[Senate Hearing 110-180]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 110-180



                               before the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION


                             WASHINGTON, DC


                              MAY 9, 2007


                            Serial No. 110-7

         Printed for the use of the Special Committee on Aging

  Available via the World Wide Web: http://www.gpoaccess.gov/congress/

38-617                      WASHINGTON : 2007
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                       SPECIAL COMMITTEE ON AGING

                     HERB KOHL, Wisconsin, Chairman
RON WYDEN, Oregon                    GORDON H. SMITH, Oregon
BLANCHE L. LINCOLN, Arkansas         RICHARD SHELBY, Alabama
EVAN BAYH, Indiana                   SUSAN COLLINS, Maine
THOMAS R. CARPER, Delaware           MEL MARTINEZ, Florida
BILL NELSON, Florida                 LARRY E. CRAIG, Idaho
KEN SALAZAR, Colorado                NORM COLEMAN, Minnesota
ROBERT P. CASEY, Jr., Pennsylvania   DAVID VITTER, Louisiana
CLAIRE McCASKILL, Missouri           BOB CORKER, Tennessee
SHELDON WHITEHOUSE, Rhode Island     ARLEN SPECTER, Pennsylvania
                      Julie Cohen, Staff Director
            Catherine Finley, Ranking Member Staff Director



                            C O N T E N T S

Opening Statement of Senator Herb Kohl...........................     1
Statement of Senator Blanche Lincoln.............................     2
Prepared Statement of Senator Gordon Smith.......................     5
Prepared Statement of Senator Larry Craig........................    44

                                Panel I

Todd P. Semla, Pharm.D., president of the American Geriatrics 
  Society; clinical pharmacy specialist, Department of Veterans 
  Affairs; and associate professor, Feinberg School of Medicine, 
  Northwestern University, Evanston, IL..........................     6
Gerard Anderson, Ph.D., professor of Public Health and Medicine, 
  Johns Hopkins Bloomsberg School of Public Health, Baltimore, MD    16
David Dorr, M.D., assistant professor, Medical Informatics and 
  Clinical Epidemiology Joint Appointment: General Internal 
  Medicine and Geriatrics, Oregon Health and Science University, 
  Portland, OR...................................................    29

                                Panel II

Stuart Guterman, senior program director, Program on Medicare's 
  Future, The Commonwealth Fund; former director of the Office of 
  Research, Development and Information, Centers for Medicare and 
  Medicaid Services, Washington, DC..............................    52
Stephen McConnell, Ph.D., vice president of Advocacy and Public 
  Policy, Alzheimer's Association, Washington, DC................    73
Ann Bowers, caregiver, Fort Smith, AR............................    80


Prepard Statement of Senator Blanche Lincoln.....................    95
Prepared Statement of Senator Hillary Rodham Clinton.............    96
Responses to Senator Smith Questions from Dr. Todd Semla.........    97
Responses to Senator Smith Questions from Gerard Anderson........    98
Responses to Senator Smith Questions from David Dorr.............   100
Responses to Senator Smith Questions from Stuart Guterman........   101
Statement submitted by American College of Physicians............   103
Statement submitted by Center for Medicare Advocacy, Inc.........   114
Statement submitted by Disease Management Association of America.   122




                              ----------                              --

                         WEDNESDAY, MAY 9, 2007

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3:09 p.m., in 
room 106, Dirksen Senate Office Building, Hon. Herb Kohl 
(chairman of the committee) presiding.
    Present: Senators Kohl, Lincoln, Casey, Whitehouse, Smith, 
Craig, and Corker.


    The Chairman. Good afternoon. At this point, we are going 
to call this hearing to order. We welcome, of course, all of 
our witnesses who are with us today.
    I am pleased today to be able to turn over the gavel to 
Senator Blanche Lincoln, who will be chairing today's hearing 
on the need for chronic care coordination under traditional 
    Today, 63 percent of our Nation's Medicare beneficiaries 
suffer from two or more chronic conditions. Studies show that 
Medicare spends two out of every three dollars on seniors with 
five or more chronic conditions, such as diabetes, emphysema, 
heart disease, arthritis or osteoporosis. These chronic 
conditions are largely preventable, treatable, and their onset 
can often be delayed through coordinated care, nutrition and 
    Unfortunately, today's Medicare program is not designed to 
serve those elderly individuals with multiple chronic 
conditions that make up the majority of beneficiaries. 
Traditional Medicare doesn't provide physicians with incentives 
to coordinate their elderly patients' chronic care conditions. 
As a result, many seniors are left receiving disjointed care 
through multiple visits to different doctors every year at an 
unnecessarily high cost.
    Research indicates that Medicare beneficiaries with chronic 
conditions are more likely to have preventable, costly 
hospitalizations, experience adverse drug interactions, undergo 
duplicate tests, and receive contradictory medical information.
    At a time when our Nation is growing older, it is clear 
that the success we have in preventing and treating chronic 
diseases will directly affect our ability to provide quality 
health care and contain future growth in Medicare spending.
    Today's hearing will shine a light on these shortcomings in 
Medicare and help us identify ways we can improve the care of 
our seniors while making Medicare more efficient.
    We will now be turning the hearing over to the Aging 
Committee's greatest advocate for geriatric chronic care 
coordination, Senator Blanche Lincoln.
    Senator Lincoln has shown great leadership highlighting 
these issues and bringing them to the attention of this 
Committee. Since 2001, she has worked on legislation to improve 
the care of our Nation's elderly, and I am proud to join her as 
she introduces the Geriatric Assessment and Chronic Care 
Coordination Act of 2007.
    I know Senator Lincoln has assembled a distinguished panel 
of witnesses today, and we are looking forward to learning more 
about the challenges that these beneficiaries and their 
physicians face. We have an obligation to modernize the 
Medicare program and ensure that it is providing the quality 
care that today's beneficiaries need.
    So, we thank Senator Lincoln for all of her work on this 
issue, and she will now take over this hearing.


    Senator Lincoln. Well, thank you, Chairman Kohl. I just 
want to say a very special thanks for your leadership in this 
Aging Committee. I think you, working with Senator Smith, have 
done a tremendous job in helping us to focus on so many of the 
issues that our American families face as their loved ones 
start that aging process.
    It is critically important for so many across this country 
that we really do look to modernize our ability to provide the 
kind of quality of care and the dignity of care that our aging 
Americans want to see. So I want to thank you so much for 
allowing me to do this today, and thank you again for your 
incredible leadership. You have done a wonderful, wonderful 
    He really has done a tremendous job in helping make the 
opportunity for today's hearing a reality.
    I also want to say a very special thanks to our panel, as I 
was not able to come and greet our witnesses. We had a vote 
immediately before this. But I want to say a special thanks to 
both of our panels of witnesses, as well as the advocacy groups 
that have worked so diligently with us.
    It is critically important that we hear from them, and hear 
from their issues relating to the constituencies that they 
represent. They have all been very, very willing to come forth 
with good, honest suggestions and proposals and ideas of how we 
can do this better. I am very proud to be a part of that team 
as well, in terms of working with them.
    As a member of the so-called Sandwich Generation, who cares 
for their children and aging parents simultaneously, I am 
keenly aware of so many issues affecting older Americans and 
have been an advocate for geriatric chronic care coordination 
for several years.
    Now, I am not just a part of the Sandwich Generation. My 
husband's grandmother turns 110 in a couple of months, still 
living in her own apartment, assisted living. So I am a part of 
the Club Sandwich Generation. [Laughter.]
    But seeing her remarkable ability to still care for herself 
in so many ways and to live a very active and fulfilling life 
at almost 110 is pretty remarkable. But it also shows that 
there is tremendous potential.
    There is certainly a lot of commitment that we need to make 
as Americans continue to live longer lives. We want to make 
sure that they are very, very healthy.
    Studies indicate that when patients are linked with a 
physician or other qualified health professionals to coordinate 
care, the results are improved quality of care, increased 
efficiency, and greater cost-effectiveness.
    That is why I am so pleased to chair today's hearing, to 
raise the awareness of the need for chronic care coordination 
for Medicare beneficiaries and to discuss how these services 
can be provided in a cost-effective way.
    This hearing will specifically focus on chronic care 
coordination in the traditional Medicare fee-for-service 
program. While some chronic care coordination occurs in other 
programs--such as Medicare Advantage and the Program for All-
Inclusive Care for the Elderly, which is known as PACE--nearly 
85 percent of Medicare beneficiaries continue to receive health 
care from the traditional fee-for-service program, which lacks 
a care coordination component.
    As we know, obviously, our focus there is on the high cost, 
and that high-cost element of Medicare is mostly in the fee-
for-service component.
    So why focus on chronic care coordination? Well, there are 
several reasons.
    First, the needs of Medicare beneficiaries have changed 
over time. When Medicare was first established in 1965, it was 
based on a health insurance model, which focused on acute care, 
not chronic conditions. But today, many of our older Americans 
suffer from multiple chronic conditions, and would benefit from 
care coordination. We know that about 78 percent of the 
Medicare population have at least one chronic condition, and 63 
percent have two or more chronic conditions.
    Second, as our population ages, the number of older 
individuals with chronic illnesses is also expected to rise. A 
recent article in The Washington Post noted that baby boomers 
are more likely to be in worse health condition than their 
parents in retirement, which may result in a greater need for 
medical services. A RAND Corporation study estimates that half 
of the population will have a chronic condition in 2020, a 
total of 157 million Americans.
    Third, Medicare beneficiaries with multiple chronic care 
conditions are expensive to treat. We know that our costs in 
Medicare are exploding as our number of aging Americans is 
beginning to explode. According to the Congressional Budget 
Office, 43 percent of Medicare costs can be attributed to 5 
percent of Medicare's most costly beneficiaries. Medicare 
beneficiaries with four or more chronic conditions are 99 times 
more likely to experience one or more potentially preventable 
hospitalizations than those without chronic conditions. If an 
individual has Alzheimer's disease or dementia, medical costs 
increase even more dramatically.
    Finally, multiple chronic conditions not only affect the 
individual suffering from them but also their caregivers. About 
5 years ago, I watched my own mother devote herself to the care 
of the man she had loved for more than 52 years. She had 
pledged to attend to him and honor his life until he departed 
this world, even if he no longer remembered her name or could 
recognize her face. My dear father suffered from Alzheimer's 
disease, and it was a long journey for all of us for almost 10 
years. My mother's strength and commitment to my father during 
his long illness remains a great source of inspiration to me.
    Unfortunately, my family's experience with the ravages of 
Alzheimer's is not unique. Millions of Medicare beneficiaries 
with chronic conditions who remain at home do so with the help 
of family and friends. Research shows us that family care for 
an older adult with chronic illness or disabilities, especially 
dementia, can have negative health effects, both physical and 
mental, on family members.
    To address these issues, I am pleased to announce that, 
today, Senator Collins and I have introduced the Geriatric 
Assessment and Chronic Care Coordination Act of 2007--it is S. 
1340--and along with Senators Kohl, Kerry, Mikulski, Clinton, 
Boxer and Casey. I am also pleased that Representatives Gene 
Green and Fred Upton are sponsoring a companion bill in the 
House and that 30 national organizations have endorsed our 
    This bill realigns Medicare to provide high-quality, cost-
effective care to elderly individuals with multiple chronic 
conditions. It is an important step forward in recognizing and 
remedying the impact that multiple chronic conditions have on 
individuals, their caregivers and the Medicare program.
    Again, a special thanks to Senator Kohl, our Chairman, and 
to Senator Smith, Ranking, for all of your incredible 
leadership on this Aging Committee, and to all of the advocacy 
groups and our panelists here today for really making all of 
this a possibility.
    We want to go to Senator Smith first, if you are prepared 
and ready.
    Senator Smith. In the interest of time, let me thank you, 
Senator Lincoln. It is a pleasure to work with you on this 
Committee, the Finance Committee, on health care issues. We 
have done so well, and will continue to do that.
    Thank you, Mr. Chairman, for allowing this important 
hearing to go forward.
    I think in the interest of time, I would like to put my 
statement in the record.
    I want to thank Dr. David Dorr, who is here from Oregon.
    I appreciate your taking your time and this long trip out 
here to share with us your important work on chronic care 
    He is a distinguished assistant professor at Oregon Health 
Sciences University, and is the principal investigator of the 
Care Management Plus Project, which is funded by the John A. 
Hartford Foundation.
    So thanks for coming.
    [The prepared statement of Senator Smith follows:]

               Prepared Statement of Senator Gordon Smith

    I want to thank Senator Lincoln for holding this important 
hearing today. I have had the pleasure of working with Senator 
Lincoln on many issues related to improving the quality of care 
for older Americans and look forward to exploring this topic 
with her.
    Medicare is the backbone of the healthcare system for 
elderly Americans. Now, more than 44.6 million Americans 
receive benefits from this important program, and the number is 
expected to grow quickly in the coming years as more and more 
baby-boomers edge towards retirement.
    We also are a nation that is living longer than ever 
before. Studies tell us that as we live longer we are more 
likely to have an increased number of chronic health 
conditions. Americans are suffering from chronic conditions, 
and asthma, emphysema, dementia, diabetes, arthritis and mental 
illnesses are just a few of the most frequently diagnosed 
conditions in the elderly. When these conditions occur 
together, they significantly compound the daily difficulties of 
those they afflict. We also know that these conditions take a 
toll on those suffering. Too often, those suffering are forced 
by their condition to spend days in bed, become dependent upon 
family members and experience a general decrease in their 
quality of life.
    The good news is that Americans suffering from chronic 
conditions are living longer and healthier lives due to medical 
advances. Where they once would have been confined to their 
home or a hospital bed, many more are able to live much fuller 
lives. This is the direction that programs like Medicare should 
continue to move towards.
    Chronic care coordination is a practice that has been tried 
and tested in many areas of our nation. In fact, we will hear 
today from Dr. Dorr about work going on in my home state of 
Oregon. The purpose of chronic care coordination is to ensure 
that a patient's care providers are working in a collaborative 
manner and that everyone who provides care does so in an 
informed way. The hope is that if care providers work closer 
together on the patient's behalf, that patient will have better 
care and a better quality of life.
    As a member of the Finance Committee, as well as Ranking 
Member of this Committee, I am always looking at ways to 
encourage quality care for our elderly. With the skyrocketing 
cost of healthcare, I am also looking to provide that care more 
efficiently. Twenty percent of Medicare beneficiaries who have 
five or more chronic conditions account for about two-thirds of 
all Medicare expenditures. I look forward to hearing about the 
body of research today that looks at how chronic care 
coordination also can achieve the goal of increased quality for 
these patients as well as how it can improve the fiscal outlook 
for the ever-increasingly expensive Medicare program.
    I want to thank all of our witnesses for being here today. 
I know that they are tireless in their work to better the 
healthcare for our aging population, as well as all Americans. 
Those we will hear from today also include advocates for those 
with chronic conditions. I appreciate your ongoing work to 
ensure that their needs, and those of their families, are met.
    I especially want to thank Dr. David Dorr for being here 
today. I greatly appreciate him taking the time to come out 
here from Oregon and inform us of his work on chronic care 
coordination. Dr. Dorr is an assistant professor at the Oregon 
Health and Science University (OHSU), and is the principal 
investigator of the Care Management Plus project, which is 
funded by the John A. Hartford Foundation. Care Management Plus 
is a project that uses information technology and care managers 
based in primary care clinics to improve coordination and 
quality of care for older adults and those with complex chronic 
illness. I look forward to hearing all of your testimony today.

