[Senate Hearing 111-972]
[From the U.S. Government Publishing Office]
S. Hrg. 111-972
DELIVERY REFORM: THE ROLES OF PRIMARY AND SPECIALTY CARE IN INNOVATIVE
NEW DELIVERY MODELS
=======================================================================
HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
ON
EXAMINING DELIVERY REFORM, FOCUSING ON THE ROLES OF PRIMARY AND
SPECIALTY CARE IN INNOVATIVE NEW DELIVERY MODELS
__________
MAY 14, 2009
__________
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut MICHAEL B. ENZI, Wyoming
TOM HARKIN, Iowa JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico RICHARD BURR, North Carolina
PATTY MURRAY, Washington JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island JOHN McCAIN, Arizona
BERNARD SANDERS (I), Vermont ORRIN G. HATCH, Utah
SHERROD BROWN, Ohio LISA MURKOWSKI, Alaska
ROBERT P. CASEY, JR., Pennsylvania TOM COBURN, M.D., Oklahoma
KAY R. HAGAN, North Carolina PAT ROBERTS, Kansas
JEFF MERKLEY, Oregon
SHELDON WHITEHOUSE, Rhode Island
J. Michael Myers, Staff Director and Chief Counsel
Frank Macchiarola, Republican Staff Director and Chief Counsel
(ii)
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C O N T E N T S
__________
STATEMENTS
THURSDAY, MAY 14, 2009
Page
Brown, Hon. Sherrod, a U.S. Senator from the State of Ohio,
opening statement.............................................. 1
Thorpe, Kenneth E., Ph.D., Professor of Health Policy, Emory
University, Atlanta, GA........................................ 4
Prepared statement........................................... 6
Murray, Hon. Patty, a U.S. Senator from the State of Washington,
statement...................................................... 11
Cooper, Richard A., M.D., Professor of Medicine and Senior
Fellow, Leonard Davis Institute of Health Economics, University
of Pennsylvania, Philadelphia, PA.............................. 12
Prepared statement........................................... 13
Schlossberg, Steven, M.D., MBA, Vice President, Clinical
Operations, Hospital-Based Surgical Specialities, Sentara
Medical Group, Chair, Health Policy, American Urological
Association, on behalf of the Alliance of Speciality Medicine,
Norfolk, VA.................................................... 18
Prepared statement........................................... 20
Nochomovitz, Michael, M.D., President and Chief Medical Officer,
University Hospitals Medical Practices and University Hospitals
Management Services Organization, Cleveland, OH................ 24
Prepared statement........................................... 26
Raulerson, Marsha, M.D., FAAP, Primary Care Pediatrician, on
behalf of the American Academy of Pediatrics, Brewton, AL...... 31
Prepared statement........................................... 34
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode
Island, statement.............................................. 42
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
American College of Surgeons (ACS), prepared statement....... 57
(iii)
DELIVERY REFORM: THE ROLES OF PRIMARY AND SPECIALTY CARE IN INNOVATIVE
NEW DELIVERY MODELS
----------
THURSDAY, MAY 14, 2009
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The committee met, pursuant to notice, at 10:04 a.m. in
Room SD-430, Dirksen Senate Office Building, Hon. Sherrod Brown
presiding.
Present: Senators Brown, Murray, and Whitehouse.
Opening Statement of Senator Brown
Senator Brown. The Senate Health, Education, Labor, and
Pensions Committee comes to order.
Thank you for joining us today. Thank you to the witnesses
especially and to others in the audience, and thank you for
being here on time.
For the first time in a long time, there is widespread
consensus that to improve the health of our people and the
strength of our Nation, we must act to reform a healthcare
system that has failed far too many Americans.
Nearly 50 million Americans, as we hear over and over, are
uninsured. Tens of millions of others underinsured. With our
Nation spending more than any other Nation on healthcare, a
whole lot more, some $2 trillion overall annually. Yet we rank
below most other developed nations across a broad range of
health indicators.
We must not settle. This year, as we move toward real
healthcare reform, we must not settle for simply improvements
at the margins. Instead, we must fight for substantial reforms
that will improve care, that will combat unjustifiable
spending, and will close the coverage gaps that leave Americans
without the healthcare they need.
That is why we are holding this hearing today to examine
ways in which we can restructure our healthcare delivery system
so that it better and more fully meets the needs of our
citizens.
As this committee has examined our Nation's healthcare
system over the past year in dozens of hearings, one thing has
become glaringly obvious. Our healthcare system lacks cohesion.
It lacks coordination. It lacks cost efficiency. It is a
patchwork system grounded in good intentions, to be sure, but
derailed by unjustifiable variations in healthcare utilization,
unproductive barriers to care coordination, and misaligned
incentives that compromise effective and efficient healthcare
delivery.
For this reason, it becomes imperative that any discussion
of healthcare reform focuses on how to build a healthcare
delivery structure that capitalizes on existing strengths like
our exceptional healthcare workforce, but dispenses with our
existing weaknesses. Among those weaknesses, I put inefficiency
at the top of the list because it captures a multitude of
sins--lack of coordination, lack of information, lack of basic
standards of care and standards of coverage to become the norm
across the Nation. And the list goes on and on and on.
That is why we are here today to discuss the roles of
primary and specialty care in innovative new delivery models.
In an effort to address the fragmentation of our healthcare
system, one policy proposal under consideration is the medical
home. The concept of the medical home has evolved over some 40
years since its introduction by the American Academy of
Pediatrics. It has gone from a specific place to receive care
for children, if you will, with chronic disease to an entire
system providing care for all Americans.
The basic premise of the medical home is that continual
care managed and coordinated by a personal physician with the
right tools will lead to better health outcomes. This concept
shifts the paradigm from episodic acute care to a continuous,
comprehensive model of care.
Central to the medical home is the premise that patient-
centered care requires a fundamental shift in the relationship
between patients and their primary care physicians. The idea
that there must be a higher degree of personalized care
coordination, access beyond the acute care episode, and
identifications, therefore, of key medical and community
resources to meet the patient's individual needs.
While there is widespread agreement that the concept of
medical home is a good one, there are concerns about how best
to design and implement such a model. For instance, some have
expressed concern that the medical home, by requiring physician
referral for specialty services, can sometimes or more than
sometimes add a costly and needless step to the process of
linking patients to the right source of care.
Additionally, some have argued that it might not make sense
for a primary care physician to always serve as the medical
home coordinator. For example, many women view their
obstetrician/gynecologist as their primary care provider and
would choose that their medical home be based out of their OB/
GYN's office.
The financing of delivery changes is another issue that has
drawn significant scrutiny and deserves our attention.
Reforming our healthcare system is a tall order. The public
deserves reforms that reduce unnecessary costs, improve the
quality of care, and increase access so that all Americans have
meaningful health coverage.
We must be careful as we undertake this task to evaluate
each change to ensure that the goals and the means of achieving
them are, in fact, truly aligned. This is as true for health
delivery reform as it is for health insurance reform.
I am confident today's hearings will provide valuable
insights that will help us reshape health delivery to squeeze
out wasted spending and build in improved health outcomes. I
look forward to hearing from our panel of five distinguished
witnesses, who represent primary care providers, specialty care
providers, and community-based providers on some of these
complicated and pressing issues.
And particularly, I would like to thank Michael
Nochomovitz, president and chief medical officer, University
Hospitals Medical Practice in Cleveland. Thank you for joining
us, especially. I only pick him out because he is the only one
from Ohio. So don't take that personally, anybody else.
[Laughter.]
University Hospitals has worked closely--and it is the one
I am certainly most familiar with, living in an area served by
UH--has worked closely with primary physicians and specialists
to introduce new technologies and quality measures which have
helped with care coordination in northeast Ohio, the most
populous part of the State. I look forward to hearing more
about these successful models and how they can be adopted
nationwide.
I would like to thank the witnesses. I will look forward to
discussing how the patient-centered medical home model can play
an important role in delivering a reformed healthcare system.
So I will introduce each of the panelists and then begin
listening to their opening statements, and then we will do
questions.
I will start with Dr. Ken Thorpe, professor of health
policy at Emory University--where my mother attended, I might
add--in Atlanta, GA. Dr. Thorpe was Deputy Assistant Secretary
for Health Policy in the U.S. Department of Health and Human
Services from 1993 to 1995. In this capacity, he coordinated
all financial estimates and program impacts of President
Clinton's healthcare reform proposals for the White House.
Dr. Thorpe has authored and co-authored over 85 articles,
book chapters, and books and is a frequent national presenter
on issues of healthcare financing, insurance, and healthcare
reform at healthcare conferences and in television and the
media.
Dr. Richard Cooper is a professor of medicine at the
University of Pennsylvania. Dr. Cooper has been a physician for
50 years whose early career was an academic hematologist, first
at Harvard and then at Penn. He helped to found a comprehensive
cancer center and served as the dean of the Medical College of
Wisconsin.
Dr. Steven Schlossberg, welcome, is the chair of health
policy for the American Urological Association, a member
organization of the Alliance of Specialty Medicine. He is a
practicing urologist from Norfolk, VA, and part of the
management team of a 400-physician multi-specialty group
practice.
Dr. Michael Nochomovitz--that is pronounced correct? Dr.
Michael Nochomovitz, right, is the president and chief medical
officer of University Hospitals Medical Practices at University
Hospitals Management Services Organization in Cleveland, a
position he has held for a little more than a decade.
He is a practicing physician, board certified in internal
medicine and pulmonary medicine. He is the architect of
University Hospitals regional multi-specialty physician network
in northeast Ohio, which is the single, largest portal of entry
into the system. This network of some 450 medical providers
includes the largest primary care group in the region, as well
as 6 urgent care sites and 5 hospitalist programs.
And Dr. Marsha Raulerson is a graduate of the University of
Florida College of Medicine, and a fellow at the American
Academy of Pediatrics. She is a primary care physician who has
practiced in Brewton, AL, for 28 years and has received many
awards in recognition of her commitment to the health and the
welfare of children.
Thank you, Dr. Raulerson, for joining us.
Dr. Thorpe, would you begin your opening statement?
STATEMENT OF KENNETH E. THORPE, Ph.D., PROFESSOR OF HEALTH
POLICY, EMORY UNIVERSITY, ATLANTA, GA
Mr. Thorpe. Well, thank you, Senator Brown. And thank you
for holding this important hearing.
I am going to make seven points very quickly. First point,
I think a central challenge we face in healthcare reform is how
to build primary prevention and care coordination into the fee-
for-service Medicare program, with the intent that it would
spill over into other payers.
Today, if you think about it, about 30 percent of the
growth in Medicare spending is linked directly to the doubling
of obesity among Medicare beneficiaries. Ninety-five percent of
what we spend in Medicare is directly linked to chronically ill
patients.
And I may add, in addition to my Emory position, I am also
the executive director of the Partnership to Fight Chronic
Disease. We just held a press event this morning with Senator
Harkin where we had most of these facts in our almanac, and we
will be sharing this with you and your colleagues.
There are six conditions in Medicare driving most of the
growth in spending--diabetes, hypertension, hyperlipidemia,
asthma, back problems, and depression. Those are all conditions
that are largely ambulatory based and require medication
therapy. And in the traditional fee-for-service program, most
of that is completely unmanaged.
Second point, the performance in the program is suboptimal.
We don't coordinate care in it. So, as a result, admission
rates are high. Re-admission rates within 30 days are 20
percent. We can do a lot better if we really build some type of
a formal coordination program into Medicare.
Third point, there is some good news here. We have a lot of
data in randomized trials and examples of systems that work
effectively in managing Medicare patients. Intermountain
Healthcare, Geisinger--you have heard of these examples. They
are largely large integrated group practices.
And in those settings, they can reduce admissions by 25
percent and reduce re-admission rates to 6, 7, 8 percent within
30 days, not 20 percent, which is the norm in fee-for-service
Medicare.
The problem is, those things are not easy to replicate and
scale. While the large integrated group practices that work, we
can't build them everywhere in the country.
So one of the things that we have been talking about as a
proposal is to let us look at what they do well. What is it
about the functions of those systems that really make them
effective? Let us see if we can't find ways to build them into
community settings to work with smaller physician practices so
that we can scale it and replicate it nationally quickly.
And if you think of the functions that work well, it is
formal transition care, close integration of care coordination
with the primary care physician's practice, having community-
based primary care prevention programs available, and having
care coordinators working directly with patients at home to
make sure that they are executing the care plan effectively.
The dilemma we face, I think, in terms of building care
coordination into the program is that 83 percent of physician
practices are in groups of one or two. That is about 40 percent
of primary care physicians.
While the medical home vehicle is a great vehicle, and we
should continue to encourage it, most Medicare beneficiaries
don't get their care through these large integrated systems. So
I think the challenge is to figure out how can we find the good
elements of those programs, replicate them, and scale them?
The fourth point is, we can do this through what some
States like Vermont, North Carolina, Rhode Island are already
doing, using community health teams. A community health team is
a collection of care coordinators, nurse practitioners, mental
and social health workers, community outreach workers that work
hand-in-hand with primary care practices to help patients
execute the care plan that is put together by the primary care
physician.
The community health teams have all the functions that are
built into the successful programs like Geisinger and
Intermountain Healthcare, including the transitional care
models, close integration with that practice, and so on. We
have seen in North Carolina in the Medicaid program, this has
saved between 5 and 15 percent relative to unmanaged care since
2003.
Fifth point is that if we make a modest investment
nationally to take this community health team concept and make
it available everywhere to work with Medicare fee-for-service
patients and spend 0.6 percent of Medicare on it, I think,
based on the data, that it is not unreasonable to expect not
only better outcomes and better quality, but a return in terms
of savings of anywhere from 3 to 7 percent, based on published
data that we have seen.
So I think, in closing, we face a choice. We are either
going to not do care coordination and traditional fee-for-
service Medicare, or we have got to find a way to scale it and
replicate it in a way, building on the best elements of the
medical home model but recognize its limitations in terms of
replication and scalability. But a community health team
approach to doing this is one that I think holds much promise.
I look forward to working with you and the committee and
would be happy to answer any questions at the end of the
remaining testimony.
[The prepared statement of Mr. Thorpe follows:]
Prepared Statement of Kenneth E. Thorpe, Ph.D.
Good morning, Senators. Thank you for inviting me here today to
discuss the urgent need to reform health care delivery in the United
States and the pivotal role that primary care providers must play in a
changed system. I am Ken Thorpe, chairman of the department of health
policy and management at Emory University. I also lead the Partnership
to Fight Chronic Disease, a national coalition of patients, providers,
community organizations, business and labor groups, and health policy
experts that are working with State partnerships to prevent chronic
illness and reform how we deliver care to patients.
I believe a central challenge we face in health reform is how to
integrate effective primary prevention and care coordination into the
traditional fee-for-service (FFS) Medicare program. Success in
integrating these care delivery components into Medicare will surely
have spillover effects in how Medicaid and the private sector work to
prevent and manage chronic illness as well. The following six facts
highlight the nature of the challenge we face and provide insights
about the design of a successful solution to the problem.
1. The majority of all U.S. medical practices (83 percent) are
composed of just one or two physicians.\1\ More than a third of primary
care physicians (36 percent) work in these small practices.\2\ Most
Medicare patients are not treated through larger integrated group
practices.
2. Eighty-one percent of Medicare beneficiaries are enrolled in
traditional FFS Medicare, and they account for about 79 percent of the
program's overall health care spending.\3\ Today, there is no care
coordination in the program, leading to high rates of preventable
hospital admissions, re-admissions, clinic and emergency room
visits.\4\
3. In 2010, we will spend about $395 billion in the traditional FFS
Medicare program. Over 95 percent of total spending in Medicare is
linked to chronically ill patients.
4. Multiple morbidities among these patients are common: More than
half of Medicare beneficiaries are treated for five or more chronic
conditions yearly.\5\ On average, the top spending 5 percent of
Medicare beneficiaries account for roughly half the FFS program's
costs.
5. Over 30 percent of the recent rise in Medicare spending in the
last 10 years is associated with the persistent rise in obesity in the
Medicare population. (Exhibit 1, graphically depicts rising rates of
overweight--obesity, and two associated chronic conditions, diabetes
and hypertension--in the United States over the last 40 years.)
6. The increase in obesity-related chronic diseases among all
Medicare beneficiaries and particularly among the most expensive 5
percent is a key factor driving growth in traditional FFS Medicare.\6\
Six medical conditions--all related to obesity: diabetes, hypertension,
hyperlipidemia, asthma, back problems and co-morbid depression--account
for most of the recent rise in spending in the Medicare population.
Treatment for these patients is largely uncoordinated, and relies
largely on therapeutic interventions in ambulatory care.\7\
Today, Medicare spends nothing to help coordinate health care in
the traditional fee-for-service program. As a result, Medicare spending
is higher than it would be if care were coordinated. For instance, 20
percent of Medicare patients are re-admitted within 30 days of leaving
the hospitals. Well-managed and coordinated plans such as Geisinger,
Puget Sound, and others have re-admissions rates of half this amount.
Moreover, since they manage and coordinate care their hospital
admission rates are about 25 percent lower than unmanaged Medicare.
Nationally, the private sector and the Federal Government (through
Medicaid) currently spend approximately 2.5 percent of total spending
to invest in care management. Well-managed programs have been
associated with savings of 5 to 7 percent--well over a 2 to 1 return on
investment. To generate these savings, private plans, Geisinger, and
others invested in new technology, transition care programs, and other
care management tools.
Medicare spends nothing on care management--and so generates no
savings from it. If Medicare took the best practice approaches with
proven results from the private sector (formal transition care model,
integration of the care management function and the physicians' office,
financial and payment incentives) and made it available nationally in
FFS Medicare, the program would save money.
The challenge is most of the good care management models are large
clinics such as Mayo, Geisinger, Cleveland, and Marshfield. Their
approach to preventing and managing disease has proven effective.
However, these models are not replicable or scalable nationally.
As an alternative, the key design features of these successful
integrated system prevention and care management programs could be
identified and incorporated into community settings to work with
smaller physician practices. These community-based health teams would
provide care coordination and prevention using the same tools and
approaches used successfully in larger integrated practices like
Geisinger. This approach would allow Medicare to quickly replicate
these effective practices nationally.
The community health team concept is an approach already used in
Vermont, North Carolina, Rhode Island and soon West Virginia and
Pennsylvania. According to several evaluations from Mercer Consulting,
North Carolina has saved between 5 to 15 percent annually in their
Medicaid program with these models.
In Vermont and elsewhere, CHTs work with primary care practices,
patients, and their families to prevent and manage chronic illnesses.
These teams variably include care coordinators, nutritionists,
behavioral and mental health specialists, nurses and nurse
practitioners, and social, public health, and community health workers.
These trained resources already exist in many communities, working for
home health agencies, hospitals, health plans, and community-based
health organizations. To better leverage their systemic impact,
dedicated teams are needed to work seamlessly with small primary care
practices in communities across every State.
The CHT model is replicable and scalable nationally and quickly,
unlike other approaches. Like other payers, Medicare must make a very
modest investment to coordinate care if it ever hopes to generate
savings, reducing admission and re-admissions in the program. A $2.5
billion per year investment--or 0.6 percent of total Medicare FFS
spending, and about 50 percent less than other payers currently invest
to generate savings in their programs--would allow CHTs to work
nationally with Medicare FFS patients.
Community health teams have the potential to reduce spending in the
program and working in tandem with other health reform proposals
(hospital bundled payments and penalties for high re-admission
policies) should generate savings higher than already scored by CBO.
The Medicare program's fragmented benefit design and reimbursement
policies discourage care coordination and disease management. At the
same time, these very same conditions present opportunities for
prevention, better care, and long-run cost savings.\8\ Health reform
should seek to reduce the rate of rise in targeted chronic conditions
(primary prevention) and implement evidence-based care management
(secondary and tertiary prevention), starting with current FFS Medicare
beneficiaries.
The most recent evaluation of the Medicare Coordinated Care
Demonstration (MCCD) and several other randomized controlled trials
substantiate the importance of five care elements that CHTs should
provide: (1) monthly (or more frequent) in-person contact with
patients, (2) targeting the right patients (treatment-control
differences were concentrated entirely in the highest severity
enrollees), (3) patient education on medication adherence and other
self-care, (4) transition care coordination to avoid preventable re-
admissions, and (5) close collaboration between care coordinators and
physician practices.\9\
To realize fully both health gains and potential cost savings, each
patient should have a care coordinator who works closely with primary
care providers in executing the care plan developed by the primary care
physician collaboratively with the patient. Depending on the patient's
constellation of illness, several members of a CHT may be involved in
working with the patient to execute the individualized care plan. Care
plans should be developed for at-risk populations (pre-diabetic,
overweight and obese, tobacco users) as well as patients with one or
more diagnosed chronic conditions.
A critical CHT focus must be transitional care. Potentially
avoidable re-admissions have been identified as a major quality and
spending problem in Medicare: About 18 percent of admissions result in
re-admissions within 30 days of discharge, accounting for $15 billion
in spending each year. Not all of these re-admissions are avoidable,
but some are, potentially as much as $12 billion worth.\10\ The CHT
care coordinator would track patients as they enter the hospital or
skilled nursing facility, conduct an on-site visit, and, most
importantly, work with the patient and admitting physician at
discharge. The care coordinator would provide information and input to
make sure the discharge plan and medication reconciliation for the
patient are completed.
CHTs are a vital link to community-based prevention programs that
can deliver effective primary prevention to avert disease as well as
programs to detect and mitigate existing conditions and avert
complications (secondary and tertiary prevention). Each team should
have a public health practitioner familiar with effective community-
based lifestyle, exercise, diet/nutrition, smoking cessation, and other
risk-reduction programs (e.g., substance abuse and mental health). An
emerging example of the value of these community-based resources is the
replication of the diabetes prevention program (DPP) and other
protocols shown through randomized trials to reduce dramatically the
incidence of diabetes among pre-diabetics and other at-risk
populations.
Absent an investment to prevent and manage disease, Medicare has no
workable tools for slowing the growth in spending and will save less.
Cutting provider payments may save money in the short term, but could
drive spending up in the longer term, as fewer physicians accept
Medicare patients and those with chronic illnesses are untreated and
their diseases unmanaged.
Chronic illnesses--mostly preventable--take an increasing toll on
Americans' health, productivity, and quality of life. Reversing or at
least slowing the rise in incidence and prevalence is critical to
better health and reduced health spending over the long term. The
stimulus bill endows a national ``Prevention and Wellness Fund'' with
$1 billion, including $650 million for ``evidence-based clinical and
community strategies that deliver specific, measureable health outcomes
that address chronic disease'' in title VII.
Reforming the way in which the U.S. health system provides care to
chronically ill patients is also essential. Episodic, uncoordinated
care is ineffective and inefficient for patients like most Medicare
beneficiaries who have multiple, chronic comorbidities. Reforming the
traditional FFS Medicare program would go a long way in spurring needed
transformation in health care delivery. The United States leads
industrialized nations in per capita and total health spending, but is
last in preventable mortality. Preventing disease, particularly chronic
illness, and providing better care for those with life-long illness,
along with how we finance and pay for care, must change.
Thank you again for the opportunity to discuss these vital reforms.
I'm happy to take your questions.
References
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Care Coordination Programs Used in Demonstration Show Promise, but
Wider Use of Payment Approach May Be Limited (GAO-08-65), Washington,
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w378-w388.
8. P.R. Orszag, April 11, 2007.
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Incentives in Medicare (Washington, DC: National Academies Press,
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Senator Brown. Dr. Thorpe, thank you.
Senator Murray, welcome. You don't want an opening
statement or are you----
Senator Murray. Mr. Chairman, I just really appreciate the
opportunity to have this hearing, and I will submit my opening
statement for the record.
So thank you.
[The prepared statement of Senator Murray follows:]
Prepared Statement of Senator Murray
Thank you Senator Brown for holding this hearing.
I am pleased that we are discussing ways that we can reform
our health care delivery system.
This is such an important issue--especially now as we work
to reform the health care system to reduce costs, make care
more affordable, and ensure that all Americans have access to
high quality health care.
I go home to Washington State almost every weekend and
spend a lot of time talking to families and business owners
about the challenges they face.
And one thing I hear from them again and again is that they
are deeply concerned about health care, and they desperately
want meaningful reform.
They tell me that especially now--as jobs are being lost
across the State, and families are worried about their economic
future--they want a health care system that they can count on--
that they know will be there for their families when they need
it.
They tell me that they want a modernized health care
system--and affordable, accessible health care for every single
American.
We all know our health care system is broken and it needs
real reform. And we have an historic opportunity to finally
tackle this challenge. These investments are not luxuries--they
are essential to our future strength.
I was very encouraged to see President Obama stand with
representatives from across the medical community this week as
they committed to bringing down health care costs by $2
trillion over 10 years.
This was a big step--but the work to reform the delivery
system is going to be just as important.
We need to alter the payment structure in health care to
ensure that there is true coordination across medical
disciplines.
Models that encourage this coordination of care--like the
medical home model--benefit the overall system by:
Encouraging disease management--particularly of
chronic diseases;
Focusing on prevention and wellness;
And cutting down on duplicative and repetitive
tests and treatments.
And while we encourage these new and innovative ways to
deliver health care, we also need to remember that not
everything can be prevented and planned, and we still need to
ensure that trauma centers continue to be there for anyone who
needs life-
saving care.
I believe that all Americans deserve high quality health
care that reduces costs and makes care more affordable--and I
know that delivery reform is going to be a big part of that.
I thank our witnesses for coming in to speak with us. They
are on the front lines of health care in America--and I look
forward to hearing from them.
Senator Brown. Thank you, Senator Murray.
Dr. Cooper, welcome. Thank you for joining us.
STATEMENT OF RICHARD A. COOPER, M.D., PROFESSOR OF MEDICINE AND
SENIOR FELLOW, LEONARD DAVIS INSTITUTE OF HEALTH ECONOMICS,
UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA, PA
Dr. Cooper. Thank you, Senator. Thank you so much for
allowing me to be here today, and thank you for your
introductory remarks, which certainly dramatically frame the
problem.
My message today is simple and direct. The problem that we
are facing is that there are currently too few physicians, and
we are training too few for the future.
There is more to say about how this occurred and much more
to say about how these shortages will affect physician
practices and the models of practice. But the fundamental
problem is too few physicians, too few generalists and too few
specialists--too few physicians overall.
These shortages actually began more than 5 years ago, but
they were initially limited to certain specialties, including
urology and some of the others represented here, and to certain
locales. But because they were limited, they largely escaped
public attention. Now that they have spread to engulf primary
care, the secret is out. There are too few doctors.
When concerns were raised in the past about too few primary
care physicians, the strategy was to shift the balance of
training from specialist to generalist. But this time, the
problem is not one of balance. There aren't enough physicians
overall.
This problem is further complicated by the fact that
although we need more physicians today, we can't get more for a
decade or more. The math is easy. It will take several years to
expand medical schools and residency programs, 4 years for
students to complete medical school, 3 to 6 years of residency.
And then it is 2025, and the Nation will be coping with
shortages far more severe than today.
These facts make it important to work doubly hard. Medical
school expansion has begun, but it needs help. And it won't
yield more physicians unless residency programs are also
expanded. And for that to happen, Medicare's caps on graduate
medical education will have to be lifted. That is one place
Congress can help.
But Congress must be aware that healthcare reform is
occurring in a new era of physician shortages. No one alive
today has carried out healthcare planning under such
conditions.
When we projected these shortages more than a decade ago,
we cautioned that if steps were not taken to correct them, the
medical profession would be forced to redefine itself in ever
more narrow scientific and technological spheres while other
disciplines evolve to fill important gaps. And that is what is
happening now.
Specialists are necessarily concentrating their efforts on
technologically advanced care, on the care of patients with
major acute disorders and complex chronic diseases and, of
course, on advanced diagnostic services.
Some specialists are trying to organize their practices to
serve as the principal physicians for patients with chronic
disease and, to do that, they are relying heavily on nurse
practitioners and physician assistants to provide general care.
The specialties are narrowing, and the overlaps among them
are decreasing. That presents challenges of the very sort you
spoke of Senator Brown--challenges for the coordination and
communication among physicians, which makes information systems
even more critically important.
There is a great deal of innovation, and we have heard a
little bit about it already from Dr. Thorpe. Lots of ways to do
it, and there will be more. No one model will fit every
circumstance, and the circumstances will be more complex as the
physician shortages deepen.
Generalists, too, are gravitating to services with a higher
average acuity and complexity. Some are now serving as
hospitalists. Some concentrate--some continue to practice in
rural communities, where a whole range of services are needed.
Many are continuing to care for patients with uncomplicated
chronic illness and for older patients with multiple
infirmities. And like specialists, many are partnering with
nurse practitioners, PAs, absolutely key to the success of such
efforts.
But the important point for consideration as one plans
ahead is that fewer will be available for front-line primary
care. Generalists instead will have to serve as consultants to
nonphysician primary care providers. This is not a matter of
taste. This is not a matter of desire. This is a matter of
reality.
It is a matter of choices. This is democracy. You represent
the people. You can choose what physicians will do. Will they
be neurosurgeons, or will they involve themselves in smoking
cessation? These are very important choices.
So these various transitions that are occurring naturally
will allow physicians to do more than physicians normally do if
there are enough physicians to do it. But there still won't be
enough.
So my message to you is simple and direct. Open the gates
for residency training so that physician supply can be
increased and free physicians to develop innovative approaches
to clinical practice of a great variety of ways.
Ultimately, high-quality care depends on the autonomous
exercise of clinical judgment by competent and empathic
physicians. We need to be sure that there will be enough for
everyone in the future.
Thank you.
[The prepared statement of Dr. Cooper follows:]
Prepared Statement of Richard A. Cooper, M.D.
Mr. Chairman and members of the committee, I very much appreciate
the opportunity to provide testimony to the committee as it undertakes
this important inquiry into the critical role that physicians will play
in a reformed health care system. It is a topic that I feel deeply
about.
OVERVIEW
The problem that we are facing is that there are worsening
shortages of physicians. I will say more about these shortages and
about how physician practices are likely to evolve because of them, but
it is important not to lose sight of the fundamental problem: too few
physicians to serve the needs of the Nation. Too few generalists and
too few specialists. Too few physicians.
This problem will have to be addressed in two ways. The first is by
expanding the capacity to train more physicians. Although difficult to
accomplish, the ways to accomplish it are generally known. The second
is more elusive. It is through innovative practice arrangements among
physicians and between physicians, hospitals and nonphysician clinician
(NPC) providers. There are infinite numbers of such arrangements, and
infinite regional and local circumstances in which they will be carried
out. Innovation is key. While some believe that the ``true'' way can be
known and applied generally through practice incentives or otherwise,
that approach is fraught with danger. Experiences can be shared, but
practices cannot be shaped by widely-applied incentives or regulations.
In health care, as in politics, everything is local.
These two lines of thinking come together when it is appreciated
that no one has carried out health care planning in the context of
physician shortages of the magnitude that are now developing. At times
like this, it is best to work toward minimizing long-term shortages,
make efforts to assure that disadvantaged populations do not bear the
brunt of the problem, and sustain an atmosphere that is conducive to
practice innovation.
BACKGROUND
I come to this after almost 50 years as a physician. My early
career was as an academic hematologist, first at Harvard and then at
Penn. While at Penn, I also helped to found a Comprehensive Cancer
Center, which I later directed. After almost 15 years there, I was
drawn back to Milwaukee, the city of my birth, to serve as dean of the
Medical College of Wisconsin. It was toward the end of that tour of
duty that the Clinton Health Plan was in the making. I was attracted to
these deliberations by the notion that there would be a vast surplus of
physicians by Century's end.
In examining the way that the Bureau of Health Professions
projected these surpluses, it quickly became apparent that outmoded
census data had been used. When correct data from the Census Bureau's
were substituted, a very different picture emerged. It was not one of
mounting surpluses but of a ``turn of the century bulge'' in physician
supply followed by increasing shortages as the new Century unfolded--
which is what is happening now.
The view that shortages would develop was very unpopular at the
time, but it has proven to be correct. Sadly, rather than beginning
then to prepare for an expansion of medical education now, the
consensus was to stop any further expansion of physician training by
freezing the number of residency positions. That was accomplished in
the Balanced Budget Act of 1997, which capped Medicare funding for
graduate medical education (GME) at its 1996 level. And that is why we
are here today.
DEFINITION OF THE PROBLEM
As I stated at the outset, the Nation is producing too few doctors
for its current and future needs. As my colleagues and I forecasted a
decade ago, economic and demographic trends, combined with insufficient
training capacity, are leading to deepening shortages of physicians.
But now there is a second part to the forecast. Because so much time
has passed, a further deepening of physician shortages cannot be
avoided. Regardless of how much effort is made to add training capacity
now, it will not be possible to correct the problem soon enough or
fully enough to avert still worse shortages over the next decade. And
that makes your deliberations doubly important, for they concern not
only the need for adequate numbers of physicians but the need for
innovative models of practice in this coming era of physician
shortages. This is uncharted territory. There is no time in the past
when the United States has had shortages of physicians of the magnitude
that are now developing. Innovation is the operative word, both for
expanding training capacity and structuring the practice of medicine.
The shortages that are now being experienced are not new. They
began to appear 7-8 years ago, even earlier than we had anticipated.
But they were limited to certain specialties, such as cardiology and
urology, and because they were limited, they largely escaped public
attention. However, they were noticed by national organizations.
Following our initial projections a decade ago, the Council on Graduate
Medical Education adopted a similar planning model and made similar
projections, and these were confirmed by a series of follow-up reports
from the Association of American Medical Colleges. With these
projections and early evidence of shortages in many specialties and
many communities, most major medical organizations called for expanding
physician supply. They included the American Medical Association, the
American Osteopathic Association, the Association of American Medical
Colleges, the American Association of Colleges of Osteopathic Medicine
and the Association of Academic Health Centers. More than 20 specialty
societies and an equal number of State medical and hospital
associations joined this chorus. Yet, it was largely ignored. However,
now that the shortages have spread to engulf primary care physicians,
whose care is sought by most patients, even when they are healthy, the
secret is out. Everyone knows. We don't have enough physicians.
On past occasions when there was concern about too few primary care
physicians, the strategy was to shift the balance of training from
specialists to primary care. But this time the problem is not simply
one of balance--it is global--there are too few physicians across
specialties. Unlike the past, there's no ``robbing Peter to pay Paul.''
The only solution is to train more physicians and allow them to
distribute among the various specialties where they are needed.
The problem is further complicated by the fact that, although we
need more physicians now, we really can't get any more for a decade or
more. This is because, even with sufficient financial support, it will
take several years to increase medical school output and expand
residency training capacity, and then it will take 4 years to educate
medical students and another 3 to 6 years for these graduates to
undergo residency and fellowship training. And by then it will be 2020,
and the Nation will be coping with shortages far more severe than
today.
EXPANDING MEDICAL EDUCATION
The fact that future shortages are unavoidable is not a reason to
do nothing. It is a reason to work doubly hard to minimize them. In
response to that need, many medical schools have already begun to
increase class size, and a small number of new schools are in various
stages of development. The pace of both is commendable, but it is too
slow and not enough, and without national support, it is unlikely to be
sufficient. Medical schools need financial help in this endeavor.
But most of all, residency programs must be expanded. Medicare's
caps on residency positions must be lifted, and support must be made
available to assist existing training programs to expand and to help
hospitals that are capable of starting new programs. And that is where
Congress can help.
Why is expanding graduate medical education so important? It is
because, regardless of where physicians are schooled (U.S.-M.D.
schools, U.S.-Osteopathic schools, U.S. citizens trained abroad or
foreign nationals trained abroad), physicians must receive residency
training in the United States in order to be licensed for practice in
the United States. This limitation does not hold for most other
countries, which allow the entry of practicing physicians, albeit with
some restrictions. However, in the United States, GME is the portal to
practice. It's a good portal, one that enhances the quality of care.
HOW MANY MORE PHYSICIANS ARE NEEDED?
Estimating the future demand for physicians requires a consensus
about the future dimensions of health care. Over the past several
decades, health care spending has grown at an annual rate approximately
2 percent higher than the rate of GDP growth (which averaged 3
percent). The 2 percent differential was not because no more health
care was desired, but because desire encountered downward pressure, and
2 percent became the equilibrium point. Even if downward pressure is
greater in the future, it seems unlikely that health care spending
would grow more slowly than the economy overall. It also is unlikely
that its growth could exceed GDP growth by as much as 4 percent, double
the historic level. So the range of predicted spending is rather
narrow.
President Obama's announcement earlier this week concerning
proposals by major health care providers to rein in the annual growth
of health care spending is in line with projections of growth within 1-
2 percent of GDP growth, a level that would cause health care's portion
of GDP to reach 20 percent by 2020 or shortly thereafter.
Long-term trends also indicate that spending will not be the same
everywhere--more prosperous States spend more, not only on health care
but on other social services. And they have better outcomes when their
diverse sub-populations are taken into consideration. While it is
difficult to predict the future, and there are extreme views in both
directions, it seems prudent to make long-term plans for facilities and
personnel based on these estimates.
Historically, as health care spending has grown, the supply of
physicians has grown much slower, while other health care workers
undertook important tasks. During the 1920s, physicians accounted for
25 percent of health care workers, but now account for fewer than 7
percent. This trend has been associated with new technical disciplines,
a vast expansion of nursing and a progressive increase in the number of
nonphysician clinicians (NPCs), principally nurse practitioners (NPs)
and physician assistants (PAs), reflecting the greater complexity of
the tasks that physicians now delegate or defer to others.
WHAT IS POSSIBLE?
The illustration below depicts the trends in physician supply and
demand over the past several decades, expressed in per capita terms. It
also shows how demand will change over the coming years, assuming a
slowing of spending growth, as indicated above. And it shows that, if
the rate of training is not increased appreciably, there will be as
many as 200,000 too few by 2020, 20 percent of the projected demand,
and larger shortages thereafter.
The illustration also shows what could happen if the number of
entry-level residency positions were increased by 10,000 over the next
decade, from approximately 25,000 to 35,000, a 40 percent increase.
While such an increase is seemingly large, it is equal to the expansion
of residencies that occurred in the 1960s and 1970s, the last major
effort to expand supply. Such an expansion would clearly lead to
meaningful increases in physicians long-term. But, because of the long
lead-times, little will occur until after 2020, and a gap between
supply and projected demand equivalent to 100,000 physicians will
continue well into the future.
Thus, there are two problems. A near-term shortage, about which we
can do very little, and a long-term shortage, which we can work to
ameliorate, recognizing that it will be impossible to correct
completely. But it is essential that Congress act quickly to aid in
that process. Helping medical schools is important, but increasing the
number of residents trained annually is the key.
While there is a tendency to want to use the funding for residency
training as a lever to influence specialty mix, it is difficult to
anticipate the precise roles that physicians will serve 20 and 30 years
hence, which is the timeframe during which current efforts to increase
the supply will come to fruition. Therefore, it is hazardous to attempt
detailed adjustments to the specialty mix of trainees. Physicians will
have to be trained to deal with the changing knowledge base of
medicine, and they will have to distribute in a manner that is
consistent with medical care in that somewhat distant future.
REDEFINING PHYSICIANS' ROLES
In 2002, we prophesized that:
``shortages of physicians will force the medical profession
to redefine itself in ever more narrow scientific and
technological spheres while other disciplines evolve to fill
important gaps.''
That transition is now occurring, as physicians gravitate to higher
complexity services that only they can provide. Faced with deepening
shortages, this trend seems certain to continue. The following
scenarios describe ways that physicians are likely to distribute
responsibility. Implicit in all of them is an interdependence among
physicians and between physicians and NPC. But most important is
innovation. The processes of restructuring physician practices will be
very fluid and will undoubtedly include characteristics that are not
evident today. It would be a mistake to favor any particular form of
organization.
Specialists will increasingly concentrate their efforts on
technologically advanced care and on the care of patients with major
acute disorders and complex chronic illnesses, and, of course, on
advanced diagnostic services. The degree of overlap among specialties
has decreased over time, as each has evolved to encompass a special
body of knowledge, and this seems certain to continue, which brings
interdependence more sharply into focus. Many specialists who care for
patients with chronic disease will organize their practices to serve as
``principal physicians'' for these patients, sharing the responsibility
for general care and care coordination with NPCs within their own
practices and with generalist physician colleagues. Relationships like
these will also facilitate the ability of some specialty practices to
retain the continuing responsibility for patients whose chronic
illnesses are quiescent or ``cured.'' Innovation and experimentation
will be important. No one model will fit every circumstance.
Generalists, too, will serve a variety of roles, but the hall marks
will be greater acuity and complexity. One is their comparatively new
role as hospitalists, an example of generalist physicians gravitating
to higher complexity care. A second is the collaborative care of
patients with complex chronic illness, as mentioned. Third, is the
traditional role of generalists in caring for patients with
uncomplicated chronic disease and multiple co-morbidities,
responsibilities that they will increasingly discharge in partnership
with NPCs. And fourth are areas with special needs, such as rural
communities, prisons and the military.
Generalist physicians have traditionally been major providers of
front-line primary care, including wellness care, patient education,
prevention and the care of acute self-limited disease. However, the
lack of sufficient numbers of physicians, combined with the decreased
interest of young physicians in such tasks and the doubtful wisdom of
committing such highly-trained professionals to this purpose, predicts
that more such care will be provided by NPCs and, through the use of
the Internet and other resources, by patients themselves. While some
have argued that this spectrum of responsibilities should be retained
by physicians and provided through physician-directed ``medical
homes,'' it seems improbable that there would be sufficient numbers of
such physicians, even if the model were ideal everywhere and for
everyone. Rather, the provision of primary care services will have to
be responsive to particular regions and subpopulations in each and to
the spectrum of providers who are available to participate. Retail
clinics, some in cooperation with hospitals or health plans, are only
the most recent innovation. As generalists relinquish their roles in
front-line primary care, they will be called upon to serve as
consultants for these various primary care systems. And they must be
appropriately compensated for the higher average acuity and complexity
of the patients they serve.
DOES IT MATTER?
This analysis of the need to expand physician supply and encourage
innovation in physician practices stands against a set of beliefs that
more physicians and more health care may not be good for the Nation and
that primary care should supplant specialty care for patients with
chronic illness. In fact, the preponderance of data do not support
these conclusions. Moreover, when the studies underlying them are
exposed to scrutiny, it becomes evident that some were confounded by
the anomalous distribution of family physicians in the upper Midwest;
some suffered from the error of aggregation and averaging; some relied
on statistical permutations rather than measures of actual physicians;
and many relied exclusively on analyses of Medicare spending, which is
not a proxy for health care spending overall. As an example,
Mississippi and Nevada, where quality is low, do not have high health
care spending, nor do they have an abundance of specialists, as
portrayed. They devote the least resources to health care, and have
corresponding outcomes.
Most important in understanding regional comparisons is an
understanding of the interplay between communal wealth and individual
income in determining health care utilization and outcomes. Viewed in
that light, more physicians, both specialists and generalists, and more
health care spending are associated with better outcomes. Simply
stated, ``more is more.'' The Nation may not be able to afford all of
the health care that would be beneficial, but it would be a mistake to
assume that spending less, or limiting physician supply in order to
spend less, would be beneficial. Rather, it seems prudent to base the
future demand for physicians on realistic projections of health care
spending, to respond to that demand by training as many physicians as
is practical, and to foster innovations in practice structures that can
aid in meeting needs as they evolve. Ultimately, high quality care
depends on the autonomous exercise of clinical judgment by competent
and empathic physicians who are accountable to their patients and
society.
Selected References
1. Cooper RA. Forecasting the physician workforce. In Papers and
Proceedings of the 11th Federal Forecasters Conference. (Washington:
U.S. Dept of Education), 2000, PP. 87-96.
2. Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic
trends signal an impending physician shortage. Health Affairs 2002;
21(1): 140-54.
3. Cooper RA. There's a shortage of specialists. Is anyone
listening? Academic Medicine 2002; 77: 761-66, 2002.
4. Cooper RA. Weighing the evidence for expanding physician supply.
Annals of Internal Medicine 2004; 141: 705-14.
5. Cooper RA. It's time to address the problem of physician
shortages: Graduate medical education is the key. Annals of Surgery
2007; 246: 527-34.
6. Cooper RA. States with more physicians have better-quality
health care. Health Affairs. 2009; 28(1): w91-102 (published online 4
December 2008) http://content
.healthaffairs.org/cgi/content/full/hlthaff.28.1.w91/DC1.
7. Cooper RA. States with more health care spending have better
quality health care--Lessons for Medicare. Health Affairs.
2009;28(1):w103-15 (published online 4 December 2008) http://
content.healthaffairs.org/cgi/content/full/hlthaff.28.1.w103
/DC1.
8. Physician shortages in the U.S.: Commentaries and controversies.
http://buzcooper.com/.
Senator Brown. Thank you, Dr. Cooper.
Dr. Schlossberg, welcome.
STATEMENT OF STEVEN SCHLOSSBERG, M.D., MBA, VICE PRESIDENT,
CLINICAL OPERATIONS, HOSPITAL-BASED SURGICAL SPECIALTIES,
SENTARA MEDICAL GROUP, CHAIR, HEALTH POLICY, AMERICAN
UROLOGICAL ASSOCIATION, ON BEHALF OF THE ALLIANCE OF SPECIALTY
MEDICINE, NORFOLK, VA
Dr. Schlossberg. Mr. Chairman and members of the committee,
I am the chair of health policy for the American Urological
Association, a member of the Alliance of Specialty Medicine,
which I am here to represent.
As a practicing urologist and part of the management team
of a 400-physician multispecialty group, I am keenly aware of
the necessity of collaboration between primary care and
specialists. Currently, I am responsible for hospital-based and
surgical specialists within our medical group, which includes
hospitalists, pulmonary critical care, general surgery,
neurology, vascular surgery, and urology.
Therefore, effective partnerships between specialty care
and primary care are absolutely essential to the delivery of
high-quality, cost-effective patient care. Through the
dissemination of clinical guidelines, offering of continuing
medical education courses, and innovative collaborations among
primary care and specialty practices, specialties educate
primary care providers and ensure timely and appropriate
referrals and resource use.
Not everything can be prevented. People get sick. They need
specialists. They need surgeons, and they need hospitalists and
emergency rooms. Primary care will not always be the most
efficient and effective provider for every condition and
disease. In fact, evidence indicates that specialists achieve
better outcomes in the treatment of their specialty area
compared to primary care providers and other specialists.
An article in the American Journal of Medicine looked at
the treatment of arthritis, rheumatic, and musculoskeletal
conditions and found that primary care providers often lack
adequate rheumatologic training. They are less skilled in the
diagnosis and management of these diseases and may order more
diagnostic studies, drugs, and consultations. Rheumatologic
care for these conditions provides better patient outcomes and
is less costly.
To foster collaboration, Congress should not divide
medicine and strive to strengthen primary care at the expense
of specialty care, whether through budget neutral changes to
reimbursement or by limiting access to specialists.
Congress must address the underlying physician payment
problem. Without a long-term solution to the flawed Medicare
payment formula, our healthcare delivery system cannot truly be
reformed. When the Government programs do not provide stable
and fair reimbursement, it equally impacts the private
insurance programs and leads to discrepancies in the true cost
of care.
One of the innovative delivery models being discussed is
the medical home. A key feature of this concept, as you have
said, is a personal physician responsible for overseeing all of
a patient's healthcare and coordinating care. Unfortunately,
the current medical home models do not include all qualified
physicians able to provide medical homes and may, in fact,
result in limiting access to some specialists.
The design of the CMS-proposed medical home excludes many
specialties, including surgery. Urology is a surgical
specialty, and a urologist may be the most appropriate medical
home for patients with certain chronic urologic conditions,
such as prostate cancer and bladder problems.
These patients often have long established relationships
with their urologist and have trust and confidence in their
care. Arbitrary severance of this relationship through the
exclusion of surgical specialties does not serve the goals of
this program. We should think in terms of having a principal
provider and not assume it is always the primary care provider.
Rather than having the Government decide which providers
are most appropriate, let individual physicians in consultation
with their patients together decide if they want to
participate. Many may not.
Finally, Congress should not move forward with innovative
delivery system models that have not been fully tested.
Implementation of the medical home is scheduled to begin next
year. Before the program is made permanent, Congress should
fully analyze the data from the demonstration project.
Finally, a couple of thoughts on information technology.
Certainly, HIT, or health information technology, has the
potential to increase collaboration, efficiency, and quality of
care and to lower healthcare costs. The alliance strongly
supports the development of an electronic health information
network that is both reliable, interoperable, secure, and
protects patient privacy.
The specialty community is appreciative for the
opportunities available for physicians to receive enhanced
Medicare payments to support the adoption and effective
utilization of HIT. I currently am doing e-prescribing, PQRI,
and using electronic medical record.
However, the alliance is concerned that many surgical
physicians will not be able to take advantage of the enhanced
payments. Therefore, the alliance urges you to consider
amending the current HIT bonus and penalty timelines.
Finally, a thought on quality. Each of the alliance's
specialty association members has been actively engaged in the
process of developing evidence-based and clinically relevant
quality measures and establishing data registries. While much
progress has been made, it takes time to develop the extensive
quality infrastructure needed for quality improvement and
simply is not yet established for the majority of physicians.
That makes participation in quality measurement and improvement
efforts very different from other providers.
Finally, just to amplify Dr. Cooper's comments about the
workforce, specialists are an integral part of American
medicine, and we cannot take for granted that specialists will
always be there. The Council on Graduate Medical Education
reported that in rural areas, there is a clear need for
specialty care and although primary care would be an essential
area of medical service and training, subspecialty and surgical
disciplines are also sorely needed in underserved areas.
It is important to consider workforce issues as you
consider healthcare reform because it takes 12 years to produce
a specialist. Like many specialists, urology requires training,
extensive training--4 years of college, 4 years of medical
school, and 5 years of residency.
As a professor of urology at Eastern Virginia Medical
School, I caution you against going too far in discouraging
young physicians from entering specialty medicine. By the time
a true crisis is visible, we will be unable to correct it.
Thank you, Mr. Chairman.
[The prepared statement of Dr. Schlossberg follows:]
Prepared Statement of Steven Schlossberg, M.D., MBA
Mr. Chairman and members of the committee, thank you for inviting
me to testify regarding the role of specialty care.
My name is Steven Schlossberg from Norfolk, VA. I am the chair of
Health Policy for the American Urological Association, a member
organization of the Alliance of Specialty Medicine, which I am here to
represent. The Alliance was founded in 2001 and its mission is to
develop sound Federal health care policy that fosters patient access to
the highest quality specialty care and improves timely access to high
quality medical care for all Americans. As patient and physician
advocates, the Alliance welcomes the opportunity to be here today and
participate in the national health care reform debate.
I am a practicing urologist and part of the management team of a
400 physician multi-specialty group practice. This makes me keenly
aware of the necessary collaboration between primary care and
specialists.
Effective partnerships between specialty care and primary care are
absolutely essential to the delivery of high quality, cost-effective,
patient-centered care. Through the dissemination of clinical
guidelines, offering of continuing medical education (CME) courses, and
innovative collaborations among primary care and specialty practices;
specialties educate primary care providers and ensure timely and
appropriate referrals and resource use. Not everything can be
prevented. People get sick. They need specialists. They need surgeons.
They need hospitals and emergency rooms.
Primary care will not always be the most cost efficient and
effective provider for every condition and disease. In fact, evidence
indicates that specialists achieve better outcomes in the treatment of
the diseases they focus on than primary care providers and other
specialists. For example, an article in the American Journal of
Medicine looked at treatment of arthritis, rheumatic and
musculoskeletal conditions and found that primary care providers often
lack adequate rheumatologic training. They are less skilled in the
diagnosis and management of these diseases and may order more
diagnostic studies, drugs, consultations and follow-up visits than
rheumatologists, making the care they provide lower quality and more
costly. Rheumatologic care for these conditions provides better patient
outcomes and is less costly to the health care system.\1\
---------------------------------------------------------------------------
\1\ Katz JN, Solomon DH, Schaffer JL, Horsky J, Burdick E, Bates
DW. ``Outcomes of care and resource utilization among patients with
knee or shoulder disorders treated by general internists,
rheumatologists, or orthopedic surgeons.'' American Journal of Medicine
Jan 2000: 108 (1) PP. 28-35.
---------------------------------------------------------------------------
A recent article in the Journal of the American Medical Association
(JAMA),\2\ directly relates subspecialty training to improved patient
outcomes. This particular case looked at outcomes for implantable
cardioverter-defibrillators (ICD) and used cases submitted to the ICD
Registry. The study confirms that specialized training enables
physicians to lower risk of complication and select the most
appropriate treatment for the patient's unique needs.
---------------------------------------------------------------------------
\2\ Curtis JP, Luebbert JJ, Wang Y, Rathore SS, Chen J, Heidenreich
PA, Hammill SC, Lampert RI, Krumholz HM. ``Association of Physician
Certification and Outcomes Among Patients Receiving an Implantable
Cardioverter-Defibrillator.'' Journal of the American Medical
Association Apr 22/29 2009--Vol. 301, No. 16, PP. 1661-1670.
---------------------------------------------------------------------------
To foster collaboration, Congress should not divide medicine and
strive to strengthen primary care at the expense of specialty care--
whether through budget neutral changes to reimbursement or by limiting
access to specialty care.
REIMBURSEMENT
Congress must address the underlying physician payment problem.
Without a long-term solution to the flawed Medicare payment formula,
our health care delivery system cannot truly be reformed. When the
government programs do not provide stable and fair reimbursement, it
equally impacts the private insurance programs and leads to
discrepancies in the true cost of care. Nor should Congress rob Peter
to pay Paul. The Alliance recognizes the importance of improving access
to primary care and strengthening the role of primary care providers.
The Alliance can not support proposals that would provide additional
payments to primary care physicians at the expense of specialists,
e.g., through budget neutral adjustments in payments made to
specialists.
INNOVATIVE DELIVERY MODELS
One of the innovative delivery models being discussed is the
Patient-Centered Medical Home--a healthcare delivery model intended to
promote patient-centered, longitudinal, integrated care. A key feature
of Medical Home is a personal physician responsible for overseeing all
of a patient's health care and appropriately coordinating care with
other qualified professionals to enhance access, improve integration,
and increase safety and quality.
Unfortunately, the current Medical Home models do not include all
qualified physicians able to provide Medical Homes and may, in fact,
result in limiting access to some specialists. Through the Tax Relief
and Health Care Act of 2006, the Center for Medicare and Medicaid
Services (CMS) was directed to launch a Medical Home demonstration.
However, the design of the CMS-proposed Medical Home excludes many
specialties such as surgery. Urology is a surgical specialty and may be
the most appropriate Medical Home for patients with certain chronic
urologic conditions, such as prostate cancer or bladder control
problems. These patients often have long-established relationships with
their urologists and have trust and confidence in their care. Arbitrary
severance of this relationship through exclusion of surgical
specialties does not serve the goals of this program. We should think
in terms of having a ``principal'' provider and not assume it always
will be a primary care provider. Rather than having government decide
which providers are most appropriate, let individual physicians, in
consultation with their patients, together decide if they want to
participate; many may not. I believe that will foster the patient-
centeredness care around which this program is built.
Finally, the Alliance requests that Congress, before enacting
Medical Home as a permanent model, fully analyze the data after the
completion of the demonstration to determine if Medical Home
significantly improved care coordination, was patient-centered,
delivered improved patient outcomes and saved money. Currently,
implementation of the demonstration project is slated to begin January
2010.
If Medical Home or other innovative delivery systems are to
succeed, there must be collaboration between primary care and specialty
medicine. Specialists are working with primary care physicians to
ensure appropriate referral and promote continuity of care. For
example, the American Urological Association has spearheaded a free
continuing medical education (CME) update tailored exclusively to
primary care practitioners on major urologic conditions, reaching out
to the American Academy of Family Physicians (AAFP) and the American
College of Physicians (ACP).
The North American Spine Society/National Association of Spine
Specialists (NASS) is unique in that it encompasses multi-specialty
care including non-operative and surgical care from entry into the
healthcare system through all phases and types of care, thus demanding
routine coordination among a range of practitioners, including primary
care providers. NASS provides specific evidence-based guidance to spine
care providers in the form of clinical guidelines to benefit patient
care, helping them diagnose, treat, and properly manage, among other
conditions, back pain.
The American Gastroenterological Association (AGA) provides
educational materials for primary care providers on such highly
prevalent GI conditions as appropriate management/evaluation of
diarrhea, Gastroesophageal reflux Disease (GERD), colorectal cancer
screening and polyp/cancer surveillance. Additionally, some larger
gastroenterological practices are working closely with primary care
practices to develop clinical care protocols for four areas: pediatric
chronic diarrhea, adult chronic diarrhea, acute abdominal pain and
chronic abdominal pain. These protocols include, for example, what
diagnostic steps should occur at the primary care level and then what
should be included in the information transfer. Having electronic
medical record (EMR) interface will help with the proper information
flow and the development of future protocols.
These are just a few examples of the kinds of essential exchange of
clinical knowledge and practice expertise that specialists are
proactively providing to primary care professionals to promote cost-
effective, timely, efficient and clinically appropriate patient care.
Other Alliance member organizations also have developed similar tools
for primary care physicians. We ask that such fruitful and functional
partnerships be explicitly recognized and actively fostered by
supportive government policies that unite diverse segments of medicine
around the patient as the center of attention, rather than
artificially, through divisive payment policies and arbitrary
definitions, perpetuate dysfunctional silos of care that both patient
and physician must struggle to navigate. Specialty care is and can
continue to be an effective, knowledgeable contributor to a reformed
healthcare system and is able and willing to do so.
HEALTH INFORMATION TECHNOLOGY (HIT)
Health information technology (HIT) provides a building block for
innovation and the delivery systems of the future. It has the potential
to increase collaboration, efficiency and quality of care, and to lower
health care costs significantly. The Alliance strongly supports the
development of an electronic health information network that is
reliable, interoperable, secure, and protects patient privacy. Congress
made significant strides towards the implementation of HIT with the
passage of the ``American Recovery and Reinvestment Act of 2009''
(ARRA)(PL11-5), and the specialty community is appreciative for the
opportunities available for physicians to receive enhanced Medicare
payments to support the adoption and effective utilization of HIT.
My practice has moved forward in this area. We viewed this as a
shared responsibility. The only reason my practice was successful is
because we had the resources to do this. If I was in a small or solo
practice, I could not have done it. Smaller physician practices, which
include the majority of the physicians practicing medicine in this
country, continue to face barriers to purchasing HIT systems. In
addition, for those practices that manage to adopt HIT, it takes a
further investment of significant time and resources to use their
systems to the fullest capacity.
However, the Alliance is concerned that many specialty physicians
will not be able to take advantage of the enhanced payments to purchase
HIT because of the ambitious bonus and penalty timelines and the fact
that current specialty systems lack certification and interoperability
standards. Further, the current certified HIT systems have been
developed for primary care settings and have not yet been fully adapted
for specialty or surgical care. The financial incentives and penalties
are based on the adoption and ``meaningful use'' of certified HIT
systems and will have a profound impact on our members and their
ability to adopt and become meaningful users. Physicians are hesitant
to make the considerable investment until certified systems are
available that meet their unique needs.
I call your attention to the fact that there are surgical
specialties that have made significant accomplishments toward achieving
interoperable HIT solutions for their members and have been placed on
the Certification Commission for Health Information Technology (CCHIT);
the only recognized certification body, roadmap for HIT Certification.
However, due to the obstacles that must be overcome to be identified by
CCHIT as one of the planned expansion areas, and the lack of CCHIT
financing and staff, most specialties are not even in the pipeline. In
addition, even those who are on the roadmap are facing challenges in
the timelines that have been outlined by the Commission.
As a result, and under the current timelines, it will be virtually
impossible for the majority of surgical specialty physicians to
purchase certified systems that are designed for their specialty,
become meaningful users, and qualify for the majority of the vitally
necessary financial incentives. Specialty medicine continually strives
to provide quality care, and the Alliance recognizes that HIT can play
an important role in achieving and maintaining high performance.
Therefore, the Alliance urges you to consider amending the current HIT
bonus and penalty timelines.
QUALITY
Likewise, quality improvement programs cannot be one-size-fits-all.
Each of the Alliance's specialty association members has been actively
engaged in the process of developing evidence-based and clinically
relevant quality measures and establishing data registries through
initiatives within their own specialty and/or through the AMA's
Physician Consortium for Performance Improvement. While much progress
has been made, it takes time to develop the extensive quality
infrastructure needed for quality improvement which simply is not yet
established for the majority of specialty physicians. That makes
participation in quality measurement and improvement efforts very
different from other providers to whom most physicians are readily
compared. Since many times the private market follows Medicare's lead,
I would like to share the Alliance's concerns with implementation of
the Physician Quality Reporting Initiative (PQRI).
Process of care measures may be more relevant for primary care, but
we need to move to a quality system that focuses also on clinical
outcomes. For the program to succeed, it first needs to extend the
timeline for full implementation so that physicians can catch up to
other providers, some of whom have had decades to create, test, and
report on measures; it must provide physicians with access to their
data in a timely manner and it must have a reasonable appeals process.
Also, the information should be verified before it is made public and
quality reporting should be voluntary, not punitive. Congress should
consider establishing a public private partnership to provide long-term
support for clinical data registries and measure development currently
undertaken solely through the limited resources of medical specialty
societies. Additionally, the PQRI program could reward physicians who
report clinical data to such registries. Finally, Congress must
recognize the increased cost to report quality measures and should
provide physicians with adequate funding to implement reporting
requirements.
PHYSICIAN WORKFORCE
Specialists are an integral part of American medicine. As a Nation,
we pride ourselves on having the best medical care has to offer.
Regardless of what insurance product people have, Americans want to
know they may see their doctor of choice when needed. However, we can
not take for granted that those specialists will be there.
The Council on Graduate Medical Education (COGME), reported that:
``In rural areas, there is a clear need for specialty care.'' \3\ The
report goes on to say that: ``Though primary care would be an essential
area of medical service and training, subspecialty and surgical
disciplines are also sorely needed in underserved areas.'' \4\
---------------------------------------------------------------------------
\3\ COGME 18th Report: ``New Paradigms for Physician Training for
Improving Access to Health Care,'' Sept 2007, page 5.
\4\ Ibid, page 13.
---------------------------------------------------------------------------
The Bureau of Health Professions (BHP) has cited significant
workforce challenges across the surgical specialties. Between 2005 and
2020, BHP projects an increase of only 3 percent among practicing
surgeons--with projected significant declines in a number of surgical
specialties. Over the same time period, BHP projects that the number of
practicing primary care physicians will increase by 19 percent.
The Association of American Medical Colleges (AAMC) published an
updated physician workforce study demonstrating essentially equivalent
shortages between primary care and surgery. Specifically, the study
projects physician supply and demand through 2025 and finds that: ``in
terms of the general projected shortage of 124,000 FTE physicians,
while 37 percent of the shortage will be in primary care [46,000], 33
percent will be in surgery [41,000] . . .'' In addition, the study
projects a shortage of 8,000 medical specialty physicians.\5\
---------------------------------------------------------------------------
\5\ The Complexities of Physician Supply and Demand: Projections
through 2025, Michael J. Dill and Edward S. Salsberg, Center for
Workforce Studies, Nov. 2008.
---------------------------------------------------------------------------
It is important to consider workforce issues as you consider health
reform because it takes more than 12 years to produce a specialist.
Like many specialists, urology requires years of training. In my case,
4 years of undergraduate education, 4 years of medical school, 5 years
of urology residency; some then also do an additional 2 or 3 years of
Fellowship training. As a professor of urology at Eastern Virginia
Medical School, I caution you against going too far and discouraging
young physicians from entering specialty medicine. By the time a true
crisis is visible, we will be unable to quickly correct it. Already,
there are shortages in many specialty areas and as I mentioned earlier,
the projections are that the problem gets worse.
Mr. Chairman, thank you again for including the Alliance of
Specialty Medicine. I'm happy to answer any questions.
Senator Brown. Thank you, Dr. Schlossberg.
Dr. Nochomovitz, welcome again.
STATEMENT OF MICHAEL NOCHOMOVITZ, M.D., PRESIDENT AND CHIEF
MEDICAL OFFICER, UNIVERSITY HOSPITALS MEDICAL PRACTICES AND
UNIVERSITY HOSPITALS MANAGEMENT SERVICES ORGANIZATION,
CLEVELAND, OH
Dr. Nochomovitz. Senator Brown and distinguished members of
the committee, it is an honor to speak to you today about the
role of primary and specialty care physicians in current and
proposed healthcare delivery models.
Senator Brown, I am particularly pleased to be here as a
physician from Ohio. Thank you for inviting me to testify.
I am a practicing physician and lead a 450-member physician
provider organization, which is the community arm of University
Hospitals System in Cleveland.
Our organization includes the largest primary care network
in northeast Ohio composed of specialists, seven urgent care
centers, and five hospitalist programs. 2008 saw 1.2 million
office visits at more than 100 locations in 42 communities,
serving 650,000 patients, and producing more than 1 million
electronic prescriptions.
I am acutely aware of the challenges daily faced by our
primary care physicians. Our model is structured with local
physician authority and responsibility, similar to private
practice, but with the leverage of our organization's
technologies, economies of scale, funded quality programs, and
self-funded malpractice insurance. We are a microcosm of
healthcare delivery in the heartland of our country.
Our overall success, however, masks the daily struggles by
primary care physicians to navigate the complexity of the
healthcare system despite our enhanced resources. Suburban,
rural, and urban populations have a myriad of healthcare
coverages with varying access to services, causing physicians
to spend significant time in unreimbursed activity.
We deal daily with issues of complex healthcare plan
structures interfering with medical decisionmaking, overly
complex regulatory requirements, inadequate reimbursement for
cognitive work and disease management, pressures to practice
defensive medicine, and provision of care to the uninsured or
working poor. These factors discourage medical trainees from
specifically considering primary care careers, and that trend
is compounded by the magnitude of educational loans and the
stresses on earning opportunities in primary care.
Our ideal future State must have seamless access to
coordinated care, utilizing primary and specialty care
providers as well as allied health professionals. This is not a
unidimensional concept. Major public and private wellness
initiatives should become the norm, and this will take years.
Cost reductions will be driven by quality, and outcome-
based bonus payments to providers based on evidence-based
quality and outcome measures. Simpler Federal rules governing
safe harbors are required to encourage the development of real
or virtual delivery networks, such as accountable care
organizations, which would include independent and employed
physician constituencies, hospitals, and other providers, all
incentivized to participate.
There are a number of significant risks to consider as we
restructure. We must not damage what works well, and we must
not disrupt existing doctor-patient relationships. Cutting
costs to pay for reform must not result in the creation of new
shortages in essential services. The concepts will fail without
appropriate technological infrastructure for timely quality and
performance reporting.
The exclusion of physicians and organized medicine from any
component of the planning and implementation process will
severely limit the chance of success. The selection of
appropriate quality measures are always key in making the most
significant impact on cost and outcome. We can't do everything.
In our organization, we were early adopters of e-
prescribing and one of the five national sites selected by CMS
for its demonstration project. We funded an American Diabetes
Association self-management program at six regional sites, in
addition to pursuing recognition for all our primary care
physicians by the National Committee for Quality Assurance,
NCQA, in diabetes. And we recruited six full-time
endocrinologists for the community.
We have opened seven urgent care centers for patients to
access care in a low-cost environment after hours or as an
extension of their physician's office rather than present at an
emergency room, and more complex diagnoses can be done in those
facilities because of the capabilities we have.
Irrespective of the initiatives, primary care disciplines
clearly need help. Multi-year increases in reimbursement with
immediate change in the sustainable growth rate methodology
will avoid reductions in reimbursement and worsening of the
situation. Reimbursement for care management will result in
reduction of admissions to hospital.
Reimbursement methods which recognize realistic practice
costs for physicians and health professionals will avoid the
current situation in reimbursement. The lifting of the Medicare
resident cap and enhancement of Government-sponsored loan
options and loan repayment programs that target primary care
and selected specialists in underserved areas are needed.
Finally, the fundamental issue of healthcare coverage and
its components with methodologies to include all Americans must
be addressed through a combination of existing payers,
employment-based coverage, and expansion of safety net
Government programs.
Thank you again for the opportunity to address you today. I
welcome any questions you may have.
[The prepared statement of Dr. Nochomovitz follows:]
Prepared Statement of Michael Nochomovitz, M.D.
Senator Brown, Ranking Member Enzi and distinguished members of the
committee, it is an honor to speak to you today about the role of
primary and specialty care physicians in current and proposed health
care delivery models. Thank you for inviting me to submit this
testimony.
I am Michael Nochomovitz, the President and Chief Medical Officer
of University Hospitals Medical Practices (UHMP) and its associated
Management Services Organization (UHMSO) in Cleveland, OH.
I am a practicing physician and lead a 450-member multi-specialty
physician network in northeast Ohio. This includes the largest primary
care network in the region, complemented by a diverse group of
specialty practices, seven urgent care centers and five hospitalist
programs.
I have led the development of these organizations through the last
decade. The enterprise has evolved into a regional force that in 2008
provided 1.2 million office visits at more than 100 locations in 42
communities. The network cared for 600,000 patients requiring more than
1 million electronic prescriptions.
I am acutely aware of the challenges primary care physicians face
in attempting to coordinate care and also am cognizant that the optimal
and most cost-effective health care cannot rely on one single specialty
or service.
UHMP is the largest portal of patient entry into the University
Hospitals system and accounts for more than 50 percent of the patients
utilizing system services.
PRIMARY CARE FOCUS
From the outset, primary care has been the foundation of the
organization. There always has been a clear vision of the critical
nature of primary care physicians in the delivery and coordination of
care. This view was unrelated to considerations of health care reform
but rather to the practice of medicine and the vision of University
Hospitals.
The organization has grown largely by merger of key established
primary care practices into the organization in many diverse
communities. Within UHMP, we are fortunate to count numerous examples
of the finest-trained and seasoned physicians in all primary and many
specialty care disciplines. The care provided by our primary care
physicians associated with regional multi-service ambulatory facilities
translates into an exceptionally high level of continuity of care. This
is, indeed, the type of care any of us in this room would want.
LIMITATIONS
Our success does not tell the entire story. Despite the enhanced
infrastructure and resources available to the physicians in our
University Hospitals (UH) system, the challenges of coordinating care
on a daily basis remain formidable. We all are familiar with the
patchwork of components that make up our current health care system and
the potential obstacles to patient and physician satisfaction. Our
organization spans northeast Ohio and includes suburban, rural and
urban locations each with varying levels of access to the full scope of
physician and allied health services. In the best situations, there are
still significant limitations on physicians who seek to provide
comprehensive services and continuity of care. The limitations include
our overly complex administrative and payer system, inadequate payer
recognition for cognitive work of primary care physicians, pressures to
practice defensive medicine, a shortage of new primary care providers
to replace the mature workforce, and the challenge of providing
necessary care to the uninsured and the working poor.
The lessons learned from our specific experience are cogent, as our
model, despite physician employment, has unique features to meet
physician and local community needs. Our model gives the local
community primary care physicians unique authority and responsibility
for managing their practices and staff in a manner akin to private
practice. We utilize our resources to grow these practices, provide the
leverage of the integrated delivery system and ensure replacement for
any attrition. The model is characterized by unusual physician
empowerment and autonomy and has promoted significant physician
engagement and physician satisfaction. Their alignment with University
Hospitals has allowed us to introduce new technology and quality
measures, which would have been impossible in the current private
practice environment. The pressures in recent years on human and
financial capital and lack of leverage with payers have impeded
progress in many ways in traditional models for the majority of
physicians in the United States.
We have a real life experience in diverse communities that
represent a microcosm of regional health care delivery in the heartland
of the country.
THE SCOPE OF AN INTEGRATED DELIVERY SYSTEM
The University Hospitals system was founded upon its academic hub,
University Hospitals Case Medical Center and Rainbow Babies &
Children's Hospital. Its physician network has become the backbone of
this system. These institutions were created more than a century ago to
serve the community and to serve as the teaching and research hospitals
affiliated with the Case Western Reserve University School of Medicine.
Today, UH has expanded to include seven hospitals, which consist of
critical access hospitals, suburban hospitals, a long-term care
hospital and skilled nursing facility, a children's hospital, and a
900-bed adult academic medical center. Currently, UH has two new
hospitals under construction: a free-standing Cancer Hospital and a
community hospital. In addition to the community-based physician
practices, UH also employs its full-time academic physicians, the Case
Western Reserve University School of Medicine faculty, in an integrated
practice plan. These physicians, who include national and international
leaders in their fields, serve the tertiary and quaternary needs of our
regional system at UH Case Medical Center. This tertiary and quaternary
component is a critical part of the ultimate continuity of care to
which we all aspire.
THE MEDICAL HOME CONCEPT
Many hearings have addressed the glaring gaps and weaknesses in
health care coverage in our country, as well as the dislocation and
fractionation of care that many citizens experience, whether insured or
uninsured. The idea of continuity of care provided through a Medical
Home with access and comprehensive services is under substantial
discussion. These concepts cannot be grounded in jargon, but need to
address the substance of patient care delivered appropriately in an
evidence-based fashion in the appropriate setting for an affordable
cost. The Medical Home is likely to be a methodology within a more
global approach to continuity of care.
HEALTH CARE REFORM: QUALITY OF CARE, COORDINATION OF CARE AND COST
CONTROL
There will be critical success factors to change the direction of
health care in the decades to come. Some of the critical success
factors include:
Wellness
It is a truism that our health care must be grounded in the
lifelong pursuit of wellness and prevention.\1\ The latter
realistically is a more difficult long-term challenge as it involves
population behavioral change. Major impacts on population behavior will
require both public and private programs to promote wellness as an
integral part of our society. Incentives for employers to promote
wellness in the workplace will need to be instituted.
---------------------------------------------------------------------------
\1\ Ross DeVol and Armen Bedroussian, et al., An Unhealthy America:
The Economic Burden of Chronic Disease, The Milken Institute, 2007: 4-
5.
---------------------------------------------------------------------------
The Role of Primary Care
It is on this background that primary care providers evaluate
symptoms and abnormal findings for evaluation and diagnosis.
Subsequently, the best treatment will result in either cure or the
transition into chronic disease management. The latter accounts for a
significant percentage of our health care costs and offers the most
opportunity for the care coordination provided access to the necessary
resources are made available and reimbursement for care management is
provided in an unequivocal manner.\2\
---------------------------------------------------------------------------
\2\ Ibid, 184.
---------------------------------------------------------------------------
It should be apparent that this ideal State will not be
unidimensional and will require a multi-disciplinary approach that
involves access to coordinated, convenient, affordable and humanistic
care for an array of medical providers. These will include primary care
physicians, specialists, and a wide variety of allied health
professionals who cover the entire spectrum of care from cradle to
grave.
Structures of Care Delivery
There will not be one solution that meets the needs of every
community and all constituencies of patients and providers.
We will need to create vehicles for integrated care that could
affect the necessary changes in all our communities. These would
provide opportunities for participating providers to be eligible for
quality and outcome-based bonus payments as well as benefit from more
global savings. Accountable Care Organizations (ACO) and existing
structures such as integrated delivery systems could be empowered to
manage the continuum of care.
The consolidation of health care in recent years could turn out to
be a distinct advantage in many communities in terms of building on
existing infrastructures to deliver coordinated care. Further modeling
will no doubt result in a variety of unique public and private vehicles
which would be evaluated in demonstration projects. In some areas we
should anticipate a growth in community health centers, and an
expansion of the National Health Service Corps locations, as well as
the optimal use of the Veterans Administration Health System and the
Indian Health Service.
There are a number of significant risks that must be called out:
We must not damage what already is working well.
We must not remove patient choice or disrupt existing
doctor patient relationships.
All physicians should have an opportunity to participate
on the basis of standards to be determined.
The imperative of cutting costs to pay for reform could
result in creating new shortages.\3\
---------------------------------------------------------------------------
\3\ Elliott Fisher, M.D., MPH, ``Building a Medical Neighborhood
for the Medical Home,'' New England Journal of Medicine 359 : (2008)
1202-5.
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The infrastructure for quality and performance reporting
will likely be more expensive and challenging in implementation than
predicted.
The reporting methodology for quality measures must be
timely and accurate.
Health care is a local phenomenon and there will be unique
regional and community specific challenges, which may or may not be
associated with cost-differentials.
The cost to expand coverage may exceed the projected
savings in the early years.
The exclusion of physicians from any component of the
planning implementation process is likely to limit the effectiveness of
implementation.
LESSONS LEARNED FROM THE UHMP EXPERIENCE: MAKING CHOICES
In our own experience, we have created a large, regional network
built mostly on aligning the best physicians in local communities who
were previously in traditional private practice. We have taken these
physician practices empowered them to succeed by investing in an
enhanced infrastructure and the ability to introduce new technologies,
quality measures and outcome evaluation which would not have been
possible in their former States.
Over the last few years despite the presence of incentives we have
chosen to make significant expenditures to position the physicians in
their local communities for quality measurement and outcome evaluation.
In a growing organization which was merging physicians from the private
practice environment we were required to make choices to achieve in our
mind the maximum impact on patient care.
The following were areas of focus:
a. Electronic Prescribing
We targeted electronic prescribing 5 years ago, as the most useful
technology for a primary care physician office. We were early adopters
long before health information technology incentives were a reality.
Indeed, we created our own incentives by affording those physicians who
utilized e-prescribing a discount on their malpractice insurance. The
cost was borne by UH because we felt that it was a critical technology
to enhance quality of patient care. We subsequently were one of the
five national sites selected by CMS for the e-prescribing demonstration
project to develop foundation standards for the current program. In the
past year our physicians submitted more than 1 million electronic
prescriptions and the number continues to grow. This has greatly
increased patient satisfaction and assured increased awareness of drug
interaction and oversight on dosage and compliance.
b. Chronic Disease Management: Diabetes
We also embarked on an ambitious program targeting diabetic care as
a prototype for chronic disease management. We funded the necessary
initiatives for the following components:
Adopted the American Diabetes Association Diabetes Self
Management Programs.--We obtained ADA certification for six regional
locations to deliver educational/instructional programs with diabetic
nurse educators working closely with primary care physicians and
endocrinologists. Particularly in the management of diabetes, there is
a need for collaboration among primary care providers, specialists and
allied health professionals. We have recruited six full-time
endocrinologists to our network to provide the specialty services
needed by the primary care physicians and their patients, and to
complement the work of diabetic nurse educators, podiatrists,
nutritionists and other professionals. This is an excellent example of
what some might call a ``Medical Home'' for diabetic patients and it
relates to the establishment of an appropriate continuity of care for
diabetic patients in any setting or structure.
National Committee for Quality Assurance (NCQA).--We have
systematically worked with our adult primary care physicians to obtain
recognition from NCQA for diabetic care. This was achieved through an
extended and ongoing educational program for physicians and their
staffs. We hired additional staff to audit medical records through our
document imaging system which has been an outstanding transitional
modality for establishing a paperless workflow and preparing physicians
and practices for our new University Hospitals electronic medical
records.
c. Alternative Sites of Care
Urgent Care Centers.--UH has established a total of seven
regionally based Urgent Care centers to provide care for patients who
need urgent but not emergent care in convenient locations, as well as
care after regular hours. We have instituted a national model for an
urgent care Fellowship program. This is done in collaboration with the
Department of Family Medicine at Case Western Reserve University at
University Hospitals Case Medical Center.
These regionally based centers serve as an extension of the primary
care physicians' office as well as a site where non-emergent
presentations are evaluated in a more sophisticated fashion and at
lower cost than an emergency department.
We have introduced a variety of system-wide protocols that can be
delivered in this low-cost environment. These include management of
dehydration, asthma, fracture care, minor trauma as well as a protocol
for chest pain which includes measuring serum troponins, a diagnostic
indicator for heart attacks, which may be positive in the presence of a
normal EKG. We also are able to rule out other serious conditions like
pulmonary embolism with the appropriate care paths established.
RETAIL CLINICS
We also are investigating and evaluating the prospects for retail
clinics staffed by nurse practitioners linked directly to our urgent
care centers for both incidental care and work-related health care. As
more payers recognize this environment as a site of care, there should
be ongoing reporting of the outcomes of this model and its cost-
effectiveness as part of a broader continuum.
PRIMARY AND SPECIALTY CARE NEEDS
The primary care disciplines do need help. They will be the
backbone of any cost-effective health system provided they have the
resources to provide necessary care for their patients. There are also
specific specialty shortages that significantly impact the provision of
cost-effective care in our communities.
Support for these deficiencies could come in a variety of methods
including:
a. Increase reimbursement for primary care physicians, with
appropriate change to the Medicare SGR methodology. Increases in
reimbursement must be guaranteed as increments to the current base over
the next number of years and not be subject to SGR-related cuts. The
methodology must recognize realistic practice costs for physicians and
other health professionals. These increases should not be at the
expense of other physicians' reimbursement.
b. Reimbursement for care coordination and management for selected
chronic disease beyond the confines of the office encounter and the
acute hospitalization.
c. Lift and expand the Medicare resident cap, established in 1998.
Achieving an increase in the physician supply requires lifting
residency training caps as well as increasing medical school
enrollment.
d. Enhance government-sponsored loan options and loan repayment
programs to increase the supply and retention of primary care
physicians, nurses, mid-level providers and practitioners who will be
critical in ensuring better coordination of patient care. Loan
forgiveness should be offered in exchange for true long-term commitment
to primary care practice in any location.
e. Early identification of medical students interested in primary
and selected specialty care that could make long-term commitments to a
clinical career. Increase funding for the National Health Service Corps
(NHSC). The number of NHSC awards should be increased by at least 1,500
per year to help more physicians practice in underserved areas while
enabling more new physicians to practice primary care.
INTEGRATED CARE DELIVERY
It is necessary to reiterate the paradox that for those in a stable
health care delivery environment in the United States, we have arguably
the most advanced and refined health care in the world. The lack of
uniformity, the exclusion of many and the spiraling costs are mandating
change for what is not sustainable.
