[Senate Hearing 111-974]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-974
 
                 HEALTHCARE REFORM ROUNDTABLE (PART 2)

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                                   ON

                         EXAMINING HEALTH CARE

                               __________

                             JUNE 12, 2009

                               __________

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                                Pensions


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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)

  
?



                            C O N T E N T S

                               __________

                               STATEMENTS

                         FRIDAY, JUNE 12, 2009

                                                                   Page
Dodd, Hon. Christopher J., a U.S. Senator from the State of 
  Connecticut....................................................     1
Mikulski, Hon. Barbara A., a U.S. Senator from the State of 
  Maryland.......................................................     2
Raskob, Gary, Dean, Ph.D., Oklahoma College of Public Health.....     3
    Prepared statement...........................................     4
Levi, Jeffrey, Ph.D., Executive Director, Trust for America's 
  Health.........................................................    16
    Prepared statement...........................................    17
Raines, C. Fay, Ph.D., RN, President, American Association of 
  Colleges of Nursing, and Dean, College of Nursing, University 
  of Alabama, Huntsville, AL.....................................    18
    Prepared statement...........................................    19
Jonas, Wayne B., M.D., President and Chief Executive Officer, 
  Samueli Institute..............................................    23
    Prepared statement...........................................    24
Brown, Hon. Sherrod, a U.S. Senator from the State of Ohio.......    25
Cosgrove, Delos M., M.D., CEO, Cleveland Clinic..................    25
    Prepared statement...........................................    26
Rother, John, AARP Executive Vice President, Policy and Strategy.    30
    Prepared statement...........................................    31
Palfrey, Judith, M.D., FAAP, President-elect, American Academy of 
  Pediatrics.....................................................    39
    Prepared statement...........................................    40

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Chip Kahn, President, Federation of American Hospitals (FAH).    64
    American Association of Colleges of Nurses (AACN), letter....    65

                                 (iii)

  


                     HEALTHCARE REFORM ROUNDTABLE 
                                (PART 2)

                              ----------                              


                         FRIDAY, JUNE 12, 2009

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:17 a.m. in 
Room 216, Hart Senate Office Building, Hon. Christopher Dodd 
presiding.
    Present: Senators Dodd, Mikulski, Brown, and Reed.

                   Opening Statement of Senator Dodd

    Senator Dodd. The committee will come to order, and my 
apologies to our witnesses and colleagues in the audience.
    As some of the staff and members know, I am the father of 
two very young children, a 4-year-old and a 7-year-old, and my 
7-year-old had a moving-on ceremony this morning from first 
grade to second grade. So I apologize that it went a little 
longer than I anticipated. I apologize for holding you and my 
colleagues up and the staff, as well.
    I thank all of you for being here this morning, and let me 
also express the apologies of my colleagues. We had the last 
vote yesterday afternoon around 3 o'clock and as happens toward 
the end of the week, you can't anticipate these things, many 
members headed back to their respective States.
    Senator Enzi particularly was going to be here earlier this 
morning and we would have started the hearing earlier but for 
this--my daughter's matriculation and so he had to go back to 
Wyoming a little earlier. So, I apologize on his behalf, as 
well, and he'll probably submit some questions for all of you 
and would ask you to respond to those. We will include every 
statement of yours in the record and any supporting materials 
you think would be helpful for us as we begin consideration of 
this most important of issues.
    Let me introduce our witnesses. I made an opening statement 
yesterday about the importance of the issue and I know all of 
you, as all of us do, agree with the magnitude of the problem 
and the determination to try and get something done here to 
move us off the status quo which is unacceptable, I think, to 
most, if not all.
    Our witnesses today include Dr. Gary Raskob, and if I 
mispronounce names, I apologize. Is that the correct 
pronunciation?
    Mr. Raskob. Perfect, Senator.
    Senator Dodd. Thank you very much. The doctor is the Dean 
of the Oklahoma College of Public Health where his research in 
the prevention of blood clots has the potential to save 15,000 
lives a year in our country.
    Dr. Jeffrey Levi, is that correct?
    Mr. Levi. Yes, it is.
    Senator Dodd. Dr. Levi is the Executive Director of the 
Trust for America's Health, where he leads the organization's 
evaluation of and the advocacy for public health preparedness 
of the United States.
    Dr. Fay Raines is a mental health nurse, thank you for 
being here, and is the President of the American Colleges of 
Nursing and the Dean of the College of Nursing at the 
University of Alabama in Huntsville.
    Dr. Wayne Jonas is the President and CEO of the Samuel--
he's not here--in Alexandria, VA. He was previously the 
Director for the Office of Alternative Medicine at the NIH.
    Dr. Delos Cosgrove is the President and CEO of the 
Cleveland Clinic where he leads the $4.6 billion healthcare 
system comprised of 4 clinics, 9 community hospitals and 14 
family health and ambulatory surgery centers.
    Dr. John Rother is the Director of the Legislation and 
Public Policy for the American Association of Retired Persons, 
considered an authority on the healthcare and long-term care.
    Last, Dr. Judith Palfrey is the President-elect of the 
American Academy of Pediatrics, researches the development of 
innovative systems of care, including medical homes for 
children with special healthcare needs, and we are honored to 
have all of you with us here today.
    Is Dr. Jonas going to be joining us, do we know?
    Senator Mikulski. Yes. He's right here.
    Senator Dodd. Oh, I am sorry.
    Senator Mikulski. Dr. Jonas, hello.
    Senator Dodd. He's in conversation. Hello, Doctor.
    Senator Mikulski. We will have that conversation later.
    Senator Dodd. Yes. Doctor, thank you.
    Senator Mikulski. I asked him to talk to my staff this 
morning.
    Senator Dodd. Oh, good.
    Senator Mikulski. I didn't mean this minute.
    Senator Dodd. No. Well, Doctor, thank you for joining us, 
as well.
    Hi. Good morning, Barbara. Nice to see you.
    Senator Mikulski. Good morning.
    Senator Dodd. Nice to see you. Dr. Raskob, we will begin 
with you.
    Barbara, do you have any opening comments you want to make?

                     Statement of Senator Mikulski

    Senator Mikulski. Well, first of all, good morning to 
everybody. We are just glad to see you and we look forward to 
this conversation.
    I also want to acknowledge we are a few minutes late 
getting started because our good colleague went to his 
daughter's preschool graduation. That was your mental health 
benefit?
    Senator Dodd. Yes, it is.
    Senator Mikulski. It was effective- and evidence-based 
which is a good thing, and we apologize and we are ready to 
roll.
    Senator Dodd. The pediatrician here.
    Doctor, we will go ahead and we will begin with you.

  STATEMENT OF GARY RASKOB, Ph.D., DEAN, OKLAHOMA COLLEGE OF 
                         PUBLIC HEALTH

    Mr. Raskob. Thank you, Mr. Chairman.
    I want to begin by thanking you and your colleagues for the 
opportunity to comment on the health reform options being 
considered by the committee.
    I am here today representing the 41 accredited schools of 
public health in the United States that have missions in 
education, research and public health service.
    In the time available, I will focus my remarks on the 
importance of building health reform on a foundation of 
prevention and public health, and the culture of the healthcare 
system in the United States needs to be transformed from one 
that emphasizes treatment, often late in the natural history of 
disease, to a different paradigm, a culture of wellness.
    Public health sections of the current bill contain several 
provisions for improving the health of the American people. I 
will highlight four overarching elements that will be key to 
creating a culture of wellness.
    First, the bill underscores the importance of the full 
spectrum of prevention, from community-based primary prevention 
to clinical preventive services. Because the rising prevalence 
of chronic diseases requiring treatment accounts for the 
majority of the growth in healthcare spending--efforts to 
prevent disease through primary prevention, what we do before 
an individual engages a healthcare provider, are critical to 
controlling costs.
    Second, the bill recognizes the importance of the 
community, the school and the workplace as locations for 
implementing prevention and wellness efforts. We applaud the 
provisions to provide technical assistance to businesses, to 
establish employer-based wellness programs, and ASPH supports 
providing tax incentives to encourage employers to adopt 
workplace wellness and prevention programs that are evidence-
based and yield a two to threefold return on investment.
    Third, the bill recognizes the need for sustained and 
expanded public health research, especially in the areas of 
prevention and public health systems, including comparative 
effectiveness research. Particular attention should be given to 
developing and translating evidence to reduce childhood 
obesity, smoking, and responding quickly and effectively to 
emerging health threats.
    Comparative effectiveness research should include research 
on a wide range of policies and interventions that affect 
health, including nonclinical programs, organizational and 
systems characteristics and policies and regulations.
    Fourth, the bill identifies the critical importance of a 
strong workforce. We emphasize that these efforts should 
address the broad public health workforce needs. The current 
public health workforce is significantly undersized, given its 
responsibilities which include ensuring safe food, clean water, 
an immunized population, and protecting the public from 
emerging threats, such as the H1N1 influenza virus.
    ASPH estimates that by 2020, the Nation will need an 
additional 250,000 public health workers, and we believe that 
the provision of scholarships, fellowships and loan repayment 
tied to a service obligation is an important strategy to 
achieve this goal.
    Thank you again for this opportunity. I look forward to 
taking your questions and I will apologize in advance that I 
will have to leave at 11:30 but I apologize for that.
    Thank you very much.
    [The prepared statement of Dr. Raskob follows:]

   Statement of Gary Raskob, Ph.D., on behalf of the Association of 
                    Schools of Public Health (ASPH)

  Policy Brief--Creating a Culture of Wellness: Building Health Care 
                 Reform on Prevention and Public Health

                           EXECUTIVE SUMMARY

    Policies and programs that emphasize both community-based 
prevention and clinical preventive services as part of primary care 
should be the foundation of health care reform, in the view of the 
Association of Schools of Public Health (ASPH).
    A consensus is emerging in the Obama administration and the U.S. 
Congress that significant reforms are necessary to provide affordable, 
high-quality health care to all Americans, and ASPH has called for 
legislation that will achieve health insurance coverage for all 
Americans, both children and adults, within 2 years. As efforts advance 
to meet those goals, the culture of the health care system needs to be 
transformed from one that emphasizes treatment to one that builds on 
public health and prevention. Targeting behavioral patterns and social 
and environmental circumstances in the home, the workplace, and the 
community, and promoting the systematic adoption of prudent clinical 
prevention practices, offer tremendous opportunities to reduce 
premature death, disability, and disease.
    ASPH recommends seven key strategies to accomplish the 
transformation of the U.S. health care system:

                       KEY STRATEGIES FOR ACTION

    The ASPH blueprint for creating a culture of wellness is based on 
the following recommendations:

    1. Emphasize leadership and articulate a vision for prevention. Use 
of the ``bully pulpit'' to articulate a vision for a prevention-
oriented health care system may do more to speed the transition than 
any other single measure. President Obama, the Department of Health and 
Human Services (HHS) Secretary, the U.S. Surgeon General, and other HHS 
leadership should use their voices and influence to clearly state that 
prevention is the core value of health care reform.
    2. Increase the Federal cigarette excise tax to prevent smoking-
related morbidity and mortality, spending much of the resulting revenue 
on prevention-focused activities. ASPH recommends an additional Federal 
cigarette tax of $1/pack, which would bring the total tax to $2.01. 
This tax increase would drive down the rate of smoking, especially 
among youth, while generating approximately $13.6 billion a year in new 
revenues, after factoring in declines in smoking associated with the 
higher costs of cigarettes. (The proposed tax is in addition to the 
$0.62 increase that went into effect March 31, 2009 and is expected to 
generate $7 billion annually, which has been allocated to the State 
Children's Health Insurance Program [SCHIP]). Revenues from a further 
$1 tax increase should support a Public Health Trust, to be used for 
tobacco cessation and prevention, public health research, and other 
public health programs. The tax revenues should also provide relief to 
the States and fund a range of other public initiatives.
    3. Implement evidence-based measures to fight the obesity epidemic. 
The worsening epidemic of obesity in America, which now rivals that of 
tobacco in its overall impact on health, accounted for more than 25 
percent of the growth in the Nation's health care costs between 1987 
and 2001. ASPH endorses a wide array of obesity prevention measures 
that would improve surveillance, support nutrition programs, promote 
physical activity, provide guidance on advertising and marketing to 
children, and significantly expand funding for obesity prevention 
research. A governmentwide, HHS-led task force on obesity should be 
established to define and coordinate all Federal actions and establish 
nutrition standards for food and beverages sold in schools. In 
addition, ASPH believes that an excise tax on sugar-sweetened beverages 
warrants consideration.
    4. Rebuild the public health workforce. Addressing the public 
health workforce crisis requires short-term and long-term initiatives 
designed to:

     Increase Federal funding to support students pursuing 
graduate degrees, expand practice opportunities, and promote a more 
diverse workforce. Expand capacity at Schools of Public Health to 
educate more graduate students, more public health professionals, and 
more workers in health care and other intersecting fields, to increase 
research training, and to develop competencies and curricula in 
emerging areas.
     Introduce public health into the curriculum at all levels, 
from primary school through undergraduate education.
     Establish a U.S. Global Health Service to coordinate U.S. 
efforts to build a workforce prepared to meet international needs.
     Institutionalize a process for enumerating the public 
health workforce to assess current capacity and future needs.

    5. Build and utilize information technology architecture to measure 
clinical prevention services and health outcomes uniformly. The 
fragmented U.S. health care system is in urgent need of world-class 
data management systems to measure performance, improve decisionmaking, 
enhance accountability, and provide surveillance data for longitudinal 
analysis and research. Developing a culture of wellness depends in part 
on the availability of uniform assessments of health outcomes and 
system performance and surveillance.
    6. Empower employers to promote wellness strategies that can be 
integrated with primary care. Employers can have a strong influence on 
the demand for more prevention-oriented health insurance and health 
care delivery services. ASPH also calls for a National Workplace 
Prevention Program, defined by the CDC and approved by the HHS 
Secretary and the Surgeon General, which would provide tax credits to 
all public and private U.S. employers that meet program requirements.
    7. Empower communities to put prevention and public health programs 
at the forefront of primary care. Public health and primary care are 
both practiced at the community level, creating opportunities to 
integrate them in ways that would change the culture of local health 
systems and emphasize prevention as a core competency. Long-term 
investments, especially in underserved communities, are needed to train 
workers, including primary care providers and community health workers; 
expand facilities to house prevention programs; and develop information 
systems and governance oversight that link public health and prevention 
with primary care, resulting in more efficient and more cost-effective 
integrated models.
    About ASPH: The recommendations in this paper reflect the consensus 
of the Association of Schools of Public Health (www.asph.org), which 
represents the 40 Council on Education for Public Health (CEPH) 
accredited schools of public health in North America. A critical 
national resource, the Nation's Schools of Public Health educate the 
next generation of public health leaders; conduct cutting-edge 
research; and translate knowledge into public health policy and 
practice. They currently enroll 22,000 students, produce more than 
7,300 graduates a year, and employ 9,600 faculty.
    ASPH is committed to collaborating with the public health practice 
community, governmental agencies, academic medicine, non-profit 
organizations, and business groups. This policy paper is part of a 
series exploring the Nation's public health priorities.
                                 ______
                                 
                        OVERVIEW: AN URGENT NEED

    High spending, low health status in the United States. At $2 
trillion in 2005, health care spending in the United States far 
surpasses that of all other countries (on a GDP per capita basis). The 
Nation also remains the global leader in biomedical research and tracks 
health care indicators with exceptional rigor. Nonetheless, it ranks 
low in many measures of health status.

     The U.S. ranked 25th in infant mortality; 22d in maternal 
mortality; 23d in life expectancy for women; and 22d in life expectancy 
for men, among the 30 developed nations within the Organization for 
Economic Cooperation and Development.
     Among all 192 nations for which 2004 data was available, 
the United States ranked 46th in life expectancy and 42d in infant 
mortality (Schroeder, 2007).

    Public health should be at the center of efforts to meet the 
Nation's health challenges. Premature death is most heavily influenced 
by human behavior (which accounts for 40 percent of the risk), as 
evidenced by the fact that the vast majority of deaths in the United 
States are associated with obesity and inactivity (365 deaths/100,000) 
and smoking (435 deaths/100,000) (Schroeder, 2007). Genetics is also an 
important risk factor (30 percent), as is the social and working 
environment (20 percent), whereas health care itself is relatively less 
important, with only a 10 percent influence on premature death.
    It is no surprise, then, that four of the six ``serious and complex 
challenges'' to health identified in a recent Institute of Medicine 
(IOM) report deal with prevention and public health (IOM, 2009).
    According to the IOM:

     The U.S. model of health care delivery does not ensure the 
efficient and effective prevention and management of chronic diseases, 
nor does it consistently apply principles of evidence-based medicine.
     The possibility of global pandemics, emerging infections, 
and bioterrorism threatens to harm many Americans and to strain limited 
resources further.
     The public health infrastructure is weak and, in many 
locales, hard-pressed to meet current demands, much less those of the 
future.
     The United States trails many other countries in achieving 
desired health outcomes and longevity, despite the world's highest 
level of per capita health care spending.

    Prevention is a cost-effective way to reduce morbidity and 
mortality. The value of public health measures in saving lives and 
reducing chronic disease and disability has been well-documented. 
Reductions in traffic fatalities as a result of the widespread use of 
seat belts, and better health outcomes from the improved control of 
workplace environmental exposures, are just two examples. We also know 
that if a basic package of cost-effective prevention measures were 
practiced by the entire population--including daily aspirin use, 
smoking cessation, influenza vaccine, and screening for colorectal 
cancer and problem drinking--more than 100,000 lives per year could be 
saved (Maciosek, et al., 2006).
    Investing in prevention is cost-effective, as the following 
evidence demonstrates:

     The Urban Institute estimates that a $10-per-person 
investment in prevention in the United States would generate a return 
of $16.543 billion in 5 years and $18.451 billion over 10 years. These 
calculations were derived from evidence-based studies on lack of 
physical activity, poor nutrition, and tobacco use (Trust for America's 
Health, 2008).
     The cost-effectiveness of preventive clinical services for 
working-age adults has been well established, using quality-adjusted, 
life-year metrics and based on U.S. Preventive Services Task Force 
recommendations (AHRQ, 2005; Maciosek, et al., 2006).
     The Congressional Budget Office concluded that potential 
savings from health behavior and health promotion activities were only 
``modest'' (CBO, 2008). However, that was based largely on assessing 
clinical preventive services, including expensive tertiary prevention, 
rather than on just cost-effective primary and secondary prevention. 
Also, the CBO did not consider the gains in health and productivity 
that accrue from employment-based wellness programs.
     IBM reports significantly improved employee health metrics 
and a $1 billion in savings since the inception of its comprehensive 
and fully integrated program for its employees and their families in 
2001. Free preventive services, first-dollar coverage for primary care, 
worker safety programs, and incentives for healthy behaviors have 
helped reduce employee health care costs to single digits (compared to 
12-15 percent for other companies) and created a more health-literate 
workforce (Sepulveda, 2008).

    The United States has made only a limited commitment to prevention 
and public health systems. At present, the United States invests less 
than 2 percent of each heath care dollar on prevention while spending 
75 percent of that dollar on treating chronic diseases, many of which 
are preventable. Those figures are even higher for the major Federal 
health insurance programs; 83 percent of every Medicaid dollar and 96 
percent of every Medicare dollar is spent on treating chronic diseases.
    As the health care reform debate gets underway, this formula must 
change. ASPH has called for legislation that will achieve health 
insurance coverage for all Americans, both children and adults, within 
2 years. Prevention and public health strategies should be the 
foundation of a newly designed system.

         A PREVENTION-FOCUSED FRAMEWORK FOR HEALTH CARE REFORM

    ASPH recommends that a prevention-focused framework for health care 
reform be built around the following priority areas:

    1. Ensuring every American an opportunity for a healthy life 
through two interrelated commitments:

          Providing access to affordable, quality health care.
          Eliminating health disparities linked to race, 
        ethnicity, socioeconomics, and other factors.

    2. Strengthening the public health infrastructure, with special 
attention to integrating health care delivery and public health, and to 
workforce development.
    3. Increasing investment in efforts to prevent disease, injury, and 
disability.
    4. Increasing investment in public health research, including 
prevention, public health systems, and population health.
    5. Strengthening American leadership and investment in global 
health.

    The remainder of this paper offers a blueprint for building that 
framework.

    STRATEGIC APPROACHES FOR A PREVENTION AND PUBLIC HEALTH EMPHASIS

    ASPH has identified the following strategies for putting prevention 
and public health at the core of the health care system, and building a 
culture of wellness:

    1. Emphasize leadership and articulate a vision for prevention.--
Use of the ``bully pulpit'' to articulate a vision for a prevention-
oriented health care system may do more to speed the transition than 
any other single measure. President Obama, the HHS Secretary, the 
Surgeon General, and other HHS leadership should use their voices and 
influence to clearly state that prevention is the core value of health 
care reform.
    Corporate America has learned that wellness programs do not succeed 
unless they are championed by the CEO and other top managers (IOM, 
2005). The Federal Government should recognize this as well. Long 
before health care reform legislation is passed, heads of the key HHS 
agencies, and other Federal agencies with health-related missions, 
should emphasize their commitment to prevention, and prioritize the 
implementation of administrative directives to advance that goal.
    The many HHS agencies with roles to play include the Agency for 
Healthcare Research and Quality (AHRQ), the Center for Medicaid and 
Medicare Services (CMS), Centers for Disease Control and Prevention 
(CDC), the Food and Drug Administration (FDA), the Health Resources and 
Services Administration (HRSA), the National Institutes of Health 
(NIH), and the Substance Abuse and Mental Health Services 
Administration (SAMHSA). Other Federal agencies with health-related 
activities in their missions should also emphasize the importance of 
prevention, including the Department of Defense, the Department of 
Homeland Security, the Environmental Protection Agency, and the 
Veterans Administration (VA).
    ASPH endorses IOM recommendations for using the authority of HHS to 
advance public health and prevention. Five IOM recommendations 
highlight opportunities for HHS to take a leadership role (IOM, 2009):

     To meet 21st-century challenges to America's health, the 
Secretary of HHS should clearly articulate and actively promote a 
vision for the Nation's health, ensure that HHS's mission supports that 
vision, and establish a small number of measurable goals focused on 
critical challenges.
     The Secretary should align and focus HHS on performance 
and encourage creative use of scientifically based approaches to meet 
new and enduring challenges.
     The Secretary should accelerate the establishment of a 
collaborative, robust system for evaluating the health care system that 
would incorporate existing HHS and external research, stimulate new 
studies as needed, synthesize findings, and provide actionable feedback 
for policymakers, purchasers, payers, providers, health care 
professionals, and the public.
     The Secretary should place a high priority on developing a 
strategy and tools for workforce improvement (1) in HHS, (2) in the 
public health and health care professions nationwide, and (3) in the 
biosciences.
     A new compact between Congress and the department is 
essential as HHS works toward achieving its vision for a healthy 
nation, departmental mission, and key health goals. Under this compact, 
the Secretary would provide regular, rigorous reports about 
departmental activities to Congress and the Nation, and assume greater 
accountability for improving performance and obtaining results. In 
return, Congress should allow HHS greater flexibility in its internal 
operations and decisionmaking.

    ASPH favors expanding the role of the Surgeon General. The IOM has 
called for a more ``prominent and powerful role'' for the Surgeon 
General (IOM, 2009). ASPH endorses the recommendation that this 
individual be ``a strong advocate for the health of the American people 
and work actively to educate Americans on important health issues.''
    The Surgeon General should issue an annual Report to the Nation 
that reviews the progress being made on disease and injury prevention. 
As a vehicle to educate all Americans and provide accountability, the 
report should include:

     Population-based survey assessments, at the national, 
State, and health plan levels, of health determinants, behaviors, and 
the Organization for Economic Cooperation and Development health 
indicators.
     Prevention report cards for all insured individuals issued 
by publicly funded health plans and based on federally approved and 
mandated clinical prevention measures. The goal is to drive the 
technology to develop new forms of patient prevention education and 
accountability by the private sector (Stagmo, et al., 2004; AHRQ, 2005; 
Campbell, et al., 2006).
     National and State-based assessments of employer 
participation in workplace prevention programs, based on documenting 
the tax credits provided for health promotion and health protection 
programs.
     Accreditation of all State and local health departments by 
a National Board of Public Health, State public health boards, and 
public health professional organizations, based on metrics developed by 
the CDC and approved by the Secretary of HHS.
     Other health behavior and health outcome national data 
authorized by the Secretary of HHS.

    2. Increase the Federal cigarette excise tax to reduce smoking-
related morbidity and mortality, spending much of the resulting revenue 
on prevention-focused activities.--ASPH recommends increasing the 
Federal cigarette tax by $1/pack, bringing the total to $2.01/pack. 
This increase would generate an annual revenue stream of $13.6 billion. 
(This is in addition to expected revenues of approximately $7 billion/
year from the $0.62 tax increase that went into effect March 31, 2009. 
Those revenues have been allocated to the State Children's Health 
Insurance Program [SCHIP]).
    Of all tobacco control measures, price increases are widely 
regarded as the most effective, reducing smoking significantly and 
quickly. Research suggests that a new tax increase of $1/pack will 
reduce smoking among adults by 6.25 percent, and lead 1.4 million 
adults to stop smoking altogether. That ultimately translates into 
approximately 700,000 fewer smoking-associated deaths. The results will 
be even more dramatic among young smokers, who are two or three times 
more responsive to cigarette price increases than adults.
    The new taxes would be in line with the 12 States, plus the 
District of Columbia, that have taxes of $2 or more, and closer to 
those in many other developed nations. In Europe, some national 
cigarette taxes exceed $7/pack.
    New revenue for public health, State relief, and other public 
purposes. The $13.6 billion/year in new revenues generated by an 
additional $1/pack increase could be used for the following purposes:

     A Public Health Trust to promote public health. Use of 
those resources should include substantial new funding for:

          A media-based antismoking campaign targeted at youth 
        and high-risk adults.
          Smoking cessation services, including quit lines and 
        nicotine replacement programs at the Federal and State levels.
          A media-based campaign to educate the public about 
        what public health is, and what it accomplishes. The goal would 
        be to promote behaviors that enhance health and reduce health 
        care expenditures, and ultimately to broaden interest in public 
        health in order to increase demand for funding.
          Public health research in population health, primary 
        prevention, and community-based and public health systems, 
        among other areas.
          Other essential public health purposes, including 
        improving access to quality health care; eliminating health 
        disparities; strengthening the public health infrastructure by 
        integrating prevention and primary care and developing the 
        public health workforce; investing in disease and injury 
        prevention and health literacy; and strengthening American 
        leadership in global public health.

     Compensation to the States for declines in their own 
excise tax revenues as cigarette sales decrease (leading to an 
anticipated loss of approximately $1.17 billion), and for the loss of 
Master Settlement Agreement revenues. Providing those funds to the 
States should encourage them to support a Federal tobacco tax increase.
     A broad range of other public purposes, which could 
include additional public health projects, educational support, deficit 
reduction, and more.

    3. Implement evidence-based measures to fight the obesity 
epidemic.--The epidemic of obesity in America now rivals that of 
tobacco in its overall impact on health. The health consequences of 
tobacco are contracting with tobacco control efforts while the much 
more recent epidemic of obesity continues to expand, with worsening 
health outcomes and higher health care costs predicted.

     The prevalence of obesity among adults, among preschool 
children ages 2-5, and among adolescents ages 12-19 has doubled since 
1970, while tripling among children ages 6-11 (CDC, 2009). Over 9 
million U.S. children are now estimated to be obese.
     Obesity is a well-recognized risk factor for diabetes, 
heart disease, hypertension, stroke, certain cancers, and a host of 
other adverse health outcomes among adults. Children are more likely to 
have diabetes, hypertension, and dyslipidemia, which presage heart 
disease. Obesity among young people also has a significant impact on 
emotional health, with a link to low self-esteem, depression, 
discrimination, and social marginalization (IOM, 2005).
     Obesity accounted for more than 25 percent of the growth 
in the Nation's health care costs between 1987 and 2001, with estimates 
of the epidemic's cost ranging from $98-$129 billion (2004 dollars) 
(IOM, 2005; Thorpe, et al.).
     Lost productivity from obesity-related morbidity and 
mortality was estimated to be $47.5 billion nationally in 1995.

    ASPH endorses recommendations made by the IOM (2005) to prevent 
childhood obesity and supports the following prevention initiatives:

     Establish a governmentwide, HHS-led task force on obesity 
to define and coordinate all Federal actions and establish nutrition 
standards for food and beverages sold in schools.
     Develop CDC-funded state-based nutrition programs designed 
to provide grant opportunities and technical assistance to local 
communities.
     Cover the costs of nutrition counseling and require body 
mass index (BMI) to be measured as a vital sign among all publically 
insured patients.
     Support nutrition counseling and physical activity as a 
component of CDC- and HRSA-funded community health programs, especially 
for high-risk individuals and vulnerable populations.
     Develop and evaluate guidelines for advertising and 
marketing to children and youth through an IOM study and a national 
conference.
     Significantly expand funding for prevention intervention 
research, experimental behavioral research, social marketing research, 
and community-based research.
     Expand and standardize surveillance and evaluation of 
dietary patterns, obesity-related health outcomes, and related costs 
through new information systems and the monitoring of electronic 
medical records.
     Develop Federal grants, and grants to States and local 
communities, to fund and evaluate changes in the built environment that 
would promote physical activity, especially in underserved communities.

    In addition, ASPH believes that an excise tax on sugar-sweetened 
beverages warrants consideration. Consumption of soft drinks and many 
other beverages sweetened with sugar, high-fructose corn syrup, or 
similar products has increased significantly over the past three 
decades (Popkin and Nielsen, 2003), and now contributes about one-third 
of the added sugar in the American diet (Guthrie and Morton, 2000). 
There is clear evidence from both observational and experimental 
studies that increased consumption of sugar-sweetened beverages leads 
to weight gain (CDC, 2006).
    Several States already levy soft drink taxes, often earmarking the 
revenues to subsidize health promotion programs and health science 
schools. The Congressional Budget Office has proposed a Federal excise 
tax of 3 cents per 12 ounces of ``sugar-sweetened'' beverages as one 
option (Option 106) to help fund health care reform, and estimates that 
it would generate an estimated $24 billion in revenues from 2009-2014, 
and an estimated $50 billion from 2009-2018 (CBO, 2008).
    The goal of an excise tax on sugar-sweetened beverages would be to 
drive down portion size and overall consumption, and to generate 
revenues that support a wide array of obesity prevention programs and 
offset obesity-related Federal health insurance costs. Further study is 
necessary to determine how best to realize these benefits.
    4. Rebuild the public health workforce.--The Nation is facing a 
public health workforce crisis, with particularly critical shortages 
forecast for public health physicians, public health nurses, 
epidemiologists, health care educators, and administrators. Drawing on 
an array of data generated by the Association of State and Territorial 
Health Officials, the National Center for Health Workforce Information 
and Analysis, and other sources, ASPH observes that:

      The public health workforce is diminishing over time even 
as the U.S. population increases. In 2000, the total workforce was 
448,000, or 50,000 fewer workers than in 1980.
      More than 100,000 public health workers in government--
approximately one-quarter of the current workforce--will be eligible to 
retire by 2012.
      By 2020, the Nation will need more than 250,000 more 
public health workers than are available today.

    Short-term and long-term workforce strategies. To meet the urgent 
need for a significantly expanded public health workforce, traditional 
models of training will have to be re-thought, and a combination of 
short-term and long-term initiatives will need to be implemented. ASPH 
endorses and extends a set of recommendations made by the Institute of 
Medicine (2002) to advance these goals and offers additional 
strategies:

     Increase Federal funding to support public health 
professional education by:

          Providing financial support to graduate students 
        pursuing public health degrees through loan repayment and 
        forgiveness programs, training and service obligation grants, 
        and fellowships.
          Strengthening ``real-world'' experiences for public 
        health students by expanding both the number and the type of 
        organizations that serve as sites for practice rotations.
          Promoting a more diverse public health workforce by 
        using financial incentives to attract underrepresented 
        populations to public health, supporting students engaged with 
        reducing racial and ethnic health disparities, and developing 
        special training opportunities targeted at minorities.

     Build capacity in Schools of Public Health, enabling them 
to:

          Enroll and train more degree-seeking graduate 
        students.
          Develop competencies and curriculum in emerging areas 
        of public health practice.
          Increase public health research training in 
        population health, primary prevention, and community-based and 
        public health systems. Particular emphasis should be placed on 
        transdisciplinary research programs at the AHRQ, CDC and the 
        NIH, which fund most research training at Schools of Public 
        Health.
          Expand joint degrees and other opportunities for 
        cross-disciplinary training (combining public health graduate 
        training with training in medicine, nursing, pharmaceutical 
        science, veterinary medicine, dentistry, law, business, health 
        and public administration, public policy, social work, and the 
        behavioral sciences, among other professions).
          Expand undergraduate public health training.
          Promote training through short courses, certificate 
        programs, distance learning, and other opportunities for 
        lifelong learning. Targeted programs are needed to meet the 
        needs of credentialed public health professionals, undertrained 
        and non-credentialed public health workers, and other workers 
        engaged in public health activities.

     Provide grants to State health departments to promote 
training. Grants can be used to encourage States to support worker 
training through MPH programs and public health certificates, and to 
promote credentialing.
     Ensure that all primary, secondary, and post-secondary 
schools offer curricula to ensure a basic understanding of public 
health and the importance of prevention in health care.
     Establish a U.S. Global Health Service to coordinate U.S. 
efforts to build a workforce prepared to meet international needs.
     Institutionalize a process for periodic enumeration of the 
public health workforce, under the guidance of the Surgeon General or 
Federal agency, to assess current capacity and evaluate future needs.

    5. Build and utilize information technology architecture to measure 
clinical prevention services and health outcomes uniformly.--The 
fragmented U.S. health care system is in urgent need of world-class 
data management systems to measure performance, improve decisionmaking, 
enhance accountability, and provide surveillance data for longitudinal 
analyses and research. Developing a culture of wellness depends in part 
on the availability of uniform assessments of health outcomes and 
system performance.
    The information technology to provide and evaluate clinical 
preventive health services is already available. Many leading U.S. 
corporations have long used some form of scorecards to manage their 
health care programs (IOM, 2002). For instance, the National Business 
Group on Health developed Employer Measures of Productivity, Absence, 
and Quality (EMPAQ), which provides the methodology and a set of 
standard metrics for employers to measure program outcomes, participate 
in benchmarking, evaluate vendor performance, and identify best 
practices (National Business Group on Health). EMPAQ offers a common 
lexicon and platform for uniform content and rigorous accountability. 
At the patient level, ``smart phones'' are now available with an array 
of prevention programs and chronic disease management tools that can be 
linked to a personal electronic medical record. Systematic, national-
level evaluation of individual prevention report cards, designed to 
provide feedback to patients and involve them in achieving prevention 
and treatment goals, is just beginning (Stagmo et al., 2004).
    Tracking and reporting on prevention should occur at many levels.--
ASPH recommends the following strategies as part of developing a 
nationwide data management system for measuring preventive health care 
and outcomes:

     HHS should develop a uniform prevention report card 
utility so that all health care plans can provide a limited dataset 
using a common lexicon and platform. Standard measures of clinical 
preventive health care, such as those defined by the U.S. Clinical 
Preventive Services Task Force, are evidence-based, reimbursed by most 
health plans, and responsive to IOM recommendations (2009). Moreover, 
these measures are already included in the electronic scorecards used 
by many businesses and insurers, and are being evaluated nationally in 
Sweden. If mandated for use in publicly financed health plans, they 
could drive the development of Smartphone-based prevention and chronic 
disease management technology (Stagmo, et al., 2004).
     Prevention report cards developed by the CDC and approved 
by the HHS Secretary and the Surgeon General, should be required of all 
health plans, regardless of payer, to assure uniform measurement and 
provide accountability and prospective surveillance. Scorecards to 
document health plan compliance with clinical prevention measures are 
well developed and available online (AHRQ, 2005; Campbell, et al., 
2006).
     Many other entities should implement, track, and report 
their compliance with clinical prevention measures, including:

          State health departments, in conjunction with public 
        and private insurers. States should have the option of 
        including other clinical prevention measures, beyond a Federal 
        minimum, as their own health care policies dictate.
          Federal health care programs, including the Veterans 
        Administration and Federally Qualified Health Centers (FQHCs), 
        which include community health centers, school-based clinics, 
        and rural and migrant health clinics. Special attention should 
        be paid to implementing and evaluating prevention measures for 
        vulnerable rural and urban subpopulations.
          Employers providing health insurance to their workers 
        should integrate clinical prevention measure reporting as a 
        part of a fully integrated employee health program.
          Hospitals and other medical providers, in line with a 
        trend among accrediting organizations, should adopt clinical 
        prevention measures as quality performance indicators.

     All parties should advance transparency and accountability 
by sharing their clinical prevention measures with the populations they 
serve, via Web sites and annual prevention and health care quality 
reports.
     Initiatives to help individuals and families become more 
health literate and to understand evidence-based health care are 
essential to promote participation in clinical prevention programs. 
While full reimbursement for all approved prevention services is 
essential, high rates of participation will not occur without 
transparent information systems, education across the lifespan, and 
continuous documentation and feedback on the benefits of prevention.

    6. Empower employers to promote wellness strategies that can be 
integrated with primary care.--Employers are a largely untapped 
resource for transforming the Nation's health care culture into one 
that emphasizes prevention. ASPH believes American employers can have a 
strong influence on demand for more prevention-oriented health 
insurance and health care delivery services.
    With appropriate incentives, employers can also be galvanized to 
develop employment-based prevention programs. To date, most fully 
integrated employee wellness programs are found among larger 
corporations (Linnan, et al., 2008; Lind, 2008). Less than 5 percent of 
employers with 50-99 employees and 24 percent of employers with more 
than 750 employees offer ``comprehensive'' workplace health promotion 
programs (Linnan, et al., 2008).
    Yet a benchmarking study found that achieving ``best practice'' 
levels of performance in health and productivity management helped 
companies annually save as much as $2,562 per employee, reflecting 
savings distributed among group health costs, turnover, absenteeism, 
and disability and workers' compensation programs (Goetzel, et al., 
2001). In general, investing in workplace wellness programs yields a 
two- to three-fold return, with savings divided equally between health 
care and productivity (Thygeson, et al., 2009).
    Defining a healthy workforce. The Institute of Medicine (2005) has 
documented the fundamental linkage between healthy employees and 
productive employees, describing a healthy workforce as follows:

     ``Healthy--demonstrating optimal health status as defined 
by positive health behaviors, minimal modifiable risk factors, and 
minimal illness, disease, and injuries.
     ``Productive--functioning to produce the maximum 
contribution to achievement of personal goals and the organizational 
mission.
     ``Ready--possessing an ability to respond to changing 
demands given the increasing pace and unpredictable nature of work.
     ``Resilient--adjusting to setbacks, increased demands, or 
unusual challenges by bouncing back to optimal well-being and 
performance without incurring severe functional decrement.''

    Guidelines for workplace wellness programs. Recent efforts to 
identify the essential elements of employer-based wellness programs and 
promote their use include:

     IOM recommendations for an employee health program, based 
on a model it designed for NASA, integrate the following elements: 
health advocate; health plan design; disease and case management; 
fitness; absence management; primary care (medical home); wellness 
programs; health risk assessment; health portal; occupational and 
environmental health; and behavioral health (IOM 2005).
     The CDC's National Institute for Occupational Safety and 
Health (NIOSH) has implemented the WorkLife Initiative, an intramural 
and extramural program designed to raise awareness and provide 
evidence-based data about employment-based prevention programs, and 
disseminate the results of research, outreach, and related information 
(http://www.cdc.gov/niosh/worklife/). NIOSH has also disseminated 
guidelines describing the Essential Elements of Effective Work site 
Programs (http://www.cdc.gov.niosh/worklife/essentials.html).
     Proposed Federal legislation would use tax incentives to 
encourage employers to adopt workplace wellness programs through tax 
incentives. Under the legislation--Incentives for a Healthy Workforce, 
a component of the Healthy Lifestyles and Prevention (HeLP) America 
Act--programs would be certified by the HHS Secretary, in conjunction 
with the CDC Director, if they:

          Are consistent with evidence-based research and best 
        practices.
          Include multiple, evidence-based strategies, such as 
        those outlined in the CDC's Guide to Community Preventive 
        Services (CDC, 2009) and the AHRQ's Guide to Clinical 
        Preventive Services (AHRQ, 2005; Campbell, et al., 2006).
          Include strategies that focus on employee populations 
        with a disproportionate burden of health problems.
          Include worksite policies related to occupational 
        safety and health exposures, tobacco use, availability of 
        nutritious food, strategies to minimize stress and promote 
        positive mental health, design of the ``built environment,'' 
        and promotion of physical activity before, during, and after 
        work.

    A two-tier tax credit program would give companies up to $200 per 
employee for the first 200 employees, and $100 per employee thereafter 
for developing certified workplace wellness programs (paying up to 50 
percent of program cost).
    Implementing a National Workplace Prevention Program. ASPH endorses 
the intent of the healthy workplace provisions of the HeLP America Act, 
which provide an excellent template for prevention programs. More 
concretely, ASPH makes the following recommendations:

     Implement a National Workplace Prevention Program, 
including an aggressive awareness campaign, an information 
clearinghouse, and benchmarks for all public and private U.S. 
employers. The program would be developed by the CDC and approved by 
the Secretary of HHS and the Surgeon General.
     Provide a four-tier schedule of tax credits for workplace 
wellness programs, based on the number of employees. Credits should not 
exceed 50 percent of the program cost for employers with fewer than 25 
employees, falling to no more than 10 percent of program costs for the 
largest employers (over 1,000 employees). Requiring electronic 
reporting of tax credits by the Secretary of the Treasury would provide 
the accountability and surveillance data essential for implementation.
     Require all participants to meet basic program 
requirements as defined by the CDC, including smoke-free workplace 
policies.
     Authorize and fund a significant expansion of the CDC/
NIOSH WorkLife Initiative, which is designed to promote evidence-based 
research and provide technical and policy assistance at the State and 
national level. This expanded initiative should include a targeted 
investigator-initiated grant program, a national network of WorkLife 
Centers of Excellence, and a robust demonstration research grant 
program to engage employers, unions, worker associations, insurers, 
wellness and informatics vendors, and universities.
     Authorize and fund a CDC/NIOSH state-level, employment-
based health promotion and protection program.
     Authorize and fund a CDC/NIOSH program for public and 
private entities to develop, implement, and evaluate health 
communication and health literacy products designed for employers, 
unions, insurers, and other vendors, and targeted at employees and 
their families.
     Authorize and fund the development of a CDC/NIOSH Web site 
to serve as a national and global clearinghouse for all elements of 
this national employee wellness program, including all applications and 
all outcome data.
    7. Empower communities to put prevention and public health programs 
at the forefront of primary care.--Public health and primary care are 
both practiced at the community level, creating opportunities to change 
the culture of local health systems to emphasize prevention as a core 
competency. Significant gaps currently exist because many community 
prevention services are not reimbursed as a part of primary care or 
adequately funded by local health departments, and are typically siloed 
organizationally, and by funding sources.
    Expanding community-based preventive services and attracting 
essential personnel to underserved rural and urban communities is as 
essential to eliminating health disparities as an element of universal 
insurance coverage. Residents in these communities typically have the 
highest rates of poverty, the most limited primary care and prevention 
services, the lowest rates of insurance coverage, and the poorest 
health outcomes. Long-term investments are especially necessary to 
provide adequate prevention and public health training to local primary 
care providers and community health workers, to expand facilities to 
house prevention programs, and to develop information and 
administration systems that link and evaluate public health programs 
with primary care and make the entire community health system more 
efficient and cost-effective.
    A new form of Federal support for prevention and public health 
programs at the local level should be used to supplement the core 
program of uniformly inadequate funding of local health departments and 
to assure that Federally Qualified Health Centers, rural clinics, free 
medical clinics and local primary care providers are integrated and 
utilize prevention in primary care. This new Federal program should 
share a common public-private governance board with the local public 
health department, hospital, and other local health programs to assure 
integration, efficiency, and accountability.
    To meet the prevention and public health needs of communities 
throughout America, especially those that are underserved, ASPH 
recommends action to:

     Develop and fund a national network of Community Health 
Education and Resource Centers (CHERs), a new entity modeled on 
Federally Qualified Health Centers, to integrate and coordinate 
community-based prevention services, including core health education, 
mental health counseling, and outreach services. CHERs could be 
integrated with existing FQHCs, and with local hospitals, public health 
departments, primary care providers, and other community health 
programs through a common public-private governing board. The Health 
Resources and Services Administration should provide adequate funding 
to finance new facilities and provide core funding for CHER staff and 
programs, which could also be supported financially by the hospital 
community-benefit programs and other charitable contributions. A CHER 
could be located at and led by any community-based health entity and 
would serve as a platform from which to advocate for additional support 
for community-based prevention programs.
     Authorize and fund a nationwide grant program to allow 
FQHCs, local health departments, and publicly owned hospitals to 
develop and fund innovative CHER models; to organize public-private 
governance boards that include all community health stakeholders; to 
administer and evaluate CHERs; and to ensure they are integrated with 
other community prevention and primary health care programs.
     Authorize and fund new state-based community preventive 
health intervention grants, based on U.S. Community Preventive Services 
Task Force recommendations, to ensure State investment and engagement 
with Federal community preventive health programs.
     Authorize and fund community prevention training grants 
for community health practitioners and educators, mental health nurses 
and counselors, and dental primary care providers. Funding should 
include support for an expanded clinical practice authority for dental 
hygienists to train to become advanced dental hygiene practitioners.
     Authorize and fund a CDC-based program of community health 
research demonstration grants. These should take advantage of current 
CDC state-based and university-based grant and center programs, 
including national networks of Injury Prevention Research Centers, 
Prevention Research Centers and Agricultural Health and Safety Centers, 
which contain many of the required research elements for developing, 
implementing, and evaluating community-based demonstration grants.
     Authorize and fund the development of a web-based national 
clearinghouse to promote the development of community-based prevention 
programs. The clearinghouse should also provide organizational 
information and track research outcomes.

    Authorize and fund Native American nations to assure that they 
receive the same benefits as other underserved communities through 
targeted Native American CHERs, community health demonstration grants, 
prevention and public health training programs, and a culturally 
appropriate community health clearinghouse for all community-based 
prevention and primary care programs.

                               CONCLUSION

    As health reform policies are debated, ASPH again emphasizes the 
importance of putting prevention and public health at the forefront of 
the debate. Even this cost-effective approach, however, will be 
expensive. Significant revenues, as well as important health benefits, 
would be generated by the $1/pack tobacco tax ASPH recommends. 
Policymakers may also want to consider two other taxes--on sugar-
sweetened beverages or other high-sugar foods, and on alcohol. ASPH is 
currently reviewing the scientific evidence for these taxes, which 
offer a possible opportunity to generate revenues while taking action 
with positive health consequences.

                               References

    Agency for Healthcare Research and Quality (AHRQ). The guide to 
clinical preventive services: recommendations of the U.S. Preventive 
Services Task Force. Rockville, MD: Agency for Healthcare Research and 
Quality; 2005. Available at: (http://odphp.osophs.dhhs.gov/pubs/
guidecps/.
    Blincoe, L., Seay, A., Zaloshnja, E., Miller, T., Romano, E., and 
Luchter, S., et al. The economic impact of motor vehicle crashes, 2000. 
Washington, DC: U.S. Dept. of Transportation, National Highway Traffic 
Safety Administration; 2002. Available at: (http://www.nhtsa.dot.gov/
staticfiles/DOT/NHTSA/Communications&Consum) 
erInformation/Article/AssociatedFiles/EconomicImpact2000.pdf).
    Campbell, KP, Lanza, A, Dixon, R, Chattopadhyay, S, Molinar, and N, 
Finch, RA, editors. A purchaser's guide to clinical preventive 
services: moving science into coverage. Washington, DC: National 
Business Group on Health; 2006. Available at: 
www.businessgrouphealth.org/prevention/purchasers.
    Center on Addiction and Substance Abuse, Columbia University. The 
cost of substance abuse to America's health care system, Report 1: 
Medicaid hospital costs, 1994.
    Centers for Disease Control and Prevention. Alcohol and public 
health. Available at: (http://www.cdc.gov/alcohol/). Accessed February 
25, 2009.
    Centers for Disease Control and Prevention. Does drinking beverages 
with added sugars increase the risk of overweight? Research to Practice 
Series, No. 3. Division of Nutrition and Physical Activity, September, 
2006.
    Centers for Disease Control and Prevention (CDC). Guide to 
community preventive services. Available at: (http://
www.thecommunityguide.org). Accessed February 5, 2009.
    Centers for Disease Control and Prevention (CDC). Obesity trends. 
Available at: (http://www.cdc.gov/nccdphp/dnpa/obesity/trend/
index.htm). Accessed February 28, 2009.
    Chaloupka, F., Grossman, M., and Saffer, H., The effects of price 
on alcohol consumption and alcohol-related problems (2002). Alcohol 
Research and Health. 26 (1), PP. 22-34.
    Congressional Budget Office. Budget options. Volume 1: Health care. 
Washington, DC: CBO; December 2008. Available at: (http://www.cbo.gov/
ftpdocs/99xx/doc9925
/12-18-HealthOptions.pdf).
    DeJong, W and Hingson, R. Strategies to reduce driving under the 
influence of alcohol. Annual Review of Public Health. 1998;19:359-78.
    Department of Transportation (U.S.), National Highway Traffic 
Safety Administration (NHTSA). Traffic safety facts 2006: alcohol-
impaired driving. Washington (DC): NHTSA 2008. Available at: (http://
www-nrd.nhtsa.dot.gov/Pubs/810801.pdf).
    Elder, R.W., Shults, R.A., and Sleet, D.A., et al. Effectiveness of 
sobriety checkpoints for reducing alcohol-involved crashes. Traffic Inj 
Prev. 2002;3:266-74
    Goetzel, et al. Health and productivity management: establishing 
key performance measures, benchmarks, and best practices. J Occ Environ 
Med 2001;43 (1):10-17.
    Guthrie, JF and Morton, JF. Food sources of added sweeteners in the 
diets of Americans. J Am Diet Assoc 2000;100 (1):43-51.
    Harwood, H. Updating estimates of the economic costs of alcohol 
abuse in the United States: estimates, update methods and data. Report 
prepared by the Lewin Group for the National Institute on Alcohol Abuse 
and Alcoholism, 2000.
    Holder, HD, Gruenewald, PJ, Ponicki, W, Treno, AJ, Grube, JW, and 
Saltz, RF, et al. Effect of community-based interventions on high-risk 
drinking and alcohol-related injuries. JAMA 2000; 284-234-7.
    Institute of Medicine (IOM). Who will keep the public healthy?: 
educating public health professionals for the 21st century. Washington, 
DC: National Academies Press; 2002. Available at: http://www.nap.edu/
catalog.php?record_id=10542#toc.
    Institute of Medicine (IOM). Integrating employee health--a model 
program for NASA. Washington, DC: National Academies Press; 2005. 
Available at: http://www.nap.edu/catalog.php?record_id=11290.
    Institute of Medicine (IOM). Preventing childhood obesity--health 
in balance. Washington, DC: National Academies Press; 2005.
    Institute of Medicine (IOM). HHS in the 21st century: charting a 
new course for a healthier America. Washington, DC: National Academies 
Press; 2009. Available at: http://www.nap.edu/
catalog.php?record_id=12513.
    Lind, DP. Iowa employer benefits study. Des Moines, IA: David P. 
Lind & Associates, LLC; 2008.
    Linnan, L, et al. Results of the 2004 national worksite health 
promotion survey. Am J Pub Health 2008; 98 (1).
    Maciosek, MV and Coffield, AB, et al. Priorities among effective 
clinical preventive services: results of a systematic review and 
analysis. Am J Prev Med 2006; 31 (1): 55-6.
    National Business Group on Health. Employer measures of 
productivity, absence, and quality. Available at: (http://
www.empaq.org. Accessed February 5, 2009.
    National Committee on Injury Prevention and Control. Injury 
prevention: meeting the challenge. Am J Prev. Med. 1989;5 (3 
Suppl):123-7.
    National Institute on Alcohol Abuse and Alcoholism (June, 2000). 
10th special report to the U.S. congress on alcohol and health (NIH 
Publication No. 00-1583). Rockville, MD: U.S. Department of Health and 
Human Services, National Institutes of Health.
    Popkin, BM and Nielsen, SJ. The sweetening of the world's diet. 
Obes Res 2003; 11 (11);1325-32.
    SAMSHSA Office of Applied Statistics. Alcohol dependence or abuse: 
2002, 2003, and 2004. Available at: http://oas.samshsa.gov/2k6/
AlcDepend/AlcDepend.htm. Accessed February 25, 2009.
    Schroeder, SA. We can do better--improving the health of the 
American people. N Engl J Med 2007; 357:1221-8.
    Sepulveda, M. Innovation in health care--an employer's perspective. 
America's Health Rankings, 2008 edition. Available at: http://
www.americashealthrankings
.org/2008/ibm.html.
    Shults, RA, Sleet, DA, Elder, RW, Ryan, GW, and Sehgal, M. 
Association between state-level drinking and driving countermeasures 
and self-reported alcohol-impaired driving. Inj Prev 2002;8:106-10.
    Stagmo, M, et al. The Swedish national programme of quality control 
of secondary prevention of coronary heart disease--results after 1 
year. Eur J Cardiovasc Prev Rehabil 2004;11 (1):18-24.
    Thorpe, KE, Florence, CS, Howard, DH, and Joski, P. The impact of 
obesity on rising medical spending. Health Affairs 2004 Jul-Dec; Suppl 
Web Exclusives: W4-480-6.
    Thygeson, NM, et al. Employee health at BAE Systems: an employer-
health plan partnership approach. In: Pronk NP, editor. ACSM's worksite 
health handbook: A guide to building healthy and productive companies. 
2nd ed. Champaign, IL: Human Kinetics. In press 2009.
    Trust for America's Health. Blueprint for a healthier America. 
Washington, DC; October, 2008. Available at: www.healthyamericans.org.
    U.S. Department of Health and Human Services and U.S. Department of 
Agriculture. Dietary guidelines for Americans, 2005. Washington, DC: 
U.S. Government Printing Office; 2005.
    U.S. Department of the Treasury, Alcohol & Tobacco Tax & Trade 
Bureau, 2007.
    U.S. Department of the Treasury, Alcohol and Tobacco Tax and Trade 
Bureau. Available at: www.thefederalregister.com/b.p/agency/
Alcohol_and_Tobacco_Tax
_and_Tradel_Bureau/2008. Accessed March 5, 2009.
    Wells-Parker, E., Bangert-Drowns, B., McMillen, R., and Williams, 
M. Final results from a meta-analysis of remedial interventions with 
drink/drive offenders. Addiction 1995; 90: 907-26.