    Senator Lincoln. Great. Thank you, Senator Smith.
    We have two panels of very distinguished witnesses with us 
today, so we will get started, as Senator Smith said, in the 
sake of time. We will ask our witnesses to present their 
testimony, and then we will open it up for questions and move 
to panel two.
    On our first panel, we will hear from Dr. Todd Semla, 
president of the American Geriatrics Society, a clinical 
pharmacy specialist at the Department of Veterans Affairs and 
an associate professor at Northwestern University at the 
Feinberg School of Medicine.
    Next we will hear from Dr. Gerard Anderson, a professor of 
public health and medicine at the Johns Hopkins Bloomberg 
School of Public Health.
    He will be followed by Dr. David Dorr, the principal 
investigator of Care Management Plus and an assistant professor 
of medical informatics and clinical epidemiology with a joint 
appointment in general internal medicine and geriatrics at the 
Oregon Health and Science University.
    Thanks to all of you gentlemen for being here today, and we 
look forward to continuing our work with you.
    Dr. Semla.


    Dr. Semla. Good afternoon. I am Todd Semla, president of 
the American Geriatric Society. I am a doctor of pharmacy with 
more than 25 years of experience in the field of geriatrics.
    The American Geriatric Society is a nonprofit organization 
of over 6,700 health professionals devoted to improving the 
health and quality of life of older Americans. Geriatric 
medicine emphasizes primary care for older persons. It promotes 
preventive care, with a focus on care management, and 
coordination that helps patients maintain functional 
independence in performing daily activities and improves their 
overall quality of life.
    I thank you, Chairman Kohl, Ranking Member Smith and the 
Members of the Special Committee on Aging, for having this 
hearing during Older Americans Month. It is a time to celebrate 
this fastest-growing segment of our population and also a time 
to look toward the future of the Medicare program.
    Today, I will outline the need for the coordination of care 
and the many benefits, particularly the increasing number of 
older Americans with multiple chronic conditions.
    As Committee Members know, America is on the threshold of a 
historic population shift upward. It is no surprise that the 
prevalence of chronic conditions--conditions that typically 
last more than one year, such as arthritis, cancer and 
hypertension--increases with age.
    Therefore, as life expectancy increases, so does the number 
of people living with multiple chronic conditions, conditions 
whose symptoms and treatment often interact in very complex 
ways. Currently, about 20 percent of the Medicare beneficiaries 
have five or more chronic conditions, and these individuals 
account for almost 70 percent of all Medicare spending.
    It is clear that we must find better ways to treat this 
population, and providers have increasingly recognized the need 
for care coordination in order to properly manage the health of 
individuals with complex and multiple chronic health 
    Simply put, care coordination puts the patient at the 
center of care. It holistically views the patient's physical, 
cognitive and caregiving needs and to result in the development 
of a plan that addresses all of the patient's medical 
conditions and takes into account the patient's ability to 
self-manage his or her health care, and functional issues in 
the patient's support system.
    A care coordinator, usually a physician, physician's 
assistant, or nurse practitioner, oversees the plan's 
implementation by the team. This may entail consultation with 
other providers, monitoring and managing medication, and 
patient and family caregiver education and counseling.
    Studies show that care coordination raises the quality of 
care, improves health outcomes, and reduces health care costs 
for individuals with chronic conditions. This means fewer 
hospital visits are needed, duplicate services and appointments 
are eliminated, sudden health crises are avoided. When a 
comprehensive geriatric assessment is combined with coordinated 
care, studies have shown even better outcomes.
    Medicare, however, is not structured for the delivery of 
these coordinated care services. Instead, the current Medicare 
fee-for-service system encourages providers to see patients 
frequently for short periods of time.
    Without a plan or a care team, the patient receives 
fragmented care by multiple providers who may or may not 
communicate with each other. This can result in duplicate tests 
and treatments, and prescribing medications without knowing 
what medicines the patient is already taking. In turn, this can 
increase the risk for hospitalizations, drug interactions, and 
adverse events, placing the patient at risk as well as driving 
up costs.
    Where do we go from here? We believe that a new chronic 
care coordination benefit needs to be fully integrated into the 
Medicare program, both in the near term and well into the 
future. This will be key to improve health outcomes, higher 
quality of health care, and greater value for every health 
dollar spent.
    Legislation introduced by Senator Lincoln would move us 
toward this goal. The Geriatric Assessment and Chronic Care 
Coordination Act will create a patient-centered approach under 
Medicare that will benefit patients with multiple chronic 
conditions and lower their health utilization rates.
    The bill's establishment of a geriatric assessment and 
chronic care coordination benefit under Medicare's fee-for-
service program will improve the care received by the sickest 
and most vulnerable patients in the Medicare population. It 
also will improve the lives of family caregivers by providing 
them with resources to better care for their parents, 
grandparents, brothers, and sisters.
    Thank you, Senator Lincoln, for your leadership. We look 
forward to working with you and Members of the Committee to 
enact this bill, as well as advance other issues to improve the 
health and quality of life of older Americans. I will be happy 
to answer any questions as the time allows.
    [The prepared statement of Dr. Semla follows:]

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    Senator Lincoln. Dr. Anderson.

                         BALTIMORE, MD

    Dr. Anderson. The Medicare Modernization Act of 2003 was 
the first step in the transformation of the Medicare program to 
one better oriented to the needs of beneficiaries with chronic 
conditions. Mrs. Lincoln and Members of this Aging Committee, 
thank you for your leadership on that issue. The transformation 
was long overdue.
    Looking to the future, I would like to propose five 
additional steps for the Aging Committee to consider.
    First, we need an evidence base that clinicians can use 
when they treat Medicare beneficiaries with multiple chronic 
conditions. Unfortunately, most clinical trials routinely 
exclude people with multiple clinical conditions, because it is 
difficult to demonstrate efficacy in this population.
    This can leave a doctor treating a Medicare beneficiary 
with multiple chronic conditions with a difficult clinical 
decision. First of all, they could assume that the exclusions 
from a clinical trial just don't matter, and use the new 
treatment. Or two, they would assume that the exclusions are 
important, and not use the new information. Both of these could 
be wrong.
    There are two ways to give the doctor the important new 
information. Thirty years ago, clinical trials routinely 
excluded women and minorities. Now, the Federal Government 
mandates that women and minorities be included in clinical 
trials. One solution is to mandate that clinical trials include 
complex patients, not just the simplest patients. A second is 
to fund follow-up studies that include the more complex 
    Second of all, most clinicians are never taught how to work 
cooperatively with a complex patient. We did a national study 
of physicians, and found that a majority of the physicians did 
not feel that they had the minimum level of training in care 
coordination or other skills necessary for taking care of 
people with multiple chronic conditions.
    Medicare is spending $10 billion a year to support graduate 
medical education. Medicare could use some of its leverage to 
put more emphasis on training residents to care for complex 
Medicare beneficiaries.
    Third of all, we need integrated electronic medical records 
that will allow clinicians to communicate easily with each 
other. Many countries will have integrated electronic medical 
records by the end of this decade. In these countries, most of 
the leadership and most of the funding has come from the 
Federal Government, because nearly all of the financial benefit 
accrues to the public and to the payers, it is appropriate for 
the public and the payers to pay the bill.
    In the U.S., we are asking the providers to purchase 
electronic medical records systems. There are two problems with 
this approach: First of all, it is expensive for providers to 
introduce electronic medical records, and the payoffs to them 
are relatively minimal. Second of all, having each provider 
select his or her own system dramatically reduces 
    What I would do is pay each provider $5 to send certain 
clinical information to a secure site maintained by the 
Medicare program. All clinicians could then access this 
information through a secure connection. Medicare beneficiaries 
would be able to restrict access to certain clinical 
information if they so desire. The cost of the Medicare program 
would be $4 billion a year, and it would pay for itself if all 
the clinicians participated.
    Fourth of all, we need to pay for assessment and care 
coordination. The legislation developed by Mrs. Lincoln, the 
Geriatric and Chronic Care Coordination Act, goes a long way to 
achieving this objective.
    My suggestion is that each Medicare beneficiary with five 
or more chronic conditions--which represents about 20, 25 
percent of the population--and/or dementia, select this care 
coordinator, and the care coordinator would help manage the 
person's care. Most likely, the person would choose a doctor, 
and the doctor would hire nurses to conduct the analysis and to 
identify potential problems.
    One example of where better care would prevent and save 
some money is adverse drug reactions. Over half of all Medicare 
beneficiaries with a chronic condition go to the pharmacist 
once a year and are told by that pharmacist not to fill a 
prescription because of another drug that they are already 
taking that could have a problem. I would pay the care 
coordinator approximately $100 per beneficiary per month, which 
is about the same as the disease-management firms receive.
    In my last few seconds, I would like to expand our horizons 
and point out that chronic disease is now the major problem in 
every country in the world, including the poorest countries. 
Yet most international aid agencies focus almost exclusively on 
infectious disease such as AIDS, TB, and malaria.
    However, the three most common reasons for death and 
disabilities in the world, both in high- and in low-income 
countries, are circulatory disease, cancer, and injuries. More 
importantly, chronic diseases can be treated inexpensively, and 
once the programs are initiated, these programs have a history 
of sustaining the chronic disease programs.
    Thank you for the opportunity to testify.
    [The prepared statement of Mr. Anderson follows:]

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    Senator Lincoln. Dr. Dorr.


    Dr. Dorr. Thank you. Good afternoon. My name is Dr. David 
Dorr, and I am honored to present testimony here today.
    I am an internal medicine physician who works in a primary 
care clinic. I am also a medical informatics researcher on the 
faculty of Oregon Health and Science University. My work has 
focused on the use of information technology to improve care 
coordination for older adults with complex chronic illnesses in 
a program called Care Management Plus.
    There is a crisis in chronic illness care. Consider Ms. 
Viera, a 75-year-old patient with five chronic illnesses. In 
most clinics, coordination of the care for her multiple chronic 
illnesses would be limited, leading to worsening of her 
conditions, unnecessary hospitalizations, and significant 
    Guidelines of care for her illnesses may conflict, and she 
and her husband may struggle to integrate the sometimes 
conflicting recommendations of six different physicians with 
their own values.
    With careful care coordination, as in Care Management Plus 
and other models, a care manager can help educate and guide the 
Vieras through their options. Care coordination for people with 
these complex illnesses can help limit the costs, improve 
health, and provide better quality of life for the growing 
number of older adults in our country.
    Care Management Plus is the integration of a tested 
information technology system with trained care managers in 
primary care clinics to treat older adults with complicated 
conditions respectfully and effectively.
    In its initial testing, Care Management Plus saved lives 
and improved health care outcomes by reducing hospitalizations 
by 24 percent, improving patients' experience with care, and 
improving disease status. Savings were estimated at more than 
$.25 million annually per clinic. If 2 percent of the Nation's 
primary care providers adopted similar care coordination 
programs, Medicare would potentially immediately save over $100 
million each year.
    We are in the process of disseminating the Care Management 
Plus model from seven clinics to more than 40 with another 
grant from the John A. Hartford Foundation. We have discovered 
three significant challenges as we do so.
    First, clinicians want to provide care coordination 
services, but especially in smaller and rural clinics, face 
significant unreimbursed costs if they do so. For instance, 
having a care manager is essential to many such models, but 
services by the care manager such as providing education, 
motivation, coaching, and monitoring over time, do not receive 
adequate payment.
    Second, the use of information technology is essential, but 
must be adapted to the needs of coordinating care. Current 
incentives have compelled most practices to use electronic 
health records to better capture billing documentation rather 
than address the needs of coordination over time.
    Third, models like ours and Eric Coleman's Care Transitions 
nurse-coaching model require time and effort to learn and 
implement. Incentives must reflect these costs.
    We are heartened that the Committee on Aging is holding 
these hearings today. With your help, we can make sure that all 
persons with multiple chronic illnesses get health care that 
meets their essential needs in the most cost-effective way 
    I thank you for the opportunity to share some of our 
exciting work with you today.
    [The prepared statement of Dr. Dorr follows:]