Medicine does not have simple metrics and most complex conditions
are multi-
factorial. The current luxury and advantage derived by those who have
access to strong stable and supported primary care would be an
important component of our health care reform but not a sole solution.
We must target the development of a new ``Continuum of Care for
America'' which would achieve the goals of necessary care for all our
citizens and optimal utilization of resources while maintaining
international leadership in specialty innovation and advancements.
This approach could include concepts such as value-based
purchasing, bundling of hospital and physician payments, and
Accountable Care Organizations (ACO). Each of these efforts would need
to be substantiated with voluntary demonstration projects for
validation before any system-wide expansion. The substantive background
for many relates to the commonsense components of access, prevention,
acute care management, chronic disease coordination and prudent use of
the full spectrum of specialty services needed to practice evidence-
based medicine and meet the needs of our patients.
Remove legal and regulatory impediments to delivering coordinated
care:
a. Make targeted changes to laws and regulations to allow
physicians, hospitals and others to work together as teams, and to be
able to use financial incentives to reduce cost and improve care.
b. Establish a simpler, consistent set of Federal rules for how
hospitals, physicians and others may structure their financial and
contractual relationships.
c. Provide clearer guidelines under Federal antitrust law to enable
clinical integration and joint hospital-physician contracting with
payers to ensure aligned performance incentives and to facilitate
continuity of care, particularly in light of electronic health record
technology.
d. Provide a simple and meaningful ``safe harbor'' under Federal
laws and regulations to encourage the development of real or virtual
delivery ``networks'' (such as Accountable Care Organizations).
e. Ensure HIPAA continues to enable providers to share information
to enable patients to receive higher quality, safer care.
Misunderstanding HIPAA requirements has led to reluctance among
providers to share information, even though doing so is in the best
interest of patient care.
There are numerous critical success factors for the massive
undertaking of health care reform. In recent days, numerous major
provider organizations and associations have petitioned our
congressional leaders with their concepts and concerns relating to
health care reform implementation.
As these ideas relate to primary and specialty physicians, there
are a number of key recommendations that I will highlight.
1. Ensure health care coverage for all Americans through a
combination of existing payers, employment-based coverage, and
expansion of safety-net government programs.
2. Drive the introduction of physician and patient-friendly
technologies to facilitate care and the physician practice environment.
3. Drive cost-reduction through evidence-based quality and outcome
measures, which are established through federally sanctioned quality
organizations, national specialty societies and organized medicine.
4. Eliminate unnecessary administrative complexity and cost through
the establishment of uniform, interoperable technologies that promote
both clinical and administrative data-sharing.
5. Reduce the impact of malpractice claims on defensive medicine
through Federal tort reform.
Thank you again for the opportunity to address you today. I welcome
any questions you may have.
Senator Brown. Thank you very much, Dr. Nochomovitz.
Dr. Raulerson, your testimony? Thank you.
STATEMENT OF MARSHA RAULERSON, M.D., FAAP, PRIMARY CARE
PEDIATRICIAN, ON BEHALF OF THE AMERICAN ACADEMY OF PEDIATRICS,
BREWTON, AL
Dr. Raulerson. Yes, thank you, Senator Brown. And I thank
you so much for the opportunity to testify before this
committee.
I am Marsha Raulerson. I am a pediatrician, and I am
representing the American Academy of Pediatrics, an
organization of over 60,000 primary care pediatricians,
pediatric medical subspecialists, and pediatric surgical
specialists. We are all dedicated to the health, safety, and
well-being of infants, children, adolescents, and young adults.
I am a pediatrician. I have been in private practice in the
same town for my entire career--Brewton, AL. It is a town of
approximately 10,000 people in the pine forests in beautiful
lower AL.
The closest large city is Pensacola, FL, which is over 60
miles away and not in my State. The closest children's hospital
is in Mobile, AL, which is over 90 miles away, and our large
children's hospital for the State of Alabama is in Birmingham,
200 miles from my home where I practice.
So I want to talk to you a little bit about what it is like
to be a primary care doctor in a rural area with no
subspecialists close by. Seventy percent of my practice is
Medicaid, about 25 percent private insurance, and about 5
percent Children's Health Insurance Program.
In 2006, my practice did not break even for the first time.
At that time, I lost my office manager, who went back to school
to become a nurse because I could not pay her an adequate
salary. I lost my head nurse because I could no longer pay her.
And my own salary was less than the physician's assistant who
has worked with me for the last 6 years, and I knew that I had
to make some changes.
I had been able to change to a rural health clinic, but it
took 1\1/2\ years to do the paperwork and work through the
Government regulations to become a certified rural health
clinic, which I finally was able to do in July 2007 and, once
again, have a viable practice that could pay for the services
that we needed to run an office seeing approximately 2,000
children a year from a large rural area in lower Alabama.
I want to tell you a little bit about what it is like to
have a medical home. I was very fortunate when I started my
training as a pediatrician. The medical home concept was just
starting. It started with an idea of providing comprehensive,
coordinated care to children with special healthcare needs, and
that is what I learned at the University of Florida.
But as the concept has developed, the medical home, as
aspired to by the American Academy of Pediatrics, is not just a
place, but it is a coordinated effort led by a physician to
provide the best care for all children, adolescents, and young
adults. So that they get not only care for illnesses when they
are acute or chronic illnesses, but they also get the
preventive care that they need to be healthy adults.
You know, most adult diseases start in childhood, and we
feel that it is our responsibility to try to prevent many
diseases that adults have.
I want to tell you about a few of my patients. I work very
closely with specialists in pediatric care in Mobile and in
Birmingham.
Several years ago, a cardiologist from Mobile called to
tell me about a young girl who lived in a small rural area
north of me about 30 miles who was dying of congenital heart
disease. He said she was a beautiful child. He had done
everything that he could for her. She needed some special
surgery that could only be done in one place in the United
States, and he got a door slammed in his face when he tried to
refer her there.
The problem was she had Medicaid. She had no other private
insurance. She needed to go to San Francisco to have a very
special procedure done by a cardiac surgeon who specialized in
children.
I was president of my State pediatric chapter at that time,
and I called the chapter president in California, discussed
this child with her. She got very excited about it and said she
knew the surgeon and she knew that he would want to do the
surgery.
Her cardiologist in Oakland Children's Hospital called me,
and he got the records from Dr. Mayer in Mobile. Soon the
community raised the money to send the child and her parents to
California, where she had the surgery, and the surgery was
performed at Oakland Children's Hospital. She was there for 3
weeks, came home, and has not been hospitalized since. That was
4 years ago.
She still has a lot of chronic problems, but she is pink.
She is no longer blue, suffering from severe congenital heart
disease.
Also, as my practice has aged, I have taken on more and
more children with chronic health problems who live in rural
Alabama. I have two children in my practice with heart
transplants. One of them born with congenital heart disease,
and the second one had a virus that destroyed his heart when he
was a year old.
I manage these patients with the help of pediatric surgeons
and cardiologists in Birmingham, 200 miles away. My feeling is
that the medical home should be able to coordinate the care of
all the children in our area, that we should have access to
specialists. There are some specialists that I can't reach.
Pediatric psychiatry is one of those areas. So 5 years ago,
Dr. Vaughan, a full professor of children's psychiatry at UAB
in Birmingham, and I began to work on a telemedicine project
where he sees approximately 15 children a month with serious
psychiatric illness from rural Alabama through telemedicine.
He e-mails me immediately his workup. I write the
prescriptions. I coordinate the counseling services through our
local mental health. Also, most of the children in my practice
have to receive part of their healthcare at school because that
is where they are. They spend their day at school.
Just yesterday, I wrote three care plans for school nurses
who live in two different cities in my area--medications and
what to do if the child has a problem or has a seizure at
school. Two of the children have asthma, and one of them has
insulin-dependent diabetes. So I work on those care plans, and
at least once or twice a week, I talk with school nurses.
Another thing that I do in coordinating the care of
patients, which I think is important, is I conference not only
with school nurses, mental health workers, and other people
like this, I also have to have time spent with the parents when
the child is not there. And are you aware that we are not paid
for that time?
This week, already I have had conferences with three sets
of parents. One of the mothers came in because we had
discovered as her child was going through puberty that she was
developing a significant chest wall deformity. I referred her
to a pediatric surgeon in Birmingham. He saw the child and said
that she was going to need a number of things, and he sent
paperwork to the mother.
The mother came to my office, and we sat down and went
through the child's chart and wrote down every illness that she
had had since birth. And then the mother began to talk about
the problems she was having with her teenage rebellion and the
fact that her chest wall deformity was causing a lot of social
problems and things that she was even more concerned about,
that the child had no friends at school. She came home at night
and went in her room and shut the door.
Mom and I spent a long time talking about that child's
emotional well-being and some services that we could find in
the local community to help her right away. When the mother
left, she told my receptionist, ``This is the best office visit
I have ever had. I need to come by myself more often.''
The problem is pediatricians are not paid to see parents
and conference with them, and I have had three of those
conferences this week. With the medical home, there needs to be
a different way of paying for services. There needs to be a way
for us to coordinate the care of our patients and work with our
subspecialists that are available to us to provide for the
child the best care that that child can receive.
I have to also speak about the problems with workforce,
which has already been raised here. There are not enough
primary care pediatricians for every rural community like mine
in the Nation. And perhaps there never will be.
But I have difficulty, when a child has a seizure disorder,
finding a pediatric neurologist who can see that child now and
not 6 months from now. When I have a child who has some form of
arthritis, and I have several of those in my practice, there is
only one pediatric rheumatologist in my State, and getting an
appointment there is very difficult.
Also, one of the other problems that we have, we do not
have mass transportation in Alabama. I have to also work the
transportation system to see that my child who has an illness
and his family can get 200 miles one way to Birmingham.
I also have to take care of children when they come home
from those tertiary care centers and they get in trouble. Last
year, we had a newborn who came to our office, who was seen by
my physician's assistant.
She came and grabbed me and said, ``Come, see this baby.
Something is terribly wrong. Mom says her stomach doesn't look
right.'' I went in and palpated the little baby's belly and
felt a huge mass in her stomach. We immediately got an
ultrasound that showed she had a liver tumor.
I called the surgeon in Birmingham. He said, ``Send her
now.'' And I said, ``Well, it is Friday afternoon. Do you
really want her on Friday afternoon?'' ``Well, not really on a
Friday afternoon.''
So mother made arrangements to take a leave of absence from
her teaching assistant's job and on Monday morning traveled to
Birmingham, where the diagnosis was made of a hepatoblastoma,
which is a type of liver cancer. This beautiful little baby
underwent treatment for the next year. She had radiation
therapy. She had chemotherapy, and then she had surgery and
removal of the tumor.
I saw her 2 weeks ago, and she has hair for the first time
in her life. And we are so proud that she is doing well.
Well, why did I mention this child? She got the most
significant care that I could not give her at a wonderful
children's hospital 200 miles away. But when she came home and
her central line got infected, I was the first person to see
her, to diagnose this, to stabilize her, and send her away.
When my heart transplant patient last summer came in trying
to die from hemolytic uremic syndrome that we thought how could
somebody with a heart transplant have this other horrible
disease? It turned out to be a reaction to one of the rejection
drugs that he was receiving for his transplant.
I had to type and cross him in my rural hospital and get
blood hanging to save that child's life and then send him by
helicopter to Birmingham.
That is what it is like to be a rural physician. But I
could not do it if I did not have my specialists--that they
were not available to me by e-mail or by telephone--in an
emergency situation.
I thank you very much for letting me testify, and I would
be glad to answer any questions about what the medical home
means to me as a primary care physician.
Thank you.
[The prepared statement of Dr. Raulerson follows:]
Prepared Statement of Marsha Raulerson, M.D., FAAP
Good morning. I appreciate this opportunity to testify today before
the Committee on Health, Education, Labor, and Pensions on Primary and
Specialty Care. My name is Marsha Raulerson, M.D., FAAP, and I am proud
to represent the American Academy of Pediatrics (AAP), a non-profit
professional organization of 60,000 primary care pediatricians,
pediatric medical sub-specialists, and pediatric surgical specialists
dedicated to the health, safety, and well-being of infants, children,
adolescents, and young adults.
I am a pediatrician in private practice in Brewton, AL; I serve as
a member of the AAP's Committee on Federal Government Affairs. I have
been taking care of children and adolescents in Brewton since 1981. In
the 2000 census, Brewton had a population of 5,498. The largest close
city is Pensacola, FL and the closest Alabama hospital specializing in
children is 90 miles away in Mobile. Brewton is located in the piney
woods of Alabama and its major industry is pulp wood. My practice,
Lower Alabama Pediatrics, is 70 percent Medicaid and we do our best to
provide a medical home to all of the children we can reach.
In 2006, I did not break even in my practice because Medicaid
patients require so many services and payments are so low. I had to dip
into my own savings to keep my practice afloat. Nevertheless, I believe
that I have a calling to provide these services to this population,
many of whom are children who have severe and long lasting health
needs. I have since converted my practice to a rural health clinic.
WHAT IS A MEDICAL HOME?
AAP believes that every child, regardless of health status, should
have a medical home. A medical home is a place, a process and people
who partner to improve health outcomes and the quality of life for
children and families. In a medical home, care is delivered or directed
by competent, well-trained physicians who provide primary care,
managing and facilitating all aspects of pediatric care: preventive,
acute and chronic. The Academy has led the development of a body of
literature surrounding the medical home, including dozens of studies
that examine the impact of care coordination on patient outcomes.\1\
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\1\ The U.S. Department of Health and Human Services' Healthy
People 2010 goals and objectives state that ``all children with special
health care needs will receive regular ongoing comprehensive care
within a medical home,'' and multiple Federal programs require that all
children have access to an ongoing source of health care.
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Children and adolescents deserve a high performance health care
system that includes medical homes to promote system-wide quality with
optimal health outcomes, family satisfaction, and value. A medical home
offers families full service high quality health care and provides
comprehensive, coordinated, compassionate, culturally competent care
for children.
HISTORY OF MEDICAL HOME
The Academy first pioneered the concept of the medical home in the
1960's as a way to describe the ``gold standard'' of primary care for
children--particularly children with special health care needs.
In March 2007, the AAP joined with the American Academy of Family
Physicians, American College of Physicians and the American Osteopathic
Association to publish a set of joint principles for the patient-
centered medical home. This consensus statement describes the
principles of a patient-centered medical home: personal physician,
physician-directed medical practice, whole person orientation,
coordinated care, quality and safety, enhanced access, and appropriate
payment. In addition to these important concepts, the specific needs of
pediatric populations also include:
Family-centered partnership: A medical home provides
family-centered care through a trusting, collaborative, working
partnership with families, respecting their diversity and recognizing
that they are the constant in a child's life.
Community-based system: The medical home is an integral
part of the community-based system. As such, the medical home works
with a coordinated team, provides ongoing primary care, and facilitates
access to and coordinates with, a broad range of specialty and related
community services.
Transitions: The goal of transitions is to optimize life-
long health and well-being and potential through the provision of high-
quality, developmentally appropriate, health care services that
continue uninterrupted as the individual moves along and within systems
of services from adolescence to adulthood.
Value and Payment: To assure optimal quality of care for
all children, the health system must provide appropriate payment for
medical home services. A high-performance health care system requires
appropriate financing to support and sustain medical homes that promote
system-wide quality care with optimal health outcomes, family
satisfaction, and cost efficiency.
MAKING A MEDICAL HOME AVAILABLE TO ALL CHILDREN: FINANCING THE
MEDICAL HOME
Medical homes do not just happen. Transforming a medical practice
into a medical home has been described as trying to rebuild a bicycle
while riding it. But change cannot just be limited to the willingness
of the doctor--everyone in the health care system has a role to play.
Thus, AAP calls for partnerships among private and public payers,
employers, clinicians, and families and patients to ensure that medical
home payment reforms are implemented in ways that assure quality,
financial sustainability, and equity among payers and providers that
assure children and youth receive all recommended and needed services.
These reforms should be based on the medical home joint principles
and the payment structure should encompass recognition of relevant
payment codes, expanded care coordination responsibility, new quality
improvement activities, and up-front investments and support for
infrastructure. AAP recommends the following:
All private and public payers should adopt a
comprehensive set of medical home payment reforms that include three
components:
A contact or visit-based fee component that
recognizes and values evaluative/cognitive services and also
preventive counseling based upon Bright Futures.
A care coordination fee to cover physician and non-
physician clinical and administrative staff work (telephone
care, on-line communication, conferences with the ``care
team'') linked to the delivery of medical home services.
A performance or pay-for-performance fee for
evidence-based process, structure, or outcome measures and paid
as a bonus. This bonus should take into consideration the
complexity of the patients who are in the panel of the
practice. In return for this bonus, physicians should assist
payers in addressing such cost centers as emergency department
utilization and unnecessary hospitalization.
Vaccines and their administration costs must be adequately
paid for to exceed total direct and indirect expenses and updated when
new vaccines are adopted into recommended schedules or when vaccine
prices increase.
Payments should be closely tied to evidence-informed
medicine, and methods used for payment should consider the child's age,
chronicity, and severity of underlying problems, and geographic
adjustment.
Payment policies should recognize and reward systems of
care that promote continuous and coordinated care ``24/7'', including
care coordinated between generalists and specialists, population-based
prevention, and should discourage the use of clinics that provide
episodic care only for minor conditions.
Competition should be structured so that practices are
rewarded for providing access, service, and quality; cheaper care is
probably not better care.
The Centers for Medicare and Medicaid Services should
update the Resource-Based Relative Value Scale to take into account the
value of the complex and comprehensive nature of cognitive care and
practice expenses associated with the medical home model of care,
provide health information technology support, and create incentives
for continuous quality improvement.
Congress should sponsor ongoing, large-scale Medicaid
medical home pilot projects for children and youth. It should also
support an all-payer pilot project of the medical home model for
children and youth. Congress should evaluate current State Medicaid and
CHIP programs and share information among the States about State
programs that are providing good medical homes for children.
MAKING A MEDICAL HOME AVAILABLE TO ALL CHILDREN: ENSURING SUFFICIENT
WORKFORCE TO MEET CHILDREN'S NEEDS
Meeting the health needs of America's 80 million infants, children,
adolescents, and young adults and providing them with a medical home
will require a strong and stable pediatrician workforce comprised of
appropriate numbers of well-trained pediatricians, pediatric medical
subspecialists, pediatric surgical specialists, and other child health
professionals and specialist physicians. Moreover these professionals
will be needed where children are--in all rural, suburban and urban
communities.
Workforce shortages exist in pediatric medical subspecialties and
pediatric surgical specialties. I previously stated that the nearest
locus of comprehensive specialty care is 90 miles away. This specialty
shortage has real impacts in my community and in urban areas as well.
Initiatives are needed to recruit medical students and residents into
specific pediatric disciplines and to underserved geographic regions.
These initiatives must address the comprehensive needs of children and
adolescents.
Federal policies should address and improve the uneven geographic
distribution of the physician workforce, including pediatrics, enhance
the delivery of culturally effective health care and include mechanisms
to educate and train an appropriate supply of pediatric medical
subspecialists and pediatric surgical specialists.
Congress should consider the extension of student-loan deferment
until the completion of residency education, and make educational loans
tax deductible. In addition, federally sponsored student loan deferment
and forgiveness programs and other incentives for residents and
pediatricians should be expanded to ensure a health care workforce that
is adequate to meet patients' needs. These incentives also should
support pediatricians pursuing academic research careers or practicing
in designated underserved communities.
CONCLUSION
In conclusion, on behalf of the American Academy of Pediatrics and
the children and adolescents I take care of in Alabama, I would like to
urge the committee to keep children foremost in mind while you consider
reforms to our health care system. This is a unique moment on our
country's history and an opportunity for us to finally place children
first.
Providing all children with health care designed for them--a
medical home--that emphasizes their healthy development and prevents
illness when possible is an investment in our country's future. This
investment coupled with needed improvements in health care financing
and a strong primary and specialty workforce will provide all children
and adolescents the greatest chance to lead long and healthy lives.
Thank you again for the opportunity to testify. I look forward to
your questions.
Senator Brown. Thank you, Dr. Raulerson.
My guess is you know the names of most of the 10,000 people
in Brewton, AL. So thank you.
I want to ask one question that all of you take a shot at,
and then I will turn it to Senator Murray for her questions.
Then I will come back and ask each of you some specific
questions.
The one question generally is, as we discuss--and I will
just start with you, Dr. Thorpe, and work your way down, and
each take a couple of minutes to answer it, if you would. As we
work on healthcare reform and we look at the inefficiencies
that you all pointed out very well, I thought, the
inefficiencies of having some Americans insured and others
uninsured, talk through, if you would, how or if ensuring that
every American has meaningful health coverage will have an
impact on the efficiency of this system.
How covering everybody will increase the efficiency. How do
we make that happen? And Dr. Thorpe, if you would start?
Mr. Thorpe. Covering everybody is certainly a necessary
condition to make the system work efficiently, both in terms of
the premium base. So if we can change the whole nature of how
health plans set premiums and how competition in the health
insurance market works and move it away from competing on risk
selection to have it compete on better metrics like outcomes
and cost, that is a step in the right direction.
So I think there is no question that we need to move to
universal coverage in order to increase and improve the
functioning of the health insurance system.
On the care delivery system, one of the problems that we
face with uninsured folks is that they come to the system too
late and at the wrong time, at the wrong place. And so, to the
extent that we have a system in place that is more geared
toward early diagnosis, early detection, and then appropriate
treatment in the right setting, that is also a plus.
So we know from all kinds of data internationally that
early detection and primary care, getting to patients earlier
to prevent disease, and if they are sick, getting treatment to
them earlier makes a big difference in terms of their
healthcare outcomes.
Senator Brown. Dr. Cooper. Oh, I am sorry.
Mr. Thorpe. Just in closing, again, as I started out, I
think our challenge here is that we have a system that works in
thousands of unconnected silos. And I use Medicare as sort of
an opening to try to make a change here, but the type of model
I am talking about really applies to everybody. It is not just
a Medicare model. It is a model that we should have for all
Americans, and it is one that really is building integration in
the system between care coordination, primary care physicians,
specialists, hospitals, and community-based resources. I think
healthcare reform can play a major role in building those
integrated links that you have heard that are not as functional
today as they could be.
Senator Brown. Thank you.
Dr. Cooper.
Dr. Cooper. Well, I won't repeat what Dr. Thorpe said. I
think it is well appreciated that insuring everyone is a matter
of fairness, and it will have its major effect on efficiency at
sort of the--picture a pyramid, a pyramid where there is a lot
of very inefficient early care, and patients who aren't insured
don't have access easily to that care.
But as the pyramid goes up, utilization goes down because
there are a lot of relatively healthy people or people who
aren't very sick who need care. But they don't use a lot of
resources.
There are very few people at the top, but then it is an
inverted pyramid. The people at the top who are the sickest use
the most resources.
There is an overlap because the people at the top who use
the most resources of all are poor. Many poor people are
uninsured. And so, one has to sort of differentiate in this
notion of adding efficiency or what causes inefficiency,
uninsurance and poverty.
The major source of inefficiency--and I hate to apply that
particular word to this circumstance, but the major source of
inefficiency is poverty. Poor people, as low as 15 percent on
the economic scale, use double the healthcare resources that
more affluent people do.
They are the people who are re-admitted. That is
inefficiency. And they are the people who have recurrence of
disease, and that is inefficient. The real inefficiency is the
disorganized life and health and care among the poor.
So, yes, have expectations that insurance will add fairness
to the system and will spread the responsibility for costs more
fairly. All of that is very important for efficiency. But the
real inefficiency, if it all was perfect in every other way, if
we had an absolute single- payer system and everybody was the
same, the poverty problem won't disappear. And that is the
major inefficiency in healthcare today.
That has to be addressed in some of the ways that we heard
in rural areas and others, systems that cope specifically with
the poor. It is not going to be through physicians alone. But
poverty is the major source of inefficiency.
Senator Brown. Thank you, Dr. Cooper.
Dr. Schlossberg.
Dr. Schlossberg. Yes, thank you, Senator Brown.
I think the inefficiency--as you call it, and certainly if
we fix the financing mechanism--I don't think we will
necessarily fix the inefficiency through the system because I
think, just as Dr. Raulerson said, all of us experience the
hassle factor. It took her 2 years to bring up the rural health
clinic.
We all suffer from a system where you walk into the office,
you buy the service, and somebody tells you 60 days later how
much you are going to get paid, if you are going to get paid,
and what is going on. As we think about fixing the system and
doing the financing, there are probably some other things we
should do as well, which is maybe real-time adjudication for
insurance reform when a patient walks in the door.
Certainly, as specialists, we don't want to see end-stage
disease. It is a lot more work for all of us. It is terrible
for the patient. And so, I think getting people in earlier is
also helpful.
I think the other thing--as I see it, and I experienced it
this weekend when I was on call--is I don't see much
conversation about personal responsibility for all of us.
I think of it as healthcare being a right, but we should
treat it as a privilege. And when people have a privilege, they
protect it. I don't hear that conversation in Washington. Maybe
that is a difficult political conversation?
This weekend, I was on call, and there was an older
gentleman. He was a Medicare patient who, unfortunately, has
bad bladder cancer. One of my partners operated on him, and his
right kidney is blocked. So he has got a tube in his back. And
as it just so happens, he can't urinate. So he is going to have
a tube in his bladder with two bags.
And the daughter was in the room, and somebody said,
``Well, home health will not take him with two bags. That is
their rules.'' So, therefore, he has to stay in the hospital.
So I turned to the daughter, and I said, ``What do you
think? '' I looked at both of them, and I said, ``What do you
think? '' They said, ``No, we can take care of this. We are
going to go home.''
Well, they were responsible. They didn't feel the
entitlement, and they were willing to participate in their
care. And I think whether it is through public service or other
things, we need to fix the financing mechanism. We need to
decrease the hassle factor. But ultimately, I think we need to
change the personal responsibility quotient in this country.
Thank you.
Senator Brown. Thank you, Dr. Schlossberg.
Dr. Nochomovitz.
Dr. Nochomovitz. Thank you, Senator Brown.
I think I would make five points as it relates to
inefficiency. As far as the universal coverage is concerned, I
think that that is a matter of public policy, and I agree with
everybody else in terms of its necessity and the fact that we
have reached a point where we just must do that.
One of the major areas of inefficiency can be improved by
administrative simplification. On the payer's side, there could
be uniform documentation and uniform approaches to
credentialing of doctors, to payment procedures, to the method
that payments are made. And technology can really assist from
the doctor's office or from the clinic's office in introducing
that degree of administrative simplification, which is now a
Byzantine collection of potpourri that is very difficult to get
one's arms around.
The third point would be related to information technology,
where true interoperability, which is not easy to achieve,
would prevent duplication of tests. We have a lot of
duplication of tests because people don't know what the patient
has had. And when a doctor sees a patient in the emergency
room, the patient may have had all sorts of diagnostic tests a
week earlier, but they are just not available to the physician.
The fourth point relates to coordination of care, and that
would be different in different communities. This is not a one-
shoe-fits-all issue. Concepts like the medical home certainly
have a place, but it is not a one-shoe-fits-all issue. You have
different issues in coordination of care in rural communities,
as so eloquently described. You have got different issues of
coordination in suburban communities or in urban communities.
I think we need to create the necessary structures and
build on existing structures, whether they be large or small,
incorporating all constituencies to provide this coordination
to create the efficiencies.
And last, one must reiterate that there has to be a focus
on practice guidelines, evidence-based medicine, that we can
stop doing redundant tests. And we need to call upon the
physicians of this country, whether they be in organized
medicine, specialty societies, academic centers, to step
forward and assist us in creating these guidelines that are not
necessarily all available and not necessarily self-evident.
But whatever we do will go a long way toward reducing waste
and improving efficiency and cutting costs.
Senator Brown. Thank you, Dr. Nochomovitz.
Dr. Raulerson.
Dr. Raulerson. I have three points I would like to make.
First, having insurance coverage is not the only thing that you
need. As I mentioned, Alabama has done an excellent job of
covering children through Medicaid, the Children's Health
Insurance Program, and Blue Cross Blue Shield's Caring
Foundation.
But with children in my practice, even with insurance, I
still went in a hole. A lot of it had to do with the way
Medicaid pays and the fact that they would be on again, off
again. And sometimes I would see them for 3 months, and I
wouldn't get paid for those 3 months. And then they would be
back on, and trying to get paid was really a hassle. So that
was a problem.
The second thing, when my patients turn 19, in Alabama,
they lose their Medicaid, and they have no hope of insurance. A
19-year-old who is in school or who has a job at Wal-Mart
cannot afford insurance. And so, I have a lot of 19- and 20-
year-olds in my practice with asthma, with diabetes, with other
kinds of problems, who have no health insurance when they turn
19.
And finally, it is not just the people in poverty because
sometimes an illness makes you in poverty. I have a family in
my practice whose child was born with a problem that she has
outgrown. She is 5. She is starting to kindergarten this year,
and she is a healthy little girl.
But she had a severe, life-threatening disease the first
few months of her life. Her mom, who is a college graduate, had
to quit her job and stay home and take care of her. Her dad,
who is also a college graduate and has a pretty good job, was
trying to pay the health insurance, trying to pay for their
travel to go to Mobile and to go to Boston, where she got some
of her care. And they actually ended up on Medicaid because
they went broke.
And now that she is 5 and doing so well and over her
illness and is going to be a beautiful, healthy child, they are
still paying on medical bills and will be for a very long time.
Senator Brown. Thank you, Dr. Raulerson.
Senator Murray.
Senator Murray. Thank you very much, Mr. Chairman.
An excellent hearing, and I really appreciate all of you
coming and giving us your very important time to help us
understand these issues.
Dr. Cooper, I wanted to ask you, you talk in your testimony
a lot about innovation and how we should deal with both the
long-term and short-term healthcare workforce shortage. I agree
it is really important to make some investments so that we can
have people in the pipeline, but it is going to be a while
before they get there.
So I have a question about the short term. What do we do in
the short term? You talked in your written testimony about
innovative practice arrangements. Can you talk to me about how
you think perhaps other primary care workforce providers, nurse
practitioners, or physician assistants could be helpful?
Dr. Cooper. Well, they are going to be absolutely helpful
and absolutely necessary. And you will hear a lot of
discussion, of course, of whether a physician can do it better
or a nurse practitioner can do it better. And they are
interesting conversations to have, but they become irrelevant
because there aren't enough people.
We don't have that choice. We don't have the opportunity to
choose from column A or column B. We either get column A or
column B.
Not only in primary care, but in specialty care offices,
nurse practitioners and physician assistants (PA) are very
effective in giving and providing the general care of specialty
patients and the vast majority of care that we consider primary
care.
Most acute self-limited disease, wellness, patient
education, prevention, all of those skills are commonplace
among nurse practitioners, and many of them are commonplace
among physician assistants. And increasingly, physicians,
whether they are in generalist or specialist practices, are
seeking to work in consort with a nurse practitioner or a PA to
even urologists or general internists, either one, to do those
tasks that a physician doesn't have to do.
If you put this in a historic context, in the 1920s, 25
percent of healthcare providers were physicians. Now it is
about 7 percent. When I was an intern, the nurses all had pink
stethoscopes, and I couldn't exactly figure out why that was.
They worked just as well as my stethoscope. In fact, I had to
use theirs because mine broke, and I couldn't afford to get a
new one.
Only later did I find out that they were pink because in
the years before I was an intern, the AMA insisted that nurses
couldn't take blood pressures. It was too technical a task. And
therefore, nurses didn't have stethoscopes.
[Laughter.]
You laugh today, but they will laugh 20 years from now
about things we are arguing about today. And so, nurses, of
course, take blood pressures today.
But they couldn't have--it was unacceptable professionally,
politically unacceptable like what we are dealing with. To be
objective about primary care is politically unacceptable. To be
objective today, just as being objective about nurse
practitioners doing blood pressures was politically
unacceptable then.
It has been a moving process, but with the process, the
educational level of those to whom work has been delegated has
risen from nurses to nurse practitioners, now to doctoral-level
programs. From brief training for a physician assistant, to
longer training, to specialty certificates.
We need that workforce. It is not large enough. I didn't
have time in my comments to comment on it. But the number of
nurse practitioners graduated annually has plateaued at about
8,000, up a little bit last year. Unclear where it is going. It
has been that way for more than 5 years. That whole population
of practitioners is aging, and the supply will plateau. The
same for PAs.
The answer is, they play an integral partnership role--that
is No. 1--with a practitioner, generalist or specialist. And in
primary care, in that spectrum of primary care services, they
are quite capable of practicing independently with a collegial
relationship, distant supervision, and accomplishing the vast
quantity of services that otherwise would have to be given by a
physician.
I would view that as a real step in the direction of
efficiency, and we see it, on the one hand, happening and, on
the other hand, being fought back by those just the same ones
who tried to fight back in the 1950s about nurses taking blood
pressure.
But the world is moving, and that is where it is moving,
and that is what they have to do.
Senator Murray. OK. Very helpful.
My time is up, but I just want to mention, Mr. Chairman,
that we do have to look at the short term, and I hope we look
not just at healthcare reform in dealing with these issues, but
in some of the things we already have in place, like graduate
medical education.
We also have the National Health Service Corps that
provides scholarships and loan repayments for doctors and
nurses and healthcare professionals. Dr. Nochomovitz, I think I
saw it in your testimony, talking about the National Health
Service Corps and the importance of that.
I have been working very hard on the Budget Committee to
try and increase those numbers for access to those programs. In
fact, this Administration increased the National Health Service
Corps, too. But those are some of the things I hope we don't
say we will have to wait until healthcare reform passes. We
have got to focus on a lot of this in our current budget and
appropriations process.
But my time is out, and I really appreciate all of your
testimony today.
Thank you.
Senator Brown. Thank you, Senator Murray.
Dr. Cooper, thank you for your answer. I want to pursue
that after Senator Whitehouse.
Senator Whitehouse.
Statement of Senator Whitehouse
Senator Whitehouse. Thank you, Chairman.
This is a happy occasion for me, not just because such a
distinguished panel is here and not just because a fellow
member of my class of 2006 is chairing a significant hearing in
the Senate, but because this is my first opportunity to speak
as a new member of the HELP Committee.
Perhaps a temporary member, I have been warned. But
nevertheless----
[Laughter.]
Nonetheless, happy to be here for that.
Senator Brown. My guess is after Senator Whitehouse's
performance today, we will want him on permanently.
Senator Whitehouse. My timing certainly could not be
better. If you are going to be a temporary member, this is the
time to be a temporary member. And it is a great honor for me
to serve on this committee while Senator Kennedy chairs it,
given his long and distinguished career of interest and
struggle on these issues.
It is a great lesson for a new Senator to see Ranking
Member Enzi and Chairman Kennedy work together on issues. The
HELP Committee has a wonderful model of bipartisan cooperation
that I think is a testament to both of their characters.
Of course, the work ahead of us is daunting. I hope, Dr.
Cooper, that when people look back at the struggles we are
having 20 years from now, they actually laugh and not weep. If
they laugh, we will have succeeded.
This hearing is important. In Rhode Island, we have a story
board that I have put up on my Web site. I do community
dinners, and I go around the State. Rhode Island is a small
enough State I can actually invite pretty much everybody to
dinner.
[Laughter.]
That is a bit of an exaggeration, but we have regular
community dinners. And people come, and they talk about
different issues.
Healthcare is the one that most captivates people because
you have stories like your young lady in Alabama who, through
no fault of her own, became ill as a child. And the result of
that was the bankruptcy of her family. Her family was
financially ruined because of that through no fault of their
own because our system is so poorly managed.
We have hundreds of people who have come in across that
story board and told their stories. And while many of them are
stories that come out of the finance, access, and coverage
failures of our healthcare system, equally as many and, indeed,
I would say probably more come out of the delivery system
failures. And we are really not as experienced yet in getting
our hands around those.
That finance, access, and coverage fight is a mature
political fight here. It goes back to the Clinton struggles of
1993 and 1994. We know less about the delivery system issues.
My question to all of you--just picking out some of the
things that have been said--there has been a reference to the
Byzantine billing and approval systems that be-devil practices
across the country, the need to move from just having equipment
on doctors' desks to true interoperability of HIT and the
establishment of health information exchanges to do that.
About how you establish meaningful guidelines for
practitioners with consequences so they don't just go gather
dust on the shelf someplace, but without getting to the point
where you have Government dictating what medicine should be
practiced or not.
How you cure the interruption of the risk and reward
feedback loop that is the fundamental premise of capitalism and
entrepreneurship, which is broken in the healthcare system,
particularly for quality investments and prevention
investments, where the party who has to take the trouble and
take the risk and put out the funds and retrain their folks and
actually assume the risk of getting it done gets a very small
sliver of whatever the reward is from that.
So we are built in to drastic underinvestment in quality
and prevention unless we fix that. And then there are all the
organizational questions about accountable care organizations
and medical homes and what the different models should be.
Given that array of issues, and I have just touched on a
few that have come up during the course of this hearing, a
question I would like your thoughts on is whether you think
that in our structure of Government right now we have the
authorities and the power in place, the accountability in place
to manage a delivery system reform that has to take all of
those questions on in an interlocking way, because they affect
each other. There are virtuous cycles that emerge, and there
are problems that emerge if it is not done in a consistent way
across many issues.
And if not, and we have had CBO testify that that authority
does not exist in Government, I would like to get you thinking
a little bit about what steps we need to take to make sure we
can manage this transition before the healthcare system finally
falls in around our ears.
Mr. Thorpe. Well, that is quite a macro----
[Laughter.]
Mr. Thorpe [continuing]. But it is a good question. I will
just sort of try to highlight a couple of things. I do think
the good news is that there are good models out there in our
healthcare system today that we should study closely, try to
replicate and scale them. And the lessons from those models,
one is in North Carolina's Medicaid program. One is in the
State of Vermont. One is starting to evolve in your own State--
what Chris Kohler and others are doing in Rhode Island.
The lessons from those models are that if you look at the
successful approaches--the Geisingers, the Mayos, the
Intermountain Healthcares--those are great case studies. Our
challenge is we can't replicate and scale those. We can learn
from why they work and how they work and see if we can't pull
those functions out and start building more integration into
the system.
You build more integration and coordination into the system
by doing two or three things. One is through payment reform. So
you have got to align the financial incentives with the
delivery system incentives. And so, much of what is being
talked about in terms of hospital bundled payments, focusing on
high re-admission rate hospitals really starts to move us down
the path of getting to think about the relationships and the
transitions as patients move from hospitals back into the home
and community and so on.
So I think we have got to change the payment environment.
Senator Whitehouse. I guess my question that I tried to ask
is can you do something like that--can we do it, something like
that just once in a piece of legislation and walk away?
Or is it too dynamic a forward-going environment not to
have to establish some continuing authority that can look at
where the payment is going and moderate it as new things are
learned? That can look at how HIEs are developing and moderate
that as new things are learned that can go through these issues
and not just sit here like a mortar and launch a trajectory
that you know is going to land someplace but understand that it
is a more dynamic environment, and you have to fly it like an
aircraft. And somewhere, somebody has to be doing some
piloting.
Mr. Thorpe. No, I think that is right. I think you have to
focus on the payment side. I think you have got to build, as I
have been talking about, a chronic care infrastructure that
deals with the fact that most of healthcare is balkanized
smaller physician practices. We don't have the types of care
coordination built into our system.
We can do that, and then we can align them with financial
incentives to make a difference. So I think we can go in the
right trajectory, but you need feedback and study and
improvement as you go along the way. So it is not going to be a
one-shot deal, where you just sort of do the legislation and
then walk away and think we have got it done.
One of the----
Senator Whitehouse. Mr. Chairman, I know I am over the time
at this point, and I apologize. And maybe what I should do is
invite anybody who wishes to add to the doctor's remarks to do
so for the record----
Senator Brown. Well, you have as much time as you need. So
if you want everyone to answer, unless you keep interrupting
each one and asking three additional questions of each one.
[Laughter.]
I don't know if he acts like this in his other committees,
but take what you need, Senator Whitehouse.
Senator Whitehouse. I am taking liberties. I am taking
liberties because of my friendship and affection for the
distinguished Senator who is chairing this hearing.
Dr. Cooper. I think you raise a very important issue. And
as I heard you describing it, I couldn't help but think of the
NIH. What the NIH does, it enables. What is very clear is we
don't have the answer. There isn't one answer. And in fact, the
medical home, which barely exists, if we were using medical
effectiveness techniques to evaluate the medical home--I mean,
the medical home is like a new drug that has been tried on four
people.
It is an anecdote that we are now going to have the FDA
approve a drug that was used on four people. So it makes no
sense whatsoever. But it happened to appear, and whatever.
As I commented in my opening remarks, nobody has ever
organized medicine, organized the practice of medicine under
the circumstances that we are entering. That is why there is
all this talk about Marcus Welby primary care because people
know about that from the 1960s. I mean, the students don't even
know about Marcus Welby. It was too long ago.
So the NIH is the example. I would say don't build, but
enable. I would say I don't know how to say this politely. I am
too old to be polite. Get out of the way and let it happen. Let
the hundreds of Geisingers and hundreds of rural communities
and many specialties figure out what to do and learn from
themselves.
You know, medical effectiveness wasn't invented yesterday.
I mean, we have actually, as physicians--you may not believe
this. We have actually been concerned about doing the right
thing.
I mean, there have been textbooks. Osler wrote about how to
do things well. It wasn't called the ``Osler book of medical
effectiveness,'' but that was the authority. We look to those
authorities, Conn's Current Therapy, clinical trials.
I mean, Congress didn't invent medical effectiveness. We
actually--I know this will surprise everyone. We actually have
been concerned about this as long as I have been in medicine,
which is half a century.
So let us do it. Enable us. Fund medical effectiveness.
Fund ways that people can actually do the sorts of things you
heard about in a rural community. Here, I want to do an
experiment in my rural community, but where can I go for the
money for infrastructure, the very thing you refer to in your
comment.
Where can I get some money to see if maybe this would work?
I would have to do it out of my practice funds. No, but if I
could go someplace. And then there would be a clearinghouse, as
there is for the NIH.
I say look to the NIH. If the NIH had done in the 1950s
what is being talked about for healthcare reform today, we
would be a Third World country in medical research.
I think we all have a lesson to learn, and that is, really,
I know it is popular not to trust physicians. They are bad. You
can succeed in life by saying physicians churn the system and
so forth. Honestly, we are not all that bad. We are actually
rather good, and most of us are really quite wonderful. Trust
us a little bit.
[Laughter.]
Trust us a little bit, and I think you will find that
without all of the machinations and all of the strangleholds
that we have to get ourselves out of, to do the very job we
want to do, we'll probably do it better.
Dr. Raulerson. Could I speak a little bit about the medical
home? Because in pediatrics, medical home is more than just for
patients. I actually have been working in the medical home
concept for over 30 years now, and I feel that my practice is a
medical home and has been for a very long time.
But I think all of us are in a continuum. We are somewhere
along the pathway of doing the best thing we can for our
patients. I look to the experiments that have been done in
North Carolina, and I wish that Alabama could model our medical
home system after North Carolina.
What they have done, with the guidance of the American
Academy of Pediatrics and what we call Bright Futures, which is
what healthcare should be for children, they have used this
model in North Carolina. And they are providing excellent care
for children there, and they have shown that it is financially
very sound. And they are saving that State's Medicaid program a
great deal of money by providing a medical home using
pediatricians, along with their nurse practitioners and their
physician assistants, to take care of children from the get-go
and to prevent things before they get to be big problems.
Senator Brown. Dr. Schlossberg, would you like to continue
on Senator Whitehouse's question?
Dr. Schlossberg. Sure. It is always hard to follow Dr.
Cooper, but I am not sure it will be quite----
Senator Brown. Dr. Raulerson actually just did it pretty
well.
[Laughter.]
Dr. Schlossberg. Yes, I will do it poorly, I will tell you
that. I would offer two threads.
One is related to health information technology and how you
change that because I think you talked about change. And so, a
month ago, we brought up at our health system, which is seven
hospitals, our tertiary care hospital, 600 beds, 1 day, big
bang. So all the systems went live with physician order entry
documentation.
It was a 4-year journey that started 3\1/2\ years ago
because we created a vision. We created a culture of shared
responsibility, and it was going to be event-driven. And we
said to the medical staff, ``If you do this, we will do that.''
We brought people along slowly. We communicated. We
participated with the medical staff in doing it. So, what I
think maybe the Congress could do is develop that vision that
says we are not going to tolerate this, this, and this.
Whatever the 80 percent is that people can agree on up here,
and pick the vision of what people want to do.
Then the specific thing you brought up, I guess, was around
guidelines? The American Urological Association is very active
in guidelines. We have been doing them for 10 years. The
problem with guidelines at the point of care is they are not
absolute.
They are not absolute for two reasons. They are not
absolute because at times the medical evidence doesn't allow us
to be. And again, sorry for an unpopular comment, but they are
not absolute because we don't have any malpractice protection
if we don't do something.
So if we sit across from a patient, and we said the
guidelines--you don't need the CT scan, or you don't need the
ultrasound. Or you are 82-year-old, you don't need the PSA. And
they say, ``Sorry, I want it. Order it, and Medicare will pay
for it.'' What do we do? We order the PSA. We order the CT
scan. We order the ultrasound.
I had that ultrasound conversation yesterday with a lady
about a renal mass that probably didn't need another
ultrasound. So somehow at the point of care, we don't have that
protection to try to do the right thing, even though a lot of
us want to do it.
So I think the answer is I think Congress could
strategically help us with some of those things. And as Dr.
Cooper said, then maybe let us solve some of the problems.
Senator Brown. Thank you.
Did you want to add something, Dr. Nochomovitz?
Dr. Nochomovitz. Yes. I think that the Federal Government
clearly can and is going to do something, and it does have
substantial power, which will influence a lot of things.
Because historically, whatever gets done in Medicare tends to
trickle down into the commercial markets, and that is a very
serious responsibility that our leaders and legislators have.
Because even if it is a mortar shell that is going, landing
somewhere, it does have an enormous trickle-down effect, and we
all have to live with it. And I think whatever is done will
immediately snowball throughout this country because of that
impact.
Now what the ongoing stewardship of that is what I think
you were asking, I think that is where we do need to look at
the different provider constituencies for help, and it is not
exclusively--with respect to Dr. Cooper--it is not exclusively
academic. It may be rural. It may be inner city. It may be
urban.
There are a lot of people who should participate in this,
organized medicine, the trade associations, because basically
what you are trying to look at is you are trying to look at
three things. You are looking at access, continuity, and
coordination.
So to the extent that what we do can impact in different
communities and different settings access, continuity, and
coordination, we are winning. And the guideline issue will just
be a work in progress forever.
Senator Brown. Thank you, Senator Whitehouse, for your good
insight and your incisive questioning.
I am going to ask each member one or two questions or each
panelist one or two questions to conclude the hearing. And if
Senator Whitehouse wants a second round, I suppose we can do
that.
I will start with Dr. Thorpe. I will just work my way. Dr.
Thorpe, you had some part of your testimony about the issue of
community health workers. And in my hometown of Mansfield, OH,
I had my first exposure to what community health workers can
do.
I did a roundtable, which Senator Whitehouse takes his
constituents to dinner. I serve them water.
[Laughter.]
In a roundtable of 15 or 20 people, and I had one in----
Senator Whitehouse. Not bread and water?
Senator Brown. Not bread and water. Just water.
In one of the poorest areas of Mansfield, and it is an area
that is mostly African-American, bordering on an Appalachian
white community. And they had the highest rate, by far the
highest rate of low-birth weight babies of anywhere in the
area, about four times the national average.
They use community health workers, young white and African-
American women, high school graduates or G--I was going to say
GME--GED. Sorry, there is a difference, I understand, Dr.
Cooper.
Dr. Cooper. Not as big a difference as you think, but there
is a difference.
[Laughter.]
But nonetheless, they were dispatched to their
neighborhoods where they lived, and they talked about
nutrition. They brought them in to OB/GYNs, pregnant women, and
they dropped the low-birth weight baby rate almost to the
national average over about a 3-year period.
I met with some of these women, and they had great
accomplishments in their lives at the age of 22 or 23. I would
also add, partly, Dr. Cooper, your comments about getting
people into the business of medicine and other ancillary
healthcare services that some of these women will be so
empowered from this experience, I would bet they will be nurses
and doctors, even though they have had little opportunity in
their lives to this point.
Without belaboring this too much, the community health
worker designation has only been in Ohio for 5 or 6 years. I
believe they are licensed by the State nursing board. So talk
to me about how we scale this up. And we are working on the
healthcare bill, particularly with Senator Harkin because this
is all about prevention, and he is, at least on this committee,
working that piece of it, if you will.
But how we scale this up in terms of training, in terms of
bringing them, these kinds of workers into the medical home
model, how we can do this nationally in a way better than the
pockets that we have seen it in places that you acknowledged
earlier?
Mr. Thorpe. Well, I think you look at the good case studies
of places that are doing this right now. North Carolina has
been mentioned. Vermont does this statewide for all patients.
And the challenge is building a primary care infrastructure. We
don't have a primary care infrastructure that really does
primary prevention such as, when somebody has five, six, seven
different chronic conditions, particularly in Medicare, and
working with patients outside the physician's office to manage
and execute the care plan.
So the vision here is to have a team of care coordinators--
nurse practitioners, nurses, social workers, mental health
workers, community outreach workers--many of the types of
community health team workers you were talking about
collaborate and, in fact, really fully integrate themselves
with smaller physician practices to build a primary care
infrastructure that does both primary prevention and care
coordination.
North Carolina does this statewide. They have been doing it
since 2003. Again, Vermont does this for all their patients in
three sites, and it does it very successfully. You build the
primary care infrastructure. You build referral patterns
appropriately to specialists. You are really building
integration in the system in a way to make it more functional.
I just go back to my basic statistics on it. You know, if
you have got 30 percent of the growth in spending in Medicare
nationally linked to a doubling of obesity, and if 75 percent
of spending is linked to chronically ill patients, these same
type of diabetic hypertensive patients, we have got to find a
way to build a primary care infrastructure and a better way of
managing them.
I think the way you do it is pretty simple. You look at the
functions that make the multispecialty clinics, that we have
seen work well, effective. It is having a formal transition
care model. We have seen it at Penn this model, a nursing-led
model for years. It has been very effective.
Geisinger does this very effectively. So you build
transition care into it. That is just simply a care coordinator
working with a patient as they go into a nursing home or a
hospital, doing an in-site visit, and working with the
admitting physician at discharge to do medication
reconciliation and make sure that the care plan is followed.
They have got to be closely integrated with the smaller
physician practice, whether it is a specialty practice or
primary care practice, but that collaboration is critical. And
having that close interaction with patients, working with them
at home.
So you build the functions in. We know the types of people
that we are looking for. It is nurses, nurse practitioners, who
do a great job of delivering primary health care. And if
Medicare wants to get into the game, just like Medicaid does
today in the private sector, we have to make a modest
investment to build that infrastructure to work with Medicare
fee-for-service patients. But it will spill over to work with
other patients as well.
So as I mentioned in the testimony, we are looking at
something about $2.5 billion a year when it is up and running
fully. It would provide nationally the capacity to have
community health teams everywhere in every hospital referral
area in the country. That if physicians wanted to work with
them or collaborate with them, they could be community health
centers, small physician practices, bigger physician practices.
You are building that infrastructure out there so that we can
do a better job of prevention and managing chronic disease.
And as I have said, if you look at the data on this in
terms of how well-functioning systems work, whether it is
Intermountain Health, Geisinger, Marshfield--you can go down
the list of them--if you can't save 2 percent in terms of the
cost structure, then we have got it set up wrong.
So I think that is the way you do it. I think it is easy to
scale it. You are focusing on the effective functions, but we
have got to make a modest investment to make it available
nationally.
Senator Brown. Thank you.
Dr. Cooper, taking a bit, connecting with that, you talked
about the shortage of physicians. And with your conversation
with Senator Murray, I thought that shed some light on some of
the next steps.
And while you talked about the training of physicians over
a
10-, 12-, 15-year period, you are precisely right on that, of
course. There are functions that are--or I guess the question
is are there functions that physicians now perform that other
healthcare workers can do?
Because without causing fights between the nurse
anesthetists and the anesthesiologists, I don't want to weigh
into that, or between a specialist and a general practitioner.
I am looking more for do we, along Dr. Thorpe's ideas and
models, is there a way--because in large part, we can train. We
can train community health workers and nurse's aides and the
physician's assistants and PTs and OTs and a whole lot of other
people. We can train them more quickly. There are different
educational levels, different training levels.
Is there a way to integrate using the, I guess you would
say the much deservedly maligned medical home model--but is
there a way of doing this, to answer your both criticisms and
prescience perhaps down the line by finding ways to bring that
together better perhaps than we have, if that is clear?
Dr. Cooper. Well, you know, you have to differentiate the
rhetoric of what should happen, like a medical home, for
example, and what is actually happening. What are primary care
or generalist physicians or specialists actually doing? And
what they are actually doing is along the lines of your
question, so that they are jettisoning things that they don't
have to do.
I couldn't help but remember being in Washington about a
decade ago. And as I was about to give a talk to the
ophthalmology association, the president said to me, as he was
putting the microphone on my tie, ``You know, 70 percent of
what we do is optometry.'' And in fact, that has been
jettisoned to optometrists.
The dentists jettison things to hygienists, dental
hygienists. So the physicians are always in the process of
offloading or delegating things that people can otherwise do.
And yes, I think one thing that is necessary for where this
rocket lands is to be sure there are enough physicians out
there. If we don't increase physician supply, they will,
Senator Whitehouse, cry rather than laugh.
It will be a disaster. It is almost a disaster already. We
can have this conversation about how to fill in for a little
while, but after all--after a little while, we will have
exhausted that ability. We will not have community health
workers. We will not have nurse practitioners and PAs, and now
physicians are backed into the corner doing what only
neurologists or neurosurgeons, urologists and oncologists can
do, and there aren't enough of them.
So your question really is, as we back them in the corner,
who can pick up what is left? And yes, encourage the nurse
practitioner programs. They need help. They are not being
developed fast enough. Be supportive of all the other kinds of
workers that Dr. Thorpe talks about within these community
networks.
Build the infrastructure. But don't look to physicians to
run that infrastructure. Look for them to participate in the
infrastructure as physicians.
Senator Brown. Fair enough. Yes, I, first of all, don't
want to back you into a corner. It might be a very dangerous
thing to do.
[Laughter.]
But I do--I wonder, and this is maybe idealizing a little
too much. If we did the community health workers right and we
did the nurse practitioners right and we did the optometrists,
ophthalmology/optometrist construct right, would the shortage
of physicians you cite or you predict be so acute?
Dr. Cooper. The answer is yes. The answer is the way we
trend this is back to the 1920s, and we assume that this
offloading process is continuous. And we don't build into our
projections that physicians will be the primary taker of blood
pressures, for example.
So as we project forward, it is the changing role of
physicians as they delegate. When we project the physician
workforce forward, it is a much slower rate than the healthcare
labor force overall. The assumption is that tasks will continue
to be delegated to others and that physicians will be able to
do what physicians do.
Our problem is that those trends can't continue with the
number of physicians we have. We don't have enough physicians
even if they delegate to community health workers and nurse
practitioners and so forth. And so, now we have to figure out
how to make it possible for even more, and that means having
other people enter into areas of care that they might otherwise
not have done.
Senator Brown. But I----
Dr. Cooper. Therefore, there are the doctoral-level nurse
practitioner programs, as an example. I am sorry.
Senator Brown. No, no, that is all right. I interrupted
you.
I would also argue if we do the community health workers
right and we do the nurse practitioners right, there will be,
in fact, fewer cases of diabetes and low-birth weight babies.
Dr. Cooper. Oh, yes.
Senator Brown. And fewer need for the specialists to take
care of those low-birth weight babies. I mean, that goes
without saying.
Dr. Cooper. I would agree with you entirely. And I would
say if it turns out, then let us start planning to expand the
physician workforce. Let us start building, and we will build
toward a target. We can always turn off the spigot if you see
this great success.
I am too old to share your great optimism that we are going
to prevent diabetes.
Senator Brown. But you are also wise enough to share my
optimism.
Dr. Cooper. But I do think we can cut those low-birth
weight babies down.
Senator Brown. I am going to have to cut you off and go to
Dr. Schlossberg next. Sorry. Because I could talk to you a long
time, Dr. Cooper. And I know Senator Whitehouse is probably
waiting even more, too.
So a bit of a more pedestrian question perhaps for Dr.
Schlossberg. You talked about rural providers and how difficult
it is to attract specialists to rural America, and almost every
one of our States, almost every one has some shortage of rural
providers. Give me prescriptively, if you will, some thoughts
about attracting specialty providers in underserved areas. And
not just rural, but also inner-city areas that also suffer from
shortages.
Dr. Schlossberg. Yes, I mean, that is a tall order that
people have been trying to solve. I think if you look at why we
got there, I think we are there because of the complexity of
specialty medicine.
So if you look at urology, for example, a functional
urology group is probably, at a minimum, three or four people
because of the medical science that goes with it. When you have
this shortage, people seek a job that they think is in their
best interest. And so, why should I go work in a rural area if
I can work with three or four other physicians?
I think the other thing that drives the lack of specialists
in the rural hospitals is the business of medicine, the
complexity of medicine, and something we haven't talked about,
which is ER call. And I am dealing with today in my job trying
to fill emergency room call for specialists because we are
trying to recruit pulmonary critical care physicians to a
smaller hospital, and none of them want to come because that
means, ``How much call do I have to do? And how is that? ''
As you look at the rural communities, one of the things
that they struggle with is staffing the emergency rooms and
staffing the acute nature of what happens. I think we do
personally need to have a lot more innovative solutions, like
Dr. Raulerson talked about, whether it is telemedicine or other
things.
I think we may need to reset the expectations of some of
these rural hospitals that says we need every specialty. We
need every procedure. In my specialty, it is robots and robotic
prostatectomies and laparoscopic stuff. It is complicated
stuff.
Should that happen at all these places? What kind of
specialty care do you need at all these places? I think we need
to look at those creative mechanisms.
Senator Brown. Thank you.
Dr. Nochomovitz, talk to us in some detail, if you will,
about the structure of the UH model in terms of primary care,
working into your answer preventive medicine, preventive care.
If there are ways that you could suggest nationally for us, for
a national model of how to use less-educated, less-trained
people like community health workers and others for preventive
care, and especially in light of dealing with the disaster that
diabetes will bring people individually and society
collectively in the next generation.
Dr. Nochomovitz. I think that is a good segue for me to
begin with a comment about some of Dr. Cooper's testimony. I
think that one of the questions we should all ask ourselves
here for the sake of transparency is who are our doctors? The
people in this room and people sitting at this table.
We probably all do have a fine internist or fine primary
care doctor who coordinates care for us. This doesn't detract
from the need for allied health professionals. But I think, as
a specialist, I think there has been somewhat of an
understatement here of the value of a well-trained, efficient,
primary care physician who can coordinate care, advise,
counsel, engage, navigate. And we shouldn't forget that, and
this needs to be reiterated.
That goes into--that is a good segue for me into the model
that we have used. And what we have done is we have taken,
first of all, what we have perceived to be the best physicians
in local communities and brought them into a structure that
gives them significant independence, authority, and autonomy
but allows them to leverage the resources of a larger
organization.
Had they not become aligned with our organization, the
quality guidelines, the technology, the e-prescribing, the
electronic office wouldn't have been possible for these
physicians. So therein is a story that is both positive and has
a negative side to it.
The positive side is that larger organizations, many of
whom have been cited, have the ability to bring in the
necessary technology, support to look at guidelines, to look at
coordinated care, to provide comprehensive diabetes programs
across a region with diabetic nurse educators and
endocrinologists and primary care doctors.
But we do need to look to the 60 percent of physicians
practicing in small practices, and again, how Dr. Thorpe is--
how do you scale that? And it might be that those parameters
need to be provided in alternate structures, some of them that
have been alluded to. And perhaps the accountable care
organizations, perhaps spin-offs or extensions of integrated
delivery systems, spin-offs or extensions of new, even from the
private sector of integration of independent doctors, hospitals
that have incented in the payer mechanism to provide these
services with some guidelines that are associated with reward.
Now there will have to be wholesale changes to some of our
regulatory laws as far as Stark, anti-kickback, and other
things if you are going to have these kinds of structures. But
I think the idea of--healthcare is a local phenomenon. So one,
first of all, needs to build on what one has. The easiest way
to build is to build on existing structures that can implement
these quality programs, technology, etc.
What we have done is we have gone even to smaller
communities, some rural communities associated with critical
access hospitals. We have organized physicians in clusters and
given them the infrastructure to do the diabetic care, the
urgent care, the after hours care in a low-cost--and we did the
urgent care to create the low- cost environment, even though we
were not essentially 100 percent fee-for-service environment.
But we anticipate the need for this, and we think it is the
right thing to do.
Senator Brown. Thank you.
Dr. Raulerson, what can we do in this healthcare
legislation, or what can the Federal Government do generally to
help you and other pediatricians at your medical homes provide
better preventive care? Again, especially about diabetes, but
preventive care generally for the children whom you serve.
Dr. Raulerson. One of the things that comes to mind
immediately is our entire vaccine program for children. The
vaccine program, I would say, is the A-plus of preventive
diseases. It certainly changed my practice.
When I started out in the wintertime, I would see one or
two children a week who needed a spinal tap because they might
have meningitis, and I don't see that anymore because of
vaccines.
When I was young, I was critically ill with the measles,
and I will never forget that illness when I was bedridden for
many weeks. We don't see measles anymore.
Vaccines are very complicated. In the first year of a
child's life, I give vaccines that add up to 30 different
vaccines in that first year of life. It is an extremely
expensive program, and payment for vaccine always lags the cost
for vaccines.
Right now, I am paid $8 for every shot that I give a
Medicaid patient in my office. It costs me somewhere between
$17 and $27 to give that vaccine, but I am paid $8. So I think
immediately something needs to be done about our vaccine
program for children. That is the No. 1 thing.
The second thing is, help us with technology. Don't expect
every small doctor in a rural area to come up with his own
electronic medical record and e-prescribing.
I have to laugh when I hear about technology. My very
closest best friend is a retired math professor and a computer
guru. She came and spent a month with me while we tried to get
my e-
prescribing system working. At the end of the day, we would
just fall apart laughing because of all of the problems.
Send it, it goes. My computer, my PalmPilot says it went.
Then the Indian reservation calls and says we don't have the
technology here to get what you sent so you will have to write
it. Well, OK. I can't call it in if it is a drug for ADHD. You
have to have a written copy. So now I have to mail it to you.
OK. So I send one to the pharmacy that is 200 yards from my
office. They got it 4 hours later.
So if my small rural practice or the practice of doctors
where there is two or three physicians together, if we are
going to have IT and it is going to be effective, someone else
has to help us do it.
There has to be a systematic way. And I am so afraid that
all of this money is going to go into a system where I get an
electronic medical record that is 14 pages long, and I just
want to know if the kid got his blood transfusion or not. And I
don't have time to read 14 pages to find out if this child got
his blood transfusion before he left Birmingham.
Senator Brown. Thank you very much, Dr. Raulerson. Well
said.
Senator Whitehouse has one brief question that we are going
to close with.
Senator Whitehouse. One brief question. I would like to
mention first that President Obama's Economic Recovery Act has
in it a, I call it ``geek squad'', for HIT. We modeled it on
the Agricultural Extension Service because people in rural
areas are very familiar with that and even very conservative
Members of the U.S. Senate are also very familiar with that.
And they know that the program works. So it is hard to devil it
as unwelcome Government intervention.
And so, people, doctors and hospitals who are installing
HIT will have access to the HIT extension help, and that is
already in the bill. It is passed. It is just a question of
standing it up.
So to your specific concern, it is very real. But I hope
help is on the way. Certainly, the infrastructure is in place
to begin to deliver it.
I would love to go back, while I have got you, to one piece
of what I asked, which is the--let me ask it this way. If you
are a doctor and you invest in electronic health records for
your patients, if you are a hospital and you invest in a
quality improvement plan for your intensive care units to
minimize infections and complications, if you are a community
health center and you invest in a prevention program for the
clients that you service, in all of those cases, there is a
common problem, which is that you have to put all the money
out. You have to take all the risk. You have to adapt your
practice to whatever the new regime is. And yet you get very
little, possibly even none of the reward of that investment.
We often hear in the Senate that if Government would just
get its hands out of the healthcare system, then the market
would work, and it would solve all these problems gloriously. I
am delighted to see every head just shook no in response to
that question because I couldn't agree with you more.
I think we have an infrastructure problem of some kind that
we have to solve, and then the market can take off. But right
now, when the fundamental risk-reward loop is broken, you are
just never going to get that investment.
If you have thoughts on how we solve that problem, because
there is an enormous amount of initiative and entrepreneurship
and innovation that can be brought to bear on this problem.
Once that is solved, a halfway measure is to say, OK,
Government is just going to pay for it in the meantime.
A better way would be to figure out how to close that risk-
reward loop so that people could actually win the benefits of
their savings, and then they are incented to keep looking and
keep digging and the machinery begins to work in the right
direction.
Dr. Cooper. If I could respond, I think you answered the
question, for me at least, in asking the question. And it
reminds me to go back to my comment about the NIH model.
Empower the community health workers in a little town in
Ohio to create a system and a demonstration project and a grant
structure. Give them access to the resources to do it, and you
will have thousands of minds creating thousands of ways to do
it.
But they won't bear the financial risk, and the reward will
be their system is better, and they will be rewarded in
nontangible ways as well. That is the NIH model--Enable.
Pre-suppose that we have geniuses in America, because we
do, who are much smarter than anyone in this room, and they
will come up with the really good ideas. But just empower them.
Don't think that we here can collectively figure out what to do
and then say, OK, here is some money. Now you go do it.
The NIH doesn't do that, and I would really encourage the
kind of a mild shift in thinking that says, ``Look, we don't
think the market can do it in the usual market way.'' But the
market, also the pharmaceutical market wouldn't have invented
all of the pharmaceuticals if the NIH hadn't supported all this
fundamental research that underpins it.
So the analogy obviously breaks down very quickly, but
there is a certain superficial analogy that comes across to me,
at least, in your question, Senator.
Senator Brown. Anyone else, or that is it?
Thank you, Senator Whitehouse. And thank you, Dr. Cooper,
for that answer.
As in all hearings, the record will stay open for 7 days.
If anyone wants to add any comments or thoughts or any other
kind of additional information to any of the comments or
questions made by each other or by Senator Murray or Senator
Whitehouse or me, feel free to submit that to the committee. We
appreciate that.
Special thanks to Keith Flanagan for his help, and to
Jessica McNease for her very good work on this hearing and on
my staff, and Eleanor Dehoney and David Mitchell, and also
David Bowen on the committee majority staff.
So the committee will adjourn. Thank you very much.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement of the American College of Surgeons (ACS)
The American College of Surgeons (ACS) commends the Senate
Committee on Health, Education, Labor, and Pensions for holding this
important hearing on ``Delivery Reform: The Roles of Primary and
Specialty Care in Innovative New Delivery Models.'' On behalf of its
more than 74,000 members, the ACS is grateful for this opportunity to
present a statement describing the surgical specialty perspective on
delivery system reform.
Reform of our Nation's health care system includes a range of
important issues, from covering the uninsured, to ensuring patient
access to trauma and emergency care, to improving the quality of care
to containing the growth of our Nation's rising health care costs. A
myriad of problems and challenges calls for not one but many steps and
solutions to put us on the path to extending the possibility and
promise of quality health care to all Americans.
INNOVATIVE DELIVERY SYSTEM MODELS
ACS Trauma Care Delivery System
An important area of health care delivery that is often times
overlooked comes through the emergency and trauma care delivered in our
Nation's hospitals and trauma centers. Sadly, the emergency health care
system in America is in crisis. Traumatic injury is the leading cause
of death for Americans aged 1 through 44. Medical evidence has shown
that the care and treatments delivered within the first hour of a
severe injury, known as the ``golden hour,'' are likely to mean the
difference between temporary and permanent disabilities, as well as
between life and death. Studies of conventional trauma care show that
as many as 25 percent of trauma patient deaths could have been
prevented if optimal acute care had been available. In addition to
saving lives, restoring function, and preventing disabilities, ensuring
appropriate trauma care also can serve an important role in the larger
goal to contain the growth of health care costs. According to a report
published by the Agency for Healthcare Research & Quality (AHRQ),
trauma injuries were the second most expensive health care condition in
2005, costing approximately $72 billion. This includes money spent for
doctor visits, clinics, emergency room visits, hospital room stays,
home health care, and prescription drugs. The cost of trauma-related
emergency room visits alone was $7.8 billion. The National Safety
Council's 2005-2006 edition of Injury Facts found that the total cost
of unintentional injuries for 2004 was $574.8 billion, with $298.4
billion in wage and productivity losses and $98.9 billion in medical
expenses alone.
Trauma systems provide for effective and efficient use of scarce
and costly community resources. Yet, only one in four Americans lives
in an area served by a trauma care system. Both the Institute of
Medicine (IOM) and the Emergency Medical Treatment and Labor Act
(EMTALA) Technical Advisory Group have documented significant gaps in
our trauma and emergency health care delivery systems, showing that
hospital emergency departments and trauma centers across the country
are severely overcrowded, emergency care is highly fractured, and
critical surgical specialties are often unavailable to provide
emergency and trauma care. The IOM found that a coordinated,
regionalized, accountable system based on the current trauma care
system model must be created. Unfortunately, the most consistent
element among the States is the lack of uniformity regarding system
development. As a result, the quality of care a trauma patient receives
largely depends on the quality of the regional and local system in
place to respond to emergency and trauma situations.
Since 1976, the ACS Committee on Trauma (COT) has developed
criteria to categorize hospitals based on the level of trauma care
available. These guidelines are now used by States to certify some
hospitals as trauma centers and many hospitals seek certification to
become a trauma center from the ACS COT. In addition, in 1989, the ACS
COT collaborated with emergency medical organizations, governmental
agencies, trauma registry vendors, and other interested parties to
develop the National Trauma Data Bank (NTDB), which contains over 2
million cases from over 600 U.S. trauma centers and is the largest
aggregation of trauma registry data ever assembled. The goal of the
NTDB is to inform the medical community, the public, and decisionmakers
about a wide variety of issues that characterize the current state of
care for injured persons in our country. The information contained in
the data bank has implications in many areas including epidemiology,
injury control, research, education, acute care, and resource
allocation. Finally, the ACS COT plans to develop a trauma quality
improvement program.
To ensure patient access to emergency and trauma care, we recommend
that Congress support:
Regionalization of Emergency Care by including legislation
like the Improving Emergency Medical Care and Response Act, legislation
introduced in the 110th Congress by then-Senator, now President Barack
Obama (D-IL) and Representative Henry Waxman (D-CA), in health care
reform to ensure a regionalized emergency and trauma care system that
provides patient access to prompt definitive care when they need it.
The Improving Emergency Care and Response Act would authorize multi-
year grants to support demonstration programs aimed at designing,
implementing, and evaluating a regionalized, accountable emergency care
system. In fact, President Obama's fiscal year 2010 budget request
includes $10 million for the Emergency Care Systems program that would
support the development of the Emergency Care Coordination Center
(ECCC) and two of its main programs: (1) the regionalization of
emergency care services; and (2) national standards on emergency care
performance measurement.
Improved Reimbursement for Emergency Services by: (1)
providing physicians a tax deduction equal to the amount of the
Medicare fee schedule payment; (2) providing a 10 percent added bonus
payment through Medicare to all physicians, including on-call
specialists, who provide EMTALA-related care to Medicare beneficiaries;
(3) allowing all Medicare participating hospitals to include stipends
paid to physicians providing emergency on-call services on their cost
reports; (4) providing necessary funding to trauma centers that are at
serious risk of closing due to the continual increase of uncompensated
and charity care costs; and (5) establishing a dedicated Federal
funding source for payments to providers for uncompensated emergency
health care services.
Medical Liability Protections by: (1) requiring any
lawsuits against physicians who provide EMTALA-mandated care be brought
under the Federal Tort Claims Act; and (2) providing immunity or
limited liability for certain medical personnel involved in the
evacuation or treatment of patients during a declared state of
emergency.
ACS National Surgical Quality Improvement Program (NSQIP)
Health system reform starts from an important and appropriate
premise that patients receive their care in a large system of care
rather than from one physician or health care provider. It is this same
premise that has been the foundation for the ACS's successful surgical
quality improvement efforts. For example, the ACS National Surgical
Quality Improvement Program (NSQIP) started with a successful effort
within the Department of Veterans Affairs, which decreased VA post-
surgical mortality by 27 percent and post-operative complications by 45
percent over 10 years. ACS NSQIP is a prospective peer-controlled,
validated database that quantifies 30-day risk-adjusted surgical
outcomes and allows for comparisons among all participating hospitals.
ACS NSQIP does not merely examine care the surgeon provides in the
operating room, but rather it captures data regarding the range of pre-
operative, intra-operative, and post-operative care that the surgical
patient receives over the 30 days following the surgery. After a pilot
to test NSQIP in three non-Federal hospitals in 1999, the ACS applied
for a grant from the Agency for Healthcare Research Quality in 2001 to
expand the program to 14 hospitals. Based on its successful application
in these hospitals, the ACS has spearheaded the effort to implement ACS
NSQIP in private hospitals across the country, with ACS NSQIP currently
in place in 220 hospitals nationwide. The program has received wide
recognition as a successful model for surgical quality improvement and
the Joint Commission acknowledges the value of participation in ACS
NSQIP and includes a Merit Badge next to the profile of all ACS NSQIP
hospitals.
ACS National Cancer Data Base
In the field of cancer care, the American College of Surgeons
Commission on Cancer (CoC) is a pioneer in measuring performance. The
more than 1,400 hospitals and free-standing cancer treatment facilities
approved by the CoC report clinical data to the National Cancer Data
Base (NCDB) and receive evidence-based benchmark comparison reports
based on accepted standards of care for breast and colorectal cancers.
These measures are endorsed by the National Quality Forum. Since 1995,
it has captured over 21 million cancer cases and includes data on about
70 percent of all newly diagnosed malignant cases of cancer nationwide
annually. To provide better ``real-time'' feedback, the CoC has also
developed a new reporting system that could link into an interoperable,
nationwide health information technology (HIT) system, which received
significant support in the recently enacted American Recovery and
Reinvestment Act of 2009 (H.R. 1). This prospective electronic
reporting system, which is called the Rapid Quality Reporting System
(RQRS), monitors evidence-based performance measures in real-time,
alerting providers when standards of care for select cancers are not
being met. The ACS believes RQRS could ultimately play an important
part in any new, outcomes-based payment models.
Through these efforts, the ACS has demonstrated a commitment to
delivery reform that both includes and extends beyond the care that the
surgeon provides to his or her patients. In addition, these efforts are
based not simply on doing more for the patient but on doing what is
most clinically appropriate for the patient. The ACS recognizes that
surgical care is provided through a surgical team in the operating room
and through a team of health care professionals, including the surgeon,
who treat and monitor a patient's progress before and after an
operation.
ENSURING PATIENT ACCESS TO SURGICAL CARE
Addressing Workforce Shortages
The number of surgeons trained in the Nation's graduate medical
education system has remained static for the past 20 years. Today, U.S.
population growth has far outpaced the supply of surgeons and as a
result, the United States is beginning to see signs of an emerging
national crisis in patient access to surgical care.
Patients need access to safe, high-quality and affordable surgical
care, whether the surgery is planned or unplanned. However, many
aspects of the current health care system contribute to workforce
shortages that threaten patient access to surgical care. Unlike many
other medical specialties, there are no good substitutes or physician
extenders for a well-trained general surgeon or surgical specialist.
Surgical training is vastly different from other physician training
programs. Mastery in surgery requires extensive and immersive
experiences that extend over a substantial period of time. Whereas non-
surgical residencies can be completed in as few as 3 years, surgical
residencies require a minimum of 5 years and often several more for
specialties such as cardiothoracic surgery. As a result, ensuring
patient access to surgical care will take many years to address.
Workforce shortages affect nearly all surgical specialties and
occur in both rural and urban areas. According to 1996 and 2006 data on
workforce numbers produced by the Dartmouth Atlas, general surgery,
urology, ophthalmology, and orthopaedic surgery declined 16.3 percent,
12 percent, 11.4 percent, and 7.1 percent, respectively. In addition,
the Archives of Surgery published an analysis last April that showed a
decline of more than 25 percent of general surgeons between 1981 and
2005 in proportion to the U.S. population. Looking to the future,
between 2005 and 2020, the Bureau of Health Professions projects an
increase of only 3 percent among practicing surgeons, with declines
projected in thoracic surgery (^15 percent), urology (^9 percent),
general surgery (^7 percent), plastic surgery (^6 percent), and
ophthalmology (^1 percent).
There are many reasons for the surgical workforce shortage
including prospects of reduced payment combined with higher practice
costs, bigger liability premiums, and the heightened threat of being
sued; a crippled workforce leading to demands for more time on call;
heavier caseloads with less time for patient care; and a U.S. health
care delivery system that is in flux. Given the rigors of a surgical
residency, these challenges can deter would-be surgeons from making the
extra sacrifices necessary to enter the surgical workforce and create a
dim long-term outlook for the profession.
Compounding the crisis, large numbers of aging, established
surgeons are either decreasing their workloads or retiring. According
to the American Medical Association's Physician Characteristics and
Distribution in the U.S. (2007 edition), approximately one-third of the
surgical specialists who are key to ensuring adequate emergency call
coverage are age 55 or older (general surgeons, 32 percent;
neurosurgeons, 34 percent; and orthopaedic surgeons, 34 percent).
Hence, it is critical that our Nation's medical schools and training
institutions start producing more surgeons in these specialties.
POSSIBLE SOLUTIONS
Preserve Medicare funding for graduate medical education
and eliminate the residency funding caps established in the 1997
Balanced Budget Act;
Fully fund residency programs through at least the initial
board eligibility;
Include surgeons under the title VII health professions
programs, including the National Health Service Corps program, and make
them eligible for loan assistance;
Promote rural/underserved care through loan forgiveness
programs that stipulate work in those areas;
Extend medical school loan deferment to the full length of
residency training for surgeons;
Allow young surgeons who qualify for the economic hardship
deferment to utilize this option beyond the current limit of 3 years
into residency;
Increase the aggregate combined Stafford loan limit for
health professions students;
Create a new health professional shortage area (HPSA),
separate from the traditional primary care HPSA, with bonus payment
structures for surgeons who provide services in designated areas;
Provide tax relief and liability protections to surgeons
who perform EMTALA-related care, especially when that care is
uncompensated;
When hospitals pay stipends to surgeons who take emergency
calls, have Medicare recognize these costs, as is currently done for
critical access hospitals; and
Expand the Federal Tort Claims Act to include surgeons who
provide services to patients who are referred through their primary
care physician at a community health center.
Payment Reform
As the committee studies the important issue of delivery reform, it
is critical not to lose sight of the fact that no delivery system, no
matter how ingenious, can survive if those who are caring for patients
are not being appropriately reimbursed, and the most immediate
challenge for patient access to surgical care is the precarious
reimbursement situation confronting surgeons and surgical practices. As
the committee is well aware, Medicare payments to physicians will be
cut 21.5 percent on January 1, 2010 if Congress does not act. The ACS
calls on Congress to take action to stop this cut, to provide an
increase in Medicare payments for all physicians in 2010, and to
initiate reform for Medicare's physician payment system this year. The
ACS greatly appreciated the leadership of Chairman Kennedy and others
on the committee to enact the Medicare Improvements for Patients and
Providers Act of 2008 (MIPPA) last July that reversed the 10.6 percent
cut in Medicare physician payments. In addition, MIPPA included the
largest Medicare payment increase for physicians since 2005 by
replacing a scheduled 5.4 percent cut in 2009 with a 1.1 percent
increase this past January. MIPPA also made changes to how work was
valued under the Relative Value Scale, increasing payments for some
surgical services. In spite of these important measures, Medicare
payments for many surgical procedures have been reduced significantly
over the past 20 years and, in some cases, have been cut by more than
half from reimbursement levels in the late 1980's.
In discussing delivery system reform, many often highlight the
importance of measures to promote primary care to both prevent illness
and disease as well as to manage the conditions that a patient may
already have. To this end, some, most notably the Medicare Payment
Advisory Commission (MedPAC), have proposed financing increased
reimbursement for primary care by simply cutting reimbursement for care
provided by other physician specialties. Such proposals, while seeking
to promote efforts to help Americans better manage their care, would
only exacerbate the workforce challenges described earlier and
establish a reimbursement structure that would ultimately undermine
patients' ability to access the life-saving acute care services that
only surgeons are qualified to provide. The ACS supports efforts to
prevent disease and to manage patient care not only because it is in
the best interests of the patient and health care system but also
because, when these patients need surgery, they are much less likely to
encounter complications and much more likely to recover quickly from
the operation. However, regardless of how well patients' care is
managed, acute situations requiring prompt and definitive access to
surgical care will continue to occur. A better alternative would be
reforms that recognize the important roles that different specialties
play in caring for the whole patient.
Much attention has been paid to the need to provide more Americans
with access to health care coverage, to increase Americans' access to
care, and to improve the value of care delivered in our health care
system. Expanding coverage to more Americans and improving the quality
of care will mean little if Americans are not able to access the care
they need--particularly in potentially life-threatening situations due
to the lack of qualified surgical practitioners. Before adopting any
proposed steps or solutions, we must carefully consider what unintended
consequences may result. So while our present situation calls for
change and health system reform, we must proceed deliberately and
thoughtfully to ensure that the policy changes we make today do not
lead to unintended consequences that could undermine Americans' access
to quality care.
The ACS looks forward to working with this committee to reform our
Nation's health care system and to preserve and improve Americans'
ability to access high quality surgical care and health care services.
[Whereupon, at 11:50 a.m., the hearing was adjourned.]