    Senator Dodd. Thank you.
    Dr. Levi, thank you for joining us.

STATEMENT OF JEFFREY LEVI, Ph.D., EXECUTIVE DIRECTOR, TRUST FOR 
                        AMERICA'S HEALTH

    Mr. Levi. Thank you, Mr. Chairman. Thank you, Senator 
Mikulski.
    I want to begin by thanking you and your colleagues for 
assuring that public health and prevention are a central part 
of this year's health reform effort.
    The public health title of this bill helps to ensure that 
reform efforts address the health of the American people, not 
just financing sick care.
    In the short time that I have, I want to emphasize the 
importance of key portions of the public health title. The 
Right Choices Program provides crucial assurance of access to 
proven clinical preventive services for the uninsured. We are 
pleased that the coverage section mandates no co-payments for 
evidence-based preventive services endorsed by independent 
authorities.
    Just as importantly, the public health title places 
emphasis on prevention that takes place outside the doctor's 
office, those initiatives that help to make healthy choices the 
easy choices by promoting lifestyle and environmental changes 
that remove barriers to healthy living.
    Ultimately, engaging in preventive behaviors is the 
personal responsibility of all Americans, but we cannot expect 
them to exercise that personal responsibility unless we make 
the communities in which they live ones that promote this 
wellness approach. That is why the community transformation 
grants and prevention education campaigns are so important.
    All the prevention programs in this title will be of 
diminished value without a concerted coordinated effort to 
implement effective programs. Thus, the mandate for a national 
prevention and health promotion strategy is an essential 
component to assure that the American people--to assure the 
American people that all parts of the Federal Government are 
working on shared goals in targeting the conditions most 
important to the public's health.
    And finally and perhaps most important of all, we are 
strongly supportive of the Prevention and Public Health 
Investment Fund. Public health programs have not achieved their 
potential primarily because public health has been chronically 
under-funded.
    The Investment Fund would assure reliable funding for 
prevention that will make Americans healthier as they become 
part of a reformed healthcare system. The $10 billion level 
will assure that a good mix of clinical and community 
prevention services will be available.
    Thank you again, Mr. Chairman, for your leadership and for 
this opportunity to express our strong support for the public 
health provisions of this historic legislation.
    [The prepared statement of Mr. Levi follows:]

               Prepared Statement of Jeffrey Levi, Ph.D.

    Thank you, Mr. Chairman for the opportunity to testify. My name is 
Jeff Levi, and I am the Executive Director of Trust for America's 
Health (TFAH), a nonpartisan, nonprofit organization dedicated to 
saving lives by protecting the health of every community and working to 
make disease prevention a national priority. I want to begin by 
thanking you and your colleagues for assuring that public health and 
prevention are a central part of this year's health reform effort. The 
public health title of this bill helps to ensure that reform efforts 
address the health of the American people, not just financing sick 
care. I want to emphasize the importance of key portions of the public 
health title:

     The Right Choices program provides crucial assurance of 
access to proven clinical preventive services for the uninsured. We are 
pleased that the coverage section mandates no copayments for evidence-
based preventive services endorsed by independent authorities.
     Just as importantly, the public health title places 
emphasis on prevention that takes place outside the doctor's office--
those initiatives that help to make healthy choices the easy choices, 
by promoting lifestyle and environmental changes that remove barriers 
to healthy living. Ultimately, engaging in preventive behaviors is the 
personal responsibility of all Americans. We cannot expect them to 
exercise that personal responsibility unless we make the communities in 
which they live ones that promote this wellness approach. That is why 
the community transformation grants and prevention education campaigns 
are so important.
     It is critical to note that we know this approach to 
prevention can and does work--and often can save us money. Trust for 
America's Health worked with the New York Academy of Medicine, 
Prevention Institute, and the Urban Institute to see if there were 
indeed evidence-based approaches to community prevention that could 
both prevent chronic diseases--the biggest cost drivers in our health 
care system today--and potentially save money. We found that for an 
investment of $10 per year per person in proven community-based 
programs to increase physical activity, improve nutrition, and prevent 
smoking and other tobacco use the country could save more than $16 
billion annually within 5 years. This is a return of $5.60 for every $1 
spent.
     We also found that the evidence base needs building in 
other areas of prevention. That is why we are pleased that this title 
provides the authority and resources to assess the data currently 
available on clinical and community preventive services and authorizes 
the Centers for Disease Control and Prevention to conduct more 
extensive public health services and systems research--to be sure that 
we are successfully and cost effectively translating prevention science 
into good practice.
     All the evidence in the world, however, is not of value 
without a concerted, coordinated effort to implement effective 
programs. Thus, the mandate for a National Prevention and Health 
Promotion Strategy is an essential component to assure the American 
people that all parts of the Federal Government are actively engaged in 
targeting the conditions most important to the public's health and that 
government agencies are accountable for achieving measurable health 
outcomes with the resources taxpayers provide for public health.
     And finally, and perhaps most important of all, we are 
strongly supportive of the Prevention and Public Health Investment 
Fund. Public health programs have not achieved their potential 
primarily because public health has been so chronically underfunded. 
This has occurred at a time when States and localities have been making 
major cutbacks due to the recession. The Investment Fund would assure 
reliable funding for prevention efforts that will make Americans 
healthier as they become part of a reformed health care system. The $10 
billion level goes a long way toward closing the funding gap and will 
assure that a good mix of clinical and community preventive services 
will be available.

    Thank you again, Mr. Chairman, for your leadership and for this 
opportunity to express our support for the public health provisions of 
this historic legislation.

    Senator Dodd. Well, thank you very much, Doctor, and we 
will have some good questions for you, as well, in a few 
minutes.
    Dr. Raines, thank you again for being with us.

  STATEMENT OF C. FAY RAINES, Ph.D., RN, PRESIDENT, AMERICAN 
            ASSOCIATION OF COLLEGES OF NURSING, AND 
       DEAN, COLLEGE OF NURSING, UNIVERSITY OF ALABAMA, 
                         HUNTSVILLE, AL

    Ms. Raines. Thank you, Senator Dodd.
    I am Fay Raines, President of the American Association of 
Colleges of Nursing, which represents baccalaureate and 
graduate programs in nursing across the country, and I am the 
Dean of the College of Nursing at the University of Alabama in 
Huntsville.
    It is my great honor to testify before you today, and 
first, I would like to commend all members of the HELP 
Committee and their staff for drafting this legislation which 
promises to re-invigorate our country's healthcare system.
    I am pleased to offer AACN's insights, especially as it 
relates to the workforce, which are further developed in our 
written statements. I hope that these insights and suggestions 
will provide some assistance as you continue working through 
this challenging, difficult but hopefully very rewarding 
process for the citizens of the country.
    AACN commends the Senate HELP Committee's work to 
reauthorize Title VII and VIII of the Public Health Service 
Act. These programs are vitally important to the efforts of 
nurses and other health professionals to address the workforce 
needs of the future.
    A major hindrance in increasing the number of practicing 
nurses is the nursing faculty shortage. While AACN strongly 
supports the effective strategies in this bill to address that 
shortage, we also highly recommend that the 10 percent cap on 
doctoral nursing programs, a no-cost measure, be removed from 
the Advanced Education Nursing Grants Program. Failing to 
remove this cap may significantly limit the number of advanced 
practice registered nurses as well as doctorally prepared 
nurses who can serve as faculty in the very near future.
    AACN also recommends that the Capitation Grants Program 
outlined in the Nurse Education, Expansion and Development Act 
of 2009, which was introduced by Senator Durbin, be included in 
this bill. Capitation Grant Programs have had historical 
success and will address the most pressing needs of our nursing 
schools, including infrastructure and clinical training.
    At my own school, for example, we turn away between 1 and 
200 qualified applicants each year due to lack of resources and 
this is typical of many schools across the country at a time of 
a very serious nursing shortage.
    Capitation Grant Programs will enable schools to expand 
capacity and produce more nurses to meet the critical workforce 
needs for health promotion and other programs cited in this 
legislation.
    AACN is very pleased that the committee thought broadly 
about healthcare providers while drafting this legislation. The 
term ``provider'' and ``practitioner'' show a commitment to a 
new model where quality care is delivered by a team rather than 
any one provider and we encourage the consistent use of that 
terminology throughout the bill.
    AACN and numerous other nursing organizations commend the 
use of community-based multidisciplinary teams to support 
primary care through the medical home model. However, we are 
concerned that the current language under section 212 suggests 
that advanced practice registered nurses cannot lead a medical 
home and the purpose of the medical home speaks directly to the 
skills and education that advance practice registered nurses 
receive and we encourage the committee to look at that part of 
the legislation again.
    Finally, we would like to suggest that, as an adjunct to 
the Senate HELP Committee's important work regarding expanding 
nursing education, parallel work be done with the Senate 
Finance Committee to expand clinical education for advance 
practice registered nurses through a modification of Medicare 
funding for nursing, to include funding for training APRNs.
    It is clear that this committee recognizes the fundamental 
need for accessible quality care and understands the 
contributions nurses will make in ensuring the implementation 
of the provisions of this bill.
    Thank you for your leadership and for the opportunity to 
testify and offer our comments on this momentous legislation.
    [The prepared statement of Ms. Raines follows:]

  Prepared Statement of C. Fay Raines, Ph.D., RN, President, American 
   Association of Colleges of Nursing and Dean, College of Nursing, 
    University of Alabama in Huntsville, On Behalf of the American 
               Association of Colleges of Nursing (AACN)

    Good afternoon distinguished committee members. I am Dr. Fay 
Raines, President of the American Association of Colleges of Nursing 
and Dean of the College of Nursing at the University of Alabama in 
Huntsville. The American Association of Colleges of Nursing (AACN) is 
the national voice of baccalaureate and graduate nursing education, 
representing over 640 schools of nursing that educate approximately 
270,000 students and employ over 13,000 faculty members. Together, 
these institutions produce about half of our Nation's Registered Nurses 
(RNs) and all of the nurse faculty and researchers. It is my great 
honor to testify before you today on the Affordable Health Choices Act 
of 2009. First, let me commend and congratulate Chairman Kennedy, 
Senator Enzi, Members of the Health, Education, Labor, and Pensions 
(HELP) Committee, and their staff for drafting this legislation, which 
promises to re-invigorate our country's healthcare system. I am pleased 
to offer AACN's insights on this comprehensive legislation.

  TITLE IV--HEALTH CARE WORKFORCE; SUBTITLE D--ENHANCING HEALTH CARE 
   WORKFORCE EDUCATION AND TRAINING; SECTION 438, ADVANCED EDUCATION 
                             NURSING GRANTS

    AACN commends the Senate HELP Committee's work to reauthorize 
Titles VII and VIII of the Public Health Service Act (PHSA). These 
programs are vitally important to the efforts of nurses and other 
health professionals to address future workforce needs. As the 
committee is well aware, our Nation's 11-year nursing shortage 
persists, and more positions continue to open for RNs across the 
country. The U.S. Bureau of Labor Statistics (BLS) recently reported 
that the healthcare sector of the economy is continuing to grow, 
despite significant job losses in nearly all other major industries. 
Hospitals, long-term care facilities, and other ambulatory care 
settings added 23,500 new jobs in May 2009, a month when 345,000 jobs 
were eliminated across the country. As the largest segment of the 
healthcare workforce, RNs likely will be recruited to fill many of 
these new positions. Moreover, according to the latest BLS projections, 
more than 1 million new and replacement nurses will be needed by 2016.
    The nursing workforce is not growing at a pace that will adequately 
meet long-term needs, including the demand for primary care, which is 
often provided by Advanced Practice Registered Nurses (APRNs). This 
challenge is further compounded by the number of nurses who will retire 
or leave the profession in the near future, ultimately reducing the 
nursing workforce. The supply of nurses nationwide is stressed due to 
an ongoing shortage of nurse faculty. The nurse faculty shortage 
continues to inhibit nursing schools from educating the number of 
nurses needed to meet the demand. According to AACN, 49,948 qualified 
applicants were turned away from baccalaureate and graduate nursing 
programs in 2008 primarily due to a lack of qualified faculty. Of those 
applicants, nearly 7,000 were students pursuing a master's or doctoral 
degree in nursing, which is the education level required to teach.
    AACN commends the committee's efforts to include effective 
strategies in the Affordable Health Choices Act of 2009 to address the 
nursing faculty shortage. Yet, we are concerned that one measure, which 
has no associated costs, was not included in the text of the bill.

     Therefore, we strongly suggest that the 10 percent cap 
imposed on traineeships awarded to doctoral students under the Advanced 
Education Nursing Grant program be lifted by striking section 
296j(f)(2) of the current title VIII authority.\1\
---------------------------------------------------------------------------
    \1\ On behalf of the American Association of Colleges of Nursing 
(AACN), we would like to amend our written and oral testimony provided 
on June 12, 2009. In the testimony we addressed that the 10 percent cap 
awarded to doctoral students under the Advanced Education Nursing Grant 
program be lifted by striking section 296j(f)(2) of the current Title 
VIII authority of the Public Health Service Act. The Affordable Health 
Choices Act of 2009, does indicate the removal of this provision. This 
was an oversight and unintentional error by AACN and we would like to 
correct our comments to reflect the legislation does include the 
removal of this cap. It was not our intent to mislead the Senate 
Health, Education, Labor, and Pensions Committee. (See Letter dated 
June 19, 2009 in Additional Material).
---------------------------------------------------------------------------
    Failing to remove this cap may significantly limit the number of 
APRNs, as well as doctorally prepared nurses who can serve as faculty 
in the very near future. The need for nurses with doctoral degrees is 
growing at an exceedingly high rate. By 2015, nursing education is 
moving toward preparing all new APRNs and other nursing specialists in 
Doctor of Nursing Practice (DNP) programs. According to AACN, between 
2007 and 2008, the number of new DNP programs and enrollments more than 
doubled. Additionally, graduations from these programs in that time 
span nearly tripled. Neglecting to remove this cap will cause 
significant strain on the educational pipeline of future APRNs and 
other nursing specialists.
    Furthermore, this cap inhibits the expansion of the doctorally 
prepared nurse faculty population. The need for nurse educators is 
acute as schools reported last year that more than 50 percent of the 
faculty vacancies required a doctoral degree. Unfortunately, schools 
are not preparing enough doctorally prepared nurses. According to 
AACN's 2008-2009 report, enrollment in research-focused doctoral 
nursing programs were up by only 0.1 percent or 3 students from the 
2007-2008 academic year. With increased access to these trainee-ship 
funds by removing the 10 percent cap mentioned above, more doctoral 
nursing students can be supported. This critical edit will directly 
impact the supply of nurse faculty and primary care providers.

   TITLE IV--HEALTHCARE WORKFORCE; SUBTITLE D--ENHANCING HEALTH CARE 
                    WORKFORCE EDUCATION AND TRAINING

    As evidenced by the rapid growth in nursing school enrollments, 
nationwide attention to the nursing shortage has sparked the interest 
of thousands of men and women across the country. However, nursing 
schools are struggling to overcome a variety of barriers beyond the 
faculty shortage that preclude them from further expanding student 
capacity and increasing the pipeline of registered nurses. Thousands of 
potential nursing students are being denied the opportunity to pursue a 
nursing education despite the high demand for RNs.
    Each year, schools of nursing turn away tens of thousands of 
students due to an insufficient number of faculty, clinical sites, 
classroom space, clinical preceptors, and budget constraints. Although, 
schools pointed to faculty shortages as a major reason for not 
accepting all qualified applicants into nursing programs, many schools 
of nursing are literally crumbling since congressional funding for 
infrastructure ceased in the mid-1970s.
    Compared to other academic disciplines, the cost of nursing 
education is relatively high, like medicine, which further increases 
the financial burden on nursing schools. Schools require specialized 
laboratory equipment, computer software, and simulated hospital units 
to prepare students to provide lifesaving nursing services in a complex 
healthcare system. Moreover, nursing education is also faculty-
intensive with a high ratio of faculty to students, on average 1:10, as 
mandated by state-registered nurse practice acts.
    From 1971 to 1978, Congress provided Capitation Grants (formula 
grants based on the number of students enrolled) to schools of nursing 
in support of nursing education. These grants have had a stabilizing 
effect on past nursing shortages by addressing the financial obstacles 
of nursing programs. Notably the Nurse Training Act of 1971 (P.L. 92-
158) and the Nurse Training Act of 1975 (P.L. 94-63) facilitated 
increased enrollments in schools of nursing and helped resolved nursing 
workforce shortages.
    The March 2002 Health Resources and Services Administration Tenth 
Report to Congress on Health Personnel in the United States recommended 
Capitation Grants funding as a strategy to expand the nursing workforce 
pipeline.

     Therefore, AACN respectfully requests that the Capitation 
Grants program outlined in the Nurse Education, Expansion, and 
Development Act of 2009, (S. 497), which was introduced by Senator 
Richard Durbin (D-IL), be included in this section of the bill.

    Just as in the past, today's schools of nursing need additional 
resources, particularly nurse faculty, to educate the next generation 
of nurses. Capitation Grants would complement and expand the existing 
authorities under Title VIII of the PHSA by providing nursing schools 
with the opportunity to improve the structural and programmatic 
conditions that inhibit student capacity growth. For these reasons, 
Capitation Grants would provide a flexible funding stream to meet the 
fiscal barriers faced by schools of nursing.

  TITLE IV--HEALTH CARE WORKFORCE; SUBTITLE D--ENHANCING HEALTH CARE 
 WORKFORCE EDUCATION AND TRAINING; SECTION 432, TRAINING OPPORTUNITIES 
                        FOR DIRECT CARE WORKERS

    Section 432, Training Opportunities for Direct Care Workers creates 
``Primary Care Training and Enhancement'' on page 493. While this 
program includes physicians and physician assistants, AACN is concerned 
that this program does not include APRNs such as Nurse Practitioners 
(NPs).
    There are over 125,000 NPs practicing in the United States today. 
Of those NPs, 66 percent serve in at least one primary care setting. 
Therefore, approximately 82,500 NPs are practicing in primary care. 
According to the American Academy of Nurse Practitioners (AANP),

     39 percent of NPs hold hospital privileges; 13 percent 
have long-term care privileges.
     96.5 percent of NPs prescribe medications and write an 
average of 19 prescriptions/day.
     NPs write over 513 million prescriptions annually.
     62 percent of NPs see three to four patients per hour; 12 
percent see over five patients per hour.
     Malpractice rates remain low; only 1.4 percent have been 
named as primary defendant in a malpractice case.

    Nurse Practitioners are widely used as primary care providers, with 
outcomes equivalent to their physician and physician assistant 
colleagues.

     AACN recommends that the ``Primary Care Training and 
Enhancement'' program, under section 432 of this bill be expanded to 
include APRNs such as Nurse Practitioners.

 TITLE IV--HEALTHCARE WORKFORCE; SUBTITLE B--INNOVATIONS IN THE HEALTH 
 CARE WORKFORCE; SECTION 411, NATIONAL HEALTH CARE WORKFORCE COMMISSION

    AACN supports the development of a National Health Care Workforce 
Commission. Quality data on the national healthcare workforce is 
critical to ensure that care is comprehensive and coordinated and all 
providers are used to their full scope of practice. This can only occur 
with the collaboration from all healthcare providers in the planning 
and development of national standards for data collection and analysis.

     AACN recommends that the membership of this commission has 
an equal representation among health professionals.

TITLE II--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE; SUBTITLE 
 B--HEALTH CARE QUALITY IMPROVEMENTS; SECTION 212 GRANTS TO ESTABLISH 
        COMMUNITY HEALTH TEAMS TO SUPPORT THE MEDICAL HOME MODEL

    AACN and numerous nursing organizations commend the use of 
``community-based multidisciplinary teams'' to support primary care 
through the Medical Home Model. For the reason cited earlier, AACN 
firmly believes that APRNs should be clearly identified as primary care 
providers and authorized to lead Medical Homes. However, we are 
concerned that the current language under section 212 suggests that 
APRNs could not lead a Medical Home.

     AACN strongly suggests using the language defining Medical 
Homes from the Schwartz-Cantwell bill, Preserving Patient Access to 
Primary Care Act of 2009 (S. 1174, H.R.  2350).

    The purpose of the Medical Home speaks directly to the skills and 
education APRNs receive.

  TITLE IV--HEALTH CARE WORKFORCE; SUBTITLE D--ENHANCING HEALTH CARE 
 WORKFORCE EDUCATION AND TRAINING; SECTION 455, PRIMARY CARE EXTENSION 
                                PROGRAM

    AACN and members of the Nursing Community are pleased to see the 
inclusion of the Institute of Medicine's definition of primary care and 
commend the committee for the emphasis the legislation places on 
delivering primary care and preventive services under a reformed 
healthcare system. However, we feel that the definition of primary care 
providers, as noted on page 573 of the legislation, could be 
unintentionally limiting as it describes the clinician as providing 
preventative and health promotion services for `` . . . men, women, and 
children of all ages.  .  .'' This suggests that a single primary care 
provider must offer care to all three populations and would indicate 
that certified nurse-midwives, pediatric nurse practitioners, 
pediatricians, and other specialists would not be viewed as a primary 
care provider since they serve a subset of the population.

     If this is not the intent of this language, we suggest its 
removal or clarification. A viable option would be to incorporate the 
definition of primary care providers from the Schwartz-Cantwell bill, 
Preserving Patient Access to Primary Care Act of 2009, with the 
inclusion of certified nurse-midwives.

                            OVERALL COMMENTS

Nurses and Quality Measures
    Nurses are a central element in healthcare quality and safety. It 
is clear that the committee recognizes the fundamental need for 
accessible quality care and understands the connection nurses will make 
in ensuring the provision of the bill are implemented. The Affordable 
Health Choices Act of 2009 details new and expansive quality programs 
in titles II (Improving the Quality and Efficiency of Health Care) and 
III (Improving the Health of the American People). These programs will 
expand the role of and need for nurses as they will be critical to 
collecting and implementing established quality indicators. Therefore, 
AACN is appreciative that Section 442 (Authorization of Appropriations 
for Parts B through D of title VIII) of the bill seeks to increase 
funding for the title VIII programs to ensure that more nurses are 
educated to address the need for emerging nursing positions.

The Future Healthcare Team
    AACN is pleased to see that the committee thought broadly about 
healthcare providers when drafting this legislation. Use of the terms 
``provider'' and ``practitioner'' demonstrates a commitment to a new 
model where quality care is delivered by a team rather than any one 
provider. We encourage consistent terminology, where applicable, 
throughout the legislation.

Clinical Education for APRNs
    We would like to suggest that as an adjunct to the important work 
the Senate HELP Committee is doing regarding expanding nursing 
education, parallel efforts be undertaken with the Senate Finance 
Committee to expand clinical education for APRNs. AACN suggest a 
modification of the Medicare funding for nursing to include funds for 
training APRNs. In hospitals, the vast majority of care is provided by 
nurses, yet nurses receive little Federal funding for clinical 
training. Unlike the Graduate Medical Education program that has been 
the primary vehicle for physician training in hospitals over the last 
40 years, nursing education programs have not had the support or the 
funding to sufficiently provide nurses with the training needed for the 
complex healthcare environment. Because of the critical role nurses 
play in quality care and patient safety, nursing clinical education 
should be viewed with the same importance as medicine when reshaping 
healthcare and move toward systemwide reform.

                               CONCLUSION

    The Affordable Health Choices Act of 2009 offers numerous programs 
that would augment the nursing workforce for the benefit of American 
patients. For example Section 412, State Health Care Workforce 
Development Grants; Section 428, Nurse-managed Health Clinics; Section 
429, Elimination of Cap on Commissioned Corp; Section 430, Establishing 
a Ready Reserve Corps all have the potential to improve the health 
professions workforce and directly impact the quality of patient care. 
AACN would like to reiterate our appreciation to the Senate HELP 
Committee for the significant efforts to draft such a comprehensive 
piece of legislation. AACN looks forward to working further with the 
committee to address the concerns raised above during the legislative 
process. Thank you for the opportunity to testify and offer our 
comments on this momentous piece of legislation.

    Senator Dodd. Well, thank you, Dr. Raines, very, very much.
    Dr. Jonas, welcome.

    STATEMENT OF WAYNE B. JONAS, M.D., PRESIDENT AND CHIEF 
              EXECUTIVE OFFICER, SAMUELI INSTITUTE

    Dr. Jonas. Thank you very much. Thank you, Senator Dodd, 
Senator Mikulski, Senator Brown, members of the committee, for 
the opportunity to testify again on the importance of health 
promotion, prevention and integrative practices in healthcare 
transformation.
    I want to congratulate you on a bill that has opened the 
dialogue beyond the treatment and funding of our current sick 
care system of which we have a major one and the importance of 
developing a 21st Century prevention and wellness system with 
equal power and equal stature.
    I think the bill opens up opportunities for this and my 
testimony will focus on specific areas that can enhance that 
practice.
    I run the Samueli Institute. It is a nonprofit research 
organization, one of the few that has a track record in 
research on integrative medicine, healing relationships, 
optimal healing environments, and military medicine in which we 
do a considerable amount.
    Let me say that it is axiomatic, self-evident in my 
opinion, that the goal of healthcare reform should be health. 
We should be producing health. The most powerful way to do that 
is to tap into the inherent healing capacities of the 
individual and the community through the systematic application 
of behavioral and lifestyle change areas and integrative 
practices that we know contribute to 70 percent of the chronic 
diseases that we suffer from.
    To achieve this goal, to create a 21st Century health 
system that is as powerful as our medical healthcare system, 
could transform and create health and flourishing Nation.
    On the Affordable Healthcare Choices Act that is currently 
before the committee, there are several provisions that I 
think, if emphasized, would create such a wellness system. The 
most important of these, in my opinion, is the National 
Prevention and Health Promotion and Public Health Council, the 
S302, in your language.
    What this does is it examines policies that cross multiple 
agencies, not just the health delivery system, and looks at 
those that enhance the production of health. The council can 
move the Nation and the culture and, most importantly, the 
healthcare industry toward prevention and wellness.
    There are other key provisions also that could support 
this, if they were done in a coordinated fashion. The Public 
Health and Prevention Investment Fund, by linking the use of 
this fund to the policies of the council, would give it some 
true powers, some true teeth in these areas.
    The clinical community preventive services that have 
already been mentioned provide delivery mechanisms for 
sustained individual and community behavioral change. These, 
however, need to be combined with others that are mentioned in 
this bill, such as the community health teams, the community 
transformation grants, the employer-based wellness programs, 
and the education and outreach campaign.
    Let me point out, however, that the educational and 
outreach campaign has to go beyond information, as it is 
currently described in the bill. It has to include actual 
training and skills, values and attitudes that promote health 
and wellness, and it has to link up with what I call the 
healthcare home, so that there are teams of qualified 
practitioners of all disciplines, not simply the medical side.
    Finally, the healthcare workforce section should include 
provisions to develop wellness professionals who are as fully 
trained and supported as we currently have medical 
professionals. Leaders in wellness would encompass nurses, 
would encompass primary care and integrative practitioners and 
there would be standards for wellness behavior and skills that 
can be further disseminated through other aspects of the act, 
such as the Primary Care Extension Program, the National Health 
Service Corps, and the Youth Public Health Program.
    Things like that, however, need to produce youth with 
leadership skills that can deliver wellness and prevention 
activities. They need to be able to model this so the 
experience in those areas is key to that.
    If the above provisions were coordinated and implemented, a 
wellness initiative for the Nation could ensue and launch to 
produce a true goal of health reform which is health from womb 
to tomb.
    I appreciate the opportunity to appear before the committee 
and look forward to any questions.
    [The prepared statement of Dr. Jonas follows:]

    Prepared Statement of Wayne B. Jonas, M.D., President and CEO, 
                         The Samueli Institute

    Thank you, Senators Kennedy and Enzi, and members of the committee 
for the invitation to testify about the central role of prevention, 
health promotion and integrative health care practices to address many 
of the ills of today's health care delivery system. First, let me 
congratulate you on your leadership in producing a bill and offering 
legislative options that go beyond the issues of medical care coverage 
and payment, and open an opportunity to deliver the central factors 
that we know can produce health and wellness, and enhance productivity 
and healing.
    The Samueli Institute, a 501(c)(3) non-profit scientific research 
organization, investigates healing processes and their application in 
promoting health and wellness, preventing illness and treating 
disease--one of the few organizations in the Nation with a track record 
in complementary and integrative health care, healing relationships and 
military medical research.
    It is axiomatic that the goal of health care reform should result 
in--health. To achieve this goal, our culture should be empowered to 
create a wellness system that is as powerful as our disease treatment 
system is today. We cannot expect to improve the health of our citizens 
through more or better access to the current broken system, or by 
simple payment or insurance reforms of that system. We need a new 
vision and approach to creating health. We need a Wellness Initiative 
for the Nation (WIN). In previous testimony before this committee, I 
presented an overview of WIN, see (http://www.samueliinstitute.org/
news/news-home/WIN-Home.html).
    The Affordable Health Choices Act currently before the committee 
has several provisions that can help create a 21st Century Wellness 
System. The most important of these is The National Prevention, Health 
Promotion and Public Health Council [S.  302]! By examining policies 
across the multiple agencies that either enhance or interfere with 
health production, the Council can move the national culture and health 
care industry toward prevention and wellness. Other key provisions for 
creating a wellness culture and system include:

    1. Prevention and Public Health Investment Fund. By linking the use 
of this Fund to the policies developed by the Council, it would have 
true power to create a wellness system;
    2. Clinical and Community Preventive Services. Delivery mechanisms 
for sustained individual and community behavioral change would be 
created if the provisions of this section were combined with the 
Community Health Teams, Community Transformation Grants, Employer-based 
Wellness Programs, and the Education and Outreach Campaign. The 
educational system must go beyond information, however, to include 
actual training in the skills, values and attitudes that promote health 
and wellness; and
    3. The Health Care Workforce section should include provisions to 
develop Wellness Professionals who are as fully trained and supported 
as medical professionals. Leaders in wellness would encompass nurses, 
and primary care and integrative practitioners. Wellness behavior and 
skills can further be disseminated through the Primary Care Extension 
Program, a National Health Service Corps, and the Youth Public Health 
Program--provided the latter produced youth with leadership skills 
needed to deliver wellness and prevention.

    Senator Dodd. That's very, very good, Doctor. We thank you.
    Dr. Cosgrove.
    By the way, I should let Senator Brown introduce you, I 
guess. Cleveland Clinic gets talked about a lot. Back at the 
White House the other day, the President was bragging on the 
Cleveland Clinic and your Senator brags about you all the time.

                       Statement of Senator Brown

    Senator Brown. Thank you. I would like to take a moment. 
Thank you, Mr. Chairman.
    Dr. Cosgrove, welcome to the committee. It was good to see 
you yesterday here, too, sitting through a long day, as we have 
all done in the last few days and few weeks on this, and Dr. 
Cosgrove is the CEO of the Cleveland Clinic and as Chairman 
Dodd said, we were at the White House last week and the 
President was talking about institutions that provide 
extraordinarily high-quality care and find a way to do it less 
expensively than most around the country and cited a very small 
number of places and the Cleveland Clinic was one of them.
    I was there this week visiting with again Dr. Cosgrove and 
much of his management team and the kinds of things that he 
will talk about, I am sure, so I will not say much, but in 
terms of what they're doing with IT, what they're doing with 
prevention, what they're doing with wellness, it was 
exceptional.
    We look forward to hearing that and welcome back and good 
to see you.
    Thank you.
    Senator Dodd. Good to have you with us.

          STATEMENT OF DELOS M. COSGROVE, M.D., CEO, 
                        CLEVELAND CLINIC

    Dr. Cosgrove. Thank you very much, Senator Dodd, Senator 
Mikulski.
    Senator Brown, you've been a great friend of the Cleveland 
Clinic and an advocate for better healthcare and we very much 
appreciate that.
    I appreciate the opportunity to tell you a little bit about 
the uniqueness of the Cleveland Clinic which is and has made it 
possible for us to achieve access, quality and affordability 
for our patients.
    We are major proponents of preventive and wellness care. 
However, we think that in order to achieve what we have, we 
also have to look after the sickness and it has to be done in a 
significantly different model.
    The organization had its beginnings in World War I when 
four doctors came together from different disciplines in France 
and worked as a unit. They came back and started the Cleveland 
Clinic at that time and the obsession with quality has driven 
this organization to grow where it is now 2,000 physicians and 
scientists and a 120 specialties, 40,000 employees, and we see 
3.3 million outpatient visits and 120,000 hospitalizations 
annually.
    The major portion of the success of the organization is its 
model which is an integrated model. The hospitals, the 
physicians, the clinics, the medical school, the research 
institutes are all one part, a part of one organization which 
are physician-led.
    The second portion of this is the group practice. The 
physicians at the Cleveland Clinic are all salaried. We all 
have 1-year contracts. There's no tenure. Each year we have an 
annual professional review which ensures quality and salaries 
are adjusted on the basis of the quality of the physician's 
performance.
    We have recently changed our organization to go from a 
physician-centered organization where the physicians were in 
Departments of Surgery and Departments of Medicine to an 
institute model which is patient-centered. Essentially, a 
Neurologic Institute will have neurosurgeons, neurologists and 
psychiatrists all in the common location with common 
leadership, and this begins to change the focus of the 
physicians' work.
    We have also had an obsession with quality. We have been 
measuring quality and publishing our outcomes. Every institute 
publishes on an annual basis the outcomes, not just the 
procedural outcomes but the actual clinical outcomes on an 
annual basis and makes it public. The transparency is vitally 
important because it begins to translate the moving of 
competition in medicine from one around reputation and cost to 
one around quality.
    The thing that holds our entire organization together is 
our healthcare IT. We have electronic medical records that goes 
from our facility in Las Vegas to Abu Dhabi, from Canada to 
Florida, and all of our facilities are connected 
electronically. This drives additional quality and allows us to 
measure the outcomes of our activities.
    I appreciate the opportunity to begin to share our 
experience with you and I look forward to answering your 
questions.
    [The prepared statement of Dr. Cosgrove follows:]

           Prepared Statement of Delos M. Cosgrove, M.D., CEO

    Cleveland Clinic is a unique medical enterprise whose organization 
and practices parallel key goals of the ``Affordable Health Care 
Choices Act.'' Cleveland Clinic's integrated structure enables it to 
control costs, measure and improve quality, and provide access to high-
quality healthcare services across a broad regional system.
    Cleveland Clinic was founded in 1921 by four physicians who had 
served in World War One and hoped to replicate the organizational 
efficiency of military medicine. They established Cleveland Clinic as a 
not-for-profit group practice with a mission of patient care, research 
and education. Today, it is one of the largest and busiest medical 
centers in the world, with the highest CMS case-mix index in America.
    Cleveland Clinic Health System includes a main tertiary care 
campus, 8 community hospitals and 16 suburban family health and 
ambulatory surgery centers. With 40,000 employees, it is the second 
largest employer in Ohio, and is responsible for an estimated $9 
billion of economic activity every year.
    Cleveland Clinic employs 1,800 physicians and scientists in 120 
medical specialties and sub-specialties. The organizational model is 
designed to optimize quality and efficiency. The system's physicians, 
employees, hospitals, clinics, medical school, and research initiatives 
are all part of one organization which is physician-led. There is no 
tenure, and all employees have 1 year contracts. Physicians are 
evaluated annually and salaries adjusted according to performance. All 
receive a salary with no bonuses or other financial incentives. 
Physicians get no financial benefit from ordering unnecessary tests or 
expensive devices. The hospital and physicians share a financial 
interest in controlling costs.
    Cleveland Clinic is organized into patient-centered Institutes 
based around diseases or organ systems (Heart & Vascular Institute, 
Neurological Institute, etc.). Each Institute combines medical and 
surgical services at the same location under the same leadership to 
provide multi-disciplinary care and improve quality and experience.
    Each Institute measures quality according to sentinel metrics. 
Institutes publish annual outcomes booklets showing volumes, results, 
innovations, publications and other information relevant to patients 
and referring physicians. This promotes competition on quality rather 
than cost or reputation.
    A pioneer in the development of health information technology 
(HIT), Cleveland Clinic integrates at all facilities with an extensive 
electronic medical records system. This system includes participating 
community physicians and patients who are able to access test results 
and portions of their medical records at home via the internet.
    We support the goals of this committee and believe the integrated 
delivery system described above is best designed to carry out the 
mandates of reform across the multiple settings through which care is 
delivered.
                                 ______
                                 
    Mr. Chairman, I am very grateful for this opportunity to appear 
before the committee to discuss the important topic of healthcare 
reform.
    I am especially pleased that Senator Sherrod Brown of Ohio is a 
member of this committee. Senator Brown is knowledgeable about the 
Cleveland Clinic and visited us earlier this week to discuss healthcare 
reform. We were thrilled last week when President Barack Obama cited 
Cleveland Clinic as a medical center that is able to provide quality 
care at a lower cost.
    I know the committee has introduced the ``Affordable Health Care 
Choices Act.'' I commend the speed and urgency you bring to the 
legislative process. Hopefully, I can add to your body of knowledge by 
telling you something about Cleveland Clinic's model of healthcare 
delivery.
    Cleveland Clinic was conceived in the battlefields of World War 
One. It was founded by four Cleveland doctors who had served in the 
medical corps. They were impressed by the model of care delivery which 
brought multiple specialists together to work as a unit. When they 
returned home, they planned a new kind of medical center, where 
specialists would collaborate selflessly for the good of the patient. 
Cleveland Clinic opened its doors in 1921.
    The mission of Cleveland Clinic is, in the words of its founders, 
``Better care of the sick, investigation into their problems, and the 
further education of those who serve them.''
    In addition to our clinical practice, we operate a vibrant research 
institute and a large graduate medical education program with 1,100 
residents and fellows. We also operate a medical school focused on 
training physician researchers. That school graduated its first class 
of MDs this year.
    Our research program and medical education programs are fully 
integrated with our clinical services. We believe that research and 
education carried out in the clinical setting add to the depth and 
quality of patient care. It promotes innovation and helps us expedite 
the movement of new treatments and technology quickly to the bedside.
    Most Cleveland Clinic patients come from Ohio and the surrounding 
regions. Additionally, they come to us from all 50 States of the United 
States, as well as from more than 80 foreign countries. In 2008 alone, 
we had 3.3 million patient visits.
    Cleveland Clinic is proud of its military legacy. The founders of 
Cleveland Clinic explicitly modeled their institution on the Army field 
hospitals of the First World War. Twenty-five years later, in the 
Second World War, Cleveland Clinic's Naval Reserve Unit established one 
of the first mobile hospitals in the South Pacific. In 1968, I had the 
personal honor of leading the casualty staging flight unit in Danang, 
Vietnam. Today, Cleveland Clinic proudly collaborates with our armed 
forces in programs to help wounded warriors and returning veterans.
    Cleveland Clinic is co-leader of the new Armed Forces Institute of 
Regenerative Medicine (AFIRM). This multi-specialty consortium is 
dedicated to finding new technologies to assist in the recovery of 
wounded service members. Cleveland Clinic and U.S. Army Reserve have 
joined in a unique program to recruit and train soldiers who are 
interested in securing a position in the growing field of healthcare 
while they continue to serve our country. Under the program, Cleveland 
Clinic guarantees a job interview for all qualified participating 
soldiers no later than 30 days after completing military occupational 
specialty training. In addition, Cleveland Clinic will give priority 
placement consideration to qualified Army Reserve soldiers. Recently, 
we have begun collaborative activities with the Military Health System.
    Cleveland Clinic is the world's second-largest group practice. We 
employ 1,800 physicians and scientists in 120 medical specialties and 
sub-specialties. The delivery of quality healthcare is the 
preoccupation of our entire organization. We believe that doctors are 
the principal drivers of quality care. To join our staff, physicians 
need to meet rigorous standards. There is no tenure. Every physician 
has a 1-year contract. All physicians are paid a salary. There are no 
bonuses or other financial incentives. Salaries and contract-renewal 
are based upon the results of a comprehensive annual performance 
review. Our physicians compete only against themselves, and work 
together to assure that every patient gets a correct diagnosis and the 
most effective treatment.
    The Cleveland Clinic group practice model has benefits that 
parallel the cost-lowering goals of the ``Affordable Health Care 
Choices Act.'' All of the elements of the system, including the 
hospitals, clinics, medical school, research institute, and physicians 
are part of one organization which is physician-led. The group practice 
model allows us to control costs by controlling utilization, and 
measuring quality and safety. It does this by aligning the financial 
interests of the hospital and the physician who practices there. It 
allows the rational deployment of hospital resources for the benefit of 
the patient. Since physician and hospital are on the same financial 
page, there is no incentive for our doctors to order expensive devices, 
or unnecessary tests or procedures. All parts of Cleveland Clinic are 
completely integrated and share billing, finance, purchasing, legal and 
all other support and medical services. Since we are all part of the 
same organization, we work together to control and rationalize 
purchasing, expenses and the use of resources. Because we all share the 
same goals, we are able to standardize recordkeeping, establish 
benchmarks, and control quality.
    We believe that value in medicine is defined by measurement of 
quality and outcomes. We believe that to improve value we need to 
measure costs against quality in terms of results. Further, we believe 
that results should be published and made widely available. Patients 
benefit when providers compete on the basis of results. Providers need 
to supply patients with data to help them make informed decisions.
    Cleveland Clinic has a long history of measuring and publishing 
results in cardiac surgery. In 2004, we began measuring outcomes in 
every medical specialty. This meant finding the metrics for specialties 
that had never measured themselves. Each specialty is now responsible 
for finding metrics, setting benchmarks for improvement, and moving the 
metrics toward greater quality. Measurement provides insight, but to be 
most effective it must be coupled with transparency.
    Cleveland Clinic is the first major medical center to publish 
annual outcomes and volume information for its medical specialties. 
Last year, we published 16 outcomes booklets. Each outcomes booklet 
includes comprehensive data on procedures, volumes, mortality, 
complications and innovations. We publish these guides consistent with 
our belief that transparency is an essential part of quality.
    Each specialty continually refines their benchmarking and includes 
more sophisticated data every year. This is information that can be 
used by referring physicians or patients to choose a doctor or hospital 
for specific procedures and specialties. They promote competition based 
on quality, not cost or reputation.
    In keeping with a policy of transparency, Cleveland Clinic became 
the first major medical center to publish the industry relationships of 
all of its physicians in our online staff directory, including the 
names of company collaborators, royalties, and fiduciary position and 
consulting relationships of more than $5,000 a year.
    Finally, we have approved a new Open Medical Record Access Policy. 
This policy gives patients (or their designated emergency contact, 
next-of-kin, or holder of power-of-attorney) the option of reviewing 
their medical record in this hospital.
    As a not-for-profit, Cleveland Clinic has no owners or 
stockholders. Income above expenses is used to support research, to 
supplement graduate medical education costs, and to provide a community 
benefit. In 2007, our most recent year of compilation, we delivered 
more than $420 million of community benefit. Our community benefit 
includes charity care ($123.4 million in 2007), Ohio's largest Medicaid 
practice, neighborhood wellness and preventive care programs, support 
for minority health programs, extensive support for local schools, and 
the provision of necessary but unprofitable services.
    Cleveland Clinic began as a single building at a single site. Over 
the years we have grown considerably. In the late 1990s, we merged with 
eight community hospitals to form a comprehensive regional health 
system. In addition, we have established 16 suburban family health and 
ambulatory service centers to serve. Altogether, we are the largest 
health system in northeast Ohio.
    Our main campus includes 50 buildings on 166 acres in a Cleveland 
inner-city neighborhood. (We are proud to collaborate with neighborhood 
organizations to provide jobs, improve housing, and bring new 
businesses and employers to the area.)
    With 40,000 employees, we are the largest employer in northeast 
Ohio, the second largest employer in the State, and the largest 
employer in the history of Cleveland.
    Cleveland Clinic is one of the largest and busiest medical centers 
in the United States. We saw 3.3 million patient visits in 2008, and 
performed almost 73,000 surgical cases. Our patients are severely ill. 
We have the highest CMS case-mix index in the country.
    Cleveland Clinic's effort to enhance care resulted in a massive 
reorganization beginning in 2007. We have abandoned the traditional 
physician-based silos of surgery and medicine. We have replaced them 
with 18 patient-centered institutes.
    Institutes are patient-oriented units based around organ systems or 
disease. All the disciplines relating to the system or diseases are co-
located in the institute and share a common leadership. The result is a 
movement from a physician-centered organization to one which is 
organized around patients' needs.
    Our Heart & Vascular Institute, for instance, includes the 
departments of Cardiovascular Medicine, Thoracic and Cardiovascular 
Surgery, and Vascular Surgery. Our Neurological Institute combines the 
departments of Neurology, Neurosurgery, and Psychiatry & Psychology.
    Institutes erase the barriers between disciplines and promote 
``flow'' among services. Patients can stay in one location for all 
their care, including consults, tests and images. Diagnostic and 
therapeutic decisions become more authentically multidisciplinary. 
Duplication of services is reduced, innovation is fostered, and 
education broadened.
    The history of Cleveland Clinic from 1921 to today is the story of 
intensifying focus on patient needs, expansion of our regional system, 
and greater integration of services across the continuum of care. These 
trends are being enabled today by our pioneering use of health 
information technology (HIT).
    As a leader in the innovative use of HIT for the effective delivery 
of healthcare, we applaud this committee's support for investment in 
the widespread adoption and implementation of interoperable HIT 
services nationwide.
    A national HIT system needs to be carefully planned. We believe 
that to maximize the value of a national HIT investment, it should be 
coupled to an integrated group practice healthcare delivery system. 
Such a system would include hospitals, physicians, sub-acute facilities 
and home healthcare professionals. They would share a common commitment 
to the delivery of coordinated care of the highest possible quality, 
supported by a secure and integrated information infrastructure. This 
infrastructure would bring the right information to the right person at 
the right time, whenever and wherever it is needed.
    Looking forward, we see movement away from reliance on the brick-
and-mortar hospital, and the growth of virtual systems of integrated, 
coordinated services, shared information and standardized quality on a 
broad geographic grid.
    The need to move information across our system has its physical 
counterpart in our need to move patients from one location to another 
within our broadly dispersed service areas. It is not possible for all 
physicians to be all things to all patients. Concentration of patients 
in centers of excellence will drive quality. As a tertiary care center, 
Cleveland Clinic transports critically ill patients to our main campus 
on a daily basis. Many of these patients need immediate care from 
trained intensivists. We have established a comprehensive international 
air and ground fleet to make this possible. Our fleet includes fixed-
wing aircraft, helicopters, and ambulances. Each aircraft and ambulance 
is a mobile ICU. Each can carry a Cleveland Clinic physician directly 
to a patient anywhere on earth to begin care according to Cleveland 
Clinic protocols.
    Respect for your time and attention limit the examples I could 
relate to illustrate the many correspondences between our organization 
and practices at Cleveland Clinic, and the goals of this committee and 
the spirit of the ``Affordable Health Care Choices Act.''
    We believe in the Cleveland Clinic model of medicine. Cleveland 
Clinic delivers high-quality care at a low cost to a large volume of 
patients with a high case complexity. We believe that this model of 
medicine can lower costs, improve quality, enhance value, improve 
access, and assure that every patient gets world-class care.
    I would like to compliment the committee on its comprehensive 
legislation to reform our healthcare system. You have recognized 
several critical issues and are confronting difficult decisions that 
must be made. Healthcare coverage for all and stemming the rising cost 
of healthcare in this country are essential elements of healthcare 
reform. By challenging the health care industry and employers to 
provide citizens with the necessary information and services to lead 
healthier lives, you are enabling Americans to take responsibility for 
their health and building the foundation of a healthcare system that 
will meet the demands of the future and in which we can be proud.
    In order for this or any healthcare legislation to succeed, the 
American people must feel that it addresses their needs. It is too much 
to ask that reform be perfect from the beginning. It will, I believe, 
meet their expectations if they can look forward to having access to a 
system that provides quality, affordable healthcare for all in which 
coordinated patient care is the central concern. I believe that 
individuals are ready, with the proper amount of education, to assume 
the responsibility for their healthy well-being. We, as providers, must 
be structured so that those expectations will not be dashed. I believe 
that an integrated delivery system which I have described is best 
designed to carry out the mandates of reform across the multiple 
settings through which care is delivered.
    Mr. Chairman and members of the committee, thank you for the 
opportunity to participate in this historic hearing.

    Senator Dodd. I apologize, Doctor. We will have a lot of 
questions for you, I can tell you that.
    Dr. Cosgrove. I am ready.
    Senator Dodd. Yes. Mr. Rother, how are you?

STATEMENT OF JOHN ROTHER, AARP EXECUTIVE VICE PRESIDENT, POLICY 
                          AND STRATEGY

    Mr. Rother. Good morning, Mr. Chairman. Thank you for your 
leadership on this. Senator Mikulski, Senator Brown, Senator 
Bingaman, AARP is very privileged to be here today.
    We have many, many priorities with healthcare reform. 
Today, I am going to try to address four. The main one is 
affordability.
    AARP's membership includes about 20 million who are over 65 
and another 20 million who are between the ages of 50 and 65. 
We have broad interests on both sides of the age 65 divide. 
Among the population 50 to 64, we estimate at least 7 million 
are uninsured today and those are the people who have a usually 
high need for healthcare services.
    To make healthcare affordable, we need fair rating rules 
for insurance premiums. We need an adequate benefit standard. 
We need Medicaid expansion combined with sliding scale 
subsidies that help those with low- and moderate-incomes.
    We believe that no American should in the end pay more than 
10 percent of their annual income for healthcare, including 
both premiums and out-of-pocket costs.
    Now today, we are nowhere near that. In the individual 
market today, a 60-year-old couple making $44,000 faces an 
average premium cost of $9,210 which is equal to 21 percent of 
their income and that average policy has a deductible of 
$2,700. This is not affordable insurance by anyone's definition 
and age rating is a big part of the problem, as is a poorly-
regulated insurance market.
    Of course, those with pre-existing conditions often cannot 
purchase at any cost. We support the important insurance 
reforms in the committee's bill that would amend these 
practices and we especially support limiting premium variation 
bans by no greater than 2:1 based on age. This is critical to 
keeping insurance affordable and keeping the costs of subsidies 
down to the taxpayer.
    Now measures to promote quality are also an important part 
of getting better value for our health dollar, and we are 
pleased with the committee's attention to creating a very 
strong quality infrastructure.
    One other aspect of affordability is the cost of 
prescription drugs. We urge the committee to promote greater 
competition in that very expensive class of drugs, biologics, 
and we think we need to authorize follow-on biologics that 
would greatly benefit consumers.
    A recent FTC report has confirmed that creating follow-on 
biologics would actually promote competition and would not harm 
the industry's ability to innovate.
    In order to save consumers and taxpayers significant costs, 
we also urge the committee to keep the exclusion period for 
such drugs to a relatively short period, perhaps as short as 5 
years.
    Now, we also believe that savings from pharmaceuticals 
should be re-invested in part in improving the Medicare 
Prescription Drug Benefit by narrowing the infamous donut hole. 
There's no issue more unpopular today among the Medicare 
population than the requirement that they pay full price for 
medications for part of the year and as a result many do not 
take their prescriptions as ordered and they put their health 
at risk as well as their finances at risk.
    A second priority for AARP, I'll mention more briefly, is 
to change the delivery system to better serve those with 
chronic conditions. Those with chronic conditions make up about 
75 percent of all Medicare spending today, yet the delivery 
system is still based largely on acute care models.
    We support a new transition benefit in Medicare to help 
people leaving the hospital. It will save money by reducing 
hospital re-admissions and we certainly support the patient-
centered medical home to better coordinate care. We applaud the 
inclusion of shared decisionmaking in the committee's bill.
    Let me just mention briefly also the issue of long-term 
care. We applaud very much the committee's inclusion of the 
Class Act in the legislative package. That's designed not to 
increase the deficit and it would make a huge difference if we 
could move long-term care away from a welfare system based on 
Medicaid to one that is more consistent with American values of 
self-reliance.
    And finally, I just want to mention we applaud the 
workforce provisions in the bill. We have to prepare now for 
greater workforce needs, particularly in primary care and 
nursing, and this is extremely important.
    Thank you very much. We look forward to working with you.
    [The prepared statement of Mr. Rother follows:]

                   Prepared Statement of John Rother

    Chairman Kennedy, Ranking Member Enzi, distinguished committee 
members, thank you for inviting AARP to this timely discussion on 
health care reform options. I am John Rother, executive vice president 
and director of policy and strategy for AARP. AARP appreciates your 
leadership and the opportunity to participate in this roundtable.
    Today, I am proud to represent nearly 40 million members of AARP--
half of whom are over age 65 and therefore participate in the Medicare 
program, and half who are under age 65. As many as 7 million of all 
persons age 50-64 are uninsured today, both age groups face serious 
problems in access to appropriate care, even if they are insured. I am 
happy to be here today to discuss some of the options you are 
considering to address these problems.

                        INSURANCE MARKET REFORMS

    There are few issues of greater concern to AARP's membership than 
improving health insurance markets across the United States to assure 
that all Americans have available to them affordable high quality 
coverage choices. Many older Americans, especially those age 50-64 who 
are not yet eligible for Medicare or those with pre-existing chronic 
conditions, often cannot secure health coverage at any price. Industry 
data show that insurers reject between 17 percent and 28 percent of 
applicants aged 50-64.\1\ Those who can find individual coverage tend 
to receive less generous benefits than those with employer coverage, 
yet on average pay premiums that are three times higher and have total 
out-of-pocket spending that is over twice that of those with employer 
coverage.\2\ The AARP Public Policy Institute estimates that 13 percent 
or 7.1 million adults aged 50-64 were uninsured in 2007--1.9 million 
more than in 2000--and this figure is growing rapidly in our current 
difficult economy.\3\
---------------------------------------------------------------------------
    \1\ HIP, ``Individual Health Insurance 2006-2007: A Comprehensive 
Survey of Premiums, Availability, and Benefits,'' December 2007.
    \2\ AARP Public Policy Institute, ``Health Care Reform: What's at 
Stake for 50- to 64-Year-Olds,'' March 2009.
    \3\ Ibid.
---------------------------------------------------------------------------
    AARP believes that the best way to make coverage affordable for 
everyone is by:

     Guaranteeing that all individuals and groups wishing to 
purchase or renew coverage can do so regardless of age or pre-existing 
conditions;
     Prohibiting insurers from charging higher premiums because 
of age, health status or claims experience;
     Providing a choice of qualified plans through a 
``Gateway'' or Exchange with subsidies based on income and the actual 
premiums each age group faces in the market so coverage is affordable 
for everyone;
     Addressing costs systemwide through prevention and 
wellness, care coordination, fighting fraud, waste, and abuse, and 
revising incentives to reward quality rather than quantity of care; and
     Ensuring that any cost-sharing obligations do not create 
barriers to needed care.

    We are pleased that many of these issues have been addressed in the 
committee's proposed legislation released this week.
    Connector/Gateway: The intent of the Gateways is to facilitate the 
purchase of coverage and products at an affordable price by qualified 
individuals and employer groups. AARP embraces the establishment of an 
Affordable Health Benefit Gateway in each State. As described, the 
Gateway construct would provide balance and flexibility--clear Federal 
guidelines and standards to assure quality coverage while maintaining 
the traditional State role in the oversight of insurance.
    Planning grants would be provided to States to create State or 
regional Gateways. Further encouragement for the State to proactively 
launch or participate in a Gateway lies in the stipulation that 
residents of the State would not be eligible for premium credits or an 
expanded Medicaid match until they adopted specified standards. If a 
State takes no action, the Federal Government would step in and operate 
that State's program. Gateways would become financially self-sustaining 
through a surcharge on participating health plans. As envisioned, 
consumers would be able to purchase insurance either inside or outside 
of the Gateway and private or public entities would offer navigation 
assistance to help individuals and employers obtain affordable 
coverage. Quality standards for health plans offering essential health 
care benefits through the Gateway would be specified.
    Policymakers have learned much by observing and studying the 
laboratory of Massachusetts and its successful health coverage 
experiment. Over the years, other States have adopted alternative 
health reform models. We are pleased that the committee bill treats 
Puerto Rico and the other territories equally with the States with 
respect to the programs in its jurisdiction. We commend the committee, 
especially the leadership of Senators Kennedy and Dodd, for recognizing 
that quality, affordable coverage should be available to all Americans 
wherever they reside. It is important to make certain that the 
insurance market rules are the same inside and outside of the Gateway.
    In short, the proposal appears to embrace a reasonable and 
practical balance between Federal policy direction and the reality of 
diverse insurance markets and State regulatory capabilities across the 
United States.
    Underwriting and Age Rating: In general, AARP supports community 
rating, where insurers do not charge higher rates or deny coverage 
based on age or pre-existing conditions. If age rating is not seriously 
constrained within national health reform, insurers will likely charge 
higher rates to older people to substitute for rating based on medical 
condition.
    If any age differential is allowed, AARP believes it should be 
narrow-- no greater than 2 to 1, as in the committee's proposed 
legislation. Individuals living in States where no or narrow age rating 
is allowed today should not be disadvantaged as a result of national 
health reform. We strongly commend the committee's leadership in 
striving to limit age rating bands to a ratio of 2 to 1. We believe it 
is essential that health care reform result in providing affordable 
coverage to those who have the most difficulty obtaining it in today's 
market and that is particularly true for older adults.
    We have serious concerns about the adverse impact on AARP members 
of alternative proposals that allow insurers to charge older Americans 
up to five times or more premium rates. We question why age rating, 
especially as high as 5 to 1, is necessary when virtually all health 
reform proposals under consideration include risk adjustment to 
compensate for higher costs of enrollees who are sicker or older. 
Independent actuaries confirm that appropriate risk adjustment should 
mitigate the need for age rating.
    Experience in Massachusetts indicates that without strict age 
rating limits and adequate subsidies, coverage would still be 
unaffordable for millions of older Americans. Although Massachusetts 
capped rate variation for factors including age at 2 to 1, 
affordability remains a significant issue for some AARP members. Even 
at a 2 to 1 age rating, the lowest priced ``bronze'' benefit package 
costs 60-year-olds 
between $420 and $575 per month. If the rate band were set at 5 to 1, 
the ``bronze'' package would cost $1,050 to $1,335 per month, or up to 
$16,020 a year--over half the median annual income of $30,000 for 
uninsured Americans aged 50-64 today \4\ AARP's concern about age 
rating and subsidies only increases as we consider most other States 
where rates of the uninsured are higher and family income levels are 
much lower than in Massachusetts.
---------------------------------------------------------------------------
    \4\ AARP Public Policy Institute analysis of U.S. Census March 2008 
Current Population Survey.
---------------------------------------------------------------------------
    Age is a poor proxy for income; older uninsured Americans do not 
have substantially higher incomes than younger uninsured individuals, 
whose median income is $28,461, only slightly lower than uninsured 50-
64 year olds.\5\ Continuing to allow health care coverage to remain 
unaffordable to those who need it most is a serious societal problem. 
Uninsured adults in their late 50s and early 60s experience worse 
health outcomes and use more services when they enter the Medicare 
program, and in the years before Medicare their uncompensated health 
care costs will continue to be shifted to those who have insurance.
---------------------------------------------------------------------------
    \5\  Ibid.
---------------------------------------------------------------------------
    Hardship exemptions are not an answer, and are cold comfort for 
those who cannot afford coverage due to high premiums and are in an age 
bracket where high quality coverage is essential for maintaining health 
and avoiding preventable conditions that will only increase 
expenditures once these individuals become eligible for Medicare.
    Subsidies: Shared responsibility is an important attribute of the 
proposed legislation. As the legislation proposes an individual 
requirement for obtaining health insurance and an employer requirement 
for providing health insurance, assuring affordability of plan premiums 
is essential if AARP is to support this legislation. Adequate subsidies 
for low- and moderate-income individuals must be guaranteed. Subsidies 
must be adequate, available, secure and administratively feasible, and 
take into account any higher cost related to any level of age rating 
that is allowed.
    For those who are low-income, expansion of Medicaid eligibility 
across the United States is an efficient and effective way to assure 
quality coverage and access to care. AARP believes that offering 
Medicaid as a wrap around benefit or offering subsidies and/or tax 
credits to help low-income individuals purchase private coverage could 
mean that the most vulnerable Americans will not benefit from health 
reform; such a design will lead to unnecessary expenditures as the 
construct is administratively unfeasible.
    Subsidies should be set on a sliding scale so individuals and 
families pay no more than a certain percentage of income on premiums as 
well as other out-of-pocket health care costs. Thus, subsidy 
calculations should include both family income and actual premium costs 
that may vary by region or age. AARP asserts that no one should spend 
more than 10 percent of their income for health care, including 
premiums and all other out-of-pocket costs. Those with more limited 
incomes should pay even less, with exemptions from cost sharing for the 
poorest for whom any cost sharing can create insurmountable barriers to 
care. In addition, in order for subsidies to remain affordable and 
sustainable over time, we must also enact measures to manage 
skyrocketing costs.
    Premium credits and subsidies should be generous enough to 
effectively help those with modest incomes comply with their new 
responsibility--to secure qualifying coverage. Premium credits and 
subsidies should be provided on a sliding scale; the scale should reach 
high enough that vulnerable families and older adults will be able to 
afford both their premiums and health costs. Otherwise, Americans will 
continue to face the prospect of being uninsured or underinsured and 
will be forced to seek an exemption from their shared responsibility. 
Further clarification is needed on how the subsidy would work.
    Benefit Packages: We strongly support requiring insurers to cover a 
broad range of essential benefits, as suggested in draft legislation on 
this committee's Web site. Preventive services--including services 
necessary to manage chronic conditions that otherwise result in 
serious, expensive complications--should be provided with no or minimal 
cost sharing. We are pleased that the committee is considering 
including provisions to provide incentives for providers to encourage 
care coordination, disease management and similar efforts to improve 
quality of care and help reduce spending for avoidable and costly 
institutional admissions, preventable complications, and errors for 
people with multiple chronic conditions.
    Individual and Employer Responsibility: The HELP proposal would 
require individuals to have health coverage that meets minimum 
standards and to report such coverage annually. Employers who do not 
provide qualifying coverage will be required to contribute to the cost 
of their coverage for their employees, including those who access forms 
of public coverage.
    Requiring everyone to participate is necessary because it greatly 
reduces insurers' interest in underwriting based on age or health 
status and because it ensures that healthier individuals are included 
in the risk pool. However, AARP can support these requirements only 
with the assurance of adequate subsides. We cannot support mandated 
coverage that people or businesses cannot afford--subsidies must be 
adequate, available, secure and administratively feasible. In order to 
ensure that subsidies remain affordable and sustainable, we must also 
enact measures to manage skyrocketing costs while improving quality.

           COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS

    AARP appreciates Chairman Kennedy's leadership and commitment to 
including long-term services and supports in comprehensive health care 
reform legislation. AARP strongly agrees that long-term services and 
supports must be included in any health reform package. People with 
disabilities and older adults need better options to help keep them 
independent and functioning at their highest level. Our members want to 
live in their homes and remain independent in their communities as long 
as possible. That is why expanding access to home and community-based 
services is one of AARP's key health care reform priorities.
    Our current welfare-based Medicaid policies vary tremendously from 
State to State, include an institutional bias, and only assist people 
after they have exhausted their assets. Medicaid provides critical 
services for millions of people and must be improved, such as by 
expanding access to Medicaid home- and community-based services. At the 
same time, individuals also need more choices to help them pay for the 
services they need to live independently. Home and community-based 
services are also often more cost-effective than institutional care, 
and an aim of health care reform is to assure affordable insurance 
coverage for everyone.
    The HELP Committee's bill includes a modified version of the 
Community Living Assistance Services and Supports Act (CLASS Act, S. 
697/H.R. 1721), which would create a voluntary public insurance program 
that individuals could purchase and if they become eligible, receive a 
cash benefit to pay for the long-term services and supports they need 
to remain independent. The CLASS Act provisions would offer a generally 
broad-based opportunity for individuals to receive a minimum level of 
coverage for long-term care services and supports without having to 
deplete their assets or be denied coverage due to a pre-existing 
condition. These are important features, as is the cash benefit that 
would give enrollees choice and control over the services and supports 
they need. We applaud Senator Kennedy's efforts in taking this positive 
step toward providing important insurance protection for individuals 
long-term care services and supports. We also appreciate that the 
program is designed to be budget-neutral. We look forward to working 
with Senator Kennedy, Senator Enzi, Senator Harkin and other leaders on 
the committee who are committed to finding solutions that meet the 
needs of families and their caregivers.
    The committee's narrative also notes that it is considering the 
Long-Term Care and Retirement Security Act that would provide tax 
incentives for the purchase of private long-term care insurance and 
address private long-term care insurance consumer protections. AARP 
believes a sustainable financing system for long-term care services and 
supports will require a combination of sustainable public and private 
resources. Tax incentives for private long-term care insurance may 
lower the cost of this insurance for some individuals and encourage 
them to purchase it, but these incentives would not benefit individuals 
who cannot afford such insurance or cannot qualify for it due to pre-
existing conditions. Updating and strengthening consumer protections 
for private long-term care insurance is critical. If a CLASS Act 
approach is enacted, individuals could choose to purchase private long-
term care insurance coverage to supplement their CLASS Act benefit and 
could be helped by the consumer protections and tax incentives.
    We also note that this legislation includes a family caregiver tax 
credit to help family caregivers who are providing assistance to their 
loved ones. AARP strongly supports efforts to support family 
caregivers. In 2007, about 34 million family caregivers provided care 
at any given point in time, and about 52 million provided care at some 
time during the year. The estimated economic value of their unpaid 
contributions was approximately $375 billion in 2007, up from an 
estimated $350 billion in 2006.\6\
---------------------------------------------------------------------------
    \6\ AARP Public Policy Institute, Valuing the Invaluable: The 
Economic Value of Family Caregiving, 2008 Update. Insight on Issues 13, 
November 2008.
---------------------------------------------------------------------------
   CREATING A PATHWAY FOR SAFE AND AFFORDABLE GENERIC BIOLOGIC DRUGS

    Spending on biologic drugs is growing nearly twice as quickly as 
spending on traditionally developed ``small molecule'' drugs. Overall 
biologic drug sales reached $75 billion in 2007,*\7\ and it is 
estimated that spending on biologics will continue to increase 
substantially through 2012.\8\
---------------------------------------------------------------------------
    * IMS Health, ``IMS Health Reports Global Biotech Sales Grew 12.5 
Percent in 2007, Exceeding $75 Billion,'' Press Release June 17, 2008.
    \7\A IMS Health, ``IMS Health Reports Global Biotech Sales 
Grew 12.5 Percent in 2007, Exceeding $75 Billion,'' June 17, 2008.
    \8\ Express Scripts, ``2007 Drug Trend Report,'' April 2008.
---------------------------------------------------------------------------
    Biologics treat serious diseases such as cancer, multiple 
sclerosis, and rheumatoid arthritis but often cost 10, 15, or even 20 
times more than most non-biologic drugs. Users of these often life-
saving medications are typically forced to pay exorbitant amounts to 
treat their conditions.
    AARP agrees with the report released just yesterday by the Federal 
Trade Commission (FTC) that lacks of competition in the biotech market 
has resulted in higher costs and less innovation. Another major 
contributor to the increase in spending on biologics is the lack of a 
statutory pathway at the Food and Drug Administration to approve 
generic, or bio-equivalent, biologic drugs.
    AARP has endorsed the ``Promoting Innovation and Access to Life-
Saving Medicine Act (S. 726/H.R. 1427),'' which would create such a 
pathway as well as a process for timely patent dispute resolution and 
we applaud Senators Brown, Collins, Schumer, and Vitter for their 
leadership in sponsoring this critical legislation.
    While we continue to have concerns--also echoed in the FTC report 
about the 12-year exclusivity period included in the Senate HELP 
Committee compromise, we believe that the underlying legislation that 
includes Chairman Kennedy's amended language to close the so-called 
``ever-greening'' loophole is a constructive and important contribution 
that merits inclusion in this package. We, therefore, believe it should 
be included in the committee health reform mark. Conversely, if the 
ever-greening provision is not addressed, we believe that this 
legislation would represent an empty promise in that it would set up an 
environment in which biotech companies could make modest changes to the 
underlying product and get continual 12-year cycles of effective 
monopoly protection.
    We appreciate the continued leadership of committee members 
Senators Kennedy, Brown, Hatch, Enzi, and Bingaman on this issue. We 
look forward to working with them on the promise that on this--the 25th 
Anniversary of the Hatch-Waxman law--we provide a workable pathway for 
generic options in order to provide more choice in a marketplace that 
works to the advantage of consumers.
    Lowering the costs of biologic drugs also presents an opportunity 
to begin to close the coverage gap--or doughnut hole--in the Medicare 
Part D benefit. This is an issue of great concern to AARP members. 
About one in four Part D enrollees, not enrolled in low-income 
subsidies, who filled one or more prescriptions in 2007 fell into the 
doughnut hole in 2007, according to a Kaiser Family Foundation report. 
On average, patients' out-of-pocket drug spending doubles when they 
reach the doughnut hole. A pathway to generic biologics can help more 
people avoid the coverage gap, as well as provide savings to begin to 
close the doughnut hole.

               HEALTH QUALITY AND DELIVERY SYSTEM REFORM

    Care for people with chronic conditions makes up three quarters of 
total health spending, yet many experts agree that much of the health 
care system is not well organized to meet the needs of people with 
chronic conditions. Clinicians tend to focus on the particular problem 
that a patient presents at each visit. Delivering good care for people 
with chronic diseases calls for proactive steps by both individuals and 
providers to care for chronic care between visits. For patients, this 
could include adhering to advice on exercise and diet, taking 
medications as prescribed, and monitoring signs and symptoms. For 
providers, this includes monitoring care over time and settings and 
having good systems and communication--among providers and with 
patients and caregivers--that allows tracking and patient-centered 
care.
    Barriers to improvements in care for people with chronic disease 
include the fragmentation of care delivery, poor transitions between 
and among settings, and misaligned payment incentives that fail to 
recognize the value of better integration of services. Poor information 
systems make these problems worse because providers find tracking 
patients over time and across settings difficult. Adherence to 
medications is a key component of effective chronic care management, 
and patient's failure (or inability) to take prescribed medicines is 
another major barrier to improvement.
    Addressing these barriers requires a multi-pronged strategy that 
relies on better knowledge, tools, and incentives. For each of these 
strategies, our recommendations are aimed at providers, family 
caregivers, and patients--who can play a critical role in managing 
their own care. Key recommendations for improving coordination of care 
for people with chronic disease include:

     More testing of care delivery models (for example, medical 
homes and accountable care organizations) to find out what works.
     Rapid adoption of those models that work. Models that 
provide care during transitions between hospitals and other settings 
have proven to improve care, reduce re-hospitalizations, and show a 
positive return on their cost, and should be adopted.
     Incorporating best practices into clinical preparation and 
training for providers.
     Engaging patients with chronic conditions who are able to 
participate in their care, providing them with tools to empower their 
conditions.
     Supporting and engaging family caregivers.
     Encouraging wise use of pharmaceuticals, including making 
medication more affordable.
     Improving coordination of care through adoption of health 
information technology and improving incentives through changes in 
payment policy.
     Ensuring an adequate workforce, including making the most 
of the workforce we have.

