[Senate Hearing 112-789]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 112-789
 
                DIVERTING NON-URGENT EMERGENCY ROOM USE:

              CAN IT PROVIDE BETTER CARE AND LOWER COSTS?
=======================================================================



                                HEARING

                               BEFORE THE

                SUBCOMMITTEE ON PRIMARY HEALTH AND AGING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,

                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                                   ON

 EXAMINING DIVERTING NON-URGENT EMERGENCY ROOM USE, FOCUSING ON IF IT 
 CAN PROVIDE BETTER CARE AND LOWER COSTS, AND HEALTH CENTER STRATEGIES 
                     THAT MAY HELP REDUCE THEIR USE

                               __________

                              MAY 11, 2011

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions


      Available via the World Wide Web: http://www.gpo.gov/fdsys/





                  U.S. GOVERNMENT PRINTING OFFICE
81-788                    WASHINGTON : 2013
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC 
20402-0001




          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                       TOM HARKIN, Iowa, Chairman

BARBARA A. MIKULSKI, Maryland
JEFF BINGAMAN, New Mexico
PATTY MURRAY, Washington
BERNARD SANDERS (I), Vermont
ROBERT P. CASEY, JR., Pennsylvania
KAY R. HAGAN, North Carolina
JEFF MERKLEY, Oregon
AL FRANKEN, Minnesota
MICHAEL F. BENNET, Colorado
SHELDON WHITEHOUSE, Rhode Island
RICHARD BLUMENTHAL, Connecticut

                                     MICHAEL B. ENZI, Wyoming
                                     LAMAR ALEXANDER, Tennessee
                                     RICHARD BURR, North Carolina
                                     JOHNNY ISAKSON, Georgia
                                     RAND PAUL, Kentucky
                                     ORRIN G. HATCH, Utah
                                     JOHN McCAIN, Arizona
                                     PAT ROBERTS, Kansas
                                     LISA MURKOWSKI, Alaska
                                     MARK KIRK, Illinois
                                       

                    Daniel E. Smith, Staff Director

                  Pamela Smith, Deputy Staff Director 

     Frank Macchiarola, Republican Staff Director and Chief Counsel

                                 ______

                Subcommittee on Primary Health and Aging

                 BERNARD SANDERS (I), Vermont, Chairman

BARBARA A. MIKULSKI, Maryland        RAND PAUL, Kentucky
JEFF BINGAMAN, New Mexico            RICHARD BURR, North Carolina
ROBERT P. CASEY, Jr., Pennsylvania   JOHNNY ISAKSON, Georgia
KAY R. HAGAN, North Carolina         ORRIN G. HATCH, Utah
JEFF MERKLEY, Oregon                 LISA MURKOWSKI, Alaska
SHELDON WHITEHOUSE, Rhode Island     MICHAEL B. ENZI, Wyoming
TOM HARKIN, Iowa (ex officio)          

                Ashley Carson Cottingham, Staff Director

                 Evan Feinberg, Minority Staff Director

                                  (ii)




                            C O N T E N T S

                               __________

                               STATEMENTS

                        WEDNESDAY, MAY 11, 2011

                                                                   Page

                           Committee Members

Sanders, Hon. Bernard, Chairman, Subcommittee on Primary Health 
  and Aging, opening statement...................................     1
Paul, Hon. Rand, a U.S. Senator from the State of Kentucky.......     3
Bingaman, Hon. Jeff, a U.S. Senator from the State of New Mexico.     4
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode 
  Island.........................................................    51
Merkley, Hon. Jeff, a U.S. Senator from the State of Oregon......    53

                            Witness--Panel I

Macrae, James, Associate Administrator, Bureau of Primary Health 
  Care, Health Resources and Services Administration, U.S. 
  Department of Health and Human Services, Rockville, MD.........     4
    Prepared statement...........................................     6

                          Witnesses--Panel II

Draper, Debra A., Director, Health Care, Government 
  Accountability Office (GAO), Washington, DC....................    15
    Prepared statement...........................................    16
Cunningham, Peter, Ph.D., Senior Fellow, Center for Studying 
  Health Systems Change, Washington, DC..........................    19
    Prepared statement...........................................    20
Eck, Alieta, M.D., Founder and Co-Director, Zarephath Health 
  Center, Zarephath, NJ..........................................    30
    Prepared statement...........................................    32
Kraus, Dana, M.D., Family Practice Physician, Northern Counties 
  Health Care, St. Johnsbury, VT.................................    37
    Prepared statement...........................................    38

                          ADDITIONAL MATERIAL

Statements, articles, publications, etc.:
    Alliance Defense Fund (ADF), Matthew S. Bowman, Esq., Legal 
      Counsel....................................................    63
    Letters:
        American College of Emergency Physicians.................    64
        U.S. Government Accountability Office (GAO)..............    65
        New Jersey Primary Care Association, Inc. (NJPCA)........    75

                                 (iii)

                  DIVERTING NON-URGENT EMERGENCY ROOM


            USE: CAN IT PROVIDE BETTER CARE AND LOWER COSTS?

                              ----------                              


                        WEDNESDAY, MAY 11, 2011

                                       U.S. Senate,
                  Subcommittee on Primary Health and Aging,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10 a.m. in 
Room 430, Dirksen Office Building, Hon. Bernard Sanders, 
chairman of the subcommittee, presiding.
    Present: Senators Sanders, Bingaman, Merkley, Whitehouse, 
and Paul.

                  Opening Statement of Senator Sanders

    Senator Sanders. Let me open the very first meeting of the 
U.S. Senate Subcommittee on Health, Education, Labor, and 
Pensions, Subcommittee on Primary Health and Aging.
    Today we have a very important hearing. Senator Paul is 
here as well and we expect other members as the hearing 
proceeds.
    We have some excellent panelists and in a bit we will be 
hearing from James Macrae who is the associate administrator 
for the Bureau of Primary Health Care, Health Resources and 
Services Administration. Our second panel will include Deborah 
Draper, the director of Health Care, Government Accountability 
Office; Peter Cunningham, senior fellow, Center for Studying 
Health Systems Change; Alieta Eck, M.D., founder and co-
director Zarephath Health Center in New Jersey; Dana Kraus, 
M.D., Family Practice Physician, Northern Counties Health Care 
in St. Johnsbury, VT. We are pleased that you are all here.
    Let me begin with an opening statement and say that I think 
most of us would agree that our health care system today has 
many very, very serious problems. In America today we have some 
50 million fellow Americans who lack any health insurance, we 
have many more who are under-insured with large copayments and 
deductibles and many more even with insurance who are finding 
it very hard to locate a primary health care physician who will 
treat them and their family.
    The United States today is the only Nation in the 
industrialized world that does not guarantee health care to all 
of its people as a right. Meanwhile, despite 50 million 
Americans without any health insurance, we end up spending--and 
this will be an important part of what this hearing is about--
we end up spending almost twice as much per person on health 
care as any other industrialized Nation. I think it is 
important to understand why that is so and how we can go 
forward in providing quality health care to all of our people 
in a cost-effective way.
    Here are just a few facts that should concern every 
American. According to a study from Harvard University, some 
45,000 Americans will die this year because they do not get to 
a doctor on time. They are sick, their sicknesses fester and by 
the time they walk into the doctor's office it is often too 
late. Further, in terms of cost, we spend an unsustainable 17.6 
percent of our GDP on health care in 2009 and that is projected 
to go up to 20 percent by 2020. So this is not just an issue of 
people who cannot afford health insurance, it is not just an 
issue of employers who are forced to pay 10, 20, 30 percent 
more a year for health insurance, it is an issue for our entire 
economy. This health care cost soaring is just not sustainable.
    Yet, despite all of that, we rank approximately 26th among 
major developed nations on life expectancy and 31st on infant 
mortality. It just seems to me that with those problems facing 
us we have to take a hard look at why these problems occur.
    One of the major focuses of today's hearing is the use of 
emergency rooms in a way that is not appropriate. While there 
are differences of opinion, and certainly the figures will vary 
in different parts of the country, nobody denies that many, 
many hospitals see large numbers of people who are coming into 
their emergency rooms, not for emergency care. It is terribly 
important, I think we all agree, that our emergency rooms are 
there for people who have heart attacks, strokes, accidents, 
etc, but there is no debate that many people use the emergency 
room as a source of primary health care because there are not 
other primary health care facilities available.
    The testimony that we will hear today, and that I think 
everyone agrees on, is that an emergency room is, in fact, the 
most expensive form of primary health care. That, for example, 
if one were to go to a federally qualified community health 
center or other primary health care facilities, the cost is 
substantially lower. So it seems to me one of our goals is to 
increase access for primary health care, get people who don't 
need the emergency room out of the emergency room and provide 
good quality primary health care to those people at a cost that 
will be substantially lower than the cost of an emergency room.
    Obviously in different parts of the country the figures are 
different, but in some cases at least, a visit to an emergency 
room for primary health care may be as much as 10 times more 
than a visit to a community health center. So my hope is that 
we can begin to understand, and we are going to hear some 
interesting testimony today, how we can do that. How we can 
keep unnecessary visits to the emergency room lower and get 
people the quality primary health care that we need.
    I very much look forward to hearing the testimony that we 
will be hearing in a few minutes.
    Senator Sanders. Senator Paul.

                       Statement of Senator Paul

    Senator Paul. Thank you, Senator Sanders.
    I do agree, as a physician I have seen it first hand, that 
ER visits are much more expensive than primary care visits and 
that the emphasis should be trying to figure out how we can get 
patients to go to primary care as opposed to clogging up the 
emergency rooms.
    I would also say though, that private clinics and 
charitable clinics are much more efficient than government 
clinics. This is true throughout all of the economy, that 
private enterprise is always more efficient than government, 
just as a matter of fact.
    I wholeheartedly agree with Dr. Eck, who will testify 
later, that charity should be voluntary. In fact, charity is, 
by definition, voluntary. The nobleness of giving is only real 
if giving is voluntary. Many on the left wish to experience the 
reward of giving by giving other people's money, but it doesn't 
work that way. When you use force to transfer money from those 
who work to those who don't, that is not charity, that is 
redistribution of wealth. When you use government to try to 
perform good works, not only is the accolade of charity 
undeserved but the effect of the good works is always less than 
satisfactory because government rarely does anything well.
    I often ask an audience, if you had a hundred dollars to 
give who would you rather give it to, the Federal Government or 
the Salvation Army. I've yet to meet a thinking adult who would 
choose the Federal Government. Government, particularly 
government that is distant from the people is inefficient and 
wasteful. Our job should not be to expand wasteful government 
programs but to get government out of the way of true charity.
    Not only is true charity good for the heart, but it is good 
for the recipient. It warms the heart to hear of those who 
receive charity, giving back with their time and effort to the 
charity itself. In fact, many charities that work well require 
the recipient to work at the charity. Many charities have come 
to the conclusion that cash payments to recipients is 
counterproductive and so the charity only pays bills directly.
    Charity encourages help in times of need, but does not 
encourage the perception of lifelong entitlement. Those who 
receive charity typically understand that charity is a 
temporary hand-up and not a permanent hand-out.
    As a physician, I have seen the difference firsthand. Time 
and again patients who I treated through the Lions Eye Clinic, 
a charity that I helped set up, were appreciative and courteous 
while others who felt entitled to free care were often 
disruptive and rude.
    Obamacare expands entitlements at a time when entitlements 
are already stretched beyond solvency. Because we are living 
longer and because of the population boom after World War II, 
entitlements are all short of money. Social Security is $6 
trillion short. Medicare is short over $30 trillion over the 
next several decades. Social Security, for the first time, last 
year pays out more than it brings in. Even without Obamacare, 
the entitlements are on a collision course to consume the 
entire budget within little more than a decade. We have serious 
problems, just adding on more programs isn't the answer.
    What we should be discussing today is, is it fiscally 
responsible to increase funding to taxpayer financed health 
centers by 68 percent over the next 5 years? Where will the 
money come from? Are we willing to borrow from China to pay for 
Obamacare? Are we willing to raise taxes to pay for the 
expansion of entitlements? Are we willing to ask the Federal 
Reserve to simply print more money to pay for the entitlements? 
Will we expand government welfare to such a degree that we 
bankrupt the entire system and no entitlements are paid?
    I know advocates of increased welfare mean well, but in the 
end good intentions must also be paired with fiscal 
responsibility and that is the discussion that we as a country 
should now be engaged in. Thank you.
    Senator Sanders. Thank you, Senator Paul.
    Senator Bingaman.

                     Statement of Senator Bingaman

    Senator Bingaman. Mr. Chairman, I am here to hear the 
witnesses and focus on this issue. I do think that diverting 
folks from emergency rooms to other opportunities to get health 
care is a great opportunity for us to save money in the health 
care system, both in the public health care system and in the 
private health care system.
    So I commend you for having the hearing.
    Senator Sanders. Thank you very much.
    Let's begin with Mr. Macrae. James Macrae is the associate 
administrator for the Bureau of Primary Health Care, Health 
Resources and Services Administration, usually referred to as 
HRSA, the U.S. Department of Health and Human Services.
    Mr. Macrae, thanks very much for being with us.

 STATEMENT OF JAMES MACRAE, ASSOCIATE ADMINISTRATOR, BUREAU OF 
      PRIMARY HEALTH CARE, HEALTH RESOURCES AND SERVICES 
 ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, 
                         ROCKVILLE, MD

    Mr. Macrae. Thank you very much Mr. Chairman, members of 
the committee and subcommittee. Thank you for the opportunity 
to testify today.
    I am Jim Macrae, the associate administrator of the Bureau 
of Primary Health Care in the Health Resources and Services 
Administration. I am very pleased to join my other colleagues 
today in appearing before you.
    Our agency, HRSA, helps the most vulnerable Americans 
receive quality primary health care, without regard to their 
ability to pay. Our agency works to expand access to health 
care for millions of Americans, the uninsured, the underserved 
and the vulnerable. HRSA recognizes that people need to have 
access primary care and through its programs and activities the 
agency seeks to meet these needs.
    HRSA's vision for the Nation is healthy communities and 
healthy people. Our mission is to improve health and achieve 
health equity through access to quality services, a skilled 
workforce and innovative programs. At HRSA we also believe that 
primary care is more than having a place to go when you are 
sick. We view primary care as an institute of what medicine 
does, providing integrated, accessible health care services 
like clinicians who are accountable for addressing a large 
majority of personal health care needs, developing a sustained 
partnership with patients and practicing in the context of 
family and community.
    Now I would like to talk more specifically about the health 
center program. For more than 40 years health centers have 
developed comprehensive, high quality, cost-effective primary 
care to patients regardless of their ability to pay. During 
that time health centers have become an essential primary care 
provider for America's most vulnerable populations, people 
living in poverty, the uninsured, the homeless, ethnic and 
racial minorities, public housing residents and people who are 
geographically isolated. Health centers advance the preventive, 
coordinated, comprehensive and patient-centered care model 
coordinating a wide range of medical, dental, behavioral and 
social services. Today more than 11,000 health centers operate 
over 8,000 delivery sites that provide care, in every U.S. 
State, the District of Columbia, Puerto Rico, the U.S. Virgin 
Islands and the Pacific Basin.
    More importantly health centers offer care that is 
affordable and accessible. The health center program 
requirements include: The provision of care to all patients 
regardless of their ability to pay; offering discounts to 
patients on a sliding fee scale for all patients at or below 
200 percent of the poverty level and the provision of services 
at times and locations that assure accessibility and meet the 
needs of the populations. Health centers frequently offer 
evening and weekend hours and are located in areas convenient 
to where the target population lives, including schools, 
homeless shelters and through mobile vans.
    Health centers are also required to provide professional 
coverage for medical emergencies during hours when the center 
is closed. This coverage must be clearly defined and include 
telephone access to a clinician who can access the patient's 
needs and recommend appropriate followup care. This includes 
advising the patient of whether a visit to the ER is 
appropriate.
    The impact of health centers can be seen in other ways as 
well. Health centers provide high quality care to rural and 
urban populations by focusing attention on improving the 
community's health through preventive care and providing direct 
patient care.
    The health center model also reduces the use of costlier 
providers of care such as emergency rooms and hospitals. 
Research has shown that Medicaid beneficiaries receiving care 
from a health center were less likely to be inappropriately 
hospitalized and less likely to visit the emergency room 
inappropriately. Rural counties with a community health center 
site had fewer than 33 percent emergency room visits than those 
without a health center.
    Health centers also improve access to care, health outcomes 
and reduce health disparities and reduce costs. For example, 
studies have demonstrated that uninsured people living within 
close proximity to a health center are less likely to have an 
unmet medical need, less likely to have postponed or delayed 
seeking needed care and more likely to have had a general 
medical visit. Health center uninsured patients are more likely 
to have a usual source of care than the uninsured nationally. 
Likewise, Medicaid beneficiaries receiving care from health 
centers are more likely to report having access to care.
    The reach of health centers is not limited to just what we 
do in HRSA. In the past several years we have been working with 
our counterparts in the Center for Medicaid and Medicare 
Services on emergency room diversion programs. In 2008 CMS 
awarded grants to 20 States with the goal of reducing hospital 
emergency rooms by Medicaid beneficiaries, with many health 
centers playing a key role in highlighting that health centers 
are well positioned to adopt and showcase innovations in care 
delivery, their experience with quality improvement and the use 
of evidence-based models like the Chronic Care Model.
    Finally, I would like to highlight an important finding 
referenced in the GAO report, that health centers reduce the 
use of hospital emergency rooms for non-urgent care because 
health centers have the attributes of the medical home. Several 
studies have shown that medical homes reduce emergency room use 
significantly, not only for healthy patients but for those who 
are sicker and have greater health care needs. HRSA is 
dedicated to helping health centers move toward the medical 
home model and to date more than 125 health centers have 
enrolled in HRSA's recently announced Patient-Centered Medical 
Home Initiative.
    In closing, we recognize the key role that health centers 
do and can play in the reduction of inappropriate emergency 
room use and I appreciate the opportunity to testify today. 
Thank you.
    [The prepared statement of Mr. Macrae follows:]
                   Prepared Statement of James Macrae
    Mr. Chairman, Ranking Member, and members of the committee, thank 
you for the opportunity to testify. I am Jim Macrae, associate 
administrator of the Bureau of Primary Health Care in the Health 
Resources and Services Administration (HRSA). I am pleased to join my 
other colleagues in appearing before you today.
                             hrsa overview
    The Health Resources and Services Administration helps the most 
vulnerable Americans receive quality primary health care, without 
regard to their ability to pay. HRSA works to expand access to health 
care for millions of Americans--the uninsured, the underserved and the 
vulnerable. HRSA recognizes that people need to have access to primary 
health care and, through its programs and activities; the Agency seeks 
to meet these needs.
    HRSA delivers on its obligation to address primary care access 
through the 6 Bureaus and 13 Offices that comprise the Agency. The 
Agency collaborates with government at the Federal, State, and local 
levels, and also with community-based organizations and non-profit 
foundations, to seek solutions to primary health care challenges. HRSA 
provides leadership and financial support to health care providers in 
every State and U.S. territory.
                    hrsa's vision, mission and goals
    HRSA's vision for the Nation is healthy communities and healthy 
people. Our mission is to improve health and achieve health equity 
through access to quality services, a skilled health workforce and 
innovative programs.
    The Agency seeks to further our vision and carry out our mission 
through four major goals:

     Improve Access to Quality Care and Services;
     Strengthen the Health Workforce;
     Build Healthy Communities; and
     Improve Health Equity.

    At HRSA we also believe that primary care is more than having a 
place to go when you are sick. We view primary care as the Institute of 
Medicine (IOM) does \1\: providing integrated, accessible health care 
services by clinicians who are accountable for addressing a large 
majority of personal health care needs, developing a sustained 
partnership with patients, and practicing in the context of the family 
and the community.
---------------------------------------------------------------------------
    \1\ Donaldson M, Yordy K, Vanselow N, eds. Institute of Medicine. 
Defining Primary Care: an Interim Report. Washington, DC: National 
Academy Press, 1994:16.
---------------------------------------------------------------------------
                     health center program overview
    For more than 40 years, health centers have delivered 
comprehensive, high-quality, cost-effective primary health care to 
patients regardless of their ability to pay. During that time, health 
centers have become an essential primary care provider for America's 
most vulnerable populations: people living in poverty, uninsured, or 
homeless; minorities; farm workers; public housing residents; people 
who are geographically isolated; and people with limited English 
proficiency.
    Health centers advance preventive, coordinated, comprehensive, and 
patient-centered care, coordinating a wide range of medical, dental, 
behavioral, and social services. Today, more than 1,100 health centers 
operate over 8,000 service delivery sites that provide care in every 
U.S. State, the District of Columbia, Puerto Rico, the U.S. Virgin 
Islands, and the Pacific Basin.
    In fiscal year 2009, these non-profit and public, community-based 
and patient-directed health centers served 18.8 million patients, 
providing almost 74 million patient visits, at an average cost of $600 
per patient. Patient services are supported through a variety of 
revenue sources, including but not limited to Medicaid, Medicare, and 
State and local grants. The Health Center Program grant funds from HRSA 
account on average for 20 percent of total revenues for health centers.
                         health center research
    Research continues to highlight health centers' success in 
increasing access to care, improving health outcomes for patients, 
reducing health disparities, and containing health care costs.
    Health centers increase access to health care through an innovative 
model of community-based, comprehensive primary health care that 
focuses on outreach, disease prevention, and patient education 
activities. For example, studies found:

     Uninsured people living within close proximity to a health 
center are less likely to have an unmet medical need, less likely to 
have postponed or delayed seeking needed care, and more likely to have 
had a general medical visit.\2\
---------------------------------------------------------------------------
    \2\ Hadley J and Cunningham P. Availability of Safety Net Providers 
and Access to Care of Uninsured Persons. Health Services Research 
2004;39(5):1527-46.
---------------------------------------------------------------------------
     Health center uninsured patients are more likely to have a 
usual source of care than the uninsured nationally (98 percent versus 
75 percent).\3\
---------------------------------------------------------------------------
    \3\ Carlson, BL, et al., ``Primary Care of Patients without Health 
Insurance by Community Health Centers.'' April 2001 Journal of 
Ambulatory Care Management 24(2):47-59.
---------------------------------------------------------------------------
     Medicaid beneficiaries receiving care from health centers 
are more likely to report having access to care.\4\
---------------------------------------------------------------------------
    \4\ Shi L, Stevens GD, and Politzer RM. ``Access to care for U.S. 
Health center patients and patients nationally: how do the most 
vulnerable populations fare?'' 2007 Med Care 45(3):206-13.

    Despite serving sicker and more at-risk patients than seen 
nationally, health centers continue to demonstrate a strong track 
record in delivering high quality care and reducing health disparities. 
---------------------------------------------------------------------------
For example, studies found:

     Health center patient rates of blood pressure control were 
better than rates in hospital-affiliated clinics or in commercial-
managed care populations, and racial/ethnic disparities in quality of 
care were eliminated after adjusting for insurance status.\5\
---------------------------------------------------------------------------
    \5\ Hicks LS, et al. The Quality of Chronic Disease Care in U.S. 
Community Health Centers. Health Affairs 2006;25(6):1713-23.
---------------------------------------------------------------------------
     Health center low-birth weight rates continue to be below 
the national averages for all infants. In particular, the health center 
low-birth weight for African-American patients is below the rate 
observed among African-Americans nationally (10.7 percent versus 14.9 
percent respectively).\6\
---------------------------------------------------------------------------
    \6\ Shi, L., et al. America's health centers: Reducing racial and 
ethnic disparities in perinatal care and birth outcomes. Health 
Services Research, 2004; 39(6):1881-1901.
---------------------------------------------------------------------------
     Health centers play a critical role in providing health 
care services to rural residents who tend to have higher rates of 
chronic diseases, such as the 27 percent of rural residents suffering 
from obesity \7\ and nearly 10 percent diagnosed with diabetes.\8\
---------------------------------------------------------------------------
    \7\ Bennett, KJ., Olatosi, B., & Probst, JC. (2008). ``Health 
Disparities: A Rural--Urban Chartbook.'' South Carolina Rural Health 
Research Center.
    \8\ Pleis JR, Lethbridge-Cejku M. Summary health statistics for 
U.S. adults: National Health Interview Survey, 2006. National Center 
for Health Statistics. Vital Health Stat 10(235). 2007.

    Health centers provide high-quality care to rural and urban 
populations alike by focusing attention on improving public health 
through preventive care in addition to direct patient care. The health 
center model of care has been shown to reduce the use of costlier 
providers of care, such as emergency departments and hospitals. For 
---------------------------------------------------------------------------
example, studies found:

     Medicaid beneficiaries receiving care from a health center 
were less likely to be hospitalized.\9\
---------------------------------------------------------------------------
    \9\ Falik M., et al. Ambulatory care sensitive hospitalizations and 
emergency visits: experiences of Medicaid patients using federally 
qualified health centers. Medical Care 2001;39(6):551-61.
---------------------------------------------------------------------------
     Medicaid beneficiaries receiving care from a health center 
were less likely to be inappropriately hospitalized and less likely to 
visit the emergency room inappropriately.\10\
---------------------------------------------------------------------------
    \10\ Falik M., et al. Comparative Effectiveness of Health Centers 
as Regular Source of Care. Journal of Ambulatory Care Management 
2006;29(1):24-35.
---------------------------------------------------------------------------
     Rural counties with a community health center site had 33 
percent fewer uninsured emergency room/department visits per 10,000 
uninsured population than those without a health center.\11\
---------------------------------------------------------------------------
    \11\ Rust George, et al. ``Presence of a Community Health Center 
and Uninsured Emergency Department Visit Rates in Rural Counties.'' 
Journal of Rural Health Winter 2009 25(1):8-16.
---------------------------------------------------------------------------
                    emergency room diversion program
    In the past several years, HRSA has worked with our counterparts in 
the Centers for Medicare & Medicaid Services (CMS) on Emergency Room 
Diversion programs. In 2008, CMS awarded grants to 20 States with the 
goal of reducing the use of hospital emergency rooms by Medicaid 
beneficiaries for non-emergent reasons. One community health center 
project in Colorado focused on three goals: (1) to educate the Medicaid 
population about alternative nonemergency care options; (2) to offer 
real time referrals to alternative non-emergency care through the use 
of Outreach Case Managers; and (3) to promote the concept of a medical 
home for Medicaid patients so that they will have a better 
understanding of their healthcare options and appropriately use health 
care services. Additionally, Connecticut proposed to utilize a Web-
based application to connect providers in federally qualified health 
centers (FQHCs) and hospitals in designated communities throughout the 
State to create a common platform to search and schedule appointments 
for Medicaid enrollees. This approach was designed to facilitate access 
to primary care and enhance linkages between emergency departments and 
community-based primary care providers.
                patient-centered medical home initiative
    As highlighted by GAO, one reason health centers reduce the use of 
hospital emergency departments for non-urgent care is because they have 
attributes of the medical home model. Studies have shown that having a 
``medical care home'' reduces emergency department use significantly, 
not only among healthy patients but also among those who are sicker and 
have greater health care needs. Patient-centered medical homes (PCMHs) 
utilize interdisciplinary teams that re-distribute care 
responsibilities to those most capable and most accessible. A PCMH then 
coordinates care within this interdisciplinary team and with others in 
the community including hospitals and specialists.
    HRSA is dedicated to assisting health centers move toward the 
medical home model, and health centers are well-positioned to adopt and 
showcase innovations in care delivery because they are experienced with 
quality improvement that uses evidence-based models like the Chronic 
Care Model. To date, more than 125 health centers have enrolled in 
HRSA's recently announced Patient Centered Medical/Health Home 
Initiative. Additionally, through the CMS Center for Medicare and 
Medicaid Innovation, a Medicare FQHC Advanced Primary Care Practice 
Demonstration project will be implemented soon to engage up to 500 FQHC 
sites and up to 195,000 fee-for-service Medicare beneficiaries in a 
medical home demonstration. One of the key expected outcomes of this 
demonstration is a decrease in ED utilization by those that 
participate.
                     health center support services
    Another core component of the comprehensive model of primary care 
provided by health centers is the non-clinical services that aim to 
increase access, improve health care quality and reduce emergency use. 
The provision of these enabling services is a distinguishing feature of 
health centers, which recognize that barriers to care take various 
forms. Health centers offer a variety of supportive and enabling 
services to their patients including:

     Case management for chronic conditions, reducing the need 
for emergency services;
     Eligibility and enrollment assistance for health and 
social services;
     Outreach and transportation services; and
     Education of patients and the community regarding the 
availability and appropriate use of health services, including 
emergency rooms.
 health center care is affordable, accessible and reduces the need for 
                          emergency room care
    Health centers offer affordable care to people in need. Health 
centers are required to provide care to all patients regardless of 
ability to pay, and to offer discounts based on a sliding fee scale for 
all patients at or below 200 percent of the Federal poverty level. This 
requirement helps ensure that financial concerns do not prevent 
patients from accessing the health center's primary and preventive 
services offered in a timely manner.
    Health Centers offer care that is accessible. Health centers are 
required to provide services at times and locations that assure 
accessibility and meet the needs of the population to be served. For 
example, health centers frequently offer evening and weekend hours to 
ensure they are accessible to working adults. They are located in areas 
convenient to where the target population lives or works, including 
schools, homeless shelters, and/or through mobile van services.
    Health centers are also required to provide professional coverage 
for medical emergencies during hours when the center is closed. This 
coverage must be clearly defined, and include telephone access to a 
clinician who can assess the patient's needs and recommend appropriate 
followup care. This includes advising the patient on whether a visit to 
an ED is appropriate.
                               conclusion
    In closing, we recognize the key role that health centers do and 
can play in the reduction of inappropriate emergency room use. I 
appreciate the opportunity to testify today, and I would be pleased to 
answer any questions at this time.

    Senator Sanders. Thank you very much.
    Let me begin. Mr. Macrae, as you know, we recently 
increased funding for community health centers and the word 
went out that more money was available. What kind of response 
did you get? In your judgment, is there a need for more 
community health centers around this country?
    Mr. Macrae. Senator, in terms of our recent announcement, 
we had an announcement for what we call community health center 
new access points, which is applications for both new community 
health centers as well as satellite sites for exciting health 
centers, to establish. We put out our application guidance 
saying that we could fund approximately 350, we received 
applications from over 800 applicants all across the country 
for those resources. So there is clearly demand for these 
services.
    Senator Sanders. All right. I want you to elaborate on a 
point that you just made. Common sense would suggest that if 
there was good quality primary health care available to people 
on a sliding scale basis, that welcomed Medicaid and Medicare, 
took private insurance as well, that people were welcomed to 
walk in the door, they would go there and they would find a 
medical home which could treat them in a general sense. What 
has been the experience, and I know we will hear more about 
this this morning, about community health centers keeping 
people from using an emergency room, what kind of experiences 
have we seen?
    Mr. Macrae. There have been several studies, as I mentioned 
in my testimony, about the impact of even having a health 
center in a particular community. The study that was done most 
recently looked at rural communities and the impact of having a 
health center in that community actually reduced the level of 
inappropriate emergency room use by almost a third. In 
addition, by expanding the access in terms of evening hours and 
weekends and making sure that care is available through a 
sliding fee scale, enables people to be able to use the 
services of a health center as opposed to going to the 
emergency room.
    In fact, one of the big initiatives that we have been 
working on with our health centers is to actually coordinate 
and work with hospitals on working with the triage group there 
to educate folks about the appropriate use of the emergency 
room and actually create opportunities for followup visits from 
emergency room visits, to actually hook them up with the health 
center. About 65 percent of ER discharges actually result in a 
referral to a clinic or a primary care provider and we are 
trying to foster that kind of connection to make sure that 
folks are aware that health centers are available.
    Senator Sanders. In your judgment, what kind of potential 
savings are out there if we can provide quality primary health 
care in areas where people are now over-using the emergency 
room? Do you see this as an opportunity for both government and 
the private sector to be saving significant sums of money?
    Mr. Macrae. It is definitely an opportunity and I think you 
will definitely hear more from our colleagues in GAO about 
this. They estimate that about 8 percent of emergency room use 
currently is for non-urgent, nonemergency types of situations. 
If we can encourage the use of primary care, in particular 
through health centers and other safety net providers or other 
primary care providers, that will definitely have an impact in 
cost. It has been estimated that the cost at a health center is 
roughly six to seven times less than what we would receive in 
an emergency room.
    Senator Sanders. In general, if one walks into an emergency 
room, one gets the care for the problem that one has. That is a 
different care than one would get if one had a medical home and 
an ongoing primary health care physician. Would you agree that 
it makes a lot more sense to try to find a medical home for 
people so that physicians can know the family history, be 
treating people on an ongoing basis, rather than just episodic 
care at an emergency room?
    Mr. Macrae. Yes. That is definitely something that we are 
promoting at the Health Resources and Services Administration 
through our medical home model, to really encourage the 
opportunity for folks to have a place to go, a regular source 
of care for their primary care needs. And through that actually 
preventing illness, preventing emergencies and making sure that 
they know they have a place to go or even a person to call when 
they are in an emergency situation and determine whether it 
makes sense to go to the emergency room or to actually followup 
with a visit at the health center.
    Senator Sanders. It appears that in many parts of this 
country there is a shortage of primary health care physicians. 
We increased funding for the National Health Service Corps to 
encourage medical school students to work in primary care in 
underserved areas. How are we doing in that regard? Are we 
finding medical school students interested in moving into 
primary health care in underserved areas?
    Mr. Macrae. We very much are. As you know, the National 
Service Corps has seen an increase in its funding and through 
that we have put out application guidance for both what we call 
our scholarship program as well as loan repayment program. The 
program has received thousands of requests for applications and 
we have been able to fulfill many of those. Actually, many of 
those providers are providing service in health centers as well 
as other clinics all across the country.
    Senator Sanders. All right. Say a word about that, because 
I am not sure everybody knows what the National Health Service 
Corps does.
    Mr. Macrae. The National Health Service Corps provides loan 
forgiveness, either through a scholarship mechanism to 
encourage folks to practice in medically underserved areas and 
for medically underserved populations. So in exchange for 
either a scholarship encouraging folks to enter medical school 
or once they have completed medical school to pay back their 
loans, there will be loan forgiveness, depending on the amount 
of time that you provide service in that particular community.
    Senator Sanders. OK. Thank you very much.
    Senator Paul.
    Senator Paul. Thank you, Mr. Macrae and thank you for 
coming this morning.
    Mr. Macrae. Yes.
    Senator Paul. At your taxpayer-funded health centers do you 
provide screening for sexually transmitted disease?
    Mr. Macrae. Yes, we do.
    Senator Paul. Birth control?
    Mr. Macrae. Yes.
    Senator Paul. Family planning and pregnancy testing?
    Mr. Macrae. Yes.
    Senator Paul. It sounds a lot like some of the things that 
Planned Parenthood does. Would you say that maybe you duplicate 
or they duplicate some of the things you do?
    Mr. Macrae. I can't comment specifically on Planned 
Parenthood, but the health center program is required to 
provide preventive and primary care services to their 
population.
    Senator Paul. It sounds to me like you exactly duplicate 
what they are doing.
    I guess my question here is, as you have heard, we are a 
little bit short of money, you are asking for a lot more money 
and I think what responsible legislators should do and what 
responsible government officials should do should be to own up 
and say, ``Look if I think this is good and the government 
needs to provide for it, why are we providing for it with three 
different entities?''
    I see no reason whatsoever, if you are wanting 68 percent 
increase in your budget, that you can't own up, stand up and 
tell us, ``Yes, we are doing the same thing Planned Parenthood 
does. It is a very emotional, political football, but we are 
doing the same darn thing they are doing and we should just 
eliminate one or the other.'' Are you willing to give up the 
money that Planned Parenthood does or do you want them to give 
it up? That is the choices, the difficult choices that should 
be made and what we should be talking about here.
    Do you have a comment on that?
    Mr. Macrae. I can't comment specifically on the family 
planning piece, but I can say in terms of health centers that 
the investment is cost-effective in the sense that, as I think 
you will hear from some of the witnesses, that investing in 
primary care and in prevention actually reduces overall cost 
for patients. There have been many studies that have 
demonstrated that the overall reduction in cost for health 
center patients is significant, especially for Medicaid 
beneficiaries as well as for other patients.
    So the investment is actually cost-effective in the sense 
of investing on the front end through prevention and primary 
care actually results in less hospitalization and less cost to 
the system overall.
    Senator Sanders. Senator Bingaman.
    Senator Bingaman. Thank you very much for being here. One 
of the points you made in your testimony is that health centers 
frequently offer evening and weekend hours to ensure they are 
accessible to working adults. When does the inappropriate use 
of emergency rooms occur; how much of that inappropriate use 
occurs during the evenings or the weekends because people 
really don't have a choice, as they see it?
    Mr. Macrae. I think my colleagues will speak to this more 
clearly, but clearly that is a huge impact in terms of people 
being able to access care. Both what we have heard from 
emergency room physicians as well as different studies that our 
counterparts in the Centers for Disease Control and Prevention 
have indicated is that a significant number of visits are 
evenings or on weekends. And that is one of the things that we 
have been working with our community health centers--to extend 
and expand the number of evening hours as well as hours on the 
weekend.
    In addition, making sure that there are people that folks 
can call and contact before they make that decision to go to 
the ER. There are many reasons why it absolutely makes sense 
for people to go directly to the ER. But in a lot of 
circumstances, as you said, it is the only place that people 
feel like they can go.
    Senator Bingaman. Yes. My impression is, and this is just 
anecdotal, that a lot of the health centers and sites in my 
State of New Mexico do not provide services regularly on 
weekends and even some evenings. That could substantially 
increase access to these community health centers and reduce 
cost in the emergency room, by expanding hours of operation. So 
I hope you can give that a real priority and as you expand the 
services or the delivery system that you folks are in charge 
of, I hope you can give priority to expanding the hours of 
service in areas where that is justified.
    Mr. Macrae. Absolutely. In fact, with the expansion it is 
not just, for us, about creating new sites and even expanded 
service, it is about redesigning how the care is provided. One 
of the key pieces of that actually is expanding the number of 
hours that are available on evenings and weekends. Most 
recently, through the Recovery Act, we actually provided 
additional resources to health centers to expand their capacity 
to provide those evening and weekend hours.
    Through the Medical Home Initiative we are actually really 
working with our health centers to look at how they even 
provide care in the clinic today. The whole idea of creating 
more open access, same day appointments so that there aren't 
wait times for appointments and other things, so that people 
can have ready access, whether that is during the day, in the 
evening or on the weekends.
    Senator Bingaman. Senator Sanders was talking about the 
importance of this--of having patients able to go to their so-
called medical home when they need medical care instead of just 
episodic visits at emergency rooms. I would think that anything 
that could be done to expand the availability of those services 
in the evenings and weekends would be a big factor.
    My recollection is, when we were raising our son, that he 
only got sick on weekends.
    [Laughter.]
    At times when it was very difficult to find a physician 
other than taking him to some emergency room, which clearly was 
not the ideal case. I commend you on what you are trying to do 
with expanding these services. They are extremely valuable to 
my State and they are really a lifeline for a lot of folks.
     I agree with the points you made that this is a cost-
effective way to spend taxpayer dollars. I mean if we are going 
to have taxpayer dollars spent to try to assist people in 
getting health care, one of the most cost-effective 
expenditures we make is through these community health centers.
    I will stop with that, Mr. Chairman.
    Senator Sanders. Thank you. If I might just open it up to 
all of the Senators here, to respond a little bit to Senator 
Paul's statement.
    Of course there is quote/unquote duplication of services. 
In my view Planned Parenthood does an excellent job and I 
strongly support it. Obviously some of the services that 
Planned Parenthood provides are also provided in community 
health centers and probably provided at almost every primary 
health care office in the United States of America.
    The issue is, it seems to me, is there a need for more 
primary health care access in the United States of America? The 
question also is, if we provide that access, do we, (a) not 
only keep people healthier, because the doors are now opened to 
walk into a primary health care physician when you are sick, 
but equally important, do we save money.
    Now you may be familiar, Mr. Macrae, with the study done by 
George Washington University, and they said, in fact, that if 
we expand community health centers and enable people to walk in 
the door, so that they don't have to go to the emergency room 
as much as 10 times the cost per visit, so that they don't get 
sicker and then when they walk in the doctor's office they end 
up in the hospital at what could be more than 50 times the cost 
of what it might have been to treat them initially, then in 
fact investing in primary health care access and community 
health centers saves substantial sums of money, both for the 
government, in terms of Medicaid and Medicare and for the 
private sector as well. Is that your understanding?
    Mr. Macrae. Yes. I would say there are several studies that 
point out that by investing on the front end, in terms of 
preventive and primary care, the services that health centers 
provide, it does, again, reduce the use of emergency rooms, 
hospitalizations and overall reduces the costs for the patients 
and for the government, in terms of care.
    Senator Sanders. Senator Paul.
    Senator Paul. So one followup on this, on the idea of 
whether Planned Parenthood is duplicate service, as obviously 
it is, and I know you don't want to comment because it is very 
emotional, political football, but they obviously do. You 
duplicate every one of their services. The real difference 
between you and Planned Parenthood is you are a civil servant, 
correct?
    Mr. Macrae. Yes.
    Senator Paul. You can be fired by the taxpayers, someone in 
the executive branch can replace you, if you don't do your job. 
Planned Parenthood is not responsive to the taxpayer or to the 
government and we give them money.
    The other question is, and this is in the scheme of the 
large picture, we are nearly $2 trillion short every year. 
Should we not, at the very least, even if I accept all of your 
arguments that the government should be doing this, if we stick 
our head in the sand and just say every program is going to 
always get money, we have 42 different programs doing Federal 
workplace training; we have 82 different programs judging 
teachers. Every year we just add on one more program.
    You are here and Obamacare is going to give you 68 percent 
increase in funding. We are throwing tons of money at community 
health centers and yet we are still throwing at it because 
Planned Parenthood is supported by the left, they give 
contributions, they lobby and they are a big organ for the 
other side. But the thing is, why don't we try to--I don't see 
you as a partisan, you are trying very hard not to be a 
partisan, but Planned Parenthood is a partisan, politically and 
otherwise. You are not. At the very least, if you want 
government to do it, if you want taxpayers to fund it, let's do 
it through a government agency and not be giving it to a 
private agency. Thank you.
    Senator Sanders. Let me just say I wasn't quite aware, 
maybe at some point we can do a hearing on Planned Parenthood. 
I am strongly supportive of what they do.
    Does the government have a serious deficit problem? It sure 
does. You are absolutely right. But some of us think maybe the 
cause of that are two wars that were unpaid for, huge tax 
breaks for the rich and a Wall Street bailout, we could talk 
about that also, Senator Paul, at some point.
    But, Mr. Macrae, that is probably not your area of 
involvement.
    [Laughter.]
    So why don't we thank you, if that is OK with Senator Paul, 
thank you very much for being here and thank you very much for 
the excellent work you and your agency do.
    Now let us bring up all of our other panelists.
    Mr. Macrae. Thank you.
    Senator Sanders. Thank you.
    Mr. Macrae. Thank you very much.
    Senator Sanders. We have a great panel and I want to, on 
behalf of the committee, thank you all very much for being with 
us today to discuss this very important issue. My request is 
that you limit your initial remarks to 5 minutes. Senator Paul 
and I and any others, we are going to ask you questions and we 
can go on from there in a kind of an informal way.
    Let's begin with Debra Draper. Am I pronouncing your name, 
last name correct?
    Ms. Draper. It is Draper.
    Senator Sanders. Draper. Sorry. All right.
    Dr. Draper is a director on the health care team at the 
U.S. Government Accountability Office. She received her 
doctorate in health services organizations and research from 
the Medical College of Virginia, Virginia Commonwealth 
University.
    Dr. Draper, thanks very much for being with us.

STATEMENT OF DEBRA A. DRAPER, DIRECTOR, HEALTH CARE, GOVERNMENT 
             ACCOUNTABILITY OFFICE, WASHINGTON, DC

    Ms. Draper. Chairman Sanders, Ranking Member Paul, thank 
you for the opportunity to be here today as you discuss the 
diversion of non-urgent use of hospital emergency departments 
in the implications for care and costs.
    Hospital emergency departments are a major component of the 
Nation's health care safety net. They are open 24 hours a day, 
7 days a week and generally are required to medically screen 
all individuals, regardless of their ability to pay. Emergency 
department use has increased over time and in 2007 there were 
approximately 117 million visits, of which 8 percent were 
classified as non-urgent.
    Like hospital emergency departments, the national network 
of health centers, which includes approximately 8,000 delivery 
sites, is an important component of the health care safety net, 
particularly for those who may have difficulty obtaining access 
to health care because of financial or other limitations. 
Health centers are funded, in part, through Section 330 grants 
and provide comprehensive health care services without regard 
to a patient's ability to pay. They also provide enabling 
services, such as case management and transportation which help 
patients to access care.
    Some emergency department visits, include those for non-
urgent conditions, may be treated in other, more cost-effective 
settings such as health centers. According to 2008 national 
survey data, the average amount paid for a nonemergency visit 
to the emergency department was seven times more than that for 
a health center visit. Individual's decisions to go to the 
emergency department vary, but often include the lack of timely 
access to care in other settings.
    In my statement today I will discuss key findings from a 
report that we are publicly releasing today that describe 
strategies that health centers have implemented that may reduce 
emergency department use. I will also highlight challenges that 
health centers may face in implementing and evaluating these 
strategies.
    Health center officials that we spoke with described three 
types of strategies they have implemented that may reduce 
emergency department use. One type of strategy focus on 
emergency department diversion, which is often implemented in 
collaboration with the hospital, and includes educating 
emergency department patients on appropriate use. Diversion 
strategies often target patients whose visits are non-urgent, 
lack a regular source of care, are uninsured or have Medicaid 
or are frequent users.
    The second type of strategy that health centers have 
implemented focuses on care coordination. Health center 
officials describe two types of care coordination strategies, 
the first is the medical home model, which uses a physician-led 
team to provide ongoing and comprehensive care to patients to 
improve outcomes. The second is chronic care management which 
aims to reduce, if not prevent, disease-related emergencies. It 
emphasizes the monitoring and management of conditions such as 
diabetes, asthma and heart disease through preventative care, 
screening and patient education on healthy lifestyles.
    The third type of strategy that health centers have 
implemented focuses on increasing awareness of and access to 
services and includes expanding health center hours to include 
evenings and weekends, making available same day or walk-in 
appointments and locating service delivery sites in or near 
hospitals, schools and homeless shelters. Health center 
officials also discuss the use of strategies that reach out to 
patients, including tele-medicine, home visits and mobile 
clinics.
    Health center officials identified a number of challenges 
implementing the strategies that I have discussed today. For 
example, they talked about the difficulty of changing the care 
seeking behaviors of some patients who are frequent emergency 
department users, including those who are homeless or have 
substance abuse and mental health issues. Health center 
officials also told us that they have mostly anecdotal evidence 
on the effectiveness of the strategies they have implemented. 
However, one health center that had participated in a diversion 
program with a formal evaluation reported a 63 percent decrease 
in emergency department visits 1 year after patients enrolled 
in the program.
    To conclude, as more people obtain health care coverage 
through the Affordable Care Act, the demands on hospital 
emergency departments are likely to increase. Health centers 
may provide a more effective alternative for some emergency 
department visits, including those for non-urgent conditions. 
The Affordable Care Act provides health centers with an 
additional $11 billion in funding over the next 5 years, which 
is expected to increase capacity, positioning these providers 
to serve more people, including those who may have sought care 
from hospital emergency departments.
    Mr. Chairman, this concludes my opening remarks. I am happy 
to answer any questions.
    [The prepared statement of Dr. Draper follows:]
                 Prepared Statement of Debra A. Draper
                                summary
    Our work found that health centers have implemented three types of 
strategies that may help reduce emergency department use. These 
strategies focus on (1) emergency department diversion, (2) care 
coordination, and (3) accessibility of services. For example, some 
health centers have collaborated with hospitals to divert emergency 
department patients by educating them on the appropriate use of the 
emergency department and the services offered at the health center. 
Additionally, by improving care coordination for their patients, health 
centers may help reduce emergency department visits by encouraging 
patients to first seek care at the health center and by reducing, if 
not preventing, disease-related emergencies from occurring. Finally, 
health centers employed various strategies to increase the 
accessibility of their services, such as offering evening and weekend 
hours and providing same-day or walk-in appointments--which help 
position the health center as a convenient and viable alternative to 
the emergency department. Health center officials told us that they 
have limited data about the effectiveness of these strategies, but some 
officials provided anecdotal reports that the strategies have reduced 
emergency department use. These officials also described several 
challenges in implementing strategies that may help reduce emergency 
department use. For example, health center officials indicated that 
some services, such as those provided by case managers who may help 
coordinate care, are generally not reimbursed by third-party payers. 
Additionally, some officials noted that it is difficult to change the 
behaviors of patients who frequent the emergency department and some 
noted challenges with recruiting the necessary health providers to 
serve their patients.
                                 ______
                                 
    Chairman Sanders, Ranking Member Paul, and members of the 
subcommittee, I am pleased to be here today to discuss strategies that 
health centers--facilities that provide primary care and other services 
to individuals in communities they serve regardless of ability to pay--
employ that may help reduce hospital emergency department use. Hospital 
emergency departments are a major component of the Nation's health care 
safety net as they are open 24 hours a day, 7 days a week, and 
generally are required to medically screen all people regardless of 
ability to pay.\1\ From 1997 through 2007, U.S. emergency department 
per capita use increased 11 percent.\2\ In 2007, there were 
approximately 117 million visits to emergency departments; of these 
visits, approximately 8 percent were classified as nonurgent.\3\ The 
use of emergency departments, including use for nonurgent conditions, 
may increase as more people obtain health insurance coverage as the 
provisions of the Patient Protection and Affordable Care Act (PPACA) 
are implemented.\4\
---------------------------------------------------------------------------
    \1\ In order to participate in Medicare, hospitals are required to 
provide a medical screening examination to any person who comes to the 
emergency department and requests an examination or treatment for a 
medical condition, regardless of the individual's ability to pay. 
Social Security Act 1866(a)(1)(I), 1867 (codified at 42 U.S.C 
1395cc(a)(1)(I), 1395dd). Medicare is the Federal health program that 
covers seniors aged 65 and older, certain disabled persons, and 
individuals with end-stage renal disease.
    \2\ In 1997, there were an estimated 35.6 emergency department 
visits per 100 people compared to 39.4 visits in 2007. See P. Nourjah, 
``National Hospital Ambulatory Medical Care Survey: 1997 Emergency 
Department Summary,'' Advance Data, no. 304 (1999), and R. Niska, F. 
Bhuiya, and J. Xu, ``National Hospital Ambulatory Medical Care Survey: 
2007 Emergency Department Summary,'' National Health Statistics 
Reports, no. 26 (2010).
    \3\ The National Center for Health Statistics developed time-based 
acuity levels based on a five-level emergency severity index 
recommended by the Emergency Nurses Association. The acuity levels 
describe the recommended timeframe for being seen by a physician. The 
recommended timeframes to be seen by a physician are less than 1 minute 
for immediate patients, between 1 and 14 minutes for emergent patients, 
between 15 minutes and 1 hour for urgent patients, greater than 1 hour 
to 2 hours for semiurgent patients, and greater than 2 hours to 24 
hours for nonurgent patients.
    \4\ We refer to the Patient Protection and Affordable Care Act, 
Pub. L. No. 111-148, 124 Stat. 119, as amended by the Health Care and 
Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat 
1029, as PPACA. According to estimates from the Congressional Budget 
Office (CBO), an additional 32 million individuals are projected to 
obtain health insurance coverage by 2019; CBO also estimates that 
gaining insurance increases an individual's demand for health care 
services by about 40 percent. See D. Elmendorf, Director, CBO, 
``Economic Effects of the March Health Legislation'' (presentation at 
the Leonard D. Schaeffer Center for Health Policy and Economics, 
University of Southern California, Los Angeles, CA, Oct. 22, 2010).
---------------------------------------------------------------------------
    Some nonurgent visits are for conditions that likely could be 
treated in other, more cost-effective settings, such as health centers. 
In 2008, the average amount paid for a nonemergency visit to the 
emergency department was seven times more than that for a health center 
visit, according to national survey data.\5\ While there are many 
reasons individuals may go to the emergency department for conditions 
that could also be treated elsewhere, one reason may be the lack of 
timely access to care in other settings, possibly due to the shortage 
of primary care providers in some areas of the country.
---------------------------------------------------------------------------
    \5\ According to estimates from 2008 Medical Expenditures Panel 
Survey (MEPS), the average amount paid for a nonemergency visit to an 
emergency department was $792, while the average amount paid for a 
health center visit was $108. Similarly, the average charge for a 
nonemergency visit to an emergency department was 10 times higher than 
the charge for a visit to a health center--$2,101 compared to $203. 
MEPS is a set of large-scale surveys of families and individuals, their 
medical providers, and their employers across the United States.
---------------------------------------------------------------------------
    Like emergency departments, the nationwide network of health 
centers is an important component of the health care safety net for 
vulnerable populations, including those who may have difficulty 
obtaining access to health care because of financial limitations or 
other factors. Health centers, funded in part through grants from the 
Department of Health and Human Services' Health Resources and Services 
Administration (HRSA), provide comprehensive primary health care 
services--preventive, diagnostic, treatment, and emergency services, as 
well as referrals to specialty care--without regard to a patient's 
ability to pay. They also provide enabling services, such as case 
management and transportation, which help patients access care. In 
2009, more than 1,100 health center grantees operated more than 7,900 
delivery sites and served nearly 19 million people. With funding from 
PPACA--projected to be $11 billion over 5 years for the operation, 
expansion, and construction of health centers \6\--health center 
capacity is expected to expand.
---------------------------------------------------------------------------
    \6\ Specifically, PPACA appropriated $9.5 billion for fiscal years 
2011 through 2015 to a new Community Health Centers Fund to enhance 
funding for HRSA's community health center program. It also provided 
$1.5 billion over that same time period for the construction and 
renovation of community health centers. Pub. L. No. 111-148, 10503, 
124 Stat. 119, 1004 (2010); Pub. L. No. 111-152, 2303, 124 Stat. 1029, 
1083.
---------------------------------------------------------------------------
    My statement will highlight key findings from a report we are 
publicly releasing today that describes strategies that health centers 
have implemented that may help reduce the use of hospital emergency 
departments.\7\ For that report, we interviewed officials from nine 
health centers, and conducted group interviews with officials from 
multiple health centers operating in three States, about strategies 
they have implemented that may help reduce emergency department use. We 
selected these health centers and States, based on our review of 
relevant literature and interviews with HRSA officials and experts, to 
provide geographic variation and to ensure that health centers serving 
rural and urban areas were represented. We also e-mailed all State and 
regional primary care associations--private, nonprofit membership 
organizations of health centers and other providers--to identify 
specific health centers in their jurisdictions that had implemented 
strategies that may have reduced emergency department use.\8\ In 
addition, we collected information about health centers' strategies 
from the literature and our interviews with agency officials and 
experts. Our work was performed from November 2010 through April 2011 
in accordance with generally accepted government auditing standards.
---------------------------------------------------------------------------
    \7\ GAO, Hospital Emergency Departments: Health Center Strategies 
That May Help Reduce Their Use, GAO-11-414R (Washington, DC: Apr. 11, 
2011).
    \8\ We received responses from 21 of 52 regional and State primary 
care associations we contacted.
---------------------------------------------------------------------------
    In brief, our work found that health centers have implemented three 
types of strategies that may help reduce emergency department use. 
These strategies focus on (1) emergency department diversion, (2) care 
coordination, and (3) accessibility of services. For example, some 
health centers have collaborated with hospitals to divert emergency 
department patients by educating them on the appropriate use of the 
emergency department and the services offered at the health center. 
Additionally, by improving care coordination for their patients, health 
centers may help reduce emergency department visits by encouraging 
patients to first seek care at the health center and by reducing, if 
not preventing, disease-related emergencies from occurring. Finally, 
health centers employed various strategies to increase the 
accessibility of their services, such as offering evening and weekend 
hours and providing same-day or walk-in appointments--which help 
position the health center as a convenient and viable alternative to 
the emergency department. Health center officials told us that they 
have limited data about the effectiveness of these strategies, but some 
officials provided anecdotal reports that the strategies have reduced 
emergency department use. These officials also described several 
challenges in implementing strategies that may help reduce emergency 
department use. For example, health center officials indicated that 
some services, such as those provided by case managers who may help 
coordinate care, are generally not reimbursed by third-party payers. 
Additionally, some officials noted that it is difficult to change the 
behaviors of patients who frequent the emergency department and some 
noted challenges with recruiting the necessary health providers to 
serve their patients.
    Chairman Sanders, Ranking Member Paul, this concludes my prepared 
remarks. I would be pleased to respond to any questions you or other 
members of the subcommittee may have at this time.

    Senator Sanders. Thank you very much, Dr. Draper.
    Our next panelist is Dr. Peter Cunningham who is a senior 
fellow and director of quantitative research at the Center for 
Studying Health System Change here in Washington. His research 
focuses on a number of crucial health care topics that have 
long been of interest to policymakers, including trends in 
health care access, utilization and expenditures.
    Dr. Cunningham, thanks very much for being with us.

STATEMENT OF PETER CUNNINGHAM, Ph.D., SENIOR FELLOW, CENTER FOR 
         STUDYING HEALTH SYSTEMS CHANGE, WASHINGTON, DC

    Mr. Cunningham. Chairman Sanders, Senator Paul and members 
of the subcommittee, thank you for the invitation to testify 
about the use of hospital emergency departments for non-urgent 
health problems.
    My name is Peter Cunningham and I am a researcher and 
director of quantitative research at the Center for Studying 
Health System Change here in Washington. We are an independent, 
nonpartisan health policy research organization. Our goal is to 
inform policymakers with objective and timely research on 
developments in the health care system and the impact on 
people. We do not make specific policy recommendations.
    Since 1996 we have been following trends in the use of 
hospital emergency departments and how it is related to other 
developments in the health care system through analyses of 
survey data as well as intensive study of the health systems in 
12 communities.
    My written testimony concurs with many of the points made 
in the GAO report in that there has been a substantial increase 
in the use of hospital emergency departments over the past 15 
to 20 years. This has certainly contributed to crowding at many 
emergency departments which has generated concern about the 
impact on the quality of patient care, the costs of care and 
the ability of hospitals to respond to mass casualty events and 
public health emergencies.
    To alleviate crowding and to improve the quality of primary 
care for patients, we have seen a number of efforts across the 
country to shift some of the excess demand for emergency 
department care, especially for non-urgent health problems, to 
other primary care providers in the community, including 
community challenge centers.
    My written testimony also notes that it is important that 
efforts to shift care out of the emergency department take the 
following into account. First, people with private insurance 
account for most of the increase in emergency department use. 
It is true that the uninsured depend on emergency departments 
for their care a lot more than people with insurance coverage. 
But the uninsured are generally not responsible for the problem 
of crowding, at least at a national level. There is compelling 
evidence that insufficient capacity with the primary care 
system is resulting in some spillover into hospital emergency 
departments.
    But it is not just a lack of primary care providers but 
also the lack of after hours care at other primary care 
providers in the availability of 24/7 at the emergency 
department that leads many people to go there for minor 
ailments.
    Also, identifying visits that should be moved out of the 
emergency department must be done very carefully and with 
consideration of other primary care resources in the community. 
It is not just the acuity level of the health problem or the 
immediacy in which the patient should be seen, but also the 
availability of after hours care, other facilities such as 
freestanding urgent care centers and community health centers 
and how easy it is for patients to get same day appointments at 
other providers in the community. This differs across 
communities as well as by patient characteristics, especially 
their insurance coverage.
    Despite concerns about crowding at the emergency 
department, hospitals are not always onboard with efforts to 
shift care out of their emergency departments or at least they 
want to do so selectively by shifting their uninsured patients 
to community health centers but retaining their paying 
patients. We have observed that lack of cooperation by 
hospitals can severely limit the effectiveness of any program 
to shift care out of the emergency department.
    I do agree that visits to emergency departments are more 
expensive than at other primary care providers. I am a little 
bit more skeptical about the overall amount of cost savings to 
the health care system that could be generating by shifting 
more of these visits outside, but I think probably more notable 
is that it would reduce the financial burden of medical care 
for the uninsured and I think it would generate a higher level 
of cost savings for the Medicaid program.
    Whatever the issue of cost, there is widespread agreement 
among medical care providers that shifting non-urgent care out 
of the emergency department and into primary care settings has 
important benefits for the quality of patient care, the 
continuity of care and reducing unnecessary or redundant 
utilization. It is also consistent with recent developments in 
health care that emphasize a more integrated health care 
delivery system and having a medical home where all of the 
patient's care, including care by specialists and 
pharmaceuticals is coordinated and managed.
    That concludes my testimony. Thank you.
    [The prepared statement of Dr. Cunningham follows:]
             Prepared Statement of Peter Cunningham, Ph.D.
                                summary
    There has been much concern over the past decade about crowded and 
overloaded hospital emergency departments (EDs). Contributing to the 
problem of ED crowding is a substantial increase in emergency 
department utilization among the U.S. population--often attributed to 
growing use for nonurgent health problems. As a result, many 
policymakers and health care providers believe it is essential to shift 
some of this use to community-based primary care providers to relieve 
crowded EDs, lower the costs of care to both the health system and 
patients, and improve the quality of care. The following points are 
key:

     Emergency department use has increased substantially over 
the past 15 years, but most of this is the result of increased use by 
people with private insurance and other health insurance coverage. The 
uninsured account for only a small share of the overall increase in 
emergency ED volumes. Thus, the problem of ED crowding will not be 
resolved by reducing utilization among the uninsured.
     Few emergency department visits are truly nonurgent, but a 
much larger number could potentially be treated in primary care 
settings depending on the circumstances of the visit, such as the time 
of day and day of the week when care is needed, the availability of 
other providers in the community such as freestanding urgent care 
centers, and the ability to get same-day appointments with primary care 
physicians.
     Capacity constraints in the ambulatory medical care system 
have likely contributed to an increase in ED use for nonurgent health 
problems, and at the same time, these capacity constraints inhibit the 
ability to shift patients from EDs to primary care settings.
     Some patients prefer going to the ED--even when they have 
a primary care physician--in large part because of the greater 
convenience of emergency departments, which are open 24 hours a day, 7 
days a week. Thus, increasing the availability of after-hours care and 
same-day appointments is critical to shifting care from EDs to primary 
care settings.
     Many hospital EDs are expanding capacity to accommodate 
the increased demand as well as to increase revenues from resulting 
inpatient admissions and procedures. Most hospitals have little 
financial incentive to discourage ED use, except for uninsured 
patients. Gaining cooperation of some hospitals to shift nonurgent ED 
visits to primary care settings could be a major obstacle to the 
success of any such program.
     Reducing the use of EDs for nonurgent health problems may 
generate much lower cost savings to the health care system than is 
commonly assumed. However, shifting more of this care to community 
health centers is likely to generate more substantial cost savings for 
both uninsured patients as well as State Medicaid programs.
                                 ______
                                 
    Chairman Sanders, Senator Paul and members of the subcommittee, 
thank you for the invitation to testify about use of hospital emergency 
departments for nonurgent health problems. My name is Peter Cunningham, 
and I am a researcher and director of Quantitative Research at the 
Center for Studying Health System Change (HSC).
    HSC is an independent, nonpartisan health policy research 
organization affiliated with Mathematica Policy Research. HSC also is 
the research arm of the nonpartisan, nonprofit National Institute for 
Health Care Reform, a 501(c)(3) organization established by the 
International Union, UAW; Chrysler Group LLC; Ford Motor Company; and 
General Motors to conduct health policy research and analysis to 
improve the organization, financing and delivery of health care in the 
United States (NIHCR.org).
    I and other HSC researchers have conducted a number of studies 
documenting the increase in the use of hospital emergency departments, 
including for nonurgent health problems, and the problems of crowding 
at some emergency departments (EDs). We have examined how these trends 
affect and are affected by larger developments in the health care 
system, the reasons why people use emergency departments for minor 
ailments, and the potential for hospitals to shift some of their 
emergency department visits to primary care providers in the community.
    Our goal at HSC is to inform policymakers with objective and timely 
research on developments in the health care system and the impact on 
people. We do not make specific policy recommendations. Our various 
research and communication activities may be found on our Web site at 
www.hschange.org.
    There has been much concern over the past decade about what many 
believe is a national crisis of crowded and overloaded hospital 
emergency departments and the consequences for patient care and the 
ability of EDs to respond to both individual and mass-casualty 
emergencies. Contributing to the problem of ED crowding is a 
substantial increase in emergency department utilization among the U.S. 
population, which is often attributed to growing use of emergency 
departments for nonurgent health problems. As a result, many 
policymakers and health care providers believe that it is essential to 
shift emergency department use for nonurgent health problems to primary 
care providers in the community to relieve crowded emergency 
departments, lower the costs of care and improve the quality of care.
    My testimony today will make the following key points:

     Emergency department use has increased substantially over 
the past 15 years, mostly because of increased use by people with 
private insurance and other health coverage. While emergency department 
crowding is often attributed to the uninsured, their use of emergency 
departments is considerably less than privately insured people. 
Increases in emergency department visits by the uninsured account for 
only a small share of the overall increase in emergency department 
volumes.
     Few emergency department visits are truly nonurgent, 
according to the most credible national data. Most ED visits are 
neither clearly nonurgent nor truly emergencies. Determining whether 
these visits could be shifted to primary care settings in the community 
is difficult because the appropriate use of the emergency department 
for health problems often depends on factors other than their urgency, 
including the time of day and day of the week when care is needed, the 
availability of other providers in the community such as freestanding 
urgent care centers, and the ability to get same-day appointments with 
primary care physicians.
     Increases in emergency department visits reflect a more 
general increase in the demand for ambulatory care, and it should be 
emphasized that physician office visits have increased at an even 
higher rate than emergency department visits. As office-based 
physicians struggle with growing practice capacity constraints, some of 
the excess demand is spilling over into hospital EDs. For their part, 
some patients prefer going to the emergency department--even when they 
have a primary care physician--because emergency departments are open 
24 hours a day, 7 days a week.
     Many hospital emergency departments are expanding capacity 
to accommodate the increased demand, as well as to increase revenues 
from resulting inpatient admissions and procedures, particularly for 
privately insured and Medicare patients. Far from perceiving emergency 
departments as money losers, most hospitals have little financial 
incentive to discourage emergency department use by privately insured 
and Medicare patients--including for nonurgent health problems--which 
could complicate efforts to shift some nonurgent visits to more-
appropriate community settings.
     Despite recent increases in utilization, hospital 
emergency departments represent a relatively small part of the U.S. 
health care system in terms of both utilization and costs. Reducing the 
use of EDs for nonurgent health problems may generate much lower cost 
savings than is commonly assumed. However, because Medicaid enrollees 
have by far the highest per person use of hospital emergency 
departments, the potential cost savings to the Medicaid program could 
be more substantial.
          the evolving role of hospital emergency departments
    Hospital emergency departments are a critical and indispensable 
component of the U.S. health care system. While their traditional 
mission is to provide trauma and emergency services for people in 
imminent danger of losing their life or suffering permanent damage to 
their health, the role of emergency departments has evolved over the 
past several decades. EDs are on the front lines of communities' 
preparedness efforts and responses to natural disasters, other mass-
casualty events, and public health emergencies arising from outbreaks 
of influenza and other communicable diseases.
    Emergency departments have become the true provider of ``last 
resort'' for uninsured people and other patients who are unable to 
afford other medical providers in the community, largely as a result of 
the 1986 Federal Emergency Medical Treatment and Labor Act (EMTALA) 
that requires hospitals to provide emergency screening and 
stabilization services regardless of patients' ability to pay. Along 
with the fact that emergency departments are often the only medical 
facilities in a community that are open 24 hours a day, 7 days a week, 
true emergencies comprise only a relatively small share of visits to 
emergency departments. Today, hospital emergency departments are a 
major source of primary health care in the community, treating a broad 
range of health problems that include many visits for minor ailments 
and other ``nonurgent'' conditions.
           use of emergency departments still relatively rare
    Americans made a total of 124 million visits to hospital emergency 
departments in 2008, the latest year for which data are available from 
the National Hospital Ambulatory Medical Care Survey (NHAMCS)--the most 
authoritative and cited source of information on emergency department 
utilization (see Table 1).\1\ Compared with other forms of ambulatory 
care use, however, use of hospital emergency departments is relatively 
rare, accounting for only 10 percent of all ambulatory care visits to 
medical providers. By contrast, Americans made 956 million visits to 
physician offices in 2008--representing 80 percent of all ambulatory 
care visits--and 110 million visits to hospital outpatient departments.
---------------------------------------------------------------------------
    \1\ National Center for Health Statistics. Health, United States: 
With Special Feature on Death and Dying. Hyattsville, MD (2011).
---------------------------------------------------------------------------
    Emergency department use is also much less frequent than physician 
office visits on a per capita basis. There were 41 emergency department 
visits for every 100 Americans in 2008, compared to 320 physician 
office visits for every 100 Americans. About 84 percent of Americans 
visited a physician's office in 2007, compared to 23 percent who 
visited a hospital emergency department.

      Table 1.--Use of Ambulatory Medical Care Services by the U.S.
                          population, 1995-2008
------------------------------------------------------------------------
                                                                Percent
                                 1995       2000       2008      change
                                                               1995-2008
------------------------------------------------------------------------
Number of visits in
 thousands:
  Emergency departments.....     96,545    108,017    123,761        28
  Physician offices.........    697,082    823,542    955,969        37
  Hospital outpatient            67,232     83,289    109,889        63
   departments..............
Number of visits per 100
 persons:
  Emergency departments.....         37         40         42        14
  Physician offices.........        271        304        315        16
  Hospital outpatient                26         31         36        38
   departments..............
------------------------------------------------------------------------
Source: CDC/NCHS, National Ambulatory Medical Care Survey and National
  Hospital Ambulatory Medical Care Survey, as reported in Health, United
  States, 2010.

          but increases in utilization contribute to crowding
    Concern about the use of hospital emergency departments increased 
substantially over the past decade because of widespread reports of 
growing demand by patients and crowding at many emergency departments. 
Indeed, in a 2007 report, the Institute of Medicine described a growing 
national crisis of crowded emergency departments leading to delays in 
care for patients, ambulance diversions to other hospitals, and 
inadequate capacity to handle a large influx of patients from a public 
health crisis or mass-casualty event.\2\
---------------------------------------------------------------------------
    \2\ Institute of Medicine, Hospital-Based Emergency Care: At the 
Breaking Point, The National Academies Press, Washington, DC (2007).
---------------------------------------------------------------------------
    Increased crowding at emergency departments has a number of causes, 
and a 2003 U.S. Government Accountability Office report concluded that 
insufficient inpatient capacity--the inability of hospitals to move 
patients from the emergency department into inpatient beds--was a major 
factor.\3\ As a result of problems with ``throughput,'' emergency 
department patients are (1) waiting longer to be seen in the emergency 
department; (2) waiting longer to be admitted as an inpatient if 
necessary, and; (3) increasingly leaving the emergency department 
without being seen. Also, there has been an increase in hospitals 
diverting ambulances to other hospitals because of emergency department 
crowding.
---------------------------------------------------------------------------
    \3\ U.S. Government Accountability Office, Hospital Emergency 
Departments: Crowded Conditions Vary Among Hospitals and Communities, 
No. GAO-03-460. Washington, DC (March 2003).
---------------------------------------------------------------------------
    Increased demand for emergency departments has exacerbated these 
problems. Between 1995 and 2008, visits to hospital emergency 
departments increased 28 percent, with much of the increase because of 
increased per person use--from 37 visits per 100 persons in 1995 to 41 
visits in 2008 (see Table 1). However, physician office visits 
increased by an even greater amount between 1995 and 2008--37 percent--
with per person use increasing from 266 visits per 100 persons in 1995 
to 320 visits in 2008. Thus, increases in emergency department use over 
the past decade and a half reflect a more general increase in the 
demand for ambulatory care and must be understood in the broader 
context of changes in the health care system. As physician practices 
have become busier and patients have greater difficulty getting timely 
appointments with their physicians, some of the excess demand for 
ambulatory care is no doubt spilling over into emergency 
departments.\4\
---------------------------------------------------------------------------
    \4\ Cunningham, Peter, and Jessica May, Insured Americans Drive 
Surge in Emergency Department Visits, Issue Brief No. 70, Center for 
Studying Health System Change, Washington, DC (October 2003).
---------------------------------------------------------------------------
   privately insured patients account for most of the increase in ed 
                                 volume
    Also, while there is a common perception that emergency department 
crowding is driven primarily by increases in utilization by the 
uninsured, most of the growth in emergency department volume during 
this period was driven by insured people. For example, the share of 
emergency department visits classified as ``self-pay'' or ``no 
charge''--mostly uninsured patients--actually decreased from 17 percent 
of visits in 1995 to 15 percent in 2008, despite the fact that the 
number of uninsured increased by 23 percent during this period.\5\ \6\ 
\7\ In contrast, the share of emergency department visits made by 
privately insured people increased from 37 percent of all visits in 
1995 to 42 percent of visits in 2008. Privately insured people 
accounted for about 60 percent of the overall increase in ED use 
between 1995 and 2008, while the uninsured accounted for only 9 percent 
of the increase.
---------------------------------------------------------------------------
    \5\ National Center for Health Statistics, National Hospital 
Ambulatory Medical Care Survey: 2008 Emergency Department Summary 
Tables, Hyattsville, MD. (2011).
    \6\ Stussman, Barbara J., ``National Hospital Ambulatory Medical 
Care Survey: 1995 Emergency Department Summary,'' National Center for 
Health Statistics Advance Data From Vital and Health Statistics; No. 
285, Hyattsville, MD (1997).
    \7\ Fronstin, Paul, The Impact of the 2007-09 Recession on Workers' 
Health Coverage, Employee Benefit Research Institute Issue Brief No. 
356, Washington, DC (April 2011).
---------------------------------------------------------------------------
    The perception that the uninsured are responsible for the problems 
of emergency department crowding may be because uninsured people depend 
more on emergency departments for access to care. For example, more 
than one-fourth of all ambulatory care visits by the uninsured are in 
emergency departments, compared to only 7 percent for the privately 
insured and 17 percent for Medicaid enrollees.\8\ Even more striking is 
that uninsured people's dependence on EDs for care has grown 
dramatically since 1995 when 16 percent of ambulatory care visits by 
the uninsured were in hospital emergency departments.
---------------------------------------------------------------------------
    \8\ The estimates in this paragraph are computed from published 
reports by the National Center for Health Statistics based on the 1995 
and 2008 National Hospital Ambulatory Medical Care Survey and the 1995 
and 2008 National Ambulatory Medical Survey.
---------------------------------------------------------------------------
    The increasing dependence on hospital emergency departments by the 
uninsured reflects an erosion in access to office-based physicians, as 
evidenced by declines in the percent of physicians providing any 
charity care during this period.\9\ Some physicians believe they are no 
longer able to afford to provide charity care because of financial 
pressures from payers, while others have much less time for charitable 
and volunteer activities because of the increased demand for care by 
privately insured patients.
---------------------------------------------------------------------------
    \9\ Cunningham, Peter, and Jessica May, A Growing Hole in the 
Safety Net: Physician Charity Care Declines Again, Tracking Report No. 
13, Center for Studying Health System Change, Washington, DC (March 
2006).
---------------------------------------------------------------------------
                what are ``nonurgent'' health problems?
    Many observers have attributed increases in ``nonurgent'' use of 
emergency departments as a key driver of crowding at some EDs. However, 
defining a ``nonurgent'' ED visit is not straightforward and has been 
the subject of much debate and controversy. Estimates of the percent of 
emergency department visits that are for nonurgent health problems vary 
widely, from about half of all visits to less than 10 percent.\10\ The 
wide differences in estimates largely reflect differences in the 
assumptions made about the feasibility of shifting certain types of 
visits to a primary care physician's office or clinic without harm to 
the patient.
---------------------------------------------------------------------------
    \10\ Simonet, Daniel, ``Cost Reduction Strategies for Emergency 
Services: Insurance Role, Practice Changes and Patient 
Accountability,'' Health Care Analysis, Vol. 17, pp. 1-19 (February 
2009).
---------------------------------------------------------------------------
    One major problem is that it is difficult to determine the 
``urgency'' of a visit based solely on a physician's diagnosis after 
examination of a patient, which may be quite different from the 
patient's perception of symptoms when deciding to seek emergency care. 
An example often used to highlight the difficulty is a patient arriving 
at an emergency department complaining of chest pains and concerns of a 
possible heart attack, only to learn after a medical examination, the 
problem is severe indigestion.
    Thus, from the patient's perspective, the visit is certainly urgent 
or emergent, but it is unlikely to be classified as such based only on 
the physician's diagnosis.
    For this reason, the ``urgency'' of a hospital emergency department 
visit is best determined by the level of immediacy (in minutes) 
assigned upon arrival at the emergency department by triage staff. The 
National Hospital Ambulatory Medical Care Survey uses this information 
to determine the urgency of a visit, which includes five categories: 
(1) Immediate (patient needs to be seen immediately; (2) emergent 
(needs to be seen within 15 minutes upon arrival); (3) urgent (between 
15-60 minutes); (4) semiurgent (1-2 hours) and nonurgent (2-24 hours). 
It is important to note that the immediacy with which a patient should 
be seen is unknown for about 16 percent of emergency department visits 
in the NHAMCS data for 2008, in part because some emergency departments 
either do not triage patients in this way or do not keep records of 
their triage decisions.
    Based on this classification system, 4 percent of emergency 
department visits in 2008 (a total of 4.6 million visits) were visits 
in which the patient needed to be seen immediately; 12 percent were 
considered emergent; 39 percent were considered urgent; and 21 percent 
were semi-urgent (see Table 2). Only 8 percent of visits--a total of 
9.9 million--were classified as nonurgent. Trends in the relative 
number of nonurgent visits have actually decreased slightly since 2000, 
when 10.7 percent of visits were classified as nonurgent.\11\ In sum, 
most visits to hospital emergency departments are neither true 
emergencies requiring that patients be seen almost immediately nor are 
they clearly nonurgent problems that could be addressed in other 
primary care settings.
---------------------------------------------------------------------------
    \11\ McCaig, Linda F., and Nghi, Ly, ``National Hospital Ambulatory 
Medical Care Survey: 2000 Emergency Department Summary,'' National 
Center for Health Statistics Advance Data From Vita and Health 
Statistics, No. 326, Hyattsville, MD (April 2002).
---------------------------------------------------------------------------
    The majority of visits that are considered urgent or semi-urgent 
reside in a gray area as to whether they could potentially be shifted 
to other primary care settings, such as freestanding urgent care 
centers or through same-day appointments with private practice 
physicians. While many conditions associated with these visits could 
likely be treated in other outpatient settings, it is not necessarily 
inappropriate for the patient to use the emergency department depending 
on the circumstances, such as the availability of other health care 
providers in the area, the time of day and day of the week when 
services are needed, and the affordability of these other providers 
based on a patient's insurance status and ability to pay.
    Two-thirds of all emergency department visits occur outside normal 
business hours--8 a.m. to 5 p.m., Monday through Friday, compared to 
only 5 percent of visits to office-based physicians and 11 percent of 
visits to hospital outpatient departments.\12\ Thus, increasing the 
number of primary care providers in the community who are available 
after normal business hours (i.e., in the evenings and on weekends) is 
essential for any effort to shift visits from the ED to other primary 
care providers in the community.
---------------------------------------------------------------------------
    \12\ Pitts, Stephen R., et al., ``Where Americans Get Acute Care: 
Increasingly, It's Not at Their Doctor's Office,'' Health Affairs, Vol. 
9, No. 1, pp. 1-10 (September 2010).

           Table 2.--Triage Status of Emergency Department Visits, by Expected Source of Payment, 2008
----------------------------------------------------------------------------------------------------------------
                                                                Percent distribution of visits
                                             -------------------------------------------------------------------
                                               Number of
                                               visits in   Immediate/   Urgent   Semiurgent  Nonurgent   Unknown
                                               thousands    Emergent
----------------------------------------------------------------------------------------------------------------
All visits..................................      123,761          16        39         21           8        16
Expected Source of Payment:
  Private insurance.........................       51,887          17        41         21           6        15
  Medicaid/SCHIP............................       29,701          14        40         22          10        15
  Medicare..................................       22,827          25        41         14           6        14
  Uninsured.................................       19,094          12        34         24          12        19
  Worker's compensation.....................        1,561           8        32         37           8        13
  Other.....................................        5,706          17        43         22           8        11
  Unknown...................................        7,492          11        33         19           7        30
----------------------------------------------------------------------------------------------------------------
Triage status is based on the following classification:

 Immediate/emergent--Patient should be seen immediately or within 15 minutes.
 Urgent--Patient should be seen within 15-60 minutes.
 Semiurgent--Patient should be seen within 61-120 minutes.
 Nonurgent--Patient should be seen between 121 minutes and 24 hours.
 Unknown--No mention of immediacy in the medical record; hospital does not perform triage; or the patient was
  dead on arrival.

Source: CDC/NCHS. National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary Tables
  (Table 7).

     most nonurgent visits made by persons with insurance coverage
    As with emergency department visits overall, people with insurance 
coverage account for most nonurgent ED visits, with privately insured 
persons alone accounting for about one-third of nonurgent visits 
(computed from Table 2). Uninsured persons account for slightly less 
than one-fourth of all nonurgent emergency department visits, while 
Medicaid enrollees account for 29 percent. Nevertheless, the uninsured 
are more likely to use emergency departments for nonurgent health 
problems compared to the privately insured: visits for nonurgent health 
problems account for 12 percent of ED visits by the uninsured compared 
to 6 percent for the privately insured. Similarly, the uninsured are 
less likely to use emergency departments for true emergencies compared 
to privately insured persons: emergencies accounted for 12 percent of 
visits for uninsured persons compared to 17 percent for privately 
insured persons (see Table 2).
          immigrants infrequent users of emergency departments
    Another common perception is that immigrants--particularly 
undocumented immigrants--are responsible for much of the crowding in 
emergency departments. Although the National Hospital Ambulatory 
Medical Care Survey has limited information on race/ethnicity and 
immigration status, other studies call into question the extent of the 
problem that emergency departments have treating undocumented 
immigrants. Recent immigrants--in the United States for 5 years or 
less--are less likely to use emergency departments (9 percent), 
compared both to immigrants who have been in the United States for 20 
years or more (19 percent), as well as native-born Americans (22 
percent).\13\ In addition, an analysis of variation in emergency 
department use across communities showed that communities with high 
levels of emergency department use had fewer Hispanic noncitizens 
compared to communities with low levels of emergency department 
use.\14\
---------------------------------------------------------------------------
    \13\ Cunningham, Peter, and Samantha Artiga, ``How Does Health 
Coverage and Access to Care for Immigrants Vary by Length of Time in 
the U.S.,'' Kaiser Commission on Medicaid and the Uninsured, 
Washington, DC (June 2009).
    \14\ Cunningham, Peter, ``What Accounts For Differences In The Use 
Of Hospital Emergency Departments Across U.S. Communities?'' Health 
Affairs, Web Exclusive (July 2006).
---------------------------------------------------------------------------
    Low ED use by recent immigrants reflects the fact that they are 
much less likely to use health care of any type, including physician 
office visits, primarily as a result of high uninsured rates and a lack 
of access to care.\15\ As with the uninsured, recent immigrants tend to 
rely on emergency departments to a much greater extent when they do use 
health care compared to native-born Americans, which may contribute to 
the perception that they are ``flooding'' local hospital emergency 
departments. Crowding of emergency departments by immigrants may occur 
in some isolated circumstances, such as in communities along the border 
with Mexico or areas that have seen a recent surge in immigration, but 
it is not a major contributor to hospital emergency department crowding 
nationally.
---------------------------------------------------------------------------
    \15\ Cunningham and Artiga (June 2009).
---------------------------------------------------------------------------
lack of primary care access not the reason for emergency department use
    It is not the case that people who use emergency departments for 
nonurgent health problems have no source of primary care they could use 
instead. One study found that among all people visiting the emergency 
department for nonurgent health problems, two-thirds reported they had 
a regular source of medical care at a physician's office.\16\ Only 3 
percent reported that the ED was their usual source of care, while 15 
percent reported they did not have any usual source of care. In 
addition, people who use the ED for nonurgent health problems tend to 
have greater use of physicians in other ambulatory care settings over a 
1-year period. This strongly suggests that use of emergency departments 
for nonurgent problems does not reflect lack of access to other primary 
care providers for most patients, although it is a much more important 
reason for uninsured patients.
---------------------------------------------------------------------------
    \16\ Cunningham, Peter, ``The Use of Hospital Emergency Departments 
for Nonurgent Health Problems: A National Perspective,'' Medical Care 
Research and Review, Vol. 52, No. 4, pp. 453-74 (1995).
---------------------------------------------------------------------------
   capacity constraints contribute to higher emergency department use
    As noted previously, it is possible that greater capacity 
constraints in the ambulatory care system are shifting some of the 
excess demand for ambulatory care from physician offices to emergency 
departments. Many experts and policymakers have been concerned about 
physician shortages--particularly of primary care physicians--resulting 
in some patients having greater difficulty finding physicians that are 
close to their home or work, scheduling same-day appointments with 
their primary care physician, and physicians being able to spend 
adequate time with patients.\17\
---------------------------------------------------------------------------
    \17\ O'Malley, Ann S., et al., Rising Pressure: Hospital Emergency 
Departments as Barometers of the Health Care System, Issue Brief No. 
101, Center for Studying Health System Change, Washington, DC (November 
2005).
---------------------------------------------------------------------------
    In examining differences between communities with low levels of ED 
use and communities with high levels of ED use, I have observed that 
communities with high levels of ED use tend to have greater capacity 
constraints among office-based physicians, as reflected in longer 
average appointment waiting times for patients and a greater number of 
visits per physician in the community.\18\ This suggests that as demand 
for medical care increases over time and the capacity of office-based 
physicians is squeezed, some of the excess demand for ambulatory care 
will spill over to hospital emergency departments.
---------------------------------------------------------------------------
    \18\ Cunningham (July 2006).
---------------------------------------------------------------------------
    At the same time, many patients prefer to use hospital emergency 
departments even if they believe that their health problem could have 
been handled by a primary care physician outside of the emergency 
department.\19\ The greater convenience of hospital emergency 
departments relative to primary care providers is among the most 
important reasons for using EDs, especially the fact that they are open 
24 hours a day and 7 days a week, and that they can ``walk-in'' to the 
emergency department at their own convenience rather than scheduling an 
appointment. The greater convenience of emergency departments is 
especially important for people who are unable or unwilling to take 
time off from work to see a physician.
---------------------------------------------------------------------------
    \19\ California HealthCare Foundation, Overuse of Emergency 
Departments Among Insured Californians, Oakland, CA (October 2006).
---------------------------------------------------------------------------
    What is less clear is whether patient preferences for the emergency 
department will continue given the increased crowding at many 
facilities and the longer wait times. The total amount of time that 
patients spend in the emergency department--including time spent 
waiting as well as for examination and treatment--has increased from 45 
percent of visits lasting 2 or more hours in 2001 to 60 percent of 
visits in 2008.\20\ Other research has shown that patients' 
satisfaction with their visit to an emergency department decreases 
rapidly the longer they wait to be seen. For example, two-thirds of 
patients who waited 15 minutes or less to be seen by a medical provider 
in the emergency department reported that the thoroughness of their 
exam was very good or excellent.\21\ However, positive ratings of their 
visit dropped to 46 percent for patients who waited between 30 and 60 
minutes, and 28 percent for patients who waited more than an hour.
---------------------------------------------------------------------------
    \20\ National Center for Health Statistics (2011); and McCaig and 
Ly (April 2002).
    \21\ Cunningham and May (October 2003).
---------------------------------------------------------------------------
           hospitals expanding emergency department capacity
    At the same time, many emergency departments have been expanding 
capacity to meet increased demand. More than one-fourth of emergency 
departments in 2008 had expanded their capacity in the previous 2 
years, and 28 percent had plans to expand their capacity in the next 2 
years.\22\ Emergency departments serving a large volume of patients 
(50,000 or more per year) were much more likely to be expanding 
capacity compared to emergency departments serving smaller volumes of 
patients.
---------------------------------------------------------------------------
    \22\ National Center for Health Statistics (2011).
---------------------------------------------------------------------------
    Expanding the capacity of hospital emergency departments appears to 
conflict with a widely held view that emergency departments are money 
losers for hospitals--i.e., they generate insufficient revenue from 
billings to cover the costs. In this view, hospitals should be 
reluctant to expand emergency department capacity and be eager to look 
for ways to decrease their volumes by shifting patients to other 
sources of primary care when appropriate.
    However, when the overall financial status of many hospitals is 
considered, emergency departments generate more revenue for the 
hospital than they lose, mainly by serving as a conduit for inpatient 
admissions. Researchers at the University of Southern California 
estimated that by closing the emergency department, a hospital would 
lose one-third or more of its inpatient admissions, which would cost 
the hospital much more than the savings generated by closing the 
emergency department.\23\ Seen in that context, it is not surprising 
that many hospitals are expanding their emergency departments, not only 
to relieve crowding because of increased demand, but also as a way to 
generate more revenue from inpatient admissions.
---------------------------------------------------------------------------
    \23\ Melnick, Glenn A., et al., California Emergency Departments: 
Do They Contribute to Hospital Profitability? California HealthCare 
Foundation, Oakland, CA (July 2003).
---------------------------------------------------------------------------
    Efforts to expand emergency department capacity and volume also 
suggest that many hospitals perceive few incentives or benefits to 
shift nonurgent care from their emergency department to primary care 
settings. Even if an emergency department visit does not result in an 
inpatient admission, nonurgent emergency department patients may 
require inpatient care or other hospital services in the future, in 
which case the assumption is that the patient would continue to use the 
same hospital to receive these more ``profitable'' services. Hospitals 
will especially encourage privately insured, Medicare and sometimes 
even Medicaid patients to use their emergency departments, as these 
patients generate revenue for the hospital. Many hospitals are likely 
to be much more selective about the patients they are willing to shift 
to primary care settings, focusing especially on their uninsured 
patients to decrease their uncompensated care costs.
    cost savings from reducing nonurgent ed use likely to be modest
    About $47.3 billion was spent on emergency department visits in 
2008, accounting for 4 percent of all health care expenditures received 
by the U.S. population during that year, according to the Medical 
Expenditure Panel Survey.\24\ Total spending on emergency department 
visits doubled between 2000 and 2008, even after accounting for general 
inflation, and has been rising at a faster rate than overall health 
care spending.\25\ The cost of emergency department use for nonurgent 
health problems is more difficult to estimate since expenditures are 
not collected in the National Hospital Ambulatory Medical Survey. 
Moreover, the wide range of estimates of the number of emergency 
department visits that could potentially be shifted to primary care 
settings also means that the potential cost savings from these shifts 
will also vary widely.
---------------------------------------------------------------------------
    \24\ Agency for Healthcare Quality and Research, ``Emergency Room 
Services--Median and Mean Expense Per Person with Expense and 
Distribution by Source of Payment, 2008,'' Summary Data Table From the 
Medical Expenditure Panel Survey--Household Component.
    \25\ Ibid. and Agency for Healthcare Quality and Research, 
``Emergency Room Services--Median and Mean Expense Per Person With 
Expense and Distribution by Source of Payment, 2000,'' Summary Data 
Table From the Medical Expenditure Panel Survey--Household Component.
---------------------------------------------------------------------------
    The GAO report, Hospital Emergency Departments: Health Center 
Strategies That May Help Reduce Their Use, included an estimate based 
on the 2008 MEPS that the average amount for a nonemergency visit to an 
emergency department was $792, less than the $1,265 per visit for all 
emergency department visits and more than seven times higher than a 
visit to a community health center.\26\ However, other research 
suggests that the potential cost-savings associated with shifting 
nonurgent emergency department visits to office-based practices may be 
much lower. An earlier study using data from the 1987 National Medical 
Expenditure Survey (the predecessor to the MEPS) compared the costs of 
nonurgent visits to the emergency department with the potential costs 
of these same visits had they occurred in office-based physician 
practices.\27\ The results showed that the cost of nonurgent visits to 
emergency departments was only three times higher compared to what they 
would have cost in an office-based practice, which is considerably less 
than the estimate in the GAO report. Also, a study based on hospitals 
in Michigan during the early 1990s found that the average cost of an 
urgent emergency department visit was five to six times higher than for 
a nonurgent visit, indicating that cost savings to the health care 
system from shifting nonurgent emergency department visits to primary 
care settings may be less than is commonly assumed.\28\
---------------------------------------------------------------------------
    \26\ U.S. Government Accountability Office, Hospital Emergency 
Departments: Health Center Strategies That May Help Reduce Their Use, 
No. GAO-11-414R, Washington, DC (May 2011).
    \27\ Baker, Laurence C., and Linda Schuurman Baker, ``Excess Cost 
of Emergency Department Visits for Nonurgent Care.'' Health Affairs, 
Vol. 13, No. 5, pp. 162-71 (1994).
    \28\ Williams, Robert M., ``The Costs of Visits to Emergency 
Departments,'' The New England Journal of Medicine, Vol. 334, No. 10, 
pp. 642-46 (March 1996).
---------------------------------------------------------------------------
    It is possible that shifting nonurgent emergency department visits 
to community health centers (CHCs) could result in greater savings than 
comparable visits to private office-based physicians. Research has 
shown that the availability of CHCs in an area is associated with lower 
rates of hospital emergency department use, particularly among the 
uninsured.\29\ There is some evidence that CHCs provide care more 
efficiently and at lower cost compared to private physician practices, 
perhaps because the large volumes of patients CHCs see permit greater 
economies of scale in the cost of patient care.\30\ Also, the typically 
tight budgets and low margins with which they operate may compel CHCs 
to identify efficiencies and cost savings in their operations. In 
addition, many CHCs provide after-hours care in the evening and on 
weekends, an important consideration for those who use emergency 
departments because of the convenience of after-hours care.\31\
---------------------------------------------------------------------------
    \29\ Rust, George, et al., ``Presence of a Community Health Center 
and Uninsured Emergency Department Visit Rates in Rural Counties,'' 
Journal of Rural Health, Vol. 25, No. 1, pp. 8-16 (2009).
    \30\ McRae, Thomas, and Robert D. Stampfly, An Evaluation of the 
Cost-Effectiveness of Federally Qualified Health Centers Operating in 
Michigan, Institute for Healthcare Studies at Michigan State University 
(October 2006).
    \31\ Michelle M. Doty, et al., Enhancing the Capacity of Community 
Health Centers to Achieve High Performance: Findings From the 2009 
Commonwealth Fund National Survey of Federally Qualified Health 
Centers, The Commonwealth Fund, New York (May 2010).
---------------------------------------------------------------------------
    Nevertheless, community health centers comprise only a small share 
of total ambulatory care volume in the United States--70 million visits 
to CHCs in 2008 compared to a total of 956 million physician office 
visits. CHCs are not present or convenient in all areas, and many do 
not provide after-hours care. Even with the increased funding for CHCs 
included in the Patient Protection and Affordable Care Act, CHCs would 
likely be able to accommodate only a relatively small share of the 
nonurgent emergency department visits that could potentially be shifted 
to primary care providers, and most of these would likely be people who 
are uninsured or enrolled in Medicaid who already comprise the majority 
of CHC patients. Privately insured people with nonurgent visits to 
emergency departments are unlikely to switch to CHCs both because of 
negative perceptions that more affluent patients may have of community 
health centers and because CHCs are generally not located in areas 
where more affluent privately insured persons tend to live.
    cost savings for the uninsured and medicaid likely to be greater
    While the cost savings to the health care system of shifting care 
out of the emergency department to Community Health Centers may be 
minimal, the cost savings to uninsured patients could be considerable. 
The average cost of an emergency department visit for uninsured persons 
was $1,203 in 2008, of which half is paid out-of-pocket.\32\ Nonurgent 
visits are likely to be less costly for the uninsured--as they are with 
the general population--but they may still be responsible for a bill of 
several hundred dollars or more. By contrast, community health centers 
typically charge patients on a sliding scale--the fee amount increases 
along with their incomes--and typically ranges from $20 to $60 per 
visit.
---------------------------------------------------------------------------
    \32\ Agency for Healthcare Quality and Research, ``Emergency Room 
Services--Median and Mean Expense Per Person with Expense and 
Distribution by Source of Payment, 2008,'' Summary Data Table From the 
Medical Expenditure Panel Survey--Household Component.
---------------------------------------------------------------------------
    It should also be noted that most hospitals have policies that 
allow their charges to be waived or reduced based on the patient's 
ability to pay, including for visits to hospital emergency departments. 
For poor or low-income patients, hospitals often use a sliding-scale 
method similar to that used by community health centers to determine 
the patient's responsibility, and charges are often waived for the 
poorest uninsured patients.\33\ Thus, depending on the hospital's 
charity care policies and the patient's income, an uninsured person 
could pay little or none of the charge, or they could be responsible 
for most or all of the charge of the emergency department visit. 
However, hospitals sometimes limit the effectiveness of their charity 
care policies by failing to advertise them or making them known to 
patients, as well as by rigorous eligibility determination process that 
includes verification of sources of income.
---------------------------------------------------------------------------
    \33\ Staiti, Andrea, et al., Balancing Margin and Mission: 
Hospitals Alter Billing and Collection Practices for Uninsured 
Patients, Issue Brief No. 99, Center for Studying Health System Change, 
Washington, DC (October, 2005).
---------------------------------------------------------------------------
    Shifting nonurgent emergency department visits to community health 
centers and other sources of primary care could generate greater cost 
savings for the Medicaid program. Medicaid enrollees have the highest 
rates of emergency department use compared to persons with private 
insurance, Medicare or who are uninsured, and Medicaid enrollees 
account for more than one-fourth of nonurgent visits to the emergency 
department.\34\ Because Medicaid patients already comprise a large 
proportion of patients at community health centers--and they tend to 
live in areas where CHCs are located--programs designed to shift 
nonurgent care from EDs to CHCs may have greater potential to generate 
cost savings in the Medicaid program than for private payers, Medicare 
or even hospital uncompensated care costs from caring for the 
uninsured.
---------------------------------------------------------------------------
    \34\ Cunningham, Peter, ``Medicaid/SCHIP Cuts and Hospital 
Emergency Department Use,'' Health Affairs, Vol. 25, No. 1, pp. 237-47 
(January/February 2006).
---------------------------------------------------------------------------
    Finally, improvements in continuity of care, patient satisfaction 
and care coordination between primary care providers and specialists 
that can be facilitated by community health centers and other primary 
care providers can also increase cost savings to the Medicaid program, 
primarily by reducing redundant and unnecessary use of health services.
       gains in quality of care may be greater than cost savings
    Shifting ED use for nonurgent problems to primary care providers in 
the community is likely to have even more important implications for 
the quality of care. ED use for nonurgent health problems is associated 
with greater fragmentation and discontinuity of care with the patients' 
primary care physicians and other medical providers they use. Studies 
have found that communication and coordination of care between EDs and 
primary care physicians tends to be haphazard and generally poor, which 
is exacerbated by a lack of shared information systems that could 
facilitate communication.\35\ The lack of coordination and continuity 
between EDs and other providers in the community often leads to 
duplicative testing and other redundant utilization, complicates 
appropriate followup care, and increases the risk of medical 
errors.\36\
---------------------------------------------------------------------------
    \35\ Carrier, Emily, et al., ``Coordination Between Emergency and 
Primary Care Physicians,'' National Institute for Health Care Reform, 
Research Brief No. 3, Washington, DC (February 2011).
    \36\ Pitts (September 2010).
---------------------------------------------------------------------------
    Shifting ED use to primary care physicians may also increase 
patient satisfaction with care. According to one survey, more than 
three-fourths of patients with scheduled appointments at a doctor's 
office gave positive ratings about the thoroughness of the exam and the 
physician's willingness to listen.\37\ By contrast, only about half of 
ED patients gave such positive assessments. Thus, patients may be 
motivated to go to the ED because of greater convenience and the 
availability of after-hours care but not necessarily because they 
believe the ED provides better quality of care.
---------------------------------------------------------------------------
    \37\ Cunningham and May (October 2003).
---------------------------------------------------------------------------
    Shifting ED visits for nonurgent health problems to primary care 
providers in the community is a necessary step for broader efforts in 
the health care system to create ``patient-centered medical homes.'' 
This would not only improve the quality of care by ensuring that 
patients have a primary care physician to see for their nonurgent 
health problems and coordinating care with specialists and other 
providers, but it is also likely to generate additional cost savings by 
reducing unnecessary or redundant utilization.

    Senator Sanders. Thank you very much, Doctor. Yes.
    Dr. Alieta Eck, do I have your first name right?
    Dr. Eck. Alieta.
    Senator Sanders. Alieta, I am sorry. Dr. Alieta Eck, M.D., 
graduated from Rutgers College of Pharmacy in New Jersey and 
the St. Louis School of Medicine in St. Louis. She studied 
internal medicine at Robert Wood Johnson University Hospital in 
New Brunswick and has been in private practice with her 
husband, Dr. John Eck, M.D., in Piscataway, NJ since 1988.
    Thanks very much for being with us, Dr. Eck.

STATEMENT OF ALIETA ECK, M.D., FOUNDER & CO-DIRECTOR, ZAREPHATH 
                  HEALTH CENTER, ZAREPHATH, NJ

    Dr. Eck. Thank you very much. I appreciate being able to 
come here and tell of my experience. I think I can give some 
really good advice as to what we could do to reduce the 
emergency room costs and reduce the overall costs of medicine 
in the entire United States.
    I have been in private practice for 23 years. I was 
involved in the Medicaid program early on but then got out when 
I realized that I was losing money with every Medicaid patient. 
That wouldn't have lasted very long if I kept going.
    So my husband and I started a free clinic 10 miles away on 
a church ground. A little building had been flooded and it got 
renovated by volunteers, we started, it was debt free. We have 
volunteer physicians, nurses, support staff, everybody 
volunteers, nobody gets paid and they love to be there. We see 
about 3 to 400 people per month, we only are open 12 hours a 
week. So it is a huge, efficient way to take care of people who 
just come in. They see smiling faces, everybody is happy to see 
them. They are there because they are volunteered and we 
provide good primary care.
    I looked at the little script in the beginning where it 
says that it is a thousand dollars to take care of a patient in 
an emergency room and it is about $140 to take care of a 
patient in a federally qualified clinic, and that is by the 
testimony of somebody who works in one or who runs one in the 
next town over. It costs us $13 to take care of a visitor.
    With all the volunteers there people come for very, very 
different reasons. People are poor for very different reasons 
and a lot of them have made social decisions that are not in 
their best interest, they have gotten involved with drugs or 
alcohol, there are single parents, just things are difficult. 
So to have somebody along side that can come and help them with 
those type of issues, which is the case in a church 
environment, is huge. Our church has gone from 150 to 2,000 
members in the 7 years since we have had our free clinic, 
because people really want to be in a community that cares. 
People want to give in a community that cares, the receivers 
and the recipients--and the givers of the care ennobled by true 
charity.
    I was looking at the Form 990, I was trying to figure out 
what it is with these federally qualified clinics that makes 
them different than us and why it costs so much to take care of 
people there. It seems like it should be a lot cheaper. I 
looked at one Form 990, they pay $113,000 for travel, $650,000 
for provision for bad debts, personnel recruitment, $265,000 a 
year. They get money from Medicaid, they get money from the 
Federal Government, grants, they get uncompensated care 
payments. Their miscellaneous income is twice the income of our 
little clinic--which $58,000 a year is all it costs for us to 
take care of these people and do a very good job.
    All of that got me thinking, and I said, Medicaid is $10 
billion of a $28 billion budget in New Jersey. I thought, what 
could we do to reduce the costs? It is really hurting the 
taxpayers, the taxpayers are reeling at the expense the 
government is putting on them. So if we could reduce taxes that 
would help the whole economy. And we came up with the idea, 
several of us came up with the idea of what we call the 
Volunteer Physicians Protection Act.
    We need more physicians. It is hard to find physicians to 
volunteer. They are very strapped by decreasing payments from 
third parties and by increasing regulations. So we thought, why 
don't we have physicians donate 4 hours a week in a 
nongovernment free clinic dotted throughout the State. Then the 
only thing we would ask the State to do is to extend the 
medical malpractice coverage that they give to the physicians 
who work in the medical schools, just extend it to those 
physicians as their only reward for doing that time, for 
putting in 4 hours a week in a free clinic. The free clinic 
could be located within the hospital, so the hospital, when 
they see a patient coming in with a sore throat, they could be 
going over to this free clinic who should be just a couple 
rooms down and the physician who is volunteering could be 
taking care of that physician for free at no cost to anybody, 
to the taxpayer. That way we could take care of the poor, the 
taxpayer would not be impoverished by the system and we could 
balance a budget.
    In fact, I ran some of the numbers. We were only open 12 
hours a week, I figure about maybe a hundred patients a month 
we are diverting from the emergency room. They are coming in 
with their sore throats, with their ear aches. Sore throats are 
the No. 1 reason Medicaid people go to the ER. We are diverting 
them. If we were open 72 hours a week, that would be 600 
patients. If there were a 100, that would be 60,000 ER visits 
we could be diverting. I am just doing the math, which might be 
wild. But $720 million we could save in New Jersey just by 
doing something like this where instead of spending a thousand 
dollars in the emergency room, we spend zero, zero cost to the 
taxpayers, a lot less cost to the donors and I think we would 
solve the problem.
    [The prepared statement of Dr. Eck follows:]
                 Prepared Statement of Alieta Eck, M.D.
                                summary
    The poor go to the emergency room for non-urgent care because there 
is no deterrence. They know that a physician will be there at any hour 
and it is easier to just go rather than wait for an appointment. 
Patients on Medicaid are twice as likely to go to the emergency room 
than those without insurance, as they feel entitled and empowered by 
their card. Some feel victimized by the inability to find a physician's 
office where the Medicaid card is welcomed, so no amount of teaching 
and reasoning will change their behavior unless they choose to go 
elsewhere for urgent care.
    Increasing payments to physicians as a way of increasing physician 
participation in Medicaid is not the answer, as the taxpayers can ill-
afford to pay more. Opportunities for fraud and abuse would simply 
multiply as more taxpayer dollars would be flowing out of the State 
House. Expanding Federally Qualified Health Centers (FQHCs) might seem 
reasonable, but they are extraordinarily expensive to run, 10-20 times 
more than non-government free clinics. (NGFCs). FQHCs are funded by 
taxpayers. NGFCs are funded by charitable donations.
    We see from 300-400 patients per month in the Zarephath Health 
Center, a NGFC. We estimate that our small clinic diverts from 100-150 
inappropriate ER visits per month. Patients tell us that they would 
have come to the clinic had we been open. We are only open 12 hours per 
week. So increasing our hours to 72 hours per week would clearly 
decrease inappropriate ER use. Greatly increasing the numbers of NGFCs 
would lead to a reduction in the number of patients who go to the 
emergency rooms for non-urgent care. One hundred similar facilities, 
including some located within the walls of the hospitals, could divert 
60,000 unnecessary ER visits, saving the taxpayers of New Jersey $60 
million per year.
    A proposal, The NJ Volunteer Physicians Protection Act (VPPA) is 
working its way through the legislature in New Jersey, whereby 
physicians would agree to volunteer 4 hours per week in a NGFC. 
Surgeons or OB-GYN's might do two cases per month for patients referred 
by the free clinic. As the physicians' only reward, we are asking for 
the State government to provide medical malpractice coverage for their 
entire practices.
    Current systems in place include:

     The Federal Tort Claims Act--provides free Federal 
malpractice coverage for work done in NGFCs.
     New Jersey currently provides medical malpractice coverage 
to physicians who teach or study in the medical school hospitals.
     Echoclinics.org is an organization that is facilitating 
the starting of new NGFCs.

    Thus, all of the programs are already in place to realign the way 
physicians care for the poor. The only legislation required will be to 
extend existing medical malpractice programs to the private practices 
of all physicians who volunteer for a stated amount of time. Gradually 
defunding the highly bureaucratic programs that are not providing 
acceptable care to the poor would lower taxes and provide a great 
stimulus to the economy. The poor would get continuity of care, and 
emergency room use for non-urgent illnesses would dramatically 
decrease.
    Goals would be to:

     Increase access for the poor to friendly non-bureaucratic 
care outside of the emergency room.
     Indirectly compensate the physicians who provide the free 
care by lowering their office overhead.
     Relieve the taxpayers of the current unbearable burden of 
the Medicaid system.
     Change the entire culture of the way we help the poor in 
America.
                                 ______
                                 
    Good morning. I am a physician specializing in Internal Medicine. I 
welcome the opportunity to speak in front of this committee, and 
explain what I have observed in both my 23 years of private medical 
practice and the 7 years of volunteering in a free clinic. I believe 
that I can give information that will be valuable in helping to develop 
policies that would be effective in deterring the unnecessary use of 
the emergency room.
    Both in the practice where I earn my living, and the free clinic 
where I see the poorest of the poor, I count it a privilege to be able 
to make a difference in the lives of my patients.
    My husband, Dr. John Eck, M.D., and I dropped out of the Medicaid 
program a few years after enrolling, realizing that it was causing our 
practice to lose money, thus jeopardizing our livelihood. The cost of 
filing the claim was greater than the sum Medicaid would pay us several 
months later.
              the founding of a non-government free clinic
    After Hurricane Floyd flooded a small house on the edge of our 
church campus at Zarephath, NJ, we convinced the church leadership to 
allow us to renovate it and turn it into a clinic. We had read Marvin 
Olasky's Tragedy of American Compassion, and we determined to do things 
differently--to see the poor for free, to solicit the help of caring 
volunteer nurses and support staff, and to work to identify the root 
causes of the poverty that brought the patients to us, helping in any 
practical way we could. The clinic began operation in September 2003. 
It has a 501(c)3 charity status and operates completely by private 
donations--with no taxpayer dollars. In fact, we would turn down 
taxpayer dollars, as we firmly believe charity should be voluntary.
    Volunteers listen to the stories of each person who comes in, 
offering kind encouragement. A verse stenciled to the wall in the 
waiting room reads, ``Come unto me, all you who labor and are heavy-
laden, and I will give you rest. (Jesus)'' Then a nurse and physician 
see the patient to handle common complaints such as a sore throat, 
bronchitis, hypertension, diabetes, thyroid disease and sometimes 
illnesses that are more serious and life threatening. We bind up the 
wounds of their limbs and their hearts. The church has a food pantry 
and a clothing thrift shop where some people pay a few dollars for 
clothes and many can get them for free. It is not one-size-fits-all 
charity situation, but varied help for very different types of people.
    We have never advertised, but the patients come--from as far away 
as Pennsylvania and New York, an hour and a half away.

     Patients are referred by their friends, other patients or 
church members.
     Patients are referred by the emergency rooms, after they 
have been seen there.
     Patients are referred by nurses in the hospitals when poor 
patients are being discharged and have no primary care physician.
     Patients are referred by local pharmacies.
     Patients are actually referred to us by the Medicaid 
office when patients have complained that they could not find a 
physician who accepts Medicaid.
     Patients are referred by all the social service agencies 
in the area.
     We see patients who have just been released from prison, 
referred by their parole officers.
     We see patients who have been released from psychiatric 
hospitals, prescriptions in hand and no means to pay for them. They are 
scheduled to see a psychiatrist 6 weeks hence at a State-run 
psychiatric facility, but are not given any help in between. We hand 
them their medicines if they are available in our little pharmacy. We 
handle them medically until they can get to the proper specialists. A 
local community food bank has a fund set aside for emergency 
prescriptions.
     We see unemployed union members who are dejected, 
wondering how to pay their mortgages and unable to pay for medical 
care.
     We see single mothers who bring their little ones to play 
with volunteers in our play area, while we take care of mom's medical 
needs. We try to have the children leave with smiles on their face and 
often a donated teddy bear.
     We see children when a pediatrician or family practitioner 
are there.
     We see people who are, temporarily unemployed and feeling 
frightened and vulnerable.
     We see patients who are referred to us by the unemployment 
office.
     We see people who are living in their cars or under 
bridges, having been evicted from their homes, estranged from their 
families for many reasons including their own poor behavior.
     We see patients referred to us by judges in family court.

    No one pays a penny, but some put a few dollars into a donