Dr. Koroshetz. I understand.
    Mr. Cummings. Dr. Koroshetz, in your written testimony you 
state, ``The structural issues in the U.S. health care system 
do not fall within the purview of NIH.''
    If that's true, then where should the doctors like those on 
the first panel turn for the research they need to help them 
improve the organization and delivery of emergency care?
    Dr. Koroshetz. Well, I think we would say that the NIH is 
going to be most effective at determining what is the best 
therapy for a patient and actually improving what that therapy 
is. But the issues that you heard about this morning are so 
complicated with regard to the finances, the regional 
organizations, specialist involvement, that going into those 
areas would really detract of our mission of making these 
therapies available.
    I would caveat that by saying that certainly we will put an 
emphasis onto bringing the therapy to market and trying to 
break down the bulwarks that prevent therapy from coming to 
market, but it is probably something we can't do alone, that we 
need to do with people who are interested. The Brain Attack 
Coalition is a nice example. So we came up with a new stroke 
therapy, but it requires a great deal of new work being done in 
emergency departments to deliver that therapy, and you heard 
how strained they are.
    We started a coalition with emergency physicians, EMS 
providers----
    Mr. Cummings. Let me ask you this. I just want to make sure 
we are able to end this hearing so we don't have to hold you up 
for another 2 hours or hour and a half. Let me ask you this: 
Would the Agency for Health Care Research and Quality [AHRQ] 
have jurisdiction over this, be helpful with this?
    Dr. Koroshetz. I think in the past that they have looked at 
delivery of health care and outcomes related to how care is 
delivered.
    Mr. Cummings. So you would recommend that?
    Dr. Koroshetz. I think from the standpoint of the questions 
about those which relate to what is the best therapy versus how 
it is actually proportioned, I think that the AHRQ, it may be 
more in their ballpark in terms of how things are delivered.
    Mr. Cummings. You realize that AHRQ, their budget is more 
than $300 million, or a little more than 1 percent of your 
agency's budget. Do you know that?
    Dr. Koroshetz. Yeah.
    Mr. Cummings. Let me leave you with this. I heard you talk 
about getting therapies, I guess, into practice. One of the 
things that, if we listen to the testimony today, we heard was 
those therapies are nice, they are important, but they are not 
getting to people in many instances because people are dying.
    Dr. Koroshetz. Because of the overcrowding issue.
    Mr. Cummings. Yes. I was just sitting here thinking anybody 
in this room could possibly, God forbid, have a heart attack 
right now, and although we may have all the research, we have 
done all the things we are supposed to do, given money to NIH, 
and then because of overcrowding, they will die. Even the 
gentleman, Dr. Johnson I think it was, from one of the more 
affluent areas, people in his district are dying.
    And so it just seems to me that we can do better. And it is 
a shame and very upsetting that CMS did not appear here today. 
I think that that is one of--when you have close to 4,250 
employees, and you can't find 1 person, and it is your 
responsibility to address this issue, and you don't show up, 
you are a no-show, that is a major, major problem. This 
committee is determined to get Dr. Norwalk here and to figure 
out what is CMS doing about this problem.
    Ladies and gentlemen, I move that the Members have 5 days 
to submit questions and comments. With that, the hearing stands 
adjourned. Thank you very much.
    [Whereupon, at 12:38 p.m., the committee was adjourned.]

                                 
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