    AARP commends the committee for recognizing the necessity of 
improving quality and efficiency in health care, focusing on outcomes 
of care, and addressing the challenge of quality improvement by 
integrating quality improvement and patient safety training into the 
clinical training of health professionals. Quality and safety problems 
in the United States pervade our health care system. We are gratified 
to see the growing determination of all sectors to attain greater value 
from the health system so that organizations deliver high quality, 
efficient, safe care and engaged patients make informed health 
decisions that reflect their values and preferences. We are convinced 
that better quality will lead to a more affordable, sustainable system. 
To accomplish this, we need better information to support clinical and 
patient decisions, enabled by the appropriate use of health information 
technology; and aligned incentives (for providers and patients) to 
encourage coordinated, patient-centered care that ensures patients the 
care they need when they need it.
    Quality Improvements Infrastructure: AARP is pleased that the 
committee proposes to support the development of an infrastructure to 
sustain quality improvements throughout the system by directing the 
Secretary of DHHS to first identify national priorities for improvement 
and then to pursue the realization of these priorities through 
performance measurement and public reporting. AARP already participates 
in multi-stakeholder activities through consensus organizations (such 
as the National Quality Forum and the National Priorities Partners) in 
pursuit of quality improvement, and we agree that the Secretary should 
help bolster these nascent, but increasingly important, collaborative 
initiatives through a variety of consultative opportunities identified 
in the draft legislation. The capacity to evaluate performance 
throughout the health care system is integral to several features of a 
reformed health care system, such as improvement in the delivery of 
chronic care, reduction in disparities among racial and ethnic 
minorities, and aligning payment with desired outcomes.
    It will be important to ensure that priorities are harmonized and 
made consistent to achieve maximum benefit from resources devoted to 
quality improvement activities. We note that the draft legislation 
would require the Secretary to receive recommendations on priorities 
for performance improvement from a qualified consensus-based entity 
(section 204(d)(1)) while section 399LL (b)(4) identifies 9 specific 
areas that the Comptroller General would be required to evaluate. 
Although we believe the identified areas are worthy, there may be some 
inconsistency in requiring input from the consensus body on the one 
hand and establishing specific priorities on the other. Similarly, 
section 213 that provides grants to implement medication management 
services in the treatment of chronic disease would allow the Secretary 
to fund (via grants or contracts) the development of performance 
measures to assess the use and effectiveness of medication management 
services. Here again, although we think medication management programs 
offered by pharmacists have merit to promote safety and encourage 
greater patient adherence, measures to evaluate performance in this 
area should be consistent with the requirements applicable to all 
performance measures specified in section 204 (i.e., that they be 
evidence-based, consistent with national goals and priorities, and 
endorsed by a national consensus body.)
    We are very pleased to see the committee's implicit recognition of 
the fact that performance measurement in support of quality improvement 
and decision support should be considered a public good. AARP agrees 
that providing the Federal resources to support measure development, 
research, dissemination of information on best practices, and the 
provision of technical assistance is necessary.
    Medical Homes and Community Health Teams: We have been a strong 
supporter of the concept of a patient-centered medical home as a 
promising approach to promote primary care and encourage not only care 
coordination throughout the care continuum but patient self-efficacy as 
well. The committee's idea of establishing ``community health teams'' 
to support the medical home model takes in to account the reality that 
most Americans receive their care from small clinical practices. 
Therefore, the infrastructure support that is proposed in the draft 
legislation could help small practices become medical homes that can 
live up to the promise of the concept. However, we urge that the 
definition of medical home be expanded to include non-physician 
clinicians, such as advance practice nurses.
    Emergency Care Response and Research: Section 1204 proposes 
competitive grants for regionalized systems for emergency care response 
and Section 498D provides support for emergency medicine research. 
Subsection (d)2(vi) requires applicants for such grants to address 
pediatric concerns related to the integration, planning, preparedness, 
and coordination of emergency medical services for infants, children, 
and adolescents; and section 498D(b) provides for pediatric emergency 
medical research. We urge the committee to also require that 
prospective grantees be required to address a similar list for 
geriatric patients and for the Secretary to conduct research applicable 
to a geriatric population as well. There is an increasing trend in 
emergency departments (ED) for visits from older patients: visit rates 
over the past 11 years have seen substantial increases among patients 
age 50 and older. In addition, patients over the age of 75 are more 
likely to arrive at the ER via emergency medical transport (49 percent) 
than all other patients (4.2 percent) Finally, older adults are 
especially vulnerable during disasters and face special risks due to 
the fact that they are more likely to have chronic illnesses, 
functional limitations, as well as greater sensory, physical, and 
cognitive disabilities than younger persons.
    Reducing and Reporting Hospital Re-admissions:  Almost one fifth of 
Medicare patients discharged from a hospital were re-admitted within 30 
days; these re-admissions cost Medicare $17.4 billion in 2004. These 
hospital stays, many of which are preventable, pose a major concern--
from both a quality and financial perspective--and must be addressed. 
AARP concurs with the committee that information about rates of re-
admission should be reported to hospitals so that they have the 
opportunity to act on the information and take steps to eliminate 
preventable re-
admissions. We also believe this information should be reported to the 
public so that patients and clinicians can factor it into their choice 
of hospitals and also to stimulate improvement (because we know that 
publishing performance information gets the attention of the provider 
community and encourages them to pay attention to the data.)
    Transitions from hospital to home can be complicated and risky, 
especially for individuals with multiple chronic illnesses. Patients 
frequently report difficulty remembering clinical instructions, 
confusion over correct use of medications, and uncertainty over their 
prognosis. In cases where multiple providers are involved, patients 
often get conflicting instructions from different providers.
    A study published in April 2009 in the New England Journal of 
Medicine found that almost one third of Medicare beneficiaries studied 
who were discharged from a hospital were re-hospitalized within 90 
days. Additionally, one-half of the individuals re-hospitalized had not 
visited a physician since their discharge, indicating a lack of follow-
up care.
    AARP has endorsed The Medicare Transitional Care Act (H.R. 2773) 
which would directly address continuity of care problems by increasing 
support to patients as they move from the hospital to their new care 
setting and ensuring that appropriate follow-up care is provided during 
this vulnerable period. The benefit would be phased-in, initially 
targeting the most at-risk individuals by providing evidence-based 
transitional care services tailored to their specific needs. We hope to 
have a Senate companion bill soon and we urge the committee to include 
this transitional benefit in any final health care reform legislation.
    Programs to Facilitate Shared Decisionmaking: The Institute of 
Medicine identified ``patient-centeredness'' as one of six attributes 
of high quality care. In addition, based on its understanding that 
engaged, activated patients are likely to have better health outcomes, 
the National Priorities Partners, a broadly representative group of 28 
organizations with an interest in improving health care, identified 
patient and family engagement as one of six national priorities and 
goals. From a patient's perspective, the concepts of patient-centered 
care and patient engagement cannot be fully realized unless patients 
(or their designated family caregivers) are able to participate as full 
partners in their health care. This means they must have access to and 
are able to use information that is relevant, meaningful, applicable, 
and reliable. Therefore, AARP commends the committee for recognizing 
the role evidence-based shared decisionmaking tools can play in 
improving care, and we support opportunities to expand the availability 
and implementation of such aids that meet specified criteria and that 
are suitable across the age span, including vulnerable populations and 
children. Since use of shared decisionmaking tools is a relatively new 
idea for patients and providers, the idea of establishing resource 
centers to provide technical assistance to providers to develop and 
disseminate best practices could accelerate adoption of these tools.
    Increasing the Supply of the Health Care Workforce: We applaud the 
committee's leadership in addressing the needs of the health care 
workforce, including their education and training. Health care services 
should be provided by a well-trained, fairly compensated workforce who 
put their patients' needs above all else and who carry out their 
responsibilities under rules that permit clinicians to maximize the 
full scope of their training. The Nation must have an adequate 
workforce trained and prepared to take on the needs of an aging 
population.
    AARP supports your proposal for a health workforce commission, 
which would develop recommendations for workforce needs in the future. 
Nurses, in particular, are in short supply. Nursing workforce 
development is appropriately included in the HELP bill. However, we are 
concerned that the bill does not go far enough in increasing nursing 
workforce capacity. Because there is no dedicated stream of funding for 
this purpose, we may be left with an inadequate supply of highly 
skilled nurses to meet the health care needs of an aging population in 
the 21st century. We do support provisions to authorize funding for 
training of primary care ``extension'' workers, which is inclusive of 
nursing. AARP also appreciates the committee's authorization of funding 
for the development of additional nurse-managed clinics. If we truly 
are going to reform our delivery system, so that it is person-centered 
and team-based, we must re-orient and re-train our Nation's health care 
workforce.
    We are pleased that provisions from the AARP-endorsed Retooling the 
Health Care Workforce for an Aging America Act (S. 245/H.R. 468) are 
included in the HELP Committee's bill. These provisions would help 
ensure that more individuals are trained in long-term care, chronic 
care management, and geriatrics and that direct care workers have new 
training opportunities. In addition, the provisions include voluntary 
training opportunities for family caregivers.

                               CONCLUSION

    Thank you again for the opportunity to be with you today. AARP 
believes our health care system costs too much, wastes too much, makes 
too many mistakes, and gives back too little value for our money. That 
is why AARP, on behalf of our 40 million members, believes Congress 
must pass health care reform that controls costs, improves quality, and 
provides all Americans with affordable, quality health care choices. We 
look forward to working with you to enact health care reform this year.

    Senator Dodd. Thank you very much, Mr. Rother. We 
appreciate it very much.
    Dr. Palfrey, we are delighted to have you with us. Speak 
right into these microphones.

   STATEMENT OF JUDITH PALFREY, M.D., FAAP, PRESIDENT-ELECT, 
                 AMERICAN ACADEMY OF PEDIATRICS

    Dr. Palfrey. Senator Dodd and members of the committee, on 
behalf of the American Academy of Pediatrics, thank you so much 
for what you have done this year already for the benefit of 
children through the CHIP authorization, the passage of 
Medicaid funding under ARA, and now by highlighting children's 
needs in your bill.
    As a Nation, we have come far but we are still not at the 
finish line. With close to 9 million children still uninsured, 
an infant mortality rate worst than 23 other nations, and 
intolerable racial disparities in healthcare, we cannot be 
proud yet.
    We must provide insurance coverage to all our children in 
this country and that coverage should mean access to the right 
benefits in the medical home with appropriate payment.
    The focus on children is the foundation of a health system 
that works. In this economic environment, we are all looking 
for cost containment. There's no better way than to invest 
early in a healthy citizenry.
    We commend the committee's recognition that all HRSA-funded 
preventive guidelines, a/k/a Bright Futures, receive first 
dollar coverage in the new gateway plans. The benefit of Bright 
Futures is that it begins family-centered life-long health 
promotion activities that emphasize healthy nutrition, 
exercise, oral health, positive mental health, injury 
prevention, healthy sexual development, violence prevention, 
the avoidance of tobacco, drugs and alcohol.
    All of these sow the seeds for healthy lifestyles. Doing 
the right thing for children will prevent the adult 
consequences, the serious adult consequences of obesity, 
cardiac disease, mental illness and even Alzheimer's.
    The HELP Committee focus on those left out is also 
critical. Many of those are our children with special 
healthcare needs. Their needs are not covered in the 
traditional healthcare insurance. The medical home with 
inclusion of care coordination provides access to full benefits 
for most of these vulnerable children.
    It is also critical that the notion of pre-existing 
condition not be a barrier to the health for young children 
whose illnesses begin early in life and continue throughout 
their lives.
    We very much appreciate the HELP Committee's recognition of 
the need to strengthen our workforce delivering pediatric 
primary care and, importantly, pediatric subspecialty and 
surgical subspecialty care.
    Finally, sometimes we as child advocates find it hard to 
understand why children's needs are such an afterthought and 
why because children are little policymakers and insurers think 
that it should take less effort and resources to provide them 
healthcare. How else could it be that there continue to be 
recommendations that Medicaid payments for healthcare for 
children are considered adequate at 70 to 80 percent of 
Medicare rates?
    There's good evidence that appropriate payment of providers 
results in children having better access to comprehensive 
health services in a medical home. As the health reform process 
evolves, thank you so much for your recognition of the priority 
of the needs of children.
    We look forward to discussing their coverage, their 
benefits and access, and I am happy to answer questions.
    [The prepared statement of Dr. Palfrey follows:]

            Prepared Statement of Judith Palfrey, M.D., FAAP

    Good morning. My name is Judith Palfrey, M.D., FAAP, and I am proud 
to be the president-elect of 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. Pediatricians believe 
that the life success of every child should be our highest national 
priority.
    I appreciate this opportunity to testify today before the Committee 
on Health, Education, Labor, and Pensions on health reform. I am a 
general pediatrician and child advocate. With my colleagues, I have 
developed medical home approaches that address health inequities and 
provided guidance for practices and school systems on the comprehensive 
care for children with special health care needs. I have advocated for 
S-CHIP and CHIP, improved school health services and payment to 
pediatricians for developmental screening and coordination of care.
    On behalf of the American Academy of Pediatrics, I want to thank 
you for what you have already done so much this year to benefit 
children, through CHIP reauthorization, passage of Medicaid funding in 
ARRA, and now by highlighting their needs in your bill. As a nation, we 
have gone far, but we are still not at the finish line. With close to 9 
million children still uninsured, an infant mortality rate worse than 
23 other nations, and intolerable racial disparities in health care, we 
cannot be proud.
    To hold our heads up high, we must provide insurance coverage to 
all children in this country. That coverage should mean access to the 
right benefits in a medical home with payment rates that allow real 
access to services in public and private programs. I am here to urge 
you to keep children's health needs prominent as the health reform 
process plays out. I urge you to do this not just for the children, but 
because a focus on children is the foundation of a health system that 
works. In this economic environment, we are all looking for cost 
containment. There is no better way to do that than to invest early in 
a healthy citizenry.
    We commend the committee's recognition that all HRSA-funded 
preventive guidelines (also known as ``Bright Futures'') receive first 
dollar coverage in new Gateway plans. The benefit of Bright Futures is 
that it begins family-centered life-long health promotion activities 
that emphasize healthy nutrition, exercise, positive mental health, 
injury prevention, healthy sexual development, violence prevention, and 
the avoidance of tobacco, drugs, and alcohol. All of these sow the 
seeds for healthy adult life styles. These preventive services will 
have enormous benefits not only for children while they are young, but 
doing the right thing for children will help prevent the adult 
consequences of obesity, mental illness and developmental dysfunction. 
Bright Futures focuses on parental responsibility for their children's 
health and places the appropriate emphasis on families and provides the 
tools they need to help their children.
    The HELP Committee's focus on ``those left out'' is critical. 
Within this group are many families of children with special health 
care needs, who face extraordinary burdens because many of the services 
their children need are not covered through traditional health care 
insurance. The medical home with its inclusion of care coordination 
addresses these concerns and can provide access to full benefits for 
these most vulnerable children. It is also critical that the notion of 
``pre-existing condition'' not be a barrier to health care for young 
people whose illnesses begin early in life.
    We appreciate the HELP Committee's recognition of the need to 
strengthen the work force delivering pediatric primary care, and 
perhaps as importantly, pediatric subspecialty and surgical specialty 
care. Once diagnosed with a serious health problem by a primary care 
pediatrician, families can find it very difficult to access the 
services of a subspecialist or pediatric surgical specialist and so we 
appreciate the committee's recognition of the unique needs of children 
in this area.
    Finally, some times we, as child advocates, find it hard to 
understand why children's needs are such an afterthought and why 
because children are little, policymakers and insurers think that it 
should take less effort and resources to provide them health care. How 
else could it be, that there continue to be recommendations that 
Medicaid payments for health care for children be considered adequate 
at 80 percent of Medicare rates? Are providers who care for children 
second-class health professionals? There is good evidence that 
appropriate payment of providers will result in children having better 
access to comprehensive health services in a medical home.
    We are hopeful that as the health reform process evolves, you 
continue to prioritize coverage, benefits and access to medical homes 
through appropriate payment rates for child health services. Health 
insurance for children is a smart investment that President Obama 
prioritized in his campaign. We hope to see all children benefit as a 
result of your important work.
    Thank you again for the opportunity to testify. I look forward to 
your questions.

    Senator Dodd. Well, thank you, Doctor, very, very much, and 
I often say this. I've chaired or been the ranking member over 
the years of the Subcommittee on Children and Families, and the 
American Academy of Pediatrics has been my best ally, whether 
it was the Family and Medical Leave Act----
    Dr. Palfrey. Exactly.
    Senator Dodd [continuing]. Legislation on premature births, 
infant screening, better pharmaceuticals for children. All of 
these issues, you and your colleagues have been great, great 
advocates, going back to Dr. Koop, C. Everett Koop, the Surgeon 
General, who was a great advocate of Family and Medical Leave. 
In fact, I am not sure I could have passed the bill without 
him. I thank you for all your work.
    I am reminded by staff, as well, each of you have caused me 
to think of this again, we'd like as a committee for you to 
submit, by the way, any ideas on this legislation. The staff 
are taking notes of what you're saying, but we want you to go 
beyond your statements now. Some of you have specifically 
looked at sections of the bill and made some recommendations.
    It would be very, very helpful for us in the coming days--
and fairly quickly, if you would, so we are sort of moving on 
this. Any specific ideas you have, either by omission or 
moderation or change would be very, very welcomed by the 
committee, and we thank you for that.
    We have been joined by Senator Jack Reed, by the way, of 
Rhode Island. I thank you, Jack, for joining us this morning.
    Let me begin, Dr. Raskob. I have a lot of questions for all 
of you, but let me begin with you.
    I understand that Oklahoma City has done a great deal in 
the area of improving the health of its citizens. I wonder if 
you could tell me what you think of our Prevention Investment 
Fund. We are putting in some $10 billion, that is the number at 
least we have crafted at this point. There's obviously costs in 
all of this and the President has said we are all determined to 
try and make this deficit-
neutral over 10 years which is going to be a challenge 
obviously with all the things you need to do in order to bring 
costs down, to bend that curve that we are all hearing about in 
the right direction.
    Some investments will be needed obviously if you're going 
to bend that curve in the right direction, but in the area that 
many of you have been talking about this morning and which all 
of us, I think, embrace, it is one of the few areas where 
there's little or no dissent and that is in the prevention, 
quality, and workforce areas.
    There's some discussion obviously, but there's no real 
debate on the fundamentals of whether or not we ought to do a 
better job in those areas and how we can achieve it, but I was 
looking at just this smoking issue.
    Yesterday, it was quite a day. It may have been lost in a 
lot of other news going around, but for the first time it looks 
like we are going to finally give the Food and Drug 
Administration the ability to regulate tobacco products. It is 
incredible to me that it has taken 50 years since the Surgeon 
General made this a priority. I am looking at all your heads 
nodding here. Talk about prevention with 400,000 deaths a year 
and 4,000 children starting to smoke every day and no ability--
we regulate mascara and pet food but I couldn't regulate 
tobacco products. That's a hard one to sell to the American 
public. That's changing now as a result of the vote yesterday.
    This whole idea, I was looking at the costs of smoking and 
I thought the number was like $90 million. Someone doubled the 
number, and said it is more like $180 billion a year if you 
take healthcare costs, lost wages and the like.
    When we start talking about $10 billion as a Prevention 
Trust Fund and considering the number of problems out there 
that could help produce wellness, reduce illness, and produce 
health as a result of those efforts, what do you think about 
that, Doctor?
    Mr. Raskob. Well, thank you. We would strongly support an 
investment in prevention, clearly. I mean, we unequivocally and 
strongly support that. The amount of $10 billion in the context 
of the numbers you mentioned and then if you take it in the 
context of total spending on healthcare or just on what the 
Federal Government spends of a little over $800 billion clearly 
isn't high.
    Where the money comes from is for Congress to decide. If 
you think we can't afford it or if anyone thinks we can't 
afford it, I would say we can't afford not to do it because it 
is clear from the economic studies that what's driving the 
growth in healthcare spending is the increasing prevalence of 
chronic diseases in the population that require treatments. 
We're doing a wonderful job of finding new drugs and new 
technologies. We have an increasing number of sick people in 
the population who need those things and it costs money. The 
solution is not more drugs, more technology but less disease in 
the population. Until we make an investment to break that 
vicious circle of increasing chronic disease in the population, 
we are not going to be able to delay and interrupt the rising 
costs.
    So, an investment in prevention is absolutely critical. The 
amount of $10 billion by any means can't be considered 
excessive, I don't think, and so we strongly support investment 
in prevention.
    Senator Dodd. Do any of you on the panel disagree with that 
at all, this idea of having this as an appropriation.
    Does anyone think that is a mistake or if it is a mistake, 
I presume what you may say is it is too little? Is that your 
general view if I am looking--I see heads nodding for the 
record anyway. It is probably too little in the context of what 
we are talking about.
    Dr. Cosgrove, again, we are so impressed with what you do 
at the Cleveland Clinic.
    Dr. Cosgrove. Thank you.
    Senator Dodd. We hear about it all the time. Senator 
Mikulski, I can hear both of you mumbling to each other as you 
were testifying.
    How do you keep physicians that you hire on a 1-year 
contract where their evaluations are based on--is it outcome or 
performance in terms of the evaluations, no tenure? How do you 
get people to even want to come when you consider other places 
will offer you multi-year contracts, I presume, and tenure and 
all sorts of protections? How does the Cleveland Clinic compete 
with other institutions that will offer a lot more, I presume, 
financially and a lot more security financially than what you 
offer? Why is it that works for you?
    Dr. Cosgrove. That's an excellent question and one which we 
have addressed.
    We try to set our salaries according to the scale of 
academic medical centers across the country, so we are 
competitive in that aspect, but as far as maintaining them, it 
is the working conditions. We try to provide physicians the 
opportunity to do physician work and support them across the 
way with all the necessary support that they need.
    For example, I've never sent a bill. The institution looks 
after that. I don't have to worry about hiring secretaries or 
nurses or equipment, et cetera, as I practice. So you're 
allowed to do what we are trained to do, the practice of 
medicine, not be business people.
    I've gone to the dark side now and tried to begin to do the 
business aspect of that, but for 33 years I had the luxury of 
being a doctor and not worrying about the business aspects.
    The conditions under which physicians can practice are 
superb.
    Senator Dodd. Yes. Did you happen to read The New Yorker 
article by Dr. Gawande?
    Dr. Cosgrove. I did.
    Senator Dodd. Have any of you read that article in The New 
Yorker? It looks like all of you have.
    I was taken aback by it. What do you think of that article, 
the conclusions of it? Do you agree with his conclusions about 
why these cost disparities exist?
    Dr. Cosgrove. Yes.
    Senator Dodd. Something like Hildalgo County?
    Dr. Cosgrove. Yes, I do, and just parenthetically, I might 
say that I think the reason that we have been able to have high 
quality and low cost is because we are an integrated system and 
because there's no financial incentives for us to do an 
additional procedure or order additional tests, that we all get 
paid the same amount whether we do that or not.
    We are very proud of the fact that we have removed the 
financial incentive from the decisionmaking around medicine and 
I think that that is part of the reason that we have very low 
cost, as demonstrated by the Weinberg-Dartmouth report.
    Senator Dodd. Yes. Experts at Dartmouth and elsewhere have 
said that nearly one-third of annual health care spending is on 
treatments and procedures with no proven benefits. Do you agree 
with that?
    Dr. Cosgrove. Yes, I think I wouldn't put a number on it 
because I haven't studied it enough personally to do that, but 
I agree that there is a great deal of that that is done. When 
you remove the financial incentives, it begins to change that.
    Senator Dodd. And last, then I'll turn to my colleagues, 
Dr. Palfrey. The work on children is something that a lot of 
us, all of us, care about up here, and Bob Casey of 
Pennsylvania, who is also very interested in this subject 
matter, has raised some very good questions in yesterday's 
panel, as well.
    I wonder if you might just comment. One of the things we 
are looking at are these--as we talk about insurance products 
sold in our gateway or exchanges, whether or not they will 
include minimum standards. I appreciate particularly your point 
that children are not just small versions of adults. We have 
proven that with the better pharmaceuticals for children, 
looking at medical device issues, as well, and the importance 
of accommodating the needs of children, particularly in the 
wellness and prevention area.
    I wonder if you might comment on that.
    Dr. Palfrey. Absolutely. Thank you very much for the 
question.
    Because we believe there are specific benefits that 
children need and we'd love to see a pediatric component to the 
benefits. Children are different. They have developmental 
needs. If you think about a 2-year-old or a 2-week-old or your 
7-year-old, those youngsters are different from our 17-year-old 
and there are specific benefits that we need for these 
children.
    Now, it is a little ironic that our Medicaid Program has 
EPSDT which is a full benefit program and yet our private 
payers don't always give all of these benefits.
    The flip side of that irony is Medicaid doesn't pay for the 
benefits. What happens is that the practitioners who are seeing 
Medicaid patients try to do the best they can but can't afford 
to do it, whereas those getting the private insurance don't 
have to do the benefits and get paid at a 120 percent of 
Medicare.
    We would like to see that evened out and we would like to 
see a specific pediatric benefit.
    We also are very interested in seeing maternity benefits 
because our young women, our young girls then become young 
mothers and we know prevention starts at the moment that that 
baby is even thought of being conceived because it is important 
that they need to be wanted and then from then on.
    We would like to see specific pediatric benefits and 
specific maternity benefits.
    Senator Dodd. I totally endorse your maternal benefits. In 
fact, a study I was looking at was developing some correlation 
between premature births and obesity.
    Dr. Palfrey. Absolutely.
    Senator Dodd. I don't think there's any argument that 
obesity is not one of the causes of four chronic illnesses we 
are grappling with and if there is a connection between that, 
then what better case could you make? There are other cases to 
make, but certainly that one, I think, makes the point.
    Senator Mikulski.
    Senator Mikulski. Good morning, everybody. First of all, I 
just want to thank you all for being here, and I also want to 
thank you for what you do every day. Each and every one of you 
every day in your own way makes a considerable difference.
    I'd like to invite you to not only in your participation 
today--but this is going to be quite a process and what's going 
to happen is that after we move out our bill and Finance moves 
out their bill, there's going to be a bill and then all this, 
and we are going to be doing things late at night and when we 
do things late at night, it is not that we want to pull fast 
ones. We could make mistakes in which the unintended 
consequences to public policy and therefore to patients could 
be significant.
    We invite both you and your organizations and so on to 
really stand sentry as we go through this and give us ongoing 
feedback that this is, oh, you've talked to us and it is done. 
There's a lot to be done before it is done. So that is one 
thing.
    The second thing I just also wanted to talk about is our 
good colleague Senator Harkin very much wanted to be here 
because of this emphasis on prevention. He's in Geneva, 
Switzerland, this morning giving a talk on child labor where 
he's been one of our leading advocates. He wanted me to say 
good morning and let's all stick together.
    Senator Harkin and I were each given a working group, Tom 
on prevention, me on quality, and we worked together because 
they were both intertwined and each one should leverage the 
other. We want to thank you for your testimony on behalf of 
Senator Harkin and his able staff is here to give feedback. I 
just wanted to set that stage.
    I want to focus on just two questions in my area of 
quality. One is on comparative effectiveness in which we had a 
robust discussion last night, and then the other one, the 
concept of medical home.
    On the issue of comparative effectiveness, we had a 
substantial discussion about, first, should we have it, second, 
are you going to do cookbook medicine, stifle innovation, and 
tie it to the payment system, and third, the confusion between 
comparative effectiveness and best practices.
    Let me say for this record, as I said last night in our 
discussion, we in comparative effectiveness or health outcomes 
are building on the stimulus language in which there is no 
mandate for either clinical practice or payment. It will be 
simply news but not simply news that you can use.
    Having said that, I would like first to turn to Dr. Raskob 
who talked about this and then any who would like to comment 
on, No. 1, do you view comparative--having health outcomes 
research and the expansion of what was done in the stimulus 
package, a crucial point to quality or are there too many fears 
around it to pick this as a fight?
    Dr. Raskob.
    Mr. Raskob. Thank you. To give a direct and brief answer, 
comparative effectiveness research is critical to quality. If 
we don't research and compare options for how patients are 
taken care of or for how other interventions occur, how can we 
possibly make decisions about what is better quality? That's 
the first point.
    The second, I would just reiterate that our view is that 
comparative effectiveness research should be broader than 
simply researching drugs and procedures but should include 
policies and interventions that affect health, non clinical 
programs, behavioral interventions, organizational systems 
characteristics, and even the impact of regulations.
    Comparative effectiveness research should be broad. It 
should engage everything we know from science about other study 
designs than just the randomized clinical trial that works well 
for drugs and medical procedures, and it should include also 
efforts to synthesize the existing evidence in ways that can be 
digested by practitioners and incorporated into useful elements 
of translation.
    Senator Mikulski. It goes beyond simply identifying the 
best practices that had been identified by the appropriate 
academies, the Academy of Pediatrics, the Academy of 
Cardiology, Family Physicians, is that right?
    Mr. Raskob. Yes, and I would say that we have been doing 
comparative effectiveness research in the United States for a 
long time under different names. To get a drug approved at the 
FDA, we have to do a comparative clinical trial.
    Senator Mikulski. But it has been wimpy.
    Mr. Raskob. So--yes.
    Senator Mikulski. The efficacy of drugs and procedures is 
important but the FDA has been primarily focused on the safety 
and efficacy's part of it, but that part has been secondary.
    Mr. Raskob. I agree with you. My only point was that there 
shouldn't be a fear of this research because we have been doing 
it and we need to broaden it and to make it----
    Senator Mikulski. Did anybody else want to comment on 
comparative effectiveness?
    Dr. Palfrey.
    Dr. Palfrey. I just want to indicate that doing comparative 
effectiveness correctly is going to be a very expensive 
procedure and while we are doing it and we should be looking 
for outcomes, we must not throw out the best practices that we 
now have and we must not hold up the care that is being 
provided currently to wait for the results of comparative 
effectiveness studies.
    Senator Mikulski. Well, and we wouldn't because it is not 
tied to a payment system. In other words, the way we envision 
it and the way I envision it as the author of this part of the 
bill is essentially, I'll use the term ``consumer report,'' but 
it is news you can use, if you want to.
    Dr. Palfrey. Right.
    Senator Mikulski [continuing]. Whether it is to administer 
a major institution or what you would do in your individual 
practice.
    John.
    Mr. Rother. Yes, Senator Mikulski. AARP very strongly 
supports comparative effectiveness, but I think really in the 
longer run, it has got to be thought of in the context of a 
learning healthcare system.
    Information fed back to providers and to patients about the 
effectiveness of various treatments, and there will be 
variation in the population. Some people will respond 
differently. It is not going to be a cookbook. It is not going 
to be just a separate study published in a journal 3 years 
later. It has to be built in to the ongoing delivery of 
healthcare.
    Senator Mikulski. Would you really look at what we said and 
how you would really either further amplify or further target?
    Dr. Cosgrove, did you want to comment on that?
    Dr. Cosgrove. Yes, Senator. I think this is a very 
important topic, and I would reaffirm that it has been going on 
now for a long period of time in medicine and these comparisons 
do regularly happen.
    I think the most important thing that you said is it is not 
going to be tagged to payment and the reason for that is it can 
be a major impediment to our innovation. For example, it takes 
10 years now to get a heart valve approved. I think if someone 
knew that they were then going to have another long period that 
they would--it would stifle innovation and that is a major--our 
devices and our pharmaceuticals are a major export from the 
United States as well as a major industry.
    I don't think you want to tag it to, in any way, payment.
    Senator Mikulski. Right. So you and Dr. Palfrey would be 
very clear that tying to payment, one, would, first of all, 
deal with the physician's concern. Are we going to mandate 
medicine, which I don't believe Congress or any arm of it 
should, or any part of our government, but, second, it also 
deals with this issue around innovation, which, when you talk 
to the guy or to the people in the U.K. who've done this, that 
was one of the other major arguments against it, innovation.
    Dr. Cosgrove. That's been a big problem.
    Senator Mikulski. Either in practice or tools of practice 
or whatever. OK.
    Did Dr. Jonas and Dr. Levi want to comment? Then, I'll stop 
and I'll come back and if I may, Mr. Chairman, and do my 
medical home.
    Dr. Jonas. Yes. I just want to say I think information is 
not enough. If all it is about is getting more information, 
then a crucial step of how do you deliver it is going to be 
key. It has to be attached to appropriateness and the processes 
for delivery and care.
    I'll give you one example I know quite well from 
integrative medicine. Ten years ago, the NIH did a consensus 
conference on acupuncture and said the evidence is currently 
well established for nausea, postoperative nausea and acute 
pain that acupuncture works.
    I daresay that very few of the clinics that we have 
surveyed actually use it. So it is effective. It is not used. 
Why? Doesn't get into the delivery system.
    There's now good comparative effectiveness research on 
chronic pain done in Europe, done in this country, done in 
England, showing that acupuncture works for chronic pain, back 
pain, headache, osteoarthritis almost twice as well as our 
current best guideline-based therapy and yet there's no 
incentives for moving it in and there are other delivery 
obstacles. Training, for example, of individuals.
    I think the information needs to be tagged to the delivery 
issue and how do you actually get it into practice.
    Senator Mikulski. But how do you do that without a mandate? 
So if you could ponder that.
    Before I move to Dr. Levi, if I could just say, Dr. Jonas 
says he was from Samueli Institute which you should know is, 
No. 1; he was a Walter Reed doc. He headed up the NIH Office on 
Complementary Medicine and now is one of our lead advisors in 
integrative medicine and how we could best achieve it.
    Dr. Levi, did you want to comment?
    Mr. Levi. Just very briefly. I want to underscore what Dr. 
Raskob said about the breadth, the scope of what we talk about 
when we are thinking about comparative effectiveness research, 
that it should not just be about medicines and devices and in 
fact, if we--a lot of the comparative effectiveness research 
already being done often compares nonclinical interventions 
with clinical interventions and sometimes those nonclinical 
interventions are more effective.
    The second point I would make is what you, Senator 
Mikulski, referred to as--you talked about looking at health 
outcomes and when the FDA approves a drug, it looks to see 
whether it is safe and effective. It isn't necessarily 
comparing or looking at the long-term outcomes and, you know, 
one of the things we strongly supported in the Recovery Act was 
that prevention programs be tied to health outcomes and I think 
it is also time to be looking at our clinical interventions and 
really providing clinicians and consumers with the information 
they need, to know what it means over the long-term in terms of 
health outcomes, because the published data, the data around 
clinical interventions that reaches FDA approval does not 
necessarily provide us that answer.
    Senator Mikulski. OK. I know my time's up.
    Senator Dodd. No. Very, very good. Very, very helpful, too, 
by the way.
    Senator Mikulski. OK. If I could, Mr. Chairman, I'd like 
to, when everyone's concluded, come back.
    Senator Dodd. Absolutely, absolutely.
    Senator Brown.
    Senator Mikulski. Thank you very much. That was a very 
helpful discussion.
    Senator Dodd. Very helpful.
    Senator Mikulski. It kind of followed on to what we talked 
about last night and drew the distinction between best 
practices which the academies often identify in a much broader 
scope.
    Senator Brown. Thank you, Mr. Chairman. Senator Mikulski, 
your comments and questions and answers you elicited were 
particularly helpful.
    As Chairman Dodd commended The New Yorker article, there 
was a--I commend to my colleagues the Time Magazine article 
that was, I guess, this week. ``This Doctor Does Not Want to 
See You,'' and it mentions--actually features--a Lifestyle 180 
Program of the clinic and Dr. Royce, who's head of the Wellness 
Institute or part of the clinic, and the work he's doing on 
everything from nutrition to smoking and other issues.
    In fact, something pretty remarkable and I don't think the 
clinic tries to take full credit for this, but they are 
certainly a major part of it. Since the clinic began, its anti-
smoking efforts in this 180 Program, this Lifestyle 180 
Program, that the smoking rates in Cuyahoga County, the county 
for which Cleveland's the county seat, it is a county of a 
million and a half people, smoking rates have gone from 21 
percent to 18 percent, some of the lowest rates in the State.
    That leads me to a question for Dr. Cosgrove about wellness 
and prevention.
    Senator Whitehouse, a colleague in my class, came here in 
2007, sits on this committee, has mentioned repeatedly that 
those who pay for the wellness programs and the prevention 
efforts often and perhaps usually don't get the payoff for it. 
The employers that pay or the public--the health entities, the 
public entities, whatever, that expend money for prevention and 
wellness often don't get significant benefit for it, which just 
sort of begs the issue of how do places like Safeway--Safeway 
has found a way with a very comprehensive program, as Dr. 
Palfrey knows, to keep their healthcare premiums almost 
constant over the last 5, 6, 7 years, while everyone else has 
gone up industry-wide or country-wide, we have gone up some 35-
38 percent during that time.
    Dr. Cosgrove, if you would sort of talk about how--and I 
understand your rates, your healthcare premiums are going to be 
pretty flat this year for 2010.
    How do you do that? How do you bring in--a couple of 
questions about it. What's your story about how the clinic does 
the program in wellness and prevention and what's your 
recommendation for this legislation, for other large employers 
to mimic it and replicate it?
    Dr. Cosgrove. Well, as you know, Senator, the 40 percent of 
the premature deaths in the United States are due to behavior 
and three things: smoking, obesity, and lack of exercise, and 
so we began to approach those systematically, starting with 
smoking, and eventually took a program where we began, I think, 
eliminating smoking on our campus, then we moved to supporting 
the legislation in the State of Ohio to prevent smoking in 
public places.
    Then we offered smoking cessation to all of the inhabitants 
of Cuyahoga County, including patches, and to all of our 
employees, as well, and then ultimately we stopped hiring 
smokers.
    We thought that this was an important step because it began 
to signal what a healthcare organization should do. In other 
words, we should walk the talk and we did that.
    The second thing that we did was, we began to look at food 
in our organization. We took trans fats out of all of the food 
that we served to patients and employees. We began to take 
things like French fries out of our cafeterias. We baked them, 
Senator.
    Senator Mikulski. No. I know. It is that you just say hello 
to a different thing. I know. We are for it. We are for you.
    Dr. Cosgrove. We also began to have portions labeled with 
the amount of calories that there were on them in our cafeteria 
and, finally, we began to look at the problem of lack of 
exercise and we gave all of our employees opportunities to go 
to Curves or Weight Watchers. We had a walking program. We had 
access to our gymnasiums and work-out areas for our entire 
organization.
    So far in the first 6 months of this program, we have lost 
76,000 pounds as an organization and we know that for every 
pound that you're overweight it is essentially $50 in 
healthcare costs per annum. We have already paid in 6 months 
for the cost of all of our activities.
    Senator Brown. Why are other employers--understanding your 
business is healthcare and your business has also become health 
prevention, but putting aside that you're the Cleveland Clinic 
instead of company X manufacturer, whatever.
    Why are so few companies doing what you're doing? If you 
can show--yesterday, the CEO of Safeway had some stunning 
statistics, as Chris heard, and it was just--the number of 
doctors visits per year for someone obese is, I believe, 10 
times the number of someone that is--some ratio. I am not sure 
of that number. That was my recollection of it. I believe it 
was 10.
    Why are more companies not doing that? How do we incent 
them to do that when perhaps they shouldn't need incentives 
when you're talking about $50 per pound?
    Dr. Cosgrove. Well, I think the incentives are generally 
not well known. Let me give you just a couple statistics about 
smoking.
    It costs essentially $3,500 a year or more in healthcare 
costs for a smoker than a nonsmoker. Smokers take an average of 
2 weeks smoking break a year. That's 2 weeks of lost 
productivity while smokers are on smoking breaks, and when 
those statistics begin to become known and available, I think 
people will begin to address that.
    One of the impediments has been the concern about pushback 
from unions and from the employees. I personally got a great 
deal of pushback from my HR group about not hiring smokers and 
so I think that there is a concern that this is going to limit 
the number of people who want to work for your organization.
    We monitored this very closely. Interestingly, the biggest 
percentage of smokers in the hospital are respiratory 
therapists. We did not have a decrease in the number of nurses 
or respiratory therapists applying for our facility when we 
made this move.
    I think once you go public about it and once you take these 
steps and everybody's quite afraid of them, I think you can 
begin to deal with it.
    Senator Brown. Sure. Dr. Levi.
    Mr. Levi. Senator, if I can add a different, slightly 
different perspective and put some larger numbers on this. The 
first is Trust for America's Health is a small employer and we 
would love to be able to model some of the things that 
Cleveland Clinic has done and we tried to walk the talk.
    We promote these kinds of workplace innovations. It is 
very, very, very hard for a small employer to patch together 
these kinds of wellness benefits because unless you have a 
certain scale, it can't be done.
    I'd also like to mention just the potential impact and I 
think you mentioned earlier that sometimes the people who are 
paying for these prevention interventions aren't necessarily 
seeing the return on that investment and we very much depend on 
the public sector to do a lot of this work.
    We worked with the Urban Institute to develop a model to 
look at what would the savings be to the healthcare system if 
we had a comprehensive program of community-based 
interventions, so changing the environment, similar to what 
Cleveland Clinic did but did it in the community, that focused 
on smoking cessation, nutrition and physical activity, and if 
we spent only $10 per person and only had a 5 percent impact on 
these conditions, we could save within 5 years a net savings of 
$16 billion and that is a return of $5.60 per dollar invested.
    The proportion of the investment, these tend to be done 
with public dollars and that is why we think the community 
transformation grants are so important because that is what 
these would be built to do, but the savings accrue mostly to 
the private sector, to the private insurers and to those 
individuals paying out-of-pocket.
    Of that $16 billion savings, there would also be a $5.2 
billion savings to the Medicare Program. Just within the 
Medicare savings the government would see its return on 
investment. If you think about this $10 billion Investment 
Fund, you'll see that money come back just in savings in the 
public sector.
    Senator Brown. Thank you. The problem we have, we have this 
arcane scoring system in this Congress where we don't--in some 
sense, as we pay for healthcare reform, we don't get the score, 
we don't get the credit, if you will, when we do prevention 
healthcare and that is our problem, but that is an impediment 
to us that we have to work through.
    A real quick question for Dr. Palfrey. I chaired for 
Senator Kennedy and the Health Committee, a couple of months 
ago, a hearing regarding access to primary and specialty care.
    Dr. Marcia Wallerson, a pediatrician from Alabama.
    Dr. Palfrey. Yes.
    Senator Brown [continuing]. Spoke about the nearest 
pediatric specialist was 90 miles from her practice. She's in a 
small town, I believe, of 9,000, if I remember right.
    Dr. Palfrey. Right. That's right.
    Senator Brown. Senator Dodd and Senator Casey, whom Chris 
mentioned earlier, introduced legislation this week, the 
Pediatric Workforce Investment Act, to create a loan repayment 
program for licensed physicians who decide to go into a 
pediatric subspecialty which should help deal with this 
problem.
    Just for a moment talk about the shortages in the pediatric 
workforce and what you think we should do about it.
    Dr. Palfrey. Well, first of all, thank you very much for 
taking this on and thank Senator Kennedy, who we all miss 
today.
    We have several problems here. One is getting people into 
medicine at all because of the heavy loans that the medical 
students have to pay, a $140,000 loans, which are being very, 
very much a barrier.
    The second thing is that we do have many subspecialists but 
they tend to aggregate near the university centers, the 
academic medical centers, for a whole variety of reasons. So 
that we do need incentives for our subspecialists to move to 
the more rural and some of the deep urban areas and it may be 
that we need to have programs of incentivizing those areas or 
more clever ways of integrating them with something like 
Cleveland Clinic where they're part of it and can be 
participating in research and that kind of thing.
    It is an absolute question for some of the subspecialties. 
In other words, there are absolutely not enough. It is a 
relative question for most of the subspecialties. It is a 
distribution issue, but we very much appreciate your looking 
into this. It is a terrible problem for many of our 
practitioners not being able to get the subspecialty care.
    If I could just have one follow-on to that? In terms of the 
primary care, because our primary care physicians are working 
on a clock that says see a patient every 10-15 minutes, et 
cetera, et cetera, a lot of our primary care physicians will 
opt to send a patient to a subspecialist for a fairly minor 
problem because they just don't have time--that 10 or 20 
minutes more, to delve into it themselves.
    When the patient ends up at the subspecialist, they are 
required in a sense to do all those extra tests because, after 
all, you sent the patient to me to check out the constipation 
or to check out the heart murmur. Having a little bit more 
leeway in our primary care offices to do the right kind of 
work-ups and diagnostics and only send the very difficult 
patients to our subspecialists would be another way of easing 
this burden.
    I think the general public wants us to do the right things 
in our offices but the incentives are aligned on this 
throughput of see patients, see patients, see patients, and it 
just doesn't work.
    Senator Brown. Very good point, and I'd like to ask one 
more question.
    Senator Dodd. By the way, that is one of those examples of 
sending us soon those provisions. That would be where are the 
restrictions in current law so we can begin to look at it.
    Senator Brown. Obviously it is two things that come about 
from that. One is saving money for everybody and, second 
obviously is the subspecialty shortage. It would obviously make 
it less acute.
    Mr. Rother, you mentioned the biologics, the follow-on 
biologics, some legislation that I've introduced with a handful 
of others, including Senator Bingaman on this committee.
    I share your concerns that costs of biologics are an 
extraordinary issue, sometimes $100,000 a year or sometimes 
upwards of that.
    The market exclusivity, there's a debate on the length of 
that. Our legislation is 5 years. It is bipartisan in the 
Senate. It is bipartisan in the House, Congressman Waxman, 
Congressman Diehl and others.
    Talk, if you would, about why this timeframe is necessary, 
5 years rather than 12 years. We know it will save a lot of 
money for the payer, for the government, for others, too, other 
payers, but we want to make sure that, as you suggest, from the 
study, the FTC report, that this actually is good for 
competition and good for innovation.
    Would you share your thoughts with us about that?
    Mr. Rother. Well, thank you, Senator Brown, for your 
leadership in this area, and I noted that the committee's draft 
had just a placeholder for biosimilars.
    I think any policy has to balance the incentives for 
innovation that you want to preserve with savings to consumers 
and taxpayers and I think the FTC report is a good guide to 
that. It is a very thorough study of the industry, that 
basically concluded that the industry does very well at getting 
a return on their investments in just a few years, and that a 
fairly short exclusionary period could actually be consistent 
with maintaining that innovation and yield very substantial 
savings to individual consumers but also to taxpayers as these 
drugs are part of the costs of the healthcare system.
    It is a balance and I certainly would favor limiting the 
exclusion period to as short as we can to keep innovation but 
to achieve----
    Senator Brown. Should it be any different from Hatch-Waxman 
which has pretty inarguably worked pretty well over the years?
    Mr. Rother. Hatch-Waxman has worked well and, as you know, 
generics now are the majority of the market for prescription 
drugs. It is a very vital way to save money again.
    I think this is a different market. I think there are 
different considerations of biologics and so I would go back to 
the FTC report.
    Senator Brown. OK.
    Mr. Rother. I think when you're talking about a small 
molecule of drugs, it is a different balance, different 
equation.
    Senator Brown. OK. Thank you. Thank you, Mr. Chairman.
    Ms. Raines. Senator Brown.
    Senator Dodd. I am sorry. I want to get you. I want to get 
one question, Dr. Levi. I know you've got to leave very shortly 
and I just wanted to raise another question with you.
    Can you describe the community transformation concept in a 
bit more detail and then how would these grants differ from the 
current CDC programs and are there examples?
    Senator Mikulski. Community transformation grants?
    Senator Dodd. Yes, yes. How would they differ from the CDC 
and are there examples of other publicly or privately financed 
programs that have taken a similar approach that we are not 
aware of?
    Mr. Raskob. I am sorry. I've not had time to really vet 
that in detail yet. With our association, I sort of can't speak 
to that in detail this morning, but we'd certainly be willing 
to follow up with your office and others with the thoughts on 
that.
    Senator Dodd. Do you have a question for Dr. Levi before he 
runs?
    Senator Mikulski. No. Dr. Raskob, no. I think he did a good 
job and I have no questions for him, because mine will go to 
the medical home which goes to Jonas, Raines, Dr. Palfrey, and 
so on.
    Senator Dodd. Why don't we get to Dr. Raines because this 
is----
    Senator Mikulski. She was going to finish up on medical 
homes.
    Senator Dodd. Yes. I'll give you a chance to respond to 
this last point that has been raised, but also obviously we are 
going to hopefully expand the universe here not only among the 
uninsured obviously accessing the system already but obviously 
in very different circumstances.
    Those who have coverage today but have high deductibles or 
are reluctant to exercise their rights under the law--so 
there's going to be an expansion obviously of our fellow 
citizens who are going to access the system, even with all the 
prevention and the like. We hope that works, but we have this 
problem with providers and I've been given the statistics, I 
think you and I have talked about this at some point, the 
average age of a teaching nurse professor is 62, I think is 
what I've been told, and the average age of a nurse is 55.
    Ms. Raines. Right.
    Senator Dodd. We have heard a lot of conversation, I want 
to expand this question not only to you but to others, and 
obviously Senator Murray's done a lot of work on the workforce 
issues. We have all provided input to this.
    In fact, I think Senator Mikulski pointed out we all have 
had so much input, it began to be a laundry list of ideas, but 
I think----
    Senator Mikulski. Workforce issues were getting longer in 
our pages than the bill itself.
    Senator Dodd. The bill itself. Obviously what we are 
missing in a lot of this is how do you do this, what we'd like 
to see, but how do you get there?
    My question is, tell me how to get there.
    Ms. Raines. You're right. It is a very complicated problem 
with many facets.
    I would like to tie into that with Dr. Palfrey's comments 
earlier relating to the need for primary care providers and 
some of the specialties because the nursing workforce also can 
feed into that issue in terms of primary care in some of the 
rural areas and in some of the subspecialties. Nurse 
practitioners are particularly effective at that type of care.
    The issues of the workforce and particularly the nursing 
workforce is really a multifaceted problem. One is sufficient 
numbers of nurses in the pipeline to meet the projected need, 
as you said, because the demand is exploding very rapidly over 
the next several years.
    The other, and that is related to numbers of people coming 
in, the increasing demand and the aging of the workforce. The 
average age of staff nurses in this country now is 55 and so 
many of those nurses will be reaching retirement age very 
shortly.
    At the same time, we have a fairly critical shortage of 
nurse faculty who are available to teach the new nurses, and 
the average age of nursing faculty in the country now is in the 
early 60s. Many of those will also be retiring.
    It is something that has to be faced, both from getting the 
students, new students, new nurses into the pipeline but also 
preparing people who can teach them when they're there.
    I think that one of the points that AACN is particularly 
supportive of is looking at the training grants for advanced 
nursing education and removing a cap that is in there that 
indicates that only 10 percent of the current funds allocated 
for advanced nursing training can be used in doctoral programs 
and our recommendation is that that cap be removed because 
those are the funds that could then be used to prepare 
additional faculty.
    I think other programs that bring more nurses in to the 
workforce in terms of student support, loan repayment plans are 
critical.
    I think that this, as other issues related to the 
workforce--while my focus is particularly nursing, I think we 
have to look across disciplines because I think the time of us 
being able to look at a single discipline solving all of the 
healthcare problems are gone.
    AACN looks forward to working with you as we look for 
solutions.
    Senator Dodd. Dr. Cosgrove, others want to comment on this? 
How do we get there? What's your ideas on how we do that?
    Dr. Cosgrove. As far as the nursing shortages and 
personnel----
    Senator Dodd. Primary care physicians, a range. I think we 
all can almost ask the question ourselves. We are all asking 
the question. We all know where we want to be, but we have 
yet--we have heard about obviously assistance on student loans 
and allocating doctors to certain areas where they're 
underserved right now in return for forgiveness on loans. 
There's a lot of ideas around there and I presume many of them 
are very good ideas.
    I just wonder if there are any ones out there that you're 
looking at or we ought to be looking at that would expand this 
opportunity.
    Dr. Cosgrove. Yes. I think you have to look at both ends of 
the spectrum. Let's take the specialists end of the spectrum to 
start with. You can't expect all hospitals to be all things to 
all people.
    Senator Mikulski. All the time.
    Dr. Cosgrove. Yes. You're going to have to have areas of 
specialty where you move patients to those facilities and that 
should be increasingly done.
    It does two things. First of all, it increases the 
efficiency and, second, it improves the quality. It is called 
the practice of medicine and the more you practice that, the 
more patients you see with that, the better you get at it.
    On the other end of the spectrum, we are going to have to 
begin to have additional groups of people come in to provide 
care. It is no longer reasonable to expect a nurse to be the 
only one that can take a blood pressure or record a 
temperature. We have to bring technicians in.
    The example of that is superbly done by the U.S. military. 
I ran a 100-bed hospital in Vietnam with two doctors, 11 
nurses, and untold number of corps people who treated people 
superbly.
    We have to develop additional groups of technicians to come 
into the healthcare arena to remove the technical tasks that 
people are charged with, particularly nurses.
    Senator Dodd. Yes. I was----
    Senator Mikulski. Dr. Palfrey.
    Dr. Palfrey. I just wanted to approach this from----
    Senator Dodd. In the pediatric area, our problem is not 
enough primary care physicians. Like in the specialty area, it 
is the reverse of almost everything else.
    Dr. Palfrey. Right. Exactly. I am actually really 
addressing this from the pediatric point of view from our 
adolescent population.
    One of the things we see with our adolescents, particularly 
among diverse populations and so forth, is a sense of no hope, 
no future, no jobs. I think addressing preparation for health 
careers might be beyond this committee's purview to do that, 
but really thinking about our new populations who are here in 
this country and working and really thinking about healthcare 
preparation as things that young people can do. Get a 17-18-
year-old who can now work as this corps person, et cetera, et 
cetera, give them a sense of a future and jobs and so forth and 
really looking at it as a double whammy. Even for our PCAs, for 
people to help with the people with disabilities, make those 
attractive, give the high schools ways to do this and get a 
more diverse population into our health systems who speak the 
variety of languages that we have now in our communities, et 
cetera.
    That's a kind of double whammy way to give people a sense 
of hope and maybe not be in gangs, not to be on drugs, et 
cetera, et cetera. I know it is not in this committee but at 
least to get----
    Senator Mikulski. But it is in this committee.
    Senator Dodd. It is. That's what----
    Senator Mikulski. Well, if I could just jump in here and, 
first of all, I think right now it is how are we going to do 
the health bill. It isn't within the purview of this committee 
and only in the purview of this committee to meet workforce 
needs.
    What we have here through the Murray framework that we have 
all collaborated on is essentially to take what we have and how 
we can amplify it or strengthen it as we go through this 
passage.
    I believe, however, we need, and Senator Murray has a 
commission identifying where the demographic challenges are, 
but I think we need the kind of fresh approach that was at the 
beginning of the 20th Century when we looked at a total 
revision of it.
    I come, as you know, from Baltimore in which a woman by the 
name of Mary Garrett radically transformed medical education 
because she held the purse strings to Johns Hopkins. Johns 
Hopkins got the money but it only got halfway done. They had to 
go to Mary Garrett, heir to a railroad fortune, and she said 
three things.
    No. 1. You have to admit women. It took them 3 years to 
agree to do that. No. 2. It has to be a graduate program. No. 
3. It has to really have a sound admissions requirement for 
students.
    Dr. Palfrey. Quality.
    Senator Mikulski. We need to focus on academic curriculum. 
Now where we are, though, is we began to look at new ways. Do 
you only begin medical school after you've graduated from 
college? Do you begin earlier on with nursing?
    As much as I really support the doctoral program efforts, 
is that really practical to really think about how many 
doctorates we are going to produce in nursing as compared to 
achieving quality, making sure everyone's properly credentialed 
and so on?
    I think that is something, though, that has to come in the 
works. I think we have to really take a look at not only what 
we have but where we need to go with our new demography, Dr. 
Palfrey, what you said, and our new challenges, recognizing 
that many people don't come into these fields after they're 
already adults.
    Dr. Cosgrove, that medical corpsman coming back from Iraq 
or Afghanistan who says, wow, I never thought I could do this 
kind of stuff and I love doing it, but I am now 27 years old, 
where do I go and what do I do and, by the way, I've only 
finished high school and everybody says uh-huh, and so new 
thinking, new approaches without sacrificing quality or 
appropriate credentialing.
    Senator Dodd. You wanted to comment on that, Dr. Cosgrove?
    Dr. Cosgrove. Yes. We have done this on two levels. We have 
done it, first of all, with high school students. We bring in 
140 or 180 high school students each summer and pay them and 
put on a program for them to encourage them to come into 
healthcare.
    The second thing was we have worked out an arrangement with 
the military so that people can come back from Iran--from Iraq 
and Afghanistan and come----
    Senator Mikulski. We don't want them to go to Iran.
    Dr. Cosgrove. No. I am sorry. I mis-spoke.
    Senator Mikulski. I am teasing.
    Dr. Cosgrove. And come--that is right.
    Senator Mikulski. Something happened overnight.
    Senator Dodd. We don't have jurisdiction over that.
    Dr. Cosgrove. Apologies.
    Senator Mikulski. But they come back.
    Dr. Cosgrove. Yes, so they can come back and work for us, 
and in fact we established our Cardiac Surgical Program totally 
on the basis of Vietnam veterans who'd been corpsmen and we 
have employed some 80 of them in the Cardiac Surgical Program.
    Senator Dodd. Are you getting any follow-on with these high 
school students, these 180 you're bringing in?
    Dr. Cosgrove. Well, we have seen them, a very high 
percentage of them go on to 4-year colleges and we have not yet 
seen them go into--the rationale for this was that I had a high 
school student who graduated--who came and worked in my 
laboratory. He graduated valedictorian, then went to Senator 
Brown's alma mater where he was also valedictorian, then to 
Johns Hopkins. He came back to the Cleveland Clinic and is now 
one of our star cardiac surgeons where he could have gone any 
place and it was on the basis of the fact that he had worked 
for us in the past.
    Senator Mikulski. Dr. Raines.
    Senator Dodd. Dr. Jonas, you wanted to comment on this, 
too.
    Dr. Jonas. I just wanted to say that sometimes we forget 
the fact that incentives are not always about money, that 
healing professions, there are still many, many people who come 
into the healing professions because they want to be healers. 
They want to work in an environment where they can serve in 
these areas.
    I think if we were able to create an environment in which 
we are healing and wellness were a focus and was an environment 
to do--you'd see droves of people coming into those areas.
    I'll give you one example. We worked with a hospital up in 
New Jersey that was having a major problem with nurse turnover. 
They could not get nurses. Twenty-five percent-plus turnover 
per year, huge expense. They brought in a training program that 
empowered the nurses to be a core part of the person-centered 
care team and leaders in that, where they were providing care, 
healthcare coordination delivery in those areas, not just 
filling out the paperwork aspect.
    Within 2 years, they dropped from 25 percent turnover to 4-
percent turnover and had a line out the door trying to get into 
that program. People wanted to do that and that can be done if 
we created the environment in those areas.
    Senator Dodd. That's great.
    Senator Mikulski. Dr. Raines.
    Senator Dodd. Yes, Dr. Raines.
    Ms. Raines. Thank you. Thank you, Dr. Mikulski, for what 
you've done to champion nursing education over the years.
    Senator Mikulski. I only have an honorary doctorate, so.
    Ms. Raines. I agree with you that we need to continue to 
look at innovations and how we educate not only nursing 
students but students across the health professions.
    In nursing, though, we have a little bit of a different 
issue than some of the others in that we have students standing 
at the door. We turned away, last year, a total of about 50,000 
qualified nursing student applicants from our baccalaureate 
programs across the country because of lack of capacity in our 
schools of nursing and that lack of capacity is primarily 
faculty which I've mentioned, infrastructure, physical 
facilities, and clinical training sites.
    Senator Mikulski. You mean classrooms and labs?
    Ms. Raines. If we could expand the capacity of our schools 
of nursing, it would be a major step in increasing the nursing 
workforce.
    Senator Dodd. Dr. Levi.
    Mr. Levi. Just one comment. It is also the public health 
workforce that is facing tremendous shortages. The provisions 
that are in this bill, I think, are excellent in moving things 
forward, everything from loan repayment programs to also youth 
initiatives that will encourage high school kids to become 
interested.
    Dr. Raskob, I hope, would agree that as important as 
master's training is and graduate training is in public health, 
there are other ways of doing public health. I teach in the 
School of Public Health at George Washington University. Public 
health nurses are a critical part of the public health 
response.
    We need to be thinking also, as we reform and re-engineer 
the healthcare system, about the different roles public health 
will be playing and the different skills that will be necessary 
and so we need to be retraining people. We need to be 
encouraging kids starting in high school to be interested in 
this field and finding alternative pathways, in addition to 
master's training, to provide this workforce.
    Senator Dodd. Yes.
    Senator Brown. Let me comment on something. We have talked 
about nurses. We have talked about pediatric specialists. We 
have talked about a large swath of the workforce.
    There's a program, and my colleagues have heard this 
before, so I apologize, but there's a program in Mansfield, OH, 
where I grew up, where they had particularly high low-birth 
weight baby rates in two zip codes. One was predominantly 
Appalachian white, one was predominantly African-American, 
something like four times the national average low-birth weight 
baby rates, and over--they brought in what are called community 
health workers.
    It is a new designation in Ohio. Other States have it in 
different iterations, been around maybe 6 or 7 years, and 
they're high school graduates with about 3- to 6-month training 
beyond that. Some got their GEDs and they took young women from 
these neighborhoods and they dramatically cut the low-birth 
weight baby rate.
    These young women--because they lived in the neighborhood--
would be able to find women when they were pregnant, in the 
early stages of their pregnancy. They got them nutrition 
counseling. They brought them in to OB-GYNs for visits.
    I mean, the beauty of it and the success of it was 
terrific. The tragedy of it in some sense is this healthcare 
system isn't really quite equipped, No. 1, to train enough of 
them but, No. 2, to pay them. These women, these young women 
are paid $11-$12 an hour. The OB-GYN is paid under Medicaid, 
but the workers that are doing this aren't and we are working 
with the Finance Committee. We are also working with Senator 
Murray on beginning to sort of recognize and train more workers 
like this.
    We need to be conscious as we practice high-tech medicine 
especially of what we can do with these young women and similar 
to Dr. Cosgrove's comments about these high school students, I 
met with several of these young women and I said to them, you 
know, you've already saved lives. You've already made lives 
better and you can bet that some of those young women who had 
very little opportunity in their lives and were in dead-end 
jobs at McDonald's and other places before this, some of them 
were going to become nurses, some of them were going to become 
doctors if we do this right and empower these young low-income 
women coming from homes where there wasn't much opportunity for 
them to move ahead with education.
    If we really do this right and find a way to focus on and 
empower those women of that age in the kind of health outcomes 
that will mean it will save us in so many ways.
    Mr. Levi. To come back to Senator Dodd's question about the 
community transformation grants, I mean that could be a part of 
what community transformation grants are about, creating within 
a community a core of people who are going to start changing 
the norms and educating people, and that is really what we need 
to be doing, not just with low-birth weight babies but about 
all of these chronic disease issues that have the behavioral 
base.
    Senator Mikulski. I'd like to jump in. I have to leave at 
12, and I'd like to ask, as really engaging as this 
conversation is, about community health teams.
    In terms of the community health teams, I mean, community-
based multidisplinary teams, excuse me. I was a little 
distracted. The medical home idea, I really am going to invite 
those at this table and others who've participated in the 
roundtable to look at this and scrub it.
    My idea that came through extensive hearings that we had on 
integrative health and others and, Dr. Jonas, you were really 
an active participant, was this, that building on the Baucus 
paper and Medicare, the idea of a medical home.
    The first discussion we had is what is a medical home and I 
looked at the CMS definition. Oh, my God. It was just so 
laborious, tedious, and technical. Who would want to live in 
that home? OK.
    I went to the definition provided by the Academy of Family 
Physicians and I did it for two reasons. I felt it was 
comprehensive and, second, when people would say to me where 
did you get that, I would say that I turned to those who 
actually have been the primary orientation.
    I'd like you to look at that and give us feedback. Am I 
right on the right track? The whole idea of a medical home was 
to leave flexibility that it would not be oriented only to a 
primary care physician but also to that who would be 
appropriate.
    For example, a child would have as his or her medical home 
a pediatrician. There might be those with MS that their medical 
home was going to be with their immunologist which is the 
person that you're going to be most likely to turn to and most 
likely to confide in and most likely to need for your ongoing 
care. We didn't want to lock it in to a narrow definition of 
primary care docs.
    The second thing was that knowing that, the management of 
chronic illness, which is three-quarters, as you said, John, of 
our funding, required behavioral change for either teaching 
self-care initiatives around diet and exercise to whatever.
    That's where we went to the access to community health 
teams. We don't have the power of the payment system in this 
committee. We established grants to States to set up these 
community health teams. I am a little ambivalent about that 
because I am not sure it will be fair--it could be uneven, et 
cetera.
    And, third, my other flashing light was that sometimes a 
physician--we want the physician to be a guide but not a narrow 
gatekeeper, so that if you wanted to go to a licensed provider 
in order to be able to seek other help, for example chronic 
back pain, if you really wanted to go use acupuncture and you 
had a doctor who was hostile to it, you still would be able to 
have access to it.
    My question to you, and I think you can give me answers 
today, fine, and if you can't, I really need the written 
testimony as we move through the legislation, No. 1, am I on 
the right track for my definition of a medical home because my 
colleagues are counting, quite frankly, on me to do this right 
as is America.
    And No. 2, the access to community health teams that get 
people what they need, knowing that it isn't all about 
medicine--not everything is medicalized.
    Dr. Jonas, do you want to kick off that, and then throw it 
open?
    Dr. Jonas. Thank you, Senator. I think that this is a very 
important concept.
    We, so much in this country, tend to get attracted to and 
invest in and value high-tech and yet at the same time we don't 
really appreciate, we under-appreciate the power of the high 
tough and the processes of care in these areas.
    Dr. Mary Jo Crissler, a nurse who runs the Institute for 
Health and Healing at the University of Minnesota, has taken 
the medical home concept and broadened it exactly to what 
you're talking about in terms of team care. She calls it the 
healthcare home, in which a leader in the area of person-
centered care could be a licensed and should be a licensed 
practitioner that then could look at what's needed to properly 
care for the complex, often multifactorial components that are 
needed for individuals with chronic illness from their mind, 
body, and spirit.
    I think a concept that looks at that team care is 
important. It leads to efficiencies. It requires efficiencies, 
similar to what Dr. Cosgrove talked about, where everyone has 
an important role.
    Senator Mikulski. Do you like the definition I've got in 
here now?
    Dr. Jonas. I like the definition from the American Academy 
of Family Physicians which has been adopted by the American 
Academy of Pediatrics, OB-GYN, and Internal Medicine.
    I think there are some modifications to it that need to 
broaden the definition beyond simply making the physician the 
healthcare leader to other health care leaders, especially if 
we want to put prevention and health promotion, as we have 
talked about in this panel, in the lead because those 
practitioners or those specialties then need to do that.
    Senator Mikulski. Dr. Raines.
    Ms. Raines. I would certainly agree with Dr. Jonas' 
comment. I think that it is an important concept and one that 
can be terribly useful in terms of revising our healthcare 
system, but I would encourage broadening the definition a bit 
to look at----
    Senator Mikulski. Well, I need specific language where we 
broaden it but we don't set ourselves up for a lot of pushback 
arguments and even ridicule because I've had to go through a 
lot to get to this.
    Dr. Palfrey.
    Dr. Palfrey. The medical home actually was born in the 
American Academy of Pediatrics in the 1960s and we are very 
proud of the medical home concept.
    The idea of it is that we have continuous care 24/7. It is 
comprehensive. It includes primary care, subspecialty care, 
access to hospitals, and that the primary care physician or the 
medical home physician takes full responsibility for what 
happens from diagnosis through treatment through care and 
accepts the malpractice or whatever happens as a result of 
that.
    The medical home should also be family-centered and 
community-based and so it is the best care that you can 
possibly get. It can be provided absolutely by a subspecialist, 
as you're mentioning, if that person makes sure that all of the 
care is delivered. If an immunologist is willing to provide--
make sure that the immunizations are given to the patient, that 
family counseling is given to the patient, that all of these 
things are done, absolutely, that can be.
    Senator Mikulski. What about the community health teams, 
the community health team concept in the bill, and what do you 
think about it?
    Dr. Palfrey. The medical homes also include community 
outreach and are community-based, and we have some very good 
examples, for instance Community Care Alliance in North 
Carolina, which have saved enormous amounts of money using 
community health as a component of this because we have to be 
able to get out to the homes. We have to be able to coordinate 
care. It is a full concept, as you're talking about.
    Senator Mikulski. Very good. John, did you want to comment?
    Mr. Rother. Senator, I just recently was in Vermont to look 
at some of the community health team innovations that they are 
sponsoring and it looks very promising and the experience in 
North Carolina equally promising.
    I think these are innovations worthy of support. I don't 
know if they're the complete answer, I doubt it, but they 
certainly are adding value at a very reasonable cost.
    Senator Mikulski. Anybody else?
    Dr. Jonas. There's an educational network within HRSA that 
does an excellent job of looking at innovations like this in 
the community health teams and then disseminates the ones that 
have been shown to work out and I think looking at that and 
supporting that would be an ideal way and an adequate way that 
you could actually begin to roll out these areas.
    Senator Mikulski. Well, first, I want to come back to Dr. 
Palfrey. We have been talking about the North Carolina model 
and various examples related to prevention and wellness.
    See, what we don't want at the end of the day is to just 
give lip service to prevention and wellness. It is like 
everybody talks about it but nobody does it. Everybody thinks 
it is swell and then they kind of want it to be an 
afterthought.
    It was the goal of Senator Kennedy, when he established 
these working groups, to make sure there was quality and that 
there was a whole working group just on prevention and I am 
very proud of what my colleague has done, but it wasn't 
separated from coverage. We have all been working together 
under Senator Dodd's inspiration and perspiration.
    Now, though, we are at the point where we are actually 
drafting language and, quite frankly, we are on new territory 
because this will be the first time we are trying to move from 
volume medicine to value medicine in what we are doing in our 
two working groups and at the same time establishing concepts 
that have been recommended. We are making them 21st Century 
concepts and we need to have those who are in the area of 
practice and who really study the policies to give us feedback 
because, quite frankly, I worry at times we are in a little 
over our head and we have to make sure we don't inadvertently 
create unintended consequences where we lock people in, I mean 
a variety of things.
    So we are asking you to really look at the definition, give 
us advice, and also look at the community health team and also 
make sure that guidance is not rigid gate-keeping and be able 
to proceed from there.
    Dr. Palfrey. We will be happy to help and follow the 
Garrett Sisters model.
    Senator Dodd. Thank you very much. I have one additional 
question, Dr. Palfrey.
    We have written a provision for the bill very similar to 
the best pharmaceuticals for children provision in the follow-
on biologics regarding children with the 6-month exclusivity. 
You may recall, the best pharmaceuticals for children produced 
a stunning number of new safety information about drugs used in 
children that came out as a result of that effort and I just 
would call for a similar 6 months of exclusivity for pediatric 
testing for biological products.
    I don't know if you had any comments about that. Are you 
familiar with this?
    Dr. Palfrey. I want to thank you for what you've done with 
it. I personally am not as familiar to give you the answer to 
that, but it is so important for children to be included in 
these trials because so many of our drugs actually literally 
say we shouldn't be using them.
    Senator Dodd. No. I appreciate----
    Dr. Palfrey. Thank you.
    Senator Dodd [continuing]. It very much. Additional 
comments. You've been a terrific panel. I regret that not more 
of my colleagues were here but I do understand how that can 
happen and so it has been tremendously valuable and we are 
going to leave the record open because I think there will be 
questions for you from additional members over the next few 
days.
    We want you to stay very much in touch with us, if you 
could, in these coming days and particularly the ideas and 
suggestions that I mentioned at the outset, if you could submit 
to us--and Senator Mikulski just pointed out some very specific 
suggestions, for instance, on the medical home definition. If 
we are going to expand it, to what degree are we expanding it? 
What are the add-ons you'd recommend for us? That's a good 
example of what we are talking about.
    So with that, I thank you all for being here today, and we 
have a very big job in front of us and, Dr. Palfrey, I 
appreciate you mentioning Senator Kennedy because obviously 
he'd be the one in this chair and he is in so many ways, even 
though he's not physically here. It has been his inspiration 
for four decades to try and get a national healthcare plan in 
place that is accessible and affordable and is value-based, 
quality-based, again principles and concepts that have been 
talked about for years and years and years, and as I've said 
over and over again, the present situation is no longer not 
only unacceptable, it is unsustainable.
    Just from a financial standpoint, we can't continue the 
path we are on and that has got to change. So your 
participation today has contributed significantly to our 
discussion and we thank you very, very much for it and look 
forward to hearing from you again.
    The committee stands adjourned.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

              Prepared Statement of Chip Kahn, President, 
                    Federation of American Hospitals

                               I. QUALITY

     The 1,000 hospitals of the Federation of American 
Hospitals (FAH) strongly supports the expansion of health coverage to 
uninsured Americans, as well as health care delivery, and congratulates 
this committee and its leadership in forwarding that process.
     We are gratified with the committee's appropriate focus on 
prevention and our health care workforce as part of reform. Today, I am 
going to focus on the quality components of the legislation, which we 
find particularly important to achieving the goals of health reform.
Stand For Quality
     The FAH has long worked with other stakeholders to develop 
a quality infrastructure to enable hospitals and clinicians to improve 
patient care.
     We deeply appreciate the leadership of Chairman Kennedy, 
Senator Dodd, and Senators Enzi and Mikulski for including in the bill 
a strong quality title which recognizes the need for a cohesive Federal 
infrastructure, essential for effectiveness research, that is built on 
the foundation of a strong public-private, multi-stakeholder 
partnership.
     The FAH is an active member of Stand For Quality, a broad 
multistake-holder coalition that includes more than 190 major 
organizations nationwide from consumers, labor, employers, purchasers, 
to clinicians and hospitals, and we appreciate the committee's 
recognition of the six key functions we believe are necessary to 
strengthen and improve quality:

    1. Setting national priorities to guide reporting and improvement 
activities and assess progress.
    2. Endorsing and maintaining measures for national use through 
multistake-holder consensus process.
    3. Developing measures to fill identified gaps in priority areas.
    4. Strengthening a public-private stakeholder consultation process.
    5. Providing a national strategy for the collection, aggregation 
and public reporting of quality measures.
    6. Identifying, developing, testing and disseminating innovative 
methodologies for improvement in quality of health care.

Delivery Reforms
     Additionally, the committee bill includes a section that 
would have insurers implementing quality programs. We would encourage 
the committee to ensure that quality programs developed by insurers are 
linked to those quality programs you included in title II (2).

                     II. GENERAL HEALTH CARE REFORM

     As I wrap up my remarks, I would like to mention three key 
points that we view as critical for reform to work:

          Ultimately, health reform must work to strengthen--
        not weaken--the hospitals that so many Americans rely on for 
        their care.
          Therefore, we need to be very careful that the bill 
        does not arbitrarily reduce hospital revenue. That would 
        undermine the ability of hospitals to meet the expectations of 
        expanded access for Americans to quality patient care.
          Medicare and Medicaid are critically important 
        programs that so many Americans depend on; however, we must 
        acknowledge that both chronically underpay hospitals for 
        services. So, tying payments under expanded coverage to these 
        programs will weaken not strengthen hospitals.

     We all support delivery reforms that will improve care and 
its efficiency, but if sufficient funding is not there, we could very 
well defeat the goals of the bill.
     Thank you for the opportunity to address the committee 
today.
                                 ______
                                 
American Association of Colleges of Nursing (AACN),
                                      Washington, DC 20036,
                                                     June 19, 2009.
Chairman Edward Kennedy,
Senate Health, Education, Labor, and Pensions Committee,
428 Dirksen Office Building,
Washington, DC 20510.

Ranking Member Michael Enzi,
Senate Health, Education, Labor, and Pensions Committee,
835 Senate Hart Office Building,
Washington, DC 20510.

    Dear Chairman Kennedy and Senator Enzi:  I am writing on behalf of 
the American Association of Colleges of Nursing (AACN) to amend our 
written and oral testimony provided on June 12, 2009. In the testimony, 
we incorrectly asked that the 10 percent cap on the availability of 
funds for doctoral students under the Advanced Education Nursing Grant 
program be lifted by striking section 296j(f)(2) of the current Title 
VIII authority of the Public Health Service Act. We were unaware that 
the Affordable Health Choices Act of 2009 does indicate the removal of 
this provision. This was an oversight and unintentional error by AACN, 
and we would like both to apologize and to correct our comments to 
reflect that the legislation does indeed include the removal of this 
cap. It was not our intent to mislead the Senate Health, Education, 
Labor, and Pensions Committee, and we sincerely apologize for this 
error.
    AACN is grateful for the tireless efforts of you and your staff to 
move forward this momentous piece of legislation. An accessible 
healthcare system that provides quality and affordable care nears 
reality under your leadership. We offer our strong support for your 
efforts to see reform passed swiftly and effectively.
    We appreciate your commitment to healthcare reform and nursing 
education. If AACN can be of any assistance with your efforts, do not 
hesitate to contact me or Dr. Geraldine Bednash, Chief Executive 
Officer and Executive Director at [email protected],edu or (202) 463-
6930.
            Sincerely,
                                  C. Fay Raines, Ph.D., RN,
                                                         President.

cc:  Senator Christopher Dodd (D-CT); Senator Tom Harkin (D-IA); 
Senator Barbara A. Mikulski (D-MD); Senator Jeff Bingaman (D-NM); 
Senator Patty Murray (D-WA); Senator Jack Reed (D-RI); Senator Bernard 
Sanders (I-VT); Senator Sherrod Brown (D-OH); Senator Robert P. Casey, 
Jr. (D-PA); Senator Kay Hagan (D-NC); Senator Jeff Merkley (D-OR); 
Senator Judd Gregg (R-NH); Senator Lamar Alexander (R-TN); Senator 
Richard Burr (R-NC); Senator Johnny Isakson (R-GA); Senator John McCain 
(R-AZ); Senator Orrin G. Hatch (R-UT); Senator Lisa Murkowski (R-AK); 
Senator Tom Coburn, M.D. (R-OK); Senator Pat Roberts (R-KS)

    [Whereupon, at 11:59 a.m., the hearing was adjourned.]

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