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    Senator Lincoln. Thank you, Dr. Dorr.
    Thanks to all of you all for your helpful input into this 
issue. We are grateful for that.
    I will just ask a few questions and then turn it over to 
the Chairman and the other Members for their questions.
    Dr. Semla, Dr. Dorr brought up some of this issue, but I 
was hoping that maybe you might elaborate as well on the 
doctors working in rural areas, the capacity or the 
infrastructure needs that they have for a team approach to 
coordinate their care. In particular, my State, in Arkansas, is 
rural, and many, many areas are medically underserved.
    Any of you that may have recommendations--and Dr. Dorr, you 
have mentioned some in terms of reimbursements and how we could 
do that--but how we would assist rural providers with providing 
care coordination, considering that there is a shortage of 
medical professional providers in many of those areas.
    Obviously, in terms of reimbursement, there is a challenge 
as well. But hopefully, there is more that we can do, if you 
have got some suggestions.
    Dr. Semla. Yes, thank you, Senator Lincoln.
    I was fortunate enough to train at the University of Iowa 
and was there for nine years, and so have some experience in 
delivering rural health care. I would look at it from a two-
pronged approach.
    First is to look at increasing the workforce that is either 
specializing in geriatrics or can employ the principles of 
geriatric medicine. There are a couple of things that are 
currently under way.
    One is that the Institute of Medicine is currently working 
on a report on the workforce, will come forth with 
recommendations in March of next year on how we will meet the 
needs of caring for older adults.
    Another would be the continuation of funding for things 
such as geriatric fellowship, geriatric residency programs, and 
Title VII, which funds the geriatric education center that not 
only trains individuals who want to specialize within their 
profession in geriatrics, but also teaches others in medicine 
and other professions the principles of geriatrics, so you are 
going to eventually get that down into the communities.
    The other idea I would have is another along those lines, 
would be loan forgiveness programs for people who choose to go 
into geriatrics as their specialty, and particularly to 
encourage people to go into rural practices. Whether that is 
through State or Federal funding, that would be a huge 
    With regard to the delivery of care, I think looking at 
things such as telemedicine, whether that be videoconferencing 
or phone conferencing or some ways. When I was at Iowa, the 
dental school had a van that was actually a mobile dental 
office with several suites that went to nursing homes and 
provided care.
    So if a patient can't come to the team for geriatric 
assessment, the team may be able to come there and then work 
with the person who is going to be their care coordinator, 
either a physician, nurse practitioner, physician's assistant 
in that area. So those are some suggestions that I would offer.
    Senator Lincoln. That is great. I know we have worked with 
great programs through Easter Seals to get that same type of 
team delivery in to special-needs children, particularly in 
underserved areas, where we can get different therapies out 
there to them. That same van travels across the State with 
seven therapists for different things.
    So there are a lot of good suggestions there. Without a 
doubt, increasing both the workforce, but more importantly, 
recognizing that we are not training the geriatricians or the 
academic geriatricians that we are going to need for the 
enormous onslaught of seniors that we will see when the baby 
boomers really do hit their full peak.
    Dr. Anderson, the health care privacy is also a major 
concern in our country. Looking at your research on care 
coordination and health technology in other countries, I was 
hoping that you maybe could enlighten us a little bit on how 
they may have handled some privacy issues.
    Maybe you might have some recommendations for how we can 
keep patient medical information private when trying to 
coordinate care for Medicare beneficiaries with these multiple 
    Dr. Anderson. I think the easiest example is Germany, where 
essentially, they have been working on this issue for about 15 
years. They have an electronic medical record. They are moving 
to the smart card that you would be able to walk around and 
could have all your electronic medical record information on 
it. You would have the ability to take off certain things if 
you chose to do so.
    So if you were particularly concerned about a mental 
illness, or you are concerned about something on your medical 
record that you didn't want all the physicians to know, you 
could take that off, and it would be your choice. So, 
essentially, it is your card, and you get to deal with it. So 
you would have control over the information very easily. I 
think that works pretty well in Germany.
    Senator Lincoln. Well, it is interesting. In our State, we 
now have a consortium group that is working to bring greater 
efficiency and quality of care through medical records.
    Wal-Mart has partnered with Intel and the University of 
Arkansas Medical Sciences to really begin to develop a very 
similar-type card that gives the information in the hands of 
the patient the ability to transfer or take that information 
with them, and to control the information in terms of things 
that they may want to keep some privacy element with.
    Dr. Anderson. About a year ago, I was down in New Orleans, 
and the New Orleans City Health Department was passing out 
smart cards, because they saw during Hurricane Katrina, there 
was a huge problem when people lost all of their medical 
records. If you had it with you in your wallet, and you ended 
up in Arkansas, you would have that information. It was a 
critical thing that they learned as a result of Katrina.
    Senator Lincoln. Well, Dr. Dorr, last--my time is up--but 
based on your experience with the Care Management Plus, you 
talked about some of the benefits that you have seen for 
patients and their caregivers since they have begun receiving 
coordinated services for their chronic illnesses.
    Is there anything else there? You talk about the 
information technology needing to be adapted, and I would think 
that as opposed to just making sure that we are having this 
coordination of information and care for the purposes of 
efficiency and cost-effectiveness, there are also other 
benefits too.
    Dr. Dorr. Yes, thank you. That is an excellent question 
about information technology and its use. I think that we have 
highlighted health information exchange as a very important 
part of the care coordination that really has to occur, and 
keeping privacy carefully monitored as we do that.
    I think there is one core way we could do that, while still 
allowing a fair amount of choice, which is to continue to 
divine the core functions and standards that are necessary to 
be able to share care plans and coordinated care between 
physicians so that it is easy to keep track, and keep track of 
the six different components as well as the patient's 
    Senator Lincoln. That is great. Thank you very much.
    Mr. Chairman.
    The Chairman. Thank you very much, Senator Lincoln.
    Dr. Semla, will you tell us more, as specifically as you 
can, which I believe you touched on, why it is that a direct 
physician involvement in the care plan rather than the use of 
disease management companies is more productive and more 
    Dr. Semla. The demonstration project that CMS has done has 
largely focused on disease management companies, more focused 
on a specific disease as opposed to multiple illnesses and 
chronic conditions that all interact, so that their 
interventions are designed specifically for that particular 
    They may be targeting heart failure, but they are not 
taking into account the patient's diabetes, their arthritis, 
all of which can lead to complications in terms of managing 
their heart failure, or lead to drug interactions, as one of 
the reasons.
    So having care coordination, some patient-centered focus on 
all of those chronic conditions, will help to make that system 
more efficient and lead to better outcomes for the patient.
    The Chairman. You don't believe a disease management 
company can do that?
    Dr. Semla. I don't believe that they have demonstrated it 
as well as chronic care coordination, particularly when 
combined with geriatric assessment, where you have an initial 
plan, and then you have the implementation of that plan. You 
have to have multiple chronic disease management systems for 
the patient, and sort of what we have now.
    The Chairman. Dr. Anderson, what role do you believe that 
the Federal Government will have to play, or should play, in 
implementing electronic systems nationwide?
    Dr. Anderson. As I said in my testimony, I think it is the 
benefit of electronic medical records accrue pretty much only 
to the payers. They don't accrue to the providers.
    If I look at other countries, almost all of the 
expenditures come from the Federal Government, come from 
whoever is paying for care. They are the ones who benefit from 
fewer drug interactions, fewer hospitalizations, fewer 
readmissions, all these things that occur because you have an 
electronic medical record.
    The hospital gets fewer admissions, so they don't benefit 
from this. The doctor gets fewer admissions. They don't benefit 
from this, but yet we are asking them in the United States to 
pay for this electronic medical record. The benefits accrue to 
the payer, because you get fewer hospitalizations.
    If I may take a second, in terms of your previous question, 
the evidence base, as I said, doesn't exist right now for 
taking care of people with multiple chronic conditions. So, a 
disease management firm going by the book doesn't know how to 
take care of somebody with multiple problems.
    Medicine is an art, not a science, in many of these people, 
with multiple chronic conditions until we have got a better 
scientific basis, disease management, as much as it tries, 
doesn't have the evidence to take care of these complex 
    The Chairman. All right. Thank you so much.
    Dr. Dorr, implementing a program like Care Management Plus, 
as you know, may cost clinics upwards of as much as $100,000. 
Small rural clinics, such as those in my State as well as 
across the country, may not be able to afford that investment.
    So what other options exist for small clinics that may 
assist them in coordinating patient care?
    Dr. Dorr. That is a great question. We are actually working 
with the Oregon Rural Practice Research Network to come up with 
an answer to that question.
    I will tell you our general approach, which we started in 
Utah, which was to invoke more of community support for the 
kinds of people who do care management in the community, to 
broaden the concept of the care team with the primary care 
clinics, as a center, but not necessarily providing all the 
care. To do that, developing relationships with the other 
resources that are available in that community, to help fill 
out the care as well.
    Health information exchange about care plans, about the 
nature of a person's needs, need to be able to be spread more 
broadly. So one of the ways we have done this, just on the 
ground, is have a nurse that is shared between multiple clinics 
who actually might otherwise be competing. Basically, she goes 
to two different clinics, and sees the patient specifically for 
care coordination.
    That is one example. Might not work in all places. But I 
don't think we have the answer to that yet, except to look to 
the broader rural communities and try and enhance the 
workforce, as Dr. Semla mentioned.
    The Chairman. Thank you, Dr. Dorr.
    Madam Chairwoman.
    Senator Lincoln. Thank you, Mr. Chairman.
    Senator Whitehouse.
    Senator Whitehouse. Thank you.
    Dr. Anderson, I would like to follow up a little bit on the 
comments you just made about health information technology. 
This is something that interests me a great deal, entirely 
apart from the question of where, within the health care 
system, the benefits of HIT accrue.
    I would agree with you that they accrue first to payers, 
second to patients, and third to providers, perhaps even not at 
all to providers, or perhaps even at cost to providers overall.
    Nobody contests that it is a wise idea to expend taxpayer 
money maintaining a national highway system, because we are all 
very pleased that goods can travel rapidly around, and we can 
drive to visit our grandmothers and family.
    Should we be looking at the national highway system as a 
model for a federally managed health information network?
    Dr. Anderson. I think if we look at other countries, we see 
in fact that that is exactly what they have done, they use that 
model. Now, the difference is that I think that the national 
highway system has both Federal money and State money.
    I think this is really a Federal responsibility, because 
many of the people spend 6 months in New York, or Rhode Island, 
and then they spend 6 months in Florida. Which State should pay 
for that cost?
    So you have got to have an information system that is in 
fact national. So with that slight modification to your idea, I 
think it makes complete sense to make it a nationally funded 
    So I would prefer that, recognizing the health care system. 
I think my second choice is to have the payers pay for it, with 
Medicare taking the lead.
    Senator Whitehouse. Before you can fund something like 
this, there has to be some agreement on what it is going to 
look like. The sort of simple analytical model I have is back 
when we were a much more primitive country, and the railways 
were the technology of the future.
    One thing Uncle Sam had to do, in a hurry, was decide how 
far apart the rails were going to be from each other. Simple 
decision, but once you made it, then the boxcar could get from 
Providence all the way down to Arkansas. If you don't make that 
decision, and you have got different track widths all over the 
country, you really don't have a railway system that can work.
    In the health information technology world, it seems to me 
that there are some similar rail-width issues having to do with 
interoperability, with what goes in an electronic health 
record, with what the privacy and confidentiality requirements 
are going to be.
    Are you comfortable that we are making enough progress on 
that in this country right now, when you consider the potential 
savings that are awaiting us if we can build out adequate 
health information technology?
    Dr. Anderson. No, I am not. I think we are in fact doing it 
the wrong way. We are essentially, by putting all the 
responsibility on the providers to develop these electronic 
medical records. We are making it almost impossible to have 
    At Johns Hopkins, we have one electronic medical record. 
The University of Maryland has a different one. A doctor 
doesn't know which one to use. So it is exactly like your 
railroad analogy here. They are dealing with two different, 
three different, five different electronic systems to try to 
connect with all of the things.
    Each one of them, Johns Hopkins wants to get as many 
doctors into their system as possible. That is how the 
competitive system would work. But in this regard, the 
competitive system may make it more difficult.
    So we do need that standardization of rails. There is some 
work at AHRQ and other places on that issue that I don't think 
is nearly enough. Until we decide we are going to put some real 
money into this activity, it is a lot of academic exercise.
    Senator Whitehouse. In terms of talking about the real 
money in this activity, I have come across three studies. The 
RAND Corporation study shows that the minimum likely level of 
savings is about $81 billion a year from adequate HIT 
investment. Before David Brailer left ONCHIT, he said it was 
about $100 billion a year. There is a Massachusetts group CITL 
which said $75 billion a year. That is a pretty good set of 
numbers. In fact, the RAND Corporation high-end number 
estimates $346 billion a year in savings.
    Are you aware of other work that has been done to cost out 
the benefits of adequate HIT investment? Those are the three 
studies that come to mind. Are you aware of others that are out 
    Dr. Anderson. There are others, but I think those are for 
me very reputable ones. They all show about the same number in 
terms of savings. Really, it depends on how many physicians 
actually participate into the system.
    The higher number, I think, is potentially achievable, by 
RAND. If we got nearly universal working on this system, and 
that physicians started to really accept the interoperability 
of it. In other countries, they are seeing significant savings.
    Senator Whitehouse. For the record, Madam Chair, in the 
context of these, the annual budget for the Office of the 
National Coordinator of Health Information Technology in the 
Federal Government has just been doubled, nearly, to $112 
million a year. If you took the $81 billion, and you divided it 
down to days, that is $220 million a day in savings. So we are 
investing about 12 hours' worth of the potential savings in 
trying to achieve them.
    My time has expired.
    Senator Lincoln. Thank you, Senator Whitehouse. It is 
really difficult to mention those kind of savings around 
Senators, because we all can think of the many places we would 
like to see them invested.
    Senator Craig.
    Senator Craig. First of all, Madam Chairman, thank you very 
much for this hearing, and to Chairman Kohl and Ranking Member 
    Thank you all.
    Let me ask unanimous consent that my full statement become 
a part of the record.
    Senator Lincoln. Without objection.
    [The prepared statement of Senator Craig follows:]

               Prepared Statement of Senator Larry Craig

    Good afternoon Madam Chairman. I want to thank you as well 
as Chairman Kohl and Ranking Member Smith for calling this 
hearing today.
    Madam Chairman, as the baby boom generation ages, we will 
see an enormous growth in the number of Medicare beneficiaries 
with multiple chronic conditions. By some estimates, this 
relatively small population of patients consumes nearly 2/3 of 
all our Medicare expenditures. Candidly Madam Chairman, that 
statistic is too startling to ignore.
    This hearing will allow us to focus on this important 
aspect of Medicare. We all agree that Medicare is in need of 
reform. Medicare's inability to properly handle the needs of 
seniors with chronic illnesses is only one of the problems with 
the program. The current system is unstainable--both 
financially and its ability to maintain quality care.
    In the testimony they provided, our witnesses have 
highlighted a variety of problems that the current structure of 
Medicare presents to beneficiaries with chronic conditions. 
While it is important to identify the problems, I also 
appreciate hearing about solutions.
    America's heavy reliance on third party payers to finance 
health care presents a number of challenges. One of those--all 
of the experts on the first panel recognize--is that better 
coordination of care suffers because providers have little 
financial incentive to change care delivery based on the needs 
and wants of their patients. Put simply, their patients aren't 
paying much of the bill. The federal government is.
    Still, ideas are beginning to surface in this important 
area. I was pleased to see that in his testimony Dr. Semla 
points out that the delivery of health care to chronically ill 
patients is focused more on the way physicians are paid, not on 
what is in the best interest of a patient.
    Every year I meet with more physicians from Idaho than I 
can count. I'm sure that Senator Lincoln and other members of 
the House and Senate meet with physicians from the States and 
Districts as often as I do. When these various physician groups 
are all put together, it is clear that they are a well-
represented profession.
    While I enjoy learning about the new innovations in health 
care or the issues important to a particular specialty, I can't 
help but notice that there are always a few common themes when 
any doctor visits my office on Capitol Hill.
    First, most of them recognize that the current Medicare 
system is not ideal for the needs of their patients. Then, that 
recognition is followed by a request that Congress increase 
Medicare payments for their particular specialty or cover some 
additional treatment service they would like to provide. In 
short, most of them identify the problem and then request 
something that will exacerbate the problem.
    I would like to hear more physicians come in with ideas for 
a new business model for how they practice medicine and then 
offer some suggestions as to how we could change Medicare to 
meet the new business model. I am pleased, Madam Chairman, that 
this distinguished group of witnesses seems to be heading down 
that road.
    When doctors begin to say they have a new business model 
that will better serve the health care needs of their patients, 
I think we in Congress will get at the business of reforming 
Medicare. But, when all we hear is that physicians believe 
Medicare payments need to increase, it is natural that we in 
Congress focus on that as the problem.
    Madam Chairman, I am pleased that we will have the 
opportunity to discuss one important facet of the challenge of 
the future of Medicare today. Individuals with chronic 
conditions stand to significantly benefit from a re-examination 
of Medicare's payment structure. I hope we move on some of 
these innovative ideas and more importantly that we begin to 
change Medicare into a more patients focused system.
    Again, I want to thank you Senator Lincoln as well as 
Chairman Kohl for calling today's hearing on this important 
issue and I look forward to hearing from our witnesses.

    Senator Craig. Obviously, to our panelists, with two-thirds 
of our Medicare expenditures being into the area that you are 
focusing on, this is a bit of a statistic too big to ignore. 
Now, we have moved over to one of the tools, and that is as 
    Let me suggest to all of you, there is a model out there 
that the Federal Government owns today that is working 
phenomenally well. In fact, Dr. Anderson, when Katrina hit, we 
didn't lose a record. We didn't lose a patient. We didn't lose 
the pharmaceuticals. We didn't lose a staff person or the staff 
person's families or the staff person's pets. It was called the 
VA system.
    We got them all out on time, on schedule, deployed them to 
other VA facilities around the country. The moment they walked 
through the door and their ID number was put into the system, 
their record was there.
    It is by far, by almost every public and private estimation 
today, the best records system in this country. It was 
federally funded. It is uniform. We are now moving the DOD into 
a similar system, so there is connectivity.
    I don't disagree with anything you are saying. The sporadic 
efforts out in the private sector to build a system is not 
working, not working the way it ought to work. There is no 
question, when I look at the quality of health care delivery 
that the VA system now brings to us.
    Harvard, Michigan, their surveys, consumer satisfaction is 
higher than almost any private or other public system, and so 
on and so forth. Why? It is the records system. It is the 
uniformity of it. It is a phenomenally good system.
    Madam Chairman, we have spent a few billion dollars getting 
there. It is available. It is a publicly owned system. Anybody 
can replicate it if we were to choose to do that. But there is 
no single force causing that to happen, or allowing it to 
    Privacy becomes a frustrating issue, as it relates to that 
kind of connectivity. I voice my concern about smart cards, and 
the need for uniformity even for a smart card to work, while 
that card houses all of the information current.
    In fact, I saw a demonstration of it today where in the 
card was also the X-rays, and so if you have got a hip that is 
metal, and you are going through a detector at the security at 
the airport, well, that system could have a system that accepts 
a smart card, and boom, up comes your X-ray to prove if you 
needed to.
    So all of that is doable, but there is no national 
coordinated effort. With a smart card, there would need to be a 
uniformity, though, of at least software to accept it at 
individual providers' locations. Would that not be true?
    Dr. Anderson. That would definitely be true. But I think 
that is something that AHRQ and other Federal agencies have 
worked on. There is a fair amount of work that has been done. 
So I think we are close to that.
    I think it is the Medicare program that should take the 
lead, because the people who would benefit most from the smart 
card are the people with multiple chronic conditions, and that 
tends to be the Medicare program.
    Senator Craig. What about that chronic condition that says, 
``When I get to my provider, I forgot my smart card''? How do 
we deal with that?
    Dr. Anderson. That is clearly a problem, that we do lose 
information. We might have to have a backup----
    Senator Craig. ``Oh, it is back home, laying on my dresser. 
I forgot to bring it.''
    Dr. Anderson. Right, and that happens. I sometimes forget 
my Blue Cross card when I go to the doctor as well. They give 
me a little bit of information.
    You could have a backup system there that is available as 
well, where you just put the smart card in at the doctor's 
office and it connects to some very large server, if you chose 
to do that. I was just trying to make sure that we didn't 
really intrude too much on the privacy thing.
    But personally, I think the VA system works incredibly 
well. I think the smart card would be in addition to that. But 
the VA system works incredibly well.
    Senator Craig. Well, I thank you. I have no questions.
    But I do believe, Madam Chairman, we have something that we 
may not necessarily want to replicate, but we have a model that 
is working. It is right in front of us every day. The taxpayers 
of America paid for it.
    We spent many years investing it, and in it, and improving 
it, and we continually do work on it today. It is without 
question a very effective system. It has brought savings. It 
has brought quality of delivery, and all kinds of things that 
are something that we are striving for.
    Thank you very much for this hearing.
    Senator Lincoln. Thank you, Senator Craig.
    It brings consistency, as you have mentioned with the 
victims of Katrina, to be able to have portability.
    Senator Craig. In fact, Madam Chairman, it was fascinating, 
in talking with the managers of those hospitals, as I have. 
They didn't worry about the records, because the records were 
in the mainframe, outside of Katrina. They just knew that when 
they got the patient, they worried about the patient.
    In fact, the great tragedy is that the public sector 
performed very well in that instance, and the private sector, 
in some instances, failed, even to the point of losing 
patients. Therein lies a great tragedy. But beyond that, they 
didn't worry about the records, because they knew when they got 
to wherever they were going, they would be there.
    Dr. Anderson. I had an opportunity to go to see it, and 
almost all the doctors' offices lost all of their records. The 
hospitals lost all of their records. It was only the VA that 
was able to maintain, because they had it on a remote site.
    Senator Craig. That is right. Thank you.
    Senator Lincoln. Thank you.
    Senator Casey.
    Senator Casey. Thank you, Senator Lincoln. I appreciate you 
getting us together today here.
    Senator Kohl, thank you for your chairmanship and the great 
hearing you have provided and the great panels, today being one 
of those.
    I want to say first that one of the things that I am 
proudest of in the last couple of days is to be a co-sponsor of 
the Geriatric Assessment and Chronic Care Coordination Act of 
2007. Senator Lincoln has shown great leadership on that issue, 
and we are just beginning that process.
    Your testimony today helps us to understand better the kind 
of coordination that we need, and the real urgency to do that 
when it comes to chronic conditions and in other challenges we 
have in our health care system, particularly with regard to 
    I come from a State where we are right now second in the 
country in terms of the population over the age of 65, second 
only to Florida. Eighty-five and up is our fastest-growing 
population, and your heads are 90, and you know this well. I 
think these issues that you have given testimony about, we are 
exploring this particular bill that I mentioned, will bring 
some light too, I think.
    All these issues come under the broad umbrella of how do we 
pay for Medicare in the future, and it is among the two or 
three most urgent domestic challenges we have for the next 50 
or 100 years. We all know that. This is one of the few efforts 
in Washington, DC, today, I think, to really deal with it.
    If we don't deal with the coordination of care in chronic 
disease or illness, we are not dealing with the cost of 
Medicare. So it is not just about dollars and cents, it is 
about whether we can deal with those costs.
    There are two data points or statistics that I want to 
read, and I think they are particularly compelling. One is, 
this comes from the summary that Senator Lincoln had for the 
bill, and it is just startling. The witnesses know this, but I 
think we can't say this enough.
    Twenty percent of Medicare beneficiaries have five or more 
chronic conditions, and these individuals account for almost 70 
percent of all Medicare spending. I mean, it is just 
staggering, the kind of money that is being expended. We have 
no strategy to deal with that at present, no strategy to take 
better advantage of the technology, and take better advantage 
of the care plans that we are talking about.
    I think also, the other number, or the other data point 
that jumped out at me, was just the impacts of this on our 
entire population, that by the year 2020, a quarter of the 
American population--not the American elderly or older 
citizens, the entire population--will be living with multiple 
chronic conditions. Costs from managing these conditions will 
reach more than $1.1 trillion, by one estimate.
    So whether those numbers are exactly accurate or not, even 
if they are in the ballpark, we are in big trouble right now. 
Washington is not dealing with this. I think this bill and this 
hearing is a step in the right direction.
    It seems that we have made a decision over many years in 
both parties, in lots of administrations and Congresses, to say 
that for someone who has a chronic condition or a long-term 
problem like diabetes, that we have made the decision we will 
pay for an amputation down the road decades later, but we won't 
pay for a care plan that leads to the prevention that is 
necessary, or a plan to prevent that amputation from taking 
place. It is real madness in terms of care, but it is fiscal 
madness in terms of the money. So that is my statement.
    But let me get to some questions. I would ask, I did have a 
longer statement, which I will submit for the record, and I 
would ask consent to do that.
    Senator Lincoln. Without objection.
    Senator Casey. One of the concerns that I have with the 
direction we are taking is whether or not this coordination--
and this is for any one of the three of you--this coordination 
and the kind of chronic care coordination that we are talking 
about can lead to the elimination or the reduction of the kind 
of independence that people want.
    I know that is always a tension between helping someone and 
coordinating their care and a lot of the independence. I don't 
know if any of you have any opinions about that.
    Dr. Anderson. What I think you want to do is to allow the 
patient to choose their own care coordinator. So, if I have 
cancer as my major concern, maybe it is my oncologist that is 
the care coordinator. If diabetes is my major concern, maybe it 
is my endocrinologist that is my care coordinator.
    If I get to choose who my care coordinator is, I am going 
to feel very comfortable with that. If somebody else chooses it 
for me, then I am not going to be comfortable. So I think it is 
really just giving that person the choice.
    Senator Casey. Anyone else have, on that question?
    Dr. Dorr. Absolutely. The most patients in the country do 
seek care from a primary care physician, a geriatrician. That 
what makes sense, at least from our perspective, is that they 
are still able to choose any primary care team that they would 
like, but that unfortunately, that to learn how to do these 
models takes time and effort.
    That somehow, if a way to understand the value of that and 
to document it more carefully through a series of standards 
that were implemented, that that would help as well. So 
patients could choose somebody who has by reputation had that 
    Senator Casey. I know I am out of time, but, Doctor?
    Dr. Semla. Well, I would just say that choice is good, and 
letting the patients choose would be a goal. Most patients are 
probably going to choose a geriatrician or a primary care 
provider, particularly if they have multiple chronic illnesses.
    Senator Casey. Thank you.
    Thank you, Mr. Chairman, Madam Chair, as well.
    Senator Lincoln. Thank you.
    Senator Corker.
    Senator Corker. Madam Chairman, thank you for this great 
    I think the testimony has been very, very good, along with 
the comments that other Senators have made. I know that the 
subject matter was selected for each of you, and we kind of 
honed in on Mr. Anderson a great deal, not to take away from 
the two of you. But I think the focus of the records and the 
smart card itself are dead-on.
    I come from a State, Tennessee, that has a lot of 
entrepreneurs, a lot of people involved in health care. What I 
find--and I really appreciate the great work that they do, and 
they have done a lot to advance medical care in America--but it 
is like we have silos of people that are doing exceptional 
things, but not talking with each other.
    I think that tying that together with technology truly is 
the only--we really do not have a health care system in 
America. We have a lot of people who are doing what they do 
well. I think that the technology has the ability to really 
cause us to have a system where people are actually 
communicating with each other.
    I think your comments have been dead-on, along with others 
up here. I really want to work with our Madam Chairman and 
others to make sure that we do focus on the public sector 
taking the lead in making sure we have a technology platform.
    I would like to move to another subject, and I think 
Senator Casey's comments about focusing on the end issue 
instead of prevention--obviously, all the money exists in the 
chronic conditions. That is where all of the prevention needs 
to even take place with younger populations.
    But if you will, describe to me, if we went this route, 
sort of the upfront investment that might take place. 
Financially, again, I realize we are seeking bigger savings 
down the road.
    But talk a little bit about how we would go about paying 
for this, through this Medicare program. Also if you would 
differentiate that from what now happens with Medicare 
Advantage and that type of thing. I would love to have an 
explanation from each of you that want to discuss it.
    Dr. Anderson. What I propose is that the Medicare program 
pays $5 for a physician, for a hospital, for whoever has the 
medical records to submit it. Then, that is the payment system, 
and that would cost about $4 billion.
    Senator Corker. Yes, I am actually not talking about it. I 
had heard you say that, both in your testimony and I know 
someone else asked a question. I am actually talking more now 
about the general coordinated care effort that would take 
place, and having someone coordinate that through the fee-for-
service program. I am focusing on the bigger picture of the 
bill itself.
    Dr. Anderson. Basically, what you want to do is provide to 
a doctor, I think in most cases--whoever is the person who the 
patient chooses to be the care coordinator--approximately $100 
per member per month. That person would probably hire somebody 
to do most of the care coordination activities.
    Then, where there is a difficult decision to be made 
clinically, it goes to those two, three, four doctors, and they 
have an actual conversation about whether or not the cardiology 
problem or the neurology problem is more significant. So, it 
would probably involve the geriatrician and others.
    You need money for that person to gather all the 
information, to have it in order to make a decision. I propose 
one more number to keep in your heads these Medicare 
beneficiaries with five or more chronic conditions see 13 
different doctors during the year and fill 50 prescriptions 
during the year. So a lot of information is flowing, and we 
need somebody paid to coordinate that.
    Senator Corker. Let me follow up on that, if I could. I 
know there are others that want to make comments.
    I was commissioner of finance for the State of Tennessee 
about a year after we privatized Medicaid. I had nothing to do 
with privatizing it, but was there to sort of deal with some of 
the issues.
    What we found was that, in a lot of the HMOs, we had 
clerks, in essence, that didn't know that much about medicine, 
that were paid like you are describing, to make major 
decisions, if you will, on behalf of patients.
    So, it turned out to be a not-so-good thing, if you have, 
in essence, somebody on the end of the telephone that really--
so if you could respond to that?
    Dr. Anderson. Mine would be different in that it would be 
paid. The money would go to the doctor, and the doctor would be 
the one that would be supervising this nurse or this person. So 
the doctor would feel responsible for the activity, not some 
clerk on a telephone.
    Senator Corker. Can I ask one more question? I know I am 
out of time, but, through an HMO, there is obviously a 
financial incentive. This would, in essence, be a fee paid to 
    Would there be additional incentives, if you will, to 
coordinate care and keep costs at a lower level? Or would it 
just be that per-member per-month payment to that person? It 
sounds like a strict administrative payment without other 
incentives in place.
    Dr. Anderson. I would love to have pay for performance 
included in that. I think the key things that you would want to 
reduce are readmission rates, and you could monitor the 
readmission rates at the hospitals.
    You can monitor what are called preventable 
hospitalizations, and these are things that have been in the 
literature for a while, like you should never be hospitalized 
for diabetes and other kinds of things. You can monitor how 
well this care coordinator is performing on all these types of 
    A third one would be drug-drug interactions. These are 
things that can be very expensive that can be relatively easily 
monitored if you have somebody who feels responsible for that 
activity. Right now, none of these 13 doctors really feel 
responsible. So paying for a care coordinator and monitoring 
his or her activities would make them feel responsible, and we 
can monitor their performance in this activity.
    Dr. Semla. I would like to comment that many geriatricians 
are already providing these services without receiving payment 
for them, because that is what they do and what they are 
committed to doing as part of their service. I would include 
others in geriatrics, such as nurse practitioners and 
physicians' assistants, who can deliver some of these same 
services under the supervision of a physician.
    With regard to pay for performance, I think we have to be 
very careful in terms of the quality indicators that we would 
choose, because we are dealing with a very vulnerable and at 
some times frail population but that does get sick. But just 
focusing on something like drug-drug interactions is a perfect 
    I am not sure the Committee is aware, but there is evidence 
that suggests that for every dollar that we spend in the United 
States on prescription medications, we are spending between 33 
cents and another dollar to treat the adverse events from those 
medications. So it is not a really good bang for our buck. That 
would certainly improve with care coordination.
    Senator Lincoln. Well, I want to thank the panel very much. 
You all have been a tremendous help, and we look forward to 
continuing this discussion and work, because I think there are 
so many things that we can agree will benefit all of us, all of 
our families, and certainly the Medicare beneficiaries in this 
country. So we look forward to working with you. Thank you so 
much for your time and for being here.
    We would like to call our second panel, if we can.
    I would like to welcome our second panel.
    We will first hear from Stuart Guterman, who is the senior 
program director of the Program on Medicare's Future at the 
Commonwealth Fund. Mr. Guterman was also the former director of 
the Office of Research, Development, and Information at the 
Centers for Medicaid Services.
    He will be followed by Dr. Stephen McConnell, who is the 
vice president of advocacy and public policy at the Alzheimer's 
    Our final witness will be Ann Bowers, who will share with 
us what it is like to be a caregiver to an individual who 
suffers from multiple chronic-care conditions. I am certainly 
especially pleased with Ann being here today, because she is 
from Arkansas.
    As a caregiver to a parent with Alzheimer's disease myself, 
along with my sisters, brother, and my mother, I think it is 
especially important that we hear from family members who face 
the day-to-day struggles of caring for a person with multiple 
illnesses and in that chronic disease.
    So thank you all for being here.
    Mr. Guterman.


    Mr. Guterman. I want to thank you, Chairman Kohl, and 
Ranking Member Smith, Senator Lincoln, and the other Members of 
the Committee for this invitation to testify on chronic care 
initiatives in Medicare.
    I am Stuart Guterman, senior program director for the 
Program on Medicare's Future at the Commonwealth Fund. The 
Commonwealth Fund is a private foundation that aims to promote 
a high-performing health care system that achieves better 
access, improved quality, and greater efficiency, particularly 
for society's most vulnerable populations, including the 
elderly and disabled. The Fund carries out this mandate by 
supporting independent research on health care issues and 
making grants to improve health care practice and policy.
    Now, the Medicare program, as you have heard, was designed 
to ensure access and needed health care for first the elderly 
and then the disabled population. It has served that purpose 
well for more than 40 years. But the population it serves has 
grown and changed, and Medicare must adjust to meet the needs 
of its beneficiaries.
    One problem faced by Medicare, as well as the rest of the 
health care system in this country and in other countries, is 
that while the health care delivery and financing system was 
originally designed to address acute care needs, the population 
they serve is characterized increasingly by multiple chronic 
    We have already heard from the Chairman and others, 20 
percent of Medicare beneficiaries have five or more chronic 
conditions, and these beneficiaries account for two-thirds of 
Medicare spending each year. That accounts for about $300 
billion next year that will be spent on people with multiple 
chronic conditions.
    The astounding fact to me in all this is that this group of 
20 percent of Medicare beneficiaries sees 13 different 
physicians--actually not see, is treated by, sometimes they 
actually don't see them--13 different physicians, and fills 50 
prescriptions each year.
    So there is not only a lot of money on the table for this 
group of people, there is also a lot of care being provided. 
Currently, there is no incentive in Medicare or most other 
systems to coordinate that care. Within Medicare, I would 
assert that neither traditional fee-for-service Medicare nor 
necessarily the Medicare Advantage program currently is 
configured to ensure that these beneficiaries get the kind of 
coordinated care that they need.
    Fee-for-service payment emphasizes provision of individual 
services in the context of a single encounter for a single 
condition. Capitation provides incentives that may be more 
consistent with better coordination, but that doesn't mean that 
plans respond to those incentives in that way.
    Capitation also provides a strong incentive to avoid 
chronically ill enrollees, even under the current risk 
adjustment mechanism. Moreover, the lucrative payment rate that 
plans currently receive under Medicare Advantage may actually 
diminish the power of any incentives, both positive and 
negative, that capitation otherwise would provide.
    CMS, though, has begun to respond to these changes in their 
population and their needs by developing a variety of 
initiatives aimed at improving the coordination of care 
provided to Medicare beneficiaries with chronic conditions. In 
my written testimony, I describe these initiatives in some 
detail, but I would like to mention a few of the projects that 
are currently underway.
    Under traditional Medicare, one of the early attempts to 
coordinate care was the Medicare Coordinated Care 
Demonstration. This was an attempt to see whether providing 
coordinated care services to Medicare fee-for-service 
beneficiaries with complex chronic conditions could yield 
better patient outcomes without increasing program costs.
    There were 15 sites, both in urban and rural areas, that 
focused on various complex chronic conditions. Enrollment in 
these programs began in April 2002, and at its maximum reached 
about 21,000 patients. However, that number was concentrated; 
about 60 percent of the total enrollment was in the five 
largest sites.
    There are initial findings from the first 2 years of that 
demonstration. They found that beneficiary recruitment in the 
fee-for-service market can be a challenge, that the most 
successful programs had close ties to physicians and other 
providers, and through the first 2 years of the demonstration, 
few effects were found on beneficiaries' overall satisfaction 
with care, patient adherence or self-care and Medicare program 
expenditures. So the results are sort of mixed at best.
    Currently, there is a major project that is not a 
demonstration, but a pilot program called Medicare Health 
Support, which was expected to involve about 160,000 
beneficiaries at eight participating sites.
    Unfortunately, two sites are in the process of dropping out 
of that program, LifeMasters in Oklahoma and McKesson in 
Mississippi. But we don't have any good results on what the 
bottom line is going to be from that demonstration.
    I am glad to say that apparently, another demonstration 
project that was in the Medicare Modernization Act is about to 
be implemented, the Medicare Care Management Performance 
Demonstration, which is a 3-year project that is scheduled to 
start July 1 in Arkansas, California, Massachusetts and Utah, 
to promote adoption of health care information technology to 
improve quality of care for chronically ill Medicare patients.
    Focused on the physicians, about 800 practices with one to 
10 physicians are going to be involved in that, a total of 
2,800 physicians focusing on patients with diabetes, heart 
failure, coronary artery disease, and preventive care. The 
special needs plans, which I won't go into, are intended to 
help, in the Medicare Advantage environment, improve 
coordinated care.
    So what do these initiatives tell us? They tell us, No. 1, 
that engaging Medicare beneficiaries in these kinds of 
initiatives can be challenging, that the more successful 
initiatives work more closely with physicians to help identify 
patients who can be helped most and to establish credibility 
with those patients.
    They tell us that designing approaches to reach different 
populations and in different circumstances and environments and 
successfully integrating those approaches can be complicated, 
and that improvements in health care for groups of individuals 
seem to be achievable, but the jury is still out on whether 
savings can be reliably achieved.
    Still, given the current lack of coordination in our health 
system, it would be hard to believe that a way can't be found 
to improve on both quality and efficiency. The current system 
basically is the example of the worst case, and any attempt to 
coordinate care, I think, would be a move in the right 
direction to use this $300 billion a year that is on the table 
more effectively for the beneficiaries in the program.
    [The prepared statement of Mr. Guterman follows:]

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    Senator Lincoln. Dr. McConnell.

                         WASHINGTON, DC

    Dr. McConnell. Madam Chair, thank you for holding this 
hearing and for your consistent leadership in improving care 
for the Nation's older population, especially for your 
leadership on behalf of people with Alzheimer's disease.
    I would also like to acknowledge the terrific staff work of 
your Brenda Sulick, who is a fellow in the program named after 
Senator Heinz, who was the Chair of this great Committee in the 
    Assessment in coordinating care is especially important for 
people with Alzheimer's disease, because they have high use of 
Medicare services, and incur very high Medicare costs. This is 
not because of the problems of treating Alzheimer's disease, it 
is what Alzheimer's disease does to complicate the care and 
treatment of other conditions.
    Let's take a look at some of the costs. Medicare now spends 
three times as much for beneficiaries with Alzheimer's disease 
as it does for those who do not have the disease. About half of 
that is on hospital care. By 2030, there will be more than 
600,000 new cases of Alzheimer's disease every year, and the 
cost to Medicare for just treating those people will be $394 
billion a year, which is the cost of the entire Medicare 
program today.
    What is behind the numbers? First of all, people with 
Alzheimer's disease have other chronic conditions. Twenty-nine 
percent have heart disease, 28 percent congestive heart 
failure, 23 percent diabetes, 17 percent had chronic lung 
disease. In fact, only 5 percent of Medicare beneficiaries aged 
65 and over with Alzheimer's disease had no comorbid medical 
conditions. Many had more than one serious condition.
    So what happens when those conditions come together? A 
couple of examples: Medicare beneficiaries with Alzheimer's 
disease plus congestive heart failure had 50 percent more 
hospital stays, and the cost of their care was 50 percent 
higher than those with congestive heart failure and no 
Alzheimer's disease.
    Alzheimer's disease plus diabetes resulted in three times 
as many hospital stays, and average Medicare costs that were 
150 percent higher than for beneficiaries with diabetes but no 
Alzheimer's or dementia.
    The reason for the higher hospitalization and higher costs 
is simple. Memory and other cognitive impairments caused by 
Alzheimer's disease greatly complicate the management of 
comorbid medical conditions. The case of Ms. X was reported in 
the Journal of the American Medical Association and illustrates 
this point.
    Ms. X had mild Alzheimer's disease and osteoporosis, and 
was prescribed a medication for her osteoporosis and told she 
had to take the medication with water and remain upright after 
taking it. Because of her dementia, Ms. X did not remember or 
follow her doctor's instructions.
    Four weeks after starting the medication, she was taken to 
the local hospital emergency room with symptoms of an ulcerated 
esophagus because of taking the medication incorrectly. Despite 
treatment, Ms. X ultimately died when the ulcer eroded into a 
major blood vessel. Ms. X and the data I have presented make 
clear why care management is essential for beneficiaries with 
Alzheimer's disease.
    For this reason, we need congressional action to create a 
new Medicare benefit targeted to the most complex patients. 
Without the adoption of a new benefit, CMS is unlikely to 
develop a comprehensive pilot program that ensures complex 
patients--that is, those with dementia and one or more other 
medical condition--are treated appropriately with meaningful 
    We did a survey of 10 of the pilots that are being done 
now, and with the exception of one, none of the rest of them 
are even screening for dementia. They are managing diseases and 
not paying attention to the fact that many of the beneficiaries 
have dementia.
    The Alzheimer's Association strongly supports the Geriatric 
Assessment and Chronic Care Coordination Act. This act is a 
very important step forward, and has the potential of 
substantially improving care and lowering costs for Medicare 
beneficiaries with Alzheimer's disease and other dementias.
    The value of this legislation is not just the numbers. It 
is about the lives of real people. Without this legislation, 
people with Alzheimer's disease and other dementias in their 
families will continue to struggle with a fragmented health 
care system, and Government will continue to pay for 
preventable hospitalizations that could be avoided with better 
assessment and care coordination.
    Do not forget the human faces behind all the statistics. 
You know that very well, and you have handled that incredibly 
well here in the Senate. There are real reasons to support this 
important legislation, and we appreciate your leadership on 
this issue.
    [The prepared statement of Dr. McConnell follows:]

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    Senator Lincoln. Thank you, Dr. McConnell.
    Now, I would like to welcome Ann Bowers from Arkansas. I 
won't need an interpreter here at all, having a fellow 
    Just to say thanks to Ann for sharing your story. I think 
our stories really do make all the difference in the world, 
because it does put a face, as Dr. McConnell said, on each of 
our families, on how we can do better, and hopefully we will.
    Thank you.


    Ms. Bowers. Yes, it does. You can provide printed versions 
for those that do need accent assistance. [Laughter.]
    Thank you first, Senator Lincoln, for inviting me and for 
everything you do for those of us struggling with the problems 
of an aging population--sometimes they are not even that aged--
as well as everything you do for those of us in the great State 
of Arkansas. Thank you.
    My name is Ann Bowers, and I represent one of the millions 
of Americans caring for loved ones with Alzheimer's.
    Seven years ago, my ex-husband Jay Sweatman, a 50-year-old 
divorced man with an MBA, two loving preteen daughters, and no 
family history of Alzheimer's, became ill. At the time, he 
maintained joint custody of our girls, owned his own company, 
and served on State and National boards throughout the country.
    Fourteen months later, everything came crashing down. 
Repeated financial mistakes, misplaced money, overlooked 
details, drove his business into the ground, and our marriage 
ended. He then took and lost a succession of jobs, with the 
last one being a position as a stock boy at Sam's Club 
    When I realized this college graduate with an advanced 
degree couldn't hold a job at Sam's, I moved him from 
Albuquerque to Denver so he could be with his daughters and 
with me. At this point, he frequently struggled to find words 
while speaking and was having difficulty carrying on a coherent 
    After 4 months of exhaustive neurological testing, a 
diagnosis of probable Alzheimer's was made in March 2002. 
Neurologists gave me the phone number of the local Alzheimer's 
Association chapter and suggested I get in touch with them to 
find out what help might be available for Jay, for our 
daughters and for me.
    I will always be grateful for that single gesture. The 
Alzheimer's Association made sure I knew about day care and 
referred me to 24-hour phone help and online bulletin boards 
where I could always find someone who had a clue what I was 
going through on any day.
    Finding help for Jay and a way to pay for services was 
overwhelming. Unemployment and financial mismanagement left him 
with absolutely no resources. He was admitted in April 2002 to 
the Colorado Indigent Care Program to help cover his medical 
    In May, he applied for Social Security Disability Income, 
but was denied, because he didn't appear to need help and he 
was under age 60. The following month, his lack of income and 
resources qualified him for Colorado's Adult Needy Disabled 
Program, providing $250 a month against any future Social 
Security benefits, as well as food stamps.
    During this time, Jay remained in an apartment across the 
street from our home, with the children spending several nights 
a week with him. He felt that independence and contact with the 
girls was critical to his well-being. However, by the winter of 
2002, he could no longer reliably keep house, cook, or even 
groom himself regularly.
    In early 2003, Jay was finally approved for Social Security 
Disability benefits. He was also at long last approved for in-
home personal assistance, but it came too late. By the time the 
services were authorized, he could no longer live 
independently. We moved him into a personal-care boarding home.
    In the midst of trying to help Jay get the help he needed, 
it never occurred to me to closely monitor his medication. We 
had been married for 20 years, and he was totally self-
sufficient. I had no idea, due to his impaired judgment, he was 
hoarding the medication that kept his other health problems, 
glaucoma and depression, under control.
    It wasn't until he tried to explain that something was 
wrong with his eyes that I realized he was losing vision from 
the sides, a classic exacerbation of his glaucoma symptoms. A 
thorough search of his apartment confirmed the worst. I found 
the pills I thought he was faithfully taking organized into 
neat piles in a dresser drawer, where he placed one each day.
    From that point on, every health problem quickly became a 
crisis. Jay's untreated glaucoma required extensive testing, 
and we briefly considered surgery. He lost most of the sight in 
one eye. Frustration coupled with lack of medication for his 
depression led to thoughts of suicide.
    He had to be hospitalized just so we could get him on an 
adequate drug regimen and determine his true needs. We didn't 
know it then, but we needed one person providing ongoing 
support and a plan of care in coordination with all of his 
doctors. Instead, I tried to hold down a full-time job, raise 
two preteenage girls, and solve all the problems myself, 
guessing what specialist he might need next and what condition 
we should manage on any given day.
    There has to be a better system. The Geriatric and Chronic 
Care Coordination Act will prevent other caregivers from facing 
the challenges that I did with my daughters.
    Maintaining Jay's health was only part of the struggle. 
Multiple wandering incidents landed Jay in the hospital yet 
again for medical re-evaluation. He was then moved to assisted 
living, but had to be discharged after only 3 months because he 
became aggressive and physical, a common progression for 
Alzheimer's disease.
    The next stop was a full-service nursing facility 
specializing in Alzheimer's. Each of these moves required weeks 
of full-time searching by me to find available beds. First 
choice was never a consideration. Just finding an open bed for 
a male patient was the biggest hurdle.
    Each move also, I will add, required a minimum of 2 to 3 
weeks of hospitalization, for reasons that we will see later. 
Moving from setting to setting was extremely hard on Jay, on 
myself and on the girls.
    Access to a care coordination benefit would have provided 
us with critical nonmedical care, including managing these 
transitions between care settings and offering guidance on how 
to find the right facility.
    Comprehensive geriatric assessment would have properly 
evaluated his needs and functional status and made changes to 
his care on an ongoing basis to preserve his independence and 
his ability to remain in the community.
    Jay is now 57. He lives in a nursing home in Denver, where 
he no longer recognizes me or his daughters or any of his 
caregivers. I am managing his care long-distance, having moved 
back to Arkansas in 2005 so my daughters could be closer to our 
extended family.
    I work full-time and serve as Jay's guardian. I am in 
charge of all medical decisions related to his care. He doesn't 
have any other family members who are ready or able to take on 
this responsibility. I speak weekly with the doctors and nurses 
at his nursing home and visit as often as possible. It is not 
an ideal situation, but it is the best we can do for now.
    I urge Congress to pass the Geriatric Assessment and 
Chronic Care Coordination Act, so that families living across 
the country, including those taking care of the 56,000 
Arkansans living with Alzheimer's, cannot wait any longer for 
this kind of help.
    Thank you.
    [The prepared statement of Ms. Bowers follows:]

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    Senator Lincoln. Thank you, Ms. Bowers, for sharing your 
    I think that so many of us feel incredibly blessed to have 
grown up in communities and certainly surroundings--I know I 
did--where I lived within walking distance of both sets of my 
grandparents and aunts and uncles close by. One of my 
grandmothers lived with us for the last two years of her life, 
and those were certainly times and experiences that I cherish 
and am enormously grateful for.
    Yet, we also find, in today's world, that is not 
necessarily the case anymore. We don't live next-door to family 
members--natural caregivers. Oftentimes we are miles and miles 
    I know that through our own experience as well, if it 
weren't for my mother's diligence and my sister's unbelievable 
ferocious appetite of going to the Internet to find out more 
and more about the progression of Alzheimer's and what my dad 
might be going through, it was hard for us to make those 
decisions as well.
    Later on, hospice came through for us in an incredible way, 
but we didn't even know to call hospice until the very last 
minute. So, it is so important that with coordination of care 
we are able to get some of those answers and directives, and to 
have someone there who can help to make those decisions. I 
think you bring that to a great realization in your testimony, 
and we are grateful to you for sharing your story with us.
    Just a couple of questions for you all, if I may. The last 
panel mentioned once something that I thought was important, 
and I didn't get to mention it before, and that was the issue 
of utilizing Medicare and our graduate medical education 
    I know my own husband is a physician, and I never will 
forget, about four or five years ago, when I really started 
focusing on this issue, I asked him which year of medical 
school of residency did he spend a specific amount of time 
better understanding the coordination of care for his patients. 
He just looked at me and said, ``That doesn't happen.''
    So I hope that we will begin to see some focus on that. I 
know our former panel mentioned it some. It is something that I 
wanted to make sure that we were aware of.
    The other was the technology platforms, and that is the 
ability to make sure that the information and the exchange of 
information in our IT efforts to bring about greater 
coordination are things that are compatible.
    I just recently visited one of my physicians at home, and 
they had gone to electronic records. It only frustrated the 
practice, because everybody that came to see them did not have 
electronic records, and they were not compatible with the 
records systems they had. So they were running dual systems, 
which were extremely costly and unbelievably frustrating. So we 
have mountains of problems to solve.
    But without a doubt, I think today's hearing has brought 
before us that there are some good solutions to be had. We have 
to have the will to make them happen, and certainly, make the 
choices of the investments that need to be there to see that 
    Mr. Guterman, even if the chronic care coordination is 
effective, which I believe it is--and I believe it can be more 
effective as we walk through the motions of improving it--we 
may not see any of those benefits or the cost savings for 
several years.
    Considering the prevalence of chronic care disease in 
America and its impact on health care utilization, it seems 
that at some point we are going to need some kind of dynamic 
scoring that takes future savings into account. I know myself 
and Senator Clinton were talking about this last week in our 
weekly policy meeting, about how critically important it is.
    But based on your research, do you have any recommendations 
for us on how we can best measure the results of a chronic care 
coordination program if it is applied to the Medicare FSS 
    I know it is difficult to measure, but you may have some 
recommendations for us on how to demonstrate those overall 
savings to Medicare as a result of that chronic care program, 
so we can convince CBO to score us some of those savings.
    Mr. Guterman. Well, Senator, I think one thing that all of 
the chronic care initiatives that Medicare is doing are 
teaching us is more about how to do these things, and more 
about the kinds of things that may work in different 
circumstances. There is a tendency, when people look at these 
various initiatives, to ask only one question, does it work or 
doesn't it work, or sometimes even more narrowly, does it save 
money or doesn't it save money?
    I think we are at a point now where we are really early on 
in the process. We need to move in a direction that we all feel 
is right. It is similar to the interstate highway system 
analogy, was brought up in the earlier panel.
    But when people talk about evaluations, I think evaluations 
are really crucial in any kind of public or private initiative, 
but I think we need to understand what we are evaluating and 
the circumstances in which we are evaluating it.
    It is similar to the interstate highway system analogy: 
before the system was built, if you were trying to estimate 
what the savings, what the benefit would be from a system like 
that, it would be difficult to come up with hard evidence of 
what that savings would have been.
    Similarly, to go back even further, if you were trying to 
estimate what the savings, what the benefit to this country 
would have been of the automobile in the era around 1900 or 
1910, to look at the potential benefits of the automobile. You 
had an automobile that was running on rutted dirt roads, and 
you really had no ability to generate hard evidence on what the 
benefit would be.
    Sometimes you just have to do things, because you feel like 
they're the right thing to do. Under the current circumstances, 
we couldn't possibly do worse than we are doing. However, along 
the way, you need to be careful. You also need to have a 
transparent process.
    I mean, part of the thing that we need is accountability 
for these initiatives, so that the public can know what works 
and what doesn't work and when it works and doesn't work, so 
that we can keep building as we move along with more care.
    Senator Lincoln. Well, certainly your point of greater 
evidence being needed is well taken. The problem, obviously, 
that without it, it takes us longer here to get consensus to 
bring about that will, to make those investments, and to reach 
out to those new technologies and the new ideas, and if nothing 
else, force the consistency that needs to be there if they are 
going to be effective.
    So it takes longer, and the longer it takes us, the less 
effective we are, because we are wasting so many of those 
dollars and efforts in that timeframe. So my hope is that we 
can bring about a consensus, and I am pleased that this 
Committee is very interested, and I know the Finance Committee 
has been as well in terms of the investments in IT.
    You did allude to, in your statement there, the report that 
has reported on the initial findings of the chronic care demos. 
I would just say that maybe perhaps the information there may 
not be astounding as we would have liked to have been, because 
it was such a short period of time. It is hard to--I don't 
know, maybe you disagree with that--but 2 years is not a very 
adequate amount time to demonstrate, I think, the true savings 
or the true benefits of what we might see.
    Mr. Guterman. Well, I think, Senator, that that early demo 
was an example of a pretty light--there wasn't very strong 
financial incentive involved in that system. It was really a 
sort of early attempt to see whether systems of coordinated 
care could be put together.
    I think the answer there is, yes, they could, and I think 
that we need to be careful when we look at those things to be 
able to determine what we expected to see in the first place, 
and how we can learn from what actually happened. One thing we 
learned was that it can be done.
    One thing we learned, most of these were very small 
attempts at doing this, and we need to pick out what we can use 
in the next step, rather than focus on whether, in the grand 
scheme of things, whether this was a success or a failure. I 
mean, the fact that it existed, and that the programs ran, I 
think, could be called a success.
    Then we need to draw out of that all the information we can 
to make the next attempts better. I believe that was done. The 
Medicare Health Support Pilot will provide more information.
    But as was mentioned earlier most of the systems that are 
being tested now are based on third-party disease management 
organizations. I think those organizations really do have a 
role, but I think they have a role in working with the 
physician in providing this care.
    That is actually one way to answer the question about rural 
areas in this context, is that these disease management 
organizations can work with doctors in rural areas on a sort of 
contract basis or itinerant basis, to able to provide the 
services to their patient under the physician's coordination 
for physicians who have practices that are too small to be able 
to afford a full-time person in the practice to be able to do 
    Senator Lincoln. Kind of contracting it out. Well, that is 
interesting, and I do think that it is important for us to give 
the time that we need to see the effects of some of the good 
things that we are seeing happen. I do think it is important. 
Thank you.
    Dr. McConnell, your written testimony, you mention the need 
for assessments as part of chronic care coordination and how 
important that is. I do see that as an important part of the 
Chronic Care Coordination bill that we introduced today.
    Maybe you might talk a little bit more about particularly 
ways that assessments would benefit individuals with dementia 
and their caregivers. I think Ann's story really alluded to a 
lot of that. But there may be some specifics here you would 
like to mention.
    Dr. McConnell. Well, the assessment is the foundation. You 
can't develop a plan, you can't implement a plan unless you 
know what it is you are addressing. I mentioned that. One of 
the biggest problems we have in the health care system is that 
frequently, we don't know that a person has dementia, just as 
an example----
    Senator Lincoln. Right. A lot of people won't even diagnose 
    Dr. McConnell. Exactly. If you don't know that a person has 
a condition, you can't do anything about it. So the assessment 
is essential to define what the problem is, and then you 
develop a care plan. I think is an example is a perfect example 
of that, the example I gave. Somebody wasn't paying attention 
to the whole person.
    You mentioned hospice. I think it is a very good example of 
coordinating somebody's care. Hospice works so well because it 
is looking at not only the whole patient, but the whole family, 
and dealing with that whole complex unit and making sure that 
they get what they need. So it is in some ways a good model.
    I worry about some of these demonstrations and pilots, 
because there are a couple of tendencies. One, I think, the 
disease management approach has problems, and as I said, they 
are not screening for dementia as far as we know. We are hoping 
that that will happen eventually. But as far as we know, we are 
not doing that.
    So, in the case of trying to manage someone's diabetes, you 
don't have dementia, you get the doctor prescribes drugs, 
prescribes the exercise regimen and diet, and you go home and 
you follow it. You have dementia, you go home, and you don't 
follow, you end up in the hospital.
    So some of these things may fail, because they are not 
really paying attention to the complex problems, particularly 
where dementia is involved. We have seen that in some previous 
demonstrations, where they haven't focused on that. Or they 
have focused not on having the physician coordinate it. So I 
think the physician role is critical.
    The other problem is that there is a tendency in these 
research projects to define the issue so narrowly, so you can 
really determine, did an intervention here produce a certain 
kind of an outcome?
    By definition, what we are talking about here is much more 
complex. If we try to narrow it down to get a good solid 
research project out of it, we are in some ways taking the 
heart out of what it is your bill would do and what is needed 
in the welfare system.
    Senator Lincoln. Well, it is interesting, because there is 
a lot of talk up here about pay for performance, and being able 
to manage care like that is going to be a critical component of 
the pay for performance.
    Because as you said, if there are instructions that 
patients don't follow, it is hard to be able to recognize what 
the end performance is of that medical provider if, in fact the 
patient is not participating, or the actual instructions or 
prescription or prescriptive plan that has been given isn't 
    So with that, a manager, looking at that overall plan, it 
is going to be really critical if we want to see that pay for 
performance, or bait outcome as a part of the tools of creating 
greater quality and efficiency in our health care delivery.
    Dr. McConnell. When you mentioned the importance of family 
caregivers in this whole system, and how, even in your 
experience, and previous generations where people lived closely 
together, families can only do so much.
    If there isn't a good care plan, and the physicians aren't 
providing the kind of information and monitoring, no matter how 
closely the family is paying attention--and I think Ann was 
doing the best she should, but the families simply can't do it 
without the assistance.
    The physicians won't do it, in part, because you mentioned 
the need for geriatric training. We have really got to pay 
attention to that. Because they just don't have the time. They 
aren't incented.
    Senator Lincoln. Well, the incentivizing, as you said, for 
the amount of time that a physician is going to spend with an 
aging parent or somebody with chronic conditions, there is no 
doubt they are going to spend more time with it.
    But the other is, in terms of rural areas and the 
physicians that you have there, that there is not more training 
about where we are going with an aging population for 
geriatrics and geriatricians.
    Particuarly academic geriatricians, because we are not 
training those, which means as med school goes, 10 years from 
now, we are going to have less in the academic world training 
the geriatricians, and we will be at a tremendous deficit in 
terms of the caregivers that we need out there to be managing 
the managers, in this opportunity.
    Just one more opportunity. You have talked about how you 
have handled coordinating your ex-husband's care. Maybe you, in 
having looked at that and continuing to do that, could reflect 
on how care coordination services would have helped your 
family, or would help your family when your husband was first 
diagnosed with Alzheimer's disease.
    Ms. Bowers. First of all, it is such a huge thing to me to 
sit here and look at this and hear people talk about budgeting 
and things like that, because to me, this is such a clear-cut 
cost-cutting measure. This is----
    Senator Lincoln. We need you at CBO. [Laughter.]
    Ms. Bowers. When I look at the times my husband had three 
hospitalizations between 14 and 21 days, those hospitalizations 
were far and away primarily for simply evaluation and placement 
needs. Those needs could have been taken care of 100 percent by 
a care coordinator, a well-trained medical background care 
coordinator, not a clerk at the end of a phone.
    It would have made a huge difference, not only in cost-
cutting--which he was Medicare by that point--how many tens of 
thousands of dollars were spent hospitalizing him simply 
because the right hand didn't know what the left was doing?
    We didn't know the progression of the disease. His 
depression got out of control. His glaucoma had gone bad. There 
were so many things that went wrong that, you know, hindsight 
is the perfect 20-20 situation. I went back, and can beat 
myself up, ``I should have seen this, I should have seen 
this.'' But the reality is, every caregiver has other 
responsibilities, and those of us in the Sandwich Generation 
invariably have lots of other responsibilities. I did the best 
I could.
    Earlier today, I was speaking with someone, and it occurred 
to me, how would someone have handled this if they were less 
well-educated than I was? I have been blessed with a good 
education and have the ability to understand the systems, 
simply getting through the Web sites on Social Security or 
Medicare. I am fairly technologically savvy. I have a lot of 
time doing that kind of stuff.
    I can't imagine how somebody without the support of a care 
coordinator could even begin to find the services, much less 
access and complete the paperwork and the regimen that is 
required and demanded to achieve the services. A care 
coordinator would have made not only a phenomenal financial 
savings, but it would have kept him in the community longer in 
the early stages, when he still had pride.
    That kind of thing is gone now. But when he still knew what 
was happening to him, and he had to try to cover, he had coping 
mechanisms that he would use to cover up things, like he forgot 
to take a shower. I mean, this strictly GQ man, who all of a 
sudden, you will see when it dawns on him, all of a sudden he 
realizes he is not well-groomed, or he is not putting his best 
foot forward.
    Those kind of things, if we could have had the in-home help 
that a care coordinator could have helped us obtain, instead of 
being turned down because the person that came to interview him 
happened to hit him on a good day. ``Well, he doesn't need in-
home help.''
    Well, if a physician recommended that through a care 
coordinator, those obstacles would be gone. It would save 
money, it would enable the patient to maintain his dignity far 
longer, and it would leave some quality of life for the 
hundreds of thousands of young children that are going to be 
affected by this.
    This is not a disease simply of our parents, Senator 
Lincoln. It is a disease of our peers, and our children are 
affected by it. I just feel so strongly about it, that it is 
not just the financial citings, which to me is so clear-cut, 
that that alone, the bill should be able to stand on. But in 
terms of dignity, ability to remain in the community, and the 
personal quality of life for both patients and caregivers.
    Senator Lincoln. Well, one of the other things that comes 
to mind as you discuss those things, is that as we mentioned, 
many of us, not all of us, represent predominantly rural 
States, but a lot of us do. Me, and certainly all of us, have 
rural areas in our States. But when you think about, too, where 
you go in rural communities, that was our concern.
    We lived in a small town, my mother was there in a small 
town. Finding somebody to help her navigate the system of 
services that exists, my sisters, my brother, we were there for 
her. Like you, we have got relatively decent educations. Just 
learning to navigate those systems is unbelievable too.
    But with a care coordinator, you have somebody who is in 
the medical field and in those services fields, who can better 
understand where you go for those services. As you said, you 
access them quicker, and in that fashion, you provide, again, 
greater savings, because you don't do those hospitalizations, 
but you also provide that kind of dignity for your loved one. 
That is so critically important.
    Ms. Bowers. It is. I would like to just point out, one 
point. It really touched me when you mentioned about hospice. 
By the time you needed it, you didn't even realize it was there 
until the very last minute, and available.
    That is an exact parallel to the fact that we had 
supposedly had access to some in-home help for him, an in-home 
health care manager that would come in once or twice a day to 
supervise his medications. I believe you had to lose a certain 
percentage of your ADLs in order to qualify.
    Of course, in his initial screening, he didn't qualify, 
because he happened to be on top of his game for 30 minutes 
while she was there. The simple ability to access those type of 
services, and know that they are available through a program 
like this, would just in the quality of life, would be 
    Dr. McConnell. Senator, I think that is one provision in 
your legislation that is really important. It is about the 
importance of linking the individuals to community-based 
    You think about just the Alzheimer's Association chapters. 
There was a clinical study in Cleveland, where the people that 
were the caregivers were linked to an Alzheimer's Association 
chapter and given some basic training on how to help care for 
somebody who had a medical problem.
    It resulted in significant reductions in unnecessary 
hospitalizations and emergency room use, just that small little 
intervention. So not only is it a comfort to caregivers, but it 
is a very important intervention that is part of your 
    Senator Lincoln. Well, without a doubt, being able to have 
someone that you can talk to and have recommendations from is 
    Mr. Guterman, just one last thing on those demonstrations. 
Of all the chronic care demonstrations that you have analyzed, 
which one do you think provides us the most promise for helping 
the chronically ill beneficiaries in the Medicare program? 
Would you pick one over the other?
    Mr. Guterman. Well, I think since these are sort of a 
sequence, and since all the results aren't in, I don't know 
that there is a definitive model that I could say was the right 
    I have my reservations about models that don't involve 
physicians directly, at least coordinating. I do think there is 
a role for third-party organizations to help physicians provide 
the services. The demonstration that is starting up in your 
State and three others, with small practice physicians, I think 
is a promising one for two reasons.
    Senator Lincoln. We wanted the physician oversight as well 
when we did this.
    Mr. Guterman. One is that it is physician-oriented, and the 
other is that it is small-practice-oriented, which is really 
where the majority of physicians practice. There is another 
demonstration going on now called the Physician Group Practice 
Demonstration, that focuses on large multi-specialty group 
practices, and that has some promise too. But most physicians 
aren't in large organizations like that.
    Again, I think what we need to do is take what we can learn 
out of all of these examples, and then decide as we go along, 
not necessarily one model, but different models. The Medicare 
Health Support Pilot is going to offer some good information on 
what works in different circumstances and what doesn't work in 
different circumstances.
    I think we have a lot of development to go, and we can 
develop as we go along. But as I said before, it is hard for me 
to believe that we can't do better than we are doing now.
    Senator Lincoln. Well, thank you so much.
    Dr. McConnell, just one more thing. You mentioned in your 
written testimony that disease management may not be the best 
way to go, because it focuses on specific diseases. Can you 
just help me understand your comments there?
    Dr. McConnell. Well, I think, again, taking the case of 
Alzheimer's disease, there is more than an additive effect 
here. When you add dementia to another condition, it really 
creates a whole new care problem. Disease----
    Senator Lincoln. You are saying that one single disease is 
managed, not multiple diseases----
    Dr. McConnell. Right. If they are doing multiple disease 
management, that is fine. But typically, it is focusing on one 
disease at a time, and as I said, and again, we want to work 
with CMS. We want to work with these demonstrations and pilots.
    The concern is that in the legislation, in the Medicare 
Modernization Act, it specifically requires physicians to 
assess each eligible beneficiary for conditions other than 
chronic conditions, such as impaired cognitive ability and 
comorbidities. It doesn't appear, and we have looked at several 
of these, that that is happening.
    Again, it may be just that it is complicated. What the 
disease management organizations know about is how to deal with 
managing diabetes. The notion of dealing with someone's 
cognitive impairment is not something perhaps that they are 
familiar with. Yet, it is very difficult to imagine that it 
will succeed without paying attention to that.
    Senator Lincoln. Well, I just want to thank all of you.
    I appreciate this panel as well as our first panel, and I 
certainly do want to say to you, please don't go far. This is 
an issue that I think we really owe to ourselves, to our 
children, and to our parents and grandparents to work hard to 
get it right.
    As I said, I just go back to the blessing of being able to 
grow up in a neighborhood with my grandparents and aunts and 
uncles, and my grandmother right there beside me. I know as 
much as I may want that for my children, today's society may 
not fit in that way. But without a doubt, I want to know that 
my parents--let's face it, we want to be cared for too. Those 
twin boys of mine, who knows where they will be when I need 
them, when I need that care?
    So I am grateful to you all for your input.
    I am also enormously grateful to my staff. I don't remember 
who, I guess it was Dr. McConnell, who mentioned Brenda Sulick 
and Ashley Ridlon on my staff, who have been enormously 
immersed in this issue. I am grateful for their hard work in 
helping us put this hearing together.
    A special thanks to the Chairman and the Ranking Member.
    So, thank you all. We will look forward to working with you 
in the future.
    With that, the Committee is adjourned.
    [Whereupon, at 5:02 p.m., the Committee was adjourned.]

                            A P P E N D I X


             Prepared Statement of Senator Blanche Lincoln

    I want to thank Chairman Kohl and Ranking Member Smith for 
the opportunity to chair today's hearing on the Future of 
Medicare: Recognizing the Need for Chronic Care Coordination. 
As a member of the so-called ``Sandwich Generation'' who cares 
for their children and aging parents simultaneously, I am 
keenly aware of many issues affecting older Americans and have 
been an advocate for geriatric chronic care coordination for 
several years. Studies indicate that when patients are linked 
with a physician or other qualified health professionals to 
coordinate care the results are improved quality of care, 
increased efficiency, and greater cost-effectiveness.
    That is why I am pleased to chair today's hearing; to raise 
awareness of the need for chronic care coordination services 
for Medicare beneficiaries and to discuss how these services 
can be provided in a cost-effective way. This hearing will 
specifically focus on chronic care coordination in the 
traditional Medicare fee-for-service (FFS) program. While some 
chronic care coordination occurs in other programs such as 
Medicare Advantage and the Program for All Inclusive Care for 
the Elderly (PACE), nearly 85 percent of Medicare beneficiaries 
continue to receive healthcare from the traditional fee-for-
service program, which lacks a chronic care coordination 
    Why focus on chronic care coordination? Well, there are 
several reasons.
    First, the needs of Medicare beneficiaries have changed 
over time. When Medicare was first established in 1965, it was 
based on a health insurance model, which focused on acute care, 
not chronic conditions. But today, many older Americans suffer 
from multiple chronic conditions and would benefit from care 
coordination. We know that about 78 percent of the Medicare 
population have at least 1 chronic condition, and 63 percent 
have two or more chronic conditions.
    Second, as our population ages, the number of older 
individuals with chronic illnesses is also expected to rise. A 
recent article in the Washington Post noted that Baby Boomers 
are more likely to be in worse health condition than their 
parents in retirement (April 20, 2007), which may result in a 
greater need for medical services. A RAND Corporation study 
estimates that half of the population will have a chronic 
condition in 2020--a total of 157 million Americans.
    Third, Medicare beneficiaries with multiple chronic care 
conditions are expensive to treat. According to the 
Congressional Budget Office, 43 percent of Medicare costs can 
be attributed to 5 percent of Medicare's most costly 
beneficiaries. Medicare beneficiaries with four or more chronic 
conditions are 99 times more likely to experience one or more 
potentially preventable hospitalizations than those without 
chronic conditions. If an individual has Alzheimer's disease or 
dementia, medical costs increase even more dramatically.
    Finally, multiple chronic conditions not only affect the 
individuals suffering from them, but also their caregivers. 
About 5 years ago, I watched my mother devote herself to the 
care of the man she had loved for more than 52 years. She had 
pledged to attend to him and honor his life until he departed 
this world, even if he no longer remembered her name or could 
recognize her face. My dear father suffered from Alzheimer's 
    My mother's strength and commitment to my father during his 
long illness remains a great source of inspiration to me. 
Unfortunately, my family's experience with the ravages of 
Alzheimer's is not unique. Millions of Medicare beneficiaries 
with chronic conditions who remain at home do so with the help 
of family and friends. Research shows that family care for an 
older adult with chronic illness or disabilities, especially 
dementia, can have negative health effects (both physical and 
mental) on family members.
    To address these issues, I am pleased to announce that 
today Senator Collins and I introduced the Geriatric Assessment 
and Chronic Care Coordination Act of 2007, along with Senators 
Kohl, Kerry, Mukulski, Clinton, Boxer, and Casey. I am also 
pleased that Representatives Gene Green and Fred Upton are 
sponsoring a companion bill in the House and that 30 national 
organizations have endorsed the bill. This bill realigns 
Medicare to provide high-quality, cost-effective care to 
elderly individuals with multiple chronic conditions. It is an 
important step forward in recognizing and remedying the impact 
that multiple chronic conditions have on individuals, their 
caregivers, and the Medicare program.

          Prepared Statement of Senator Hillary Rodham Clinton

    I would like to thank Chairman Kohl and Ranking Member 
Smith for convening today's hearing on the importance of 
chronic care coordination for older Americans who rely on 
Medicare to pay for treatment for multiple illnesses. And I 
applaud Senator Lincoln for organizing today's hearing and for 
her leadership on the Geriatric Assessment and Chronic Care 
Coordination Act, of which I am a proud original cosponsor.
    In less than ten years, the first wave of baby boomers will 
turn 65. In light of the growing longevity of Americans, we 
must consider how we will meet the increasing needs of this 
elder boom and the growing demands placed on our local, state, 
and federal health and social service systems in the years 
    To ensure that we are prepared, we must reevaluate whether 
our health care system is helping or hindering those who are 
struggling with the burdens of age.
    Medicare has long been a vital source of health insurance 
for our nation's seniors, providing them with access to medical 
treatment at a time of life when care is needed most. However, 
a critical weakness of Medicare that Senator Lincoln's bill 
addresses is the lack of incentives to provide coordinated 
healthcare. It is crucial that we provide care coordination and 
geriatric assessments for older Americans who suffer from one 
or more chronic conditions.
    We spend more and use more services to treat catastrophic, 
complex, chronic care cases. Our lack of a system to manage the 
multiple, complex health care needs of people with chronic 
illness leads to higher costs and often poor quality. Chronic 
diseases, such as cardiovascular disease and diabetes, account 
for 75 percent of our total national health expenditures and 
are the leading cause of death in the U.S. Further, the number 
of Americans with at least one chronic illness is expected to 
rise 25 percent by 2020.
    Under Medicare, at least 83 percent of Medicare 
beneficiaries suffer from one chronic illness and the 23 
percent of beneficiaries who suffer from five or more chronic 
illnesses account for 68 percent of costs to the program. 
Further, the combination of a chronic condition and Alzheimer's 
disease causes Medicare costs to soar. According to the 
Alzheimer's Association, the combination of Alzheimer's and 
another chronic condition, such as heart disease or diabetes, 
approximately doubles the Medicare cost. All of us here realize 
that as the Baby Boomer generation ages, there will be a 
dramatic increase in the number of Alzheimer's cases. By the 
year 2050, if we do not make headway, up to 16 million 
Americans are expected to suffer from this devastating disease.
    For the people that will confront this disease in their own 
lives, this is about more than statistics: it represents an 
emotional struggle, a tremendous financial burden, a new strain 
on our already stressed healthcare system, particularly for 
Medicaid and Medicare costs.
    As co-chair of the Senate Task Force on Alzheimer's Disease 
with my colleague Senator Collins, I have worked to address 
issues faced by Alzheimer's patients and their caregivers. I'm 
pleased that Dr. Steve McConnell is here today. The Alzheimer's 
Association has been a wonderful partner in raising awareness 
and support for people living with Alzheimer's and their 
    We know that it's crucial to make caregiver health and 
well-being a priority, which is why I am fighting for full 
funding of the Lifespan Respite Care Act, which was signed into 
law last December.
    But today's hearing is not just about improving Medicare 
programs for older Americans. It's also about improving 
management conditions for all ages, including education on how 
individuals can better manage their own health in order to 
avoid further complications.
    That's why I am a strong supporter of chronic disease 
management programs. The money we invest in prevention, early 
diagnosis and management programs today can reduce treatment 
costs down the road.
    Let's take, for example, diabetes--over 20 million 
Americans are currently living with this disease. Six million 
of them have not yet been diagnosed. Another 54 million are 
classified as ``pre-diabetic,'' with a high risk of developing 
this condition. Diabetes accounts for over $92 billion in 
direct medical costs every year, and these numbers are only 
likely to increase.
    Last year, a New York Times series focusing on diabetes 
spelled it out the problem. The healthcare system will pay tens 
of thousands of dollars for an amputation, but won't pay for a 
low-cost visit to the podiatrist that could have saved the 
    The incentives inside our health care system are backwards, 
and the payment system is upside-down: too often paying for 
costly and debilitating treatment but not for low-cost 
    Today, Senator Collins and I are introducing the Diabetes 
Treatment and Prevention Act of 2007, legislation that will 
strengthen our support for chronic disease management programs 
of the CDC and state and local health departments.
    Our bill would allow the Diabetes Prevention Program to be 
brought into clinical practice where it can be replicated at 
the state, local and provider level, along with other 
interventions to control diabetes. This program has shown that 
diet and exercise interventions were successful at preventing 
    Our bill would also establish a demonstration grant program 
that would help state and local health departments to establish 
disease management programs for individuals with diabetes and 
other co-occurring chronic conditions like heart disease, 
mental illness and HIV. In some cases, the medications for 
these other conditions can cause diabetes and aggravate its 
    I believe we must do more to help people who are dealing 
with multiple chronic conditions manage them in a coordinated 
manner and our bill will help accomplish this goal.
    Again, I thank Chairman Kohl and Ranking Member Smith for 
convening today's hearing, and Senator Lincoln for her 
leadership on this issue. I look forward to continuing to 
working with my colleagues to make progress for our seniors and 
families on these important issues.

      Responses to Senator Smith Questions from Dr. Todd P. Semla

    Question. How would you rank the importance of better 
training for doctors, implementation of electronic-records 
keeping and utilization of chronic care coordination through 
case mangers?
    Answer. All three of these are critically important for 
providing care to chronically ill patients and it is hard to 
rank them in terms of priority. However, chronic care 
coordination is the lynchpin of the system. Without care 
coordination, better training and better electronic records 
systems would have very limited effect and the cost savings 
might be limited. Thus, we would rank chronic care coordination 
through case managers first, better training (in geriatrics) 
for doctors and health care professionals second, and 
implementation of electronic records third.
    Question. For all of our panelists, though your focus has 
been to institute systems of care management for persons with 
multiple chronic conditions to prevent these situations, aren't 
many of these examples prevalent even among those who only 
enter the health care system because of an acute health need?
    Answer. America's health care needs are changing 
dramatically with the aging of its population--from a system 
focusing on acute care to one that must address chronic care 
either after an acute event, such as stroke, or for ongoing 
conditions that may take years to culminate in an acute event 
(e.g., Type II diabetes). With the aging of the population, 
conditions that were not that prevalent 50 years ago are quite 
prevalent today; osteoporosis and all its complications is one 
    Patients who enter the health care system because of an 
acute health need, such as a heart attack, are indeed at risk 
for many of negative outcomes that the chronic care 
coordination model could prevent. It is less complicated to 
coordinate care for a single condition during a specific acute 
care event, which is what the current health care system (under 
Medicare) is designed to do--it's modeled for acute care. Many 
of the patients that fit your example may derive benefits from 
existing single disease management programs. The patient, 
however, with multiple and complex chronic conditions would 
typically benefit from a comprehensive and coordinated regimen 
of care that holistically addresses his or her health care 
needs. The recent MedPAC Commission report of June 2007 has 
reached many of these same conclusions.
    Question. Can you talk a bit more about this and explain 
how a more formal case manager or group of doctors working 
closely together can relieve some of the pressure on family 
caregivers and how this could reduce errors since most family 
caregivers are not trained for this type of work?
    Answer. The burden currently being placed on family 
caregivers is huge and frequently detracts from their ability 
to care for loved ones. Care managers should collect and 
maintain all health related information for the chronically 
ill, such as a list of current diagnoses, medications and 
treatment goals so that it is not only the family doing the 
task of conveying sometimes complex information. A care manager 
can much more effectively and efficiently communicate with 
other caregivers and can, for example, make sure that patients 
are getting the right medications in the right dose at the 
right time. A care manager would also see that changes in the 
patient's care plan are communicated in a timely manner to all 
health care providers caring for the patient. This legislation 
introduced by Senator Lincoln (S. 1340) will allow family 
members to do what they do best--provide day to day care and 
not force them to be responsible for communicating to an array 
of health professionals.
    Question. Can you talk a little more on this culture of 
specialties working in silos and its impact on patient care? 
What steps can be taken to break down these outdated practices?
    Answer. Historically, specialists have taken care of 
patients with acute illnesses, or single illnesses affecting 
one organ system, and have not provided ongoing or coordinated 
care. Only recently have specialists begun to take care of 
chronic illness, but even then those illnesses tend to consist 
of a single disease or a few diseases that affect a single 
organ system. Their practices are not set up to provide care 
for patients with multiple diseases that affect many organ 
systems. Neither the specialist nor their staff has the 
expertise to do that. It is critical to have a care 
coordinator, such as a physician or nurse practitioner, who can 
collect and coordinate care from multiple specialists.
    AGS believes in inculcating principles of geriatric care 
across all disciplines--the coordinated care approach. The 
geriatrics based whole patient approach looks at the different 
functions of each member of the team treating the whole 
patient. A care coordinator can bring in specialists to 
consider their areas of expertise in the context of the big 
picture. Many presently do this well and, in other cases, a 
care manager is critical, in all cases, a care manager will 
make it more likely that the whole patient is cared for.
    S. 1340 would be strong first step in changing the culture 
of medical practice silos. To change practice habits, changes 
would need to be made in medical education and residency 
programs for specialists. Additionally, the mere existence of 
care coordinators is likely to induce specialists to make sure 
their patients participate in care coordination because it will 
allow them to continue doing what they do best--take care of 
acute illnesses affecting a single organ system.

       Responses to Senator Smith Questions from Gerard Anderson

    Question. How would you rank the importance of better 
training for doctors, implementation of electronic-records 
keeping and utilization of chronic care coordination through 
case mangers?
    Answer. All three are critically important and they are 
synergistic. Better training for doctors is needed because most 
doctors currently are not being told how to coordinate care and 
perform other activities that would benefit people with 
multiple chronic conditions. Electronic medical records are the 
only feasible methods to have the multiple clinicians caring 
for the complex patient interact with one another. Currently 
most payment systems do not pay for care coordination and with 
payment many clinicians will not perform the service. Unless 
the clinician is trained in care coordination, has the 
information to perform care coordination, and is paid to do 
care coordination, care coordination is unlikely to happen. All 
three are needed.
    Question. For all of our panelists, though your focus has 
been to institute systems of care management for persons with 
multiple chronic conditions to prevent these situations, aren't 
many of these examples prevalent even among those who only 
enter the health care system because of an acute health need?
    Answer. The problems are also important for people with 
just an acute illness. There is, however, one important 
distinction. An acute illness typically is treated in one 
location with all the clinicians able to share information and 
perhaps to meet and discuss the case. For people with multiple 
chronic conditions it is often that the clinicians are miles 
apart, never see each other, are unable to coordinate their 
care and as a result costs increase and quality suffers. The 
problems compound for people with multiple chronic diseases 
because the problems are ongoing instead of happening at one 
    Question. You mention in your testimony that half of 
Medicare beneficiaries with multiple chronic conditions will be 
told by their pharmacist at least once a year not to fill a 
prescription because of possible interactions with other drugs 
that they take. This number strikes me as shockingly high. I 
assume that there could be a variety of reasons for this 
happening, including the patient not being able to remember 
their list of medications, incomplete medical records or 
medical error.
    Do you think that physicians are resistant to changes in 
their training and why do you think physicians are resistant to 
moving to more advanced approaches such as electronic medical 
records keeping?
    Answer. I agree the number is high. I was shocked when we 
got the numbers from the Gallup Organization. I think the main 
reason why half of all people with multiple chronic conditions 
go to fill a prescription and are told of a potential drug drug 
interaction is that the physicians do not always know the drugs 
that other doctors have prescribed. An electronic medical 
record would make the information available.
    I do not think physicians are resistant to changing their 
training programs. I teach the importance of care coordination 
to all 1st year medical students at the Johns Hopkins School of 
Medicine. Medical students and the teaching physicians 
understand the importance of care coordination. However, until 
it is reimbursed, they are unlikely to emphasize it in the 
training programs.
    I think most physicians are resistant to electronic medical 
record keeping because we are asking them to pay for it when it 
does not benefit them financially and may actually be very 
expensive for them to install. Purchasing the software and the 
computers necessary to have an electronic medical record is 
only a small portion of the cost. The major cost is in 
redesigning the office's entire information system from paper 
to electronic medical records. During the conversion the 
physician's office must maintain two parallel information 
systems and this could go on for years. Once the electronic 
medical record system is implemented it is unlikely to save the 
physician much money and it could mean fewer visits. Nearly all 
of the benefits accrue the payors (reduced readmissions, fewer 
preventable hospitalizations, and fewer drug drug 
interactions). In other countries the payors are funding the 
diffusion and operation of electronic medical records.
    Question. In your testimony, you also mention that many 
physicians are not trained to work cooperatively to treat a 
patient with multiple chronic conditions. It seems that a lack 
of care coordination also is due to some gaps in training or 
limited emphasis on the importance of coordination within the 
    What do you think can be done to change this aspect of the 
culture of medicine and how do you think training programs can 
be enhanced to emphasize chronic care coordination?
    Answer. Currently most medical schools and residency 
programs emphasize acute care medicine and emphasize training 
in a particular disease. We need to emphasize that care 
coordination is important because patients often have multiple 
problems and all of the problems need to be considered not just 
one of the problems. Physicians are becoming increasingly aware 
of the need to coordinate care; however, the current system 
stifles care coordination. I propose three things:
    Medicare use the $10 billion it spends on graduate medical 
education each year to push medical schools and teaching 
hospitals to place greater emphasis on training physicians in 
care coordination.
    Medicare pays $5 each time a physician submits an 
electronic medical record. This will fund the creation of an 
integrated electronic medical record that will allow 
information to flow easily.
    Medical pays $100 per beneficiary per month for a clinician 
to perform care coordination activities on Medicare 
beneficiaries who want care coordination and who will benefit 
from care coordination. I would begin by focusing on Medicare 
beneficiaries with 5+ chronic conditions and/or dementia.
    Question. In your testimony, you also mention that many 
persons with multiple chronic conditions are left out of 
clinical trials. You state that this leads to inadequate data 
on evidence-based methods to treat them.
    Are patients with multiple chronic conditions being left 
out of these trials because it makes the research more 
difficult in that they have to account for more variables?
    Answer. Patients with multiple chronic conditions are being 
left out of the clinical trials because it makes the research 
more difficult. Currently the research emphasizes efficacy. 
Efficacy measures what works in a controlled environment. 
However, in the real world the critical term is effectiveness. 
Effectiveness measures how well the drug, device or procedure 
works in actual practice. Effectiveness is more important in 
the long run.
    Question. Given that such a large percentage of Americans 
have multiple conditions wouldn't it benefit medicine to see 
how treatments impact people with multiple diseases?
    Answer. I totally agree that it would benefit medicine to 
know how treatments impact people with multiple diseases. There 
are two ways to obtain this information. One option is to 
expand the inclusion criterion in the initial clinical trail. 
In the 1980s we required that women and minorities be included 
in all clinical trials (if clinically appropriate). Previously 
most clinical trials were restricted to white males. Women and 
minorities wondered if the drug, device, or procedure would 
work equally as well for them. Now we require their inclusion.
    The second option is to require follow-up studies to 
include people with multiple chronic conditions. These studies 
would be performed only after the efficacy has been 

          Responses to Senator Smith Questions from David Dorr

    Question. In your testimony you mention the savings to 
clinics by implementing chronic care coordination plans, like 
Care Management Plus. You state that the savings can be more 
than a quarter of a million dollars annually at each clinic.
    How do you see these potential savings playing out widely 
within Medicare and Medicaid?
    Answer. The Care Management Plus process focuses on 
prevention and patient education, keeping chronically ill 
patients healthier and out of the hospital setting. We 
anticipate that savings would accrue to the clinic from an 
increase in clinician productivity, a shift in clinical 
practice, and a change in overall patient utilization patterns. 
In addition, public payers such as Medicaid and Medicare would 
see savings from the implementation of coordinated care 
programs that use clinical tools and processes that emphasize 
effective and efficient patient care. Incentive structures 
within the reimbursement system, both public and private, must 
be implemented to support this change in care delivery.
    There are substantial benefits from the efficiency gains 
that arise from better information technology (IT) and care 
coordination. Many researchers have documented the enormous 
amount of waste in medical care services. Estimates vary 
substantially but generally suggest that 20 to 50 percent of 
medical care spending, including Medicare and Medicaid, could 
be eliminated without reductions in quality services.
    Question. We know that rural hospitals, clinics, and 
practices have very different concerns than those located in 
more urban areas. For instance, there is more likelihood that a 
person will see a general practitioner in a rural area than the 
specialist more urban patients will see.
    How do models of care coordination for patients with 
chronic illness differ in urban versus rural areas?
    Answer. Care Management Plus is designed to be flexible for 
the variety of clinical settings that exist. The program tools 
and curriculum can be used to accommodate the varying size and 
structure of clinics/systems, the differing amount of resource 
capacity within each clinic/system, and the multiple and 
complex patient populations in need of coordinated care.
    We will be implementing Care Management Plus in six rural 
clinic settings over the next two years in collaboration with 
the Oregon Rural Practice-based Research Network through a 
grant funded by the Agency for Healthcare Research and Quality 
(AHRQ). This project will provide important information about 
the gains and the limitations of a care management program in a 
rural setting. Implementing Care Management Plus in these rural 
clinics will require special attention not only to the 
information technology capacity. Its success will also depend 
on available specialty care in each clinic, available clinical 
staff to participate in the care management process, and the 
patient demographics served in each rural area.
    Question. In your testimony, and in some of the testimony 
that we will hear during the second panel, there are some very 
troubling stories and statistics on the lack of important 
information being given to a person with a chronic disease and 
the dangers that can arise when patients can't or don't tell 
one specialist about care they are receiving from another. Many 
of these examples and statistics lead me to wonder about what 
can be done to better train doctors in working collaboratively 
and how to improve our records systems such as through 
electronic records-keeping.
    How would you rank the importance of better training for 
doctors, implementation of electronic-records keeping and 
utilization of chronic care coordination through case managers?
    For all of our panelists, though your focus has been to 
institute systems of care management for persons with multiple 
chronic conditions to prevent these situations, aren't many of 
these examples prevalent even among those who only enter the 
health care system because of an acute health need?
    Answer. Care coordination can address all three areas of 
improvement required for high quality care. Care coordination 
programs like Care Management Plus use a team-driven workforce 
to provide high quality care with the most appropriate 
information technology (IT) and clinical tools available. 
Training for nurses, care coordinators, clinic supervisors and 
administrators, and medical directors is necessary to 
successfully transform care for the chronically ill. IT tools 
and electronic-record keeping play an important role in helping 
the health care team track patient needs and follow the best 
evidence-based guidelines for a chronically ill population. 
Health care providers can also utilize appropriate IT tools to 
inform and educate patients about their conditions and teach 
self management strategies. Patient-centered care directly by a 
care/case manager has proven effects on disease improvement, 
patient satisfaction, physician productivity, and the resulting 
change in health care utilization.
    Prevention and early recognition are key components in 
programs like Care Management Plus. The primary care team 
treats patients' chronic diseases early, trying to prevent 
problems rather than treating them after they occur. This can 
result in time and cost savings in managing care for not only 
the chronically ill population, but for those patients that 
have more acute/episodic health care needs.
    Many patients do enter the health care system only for 
acute needs. Each contact with the health care system can still 
be used to help educate and motivate people to think about 
their chronic illnesses. Health Information Technology, 
especially where information is shared readily, can help 
connect these often fragmented acute visits by reminding about 
the need to educate and consider their chronic needs without 
overly burdening the acute care team and to facilitate contacts 
with the primary care system. Our care management program was 
borne of the fact that so many patients have no follow-up after 
their acute care episode; having the care manager whose goal is 
to understand the barriers and move patients towards more 
preventative and chronic illness care was a solution to just 
the problem posed by the follow-up question.

       Responses to Senator Smiths Questions from Stuart Guterman

    Question. Mr. Guterman, in your testimony you mention 
research that shows that persons with multiple chronic 
conditions are more likely to have preventable 
hospitalizations, experience adverse drug interactions, undergo 
duplicate tests and receive contradictory information from 
    How much of this is due to the simple fact that these 
persons are sicker than other patients so they see doctors more 
often and are in more acute health situations and therefore 
there is more change of error?
    Answer. Senator Smith, there may well be a relationship 
between the fact that persons with multiple chronic conditions 
are sicker than other patients and have more interactions with 
the health care system at a higher level of acuity and the fact 
that they experience more problems with their health care than 
other patients. But that relationship only emphasizes the fact 
that better coordination is needed for these patients to avoid 
those kinds of problems. Even if the same proportion of care 
provided results in problems for the patient who needs more 
care, it still means that the patient who receives more care is 
at greater risk for adverse events, and therefore that more 
needs to be done to reduce that risk. Also, it stands to reason 
that patients with multiple conditions require more 
coordination across those conditions, because they receive not 
only more care, but care from more different providers--each of 
whom may not be aware of what the other providers are doing to 
the patient.
    Question. Do these studies control for the fact that these 
persons simply have more opportunity for error due to the sheer 
number of their interactions with medical professionals in a 
given year?
    Answer. To my knowledge, the studies I refer to do not 
control for the number of each individual's interactions with 
medical professionals. But the focus of interest here is the 
individual and his or her risk of adverse events, rather than 
the medical encounter, so the point that patients with chronic 
conditions are a greater risk still holds, I believe.
    Question. In your testimony you mention that only 67 
percent of hospitalized patients in the U.S. reported having 
their medications reviewed at the time of a hospital discharge 
and that patients with congestive heart failure receive 
discharge instructions only 50 percent of the time.
    Question. At what point is it a question of providing 
incentives for chronic care coordination or are we at a 
question of doctors doing their due diligence in treating the 
patient? It seems to me that these are questions that doctors 
should be asking all patients--not just those with multiple 
chronic diseases.
    Answer. That is an important question. My answer would be 
that certainly, physicians should be providing appropriate 
care, not only to patients with multiple chronic conditions, 
but to all their patients. But part of the problem we have with 
the quality of care across our health care system is that we 
have provided distorted incentives that emphasize providing 
more services and more complex services--sometimes to the 
detriment of the patient. We can blame physicians for 
responding to those very string incentives, or we can search 
for ways to try and fix the distorted incentives we've 
presented them with. Moreover, in many cases the problem that 
patients with multiple chronic conditions face is that multiple 
providers are responsible for their services, and many times 
those providers don't communicate with each other--not because 
they are bad providers, but because the way that medicine is 
practiced in our health system doesn't really allow for them to 
devote resources to those types of activities. My point is that 
if we want to see our health system provide coordinated, 
appropriate care, that is what we ought to pay for.