[Senate Hearing 110-180]
[From the U.S. Government Publishing Office]
S. Hrg. 110-180
THE FUTURE OF MEDICARE: RECOGNIZING THE NEED FOR CHRONIC CARE
COORDINATION
=======================================================================
HEARING
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/
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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
HILLARY RODHAM CLINTON, New York ELIZABETH DOLE, North Carolina
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
(ii)
C O N T E N T S
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Page
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
APPENDIX
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
(iii)
THE FUTURE OF MEDICARE: RECOGNIZING THE NEED FOR CHRONIC CARE
COORDINATION
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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.
OPENING STATEMENT OF SENATOR HERB KOHL, CHAIRMAN
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
Medicare.
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
exercise.
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.
STATEMENT OF SENATOR BLANCHE LINCOLN
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
job.
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
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.
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
coordination.
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.
STATEMENT OF 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
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
conditions.
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.
STATEMENT OF GERARD ANDERSON, PH.D., PROFESSOR OF PUBLIC HEALTH
AND MEDICINE, JOHNS HOPKINS BLOOMSBERG SCHOOL OF PUBLIC HEALTH,
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
patients.
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
interoperability.
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.
STATEMENT OF 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
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
costs.
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
possible.
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
incentive.
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
providers.
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
preferences.
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
efficient?
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
intervention.
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
patients.
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
system.
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
interoperability.
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
there?
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
Smith.
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
important.
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
happen.
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
Medicare.
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.
Doctor.
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
opportunity.
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
hearing.
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
someone.
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
indicators.
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
example.
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
Association.
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.
STATEMENT OF 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
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
conditions.
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.
STATEMENT OF STEPHEN MCCONNELL, PH.D., VICE PRESIDENT OF
ADVOCACY AND PUBLIC POLICY, ALZHEIMER'S ASSOCIATION,
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
past.
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
assessments.
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
Arkansan.
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.
STATEMENT OF ANN BOWERS, CAREGIVER, FORT SMITH, AR
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
Warehouse.
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
conversation.
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
expenses.
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
story.
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
apart.
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
dollars.
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
happen.
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
program?
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
this.
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
it.
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
followed.
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
unbelievable.
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
services.
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
legislation.
Senator Lincoln. Well, without a doubt, being able to have
someone that you can talk to and have recommendations from is
critical.
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
model.
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
component.
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
disease.
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
ahead.
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
families.
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
foot.
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
prevention.
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
diabetes.
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
management.
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.
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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
example.
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.
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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
time.
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
profession.
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
demonstrated.
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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.
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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
doctors.
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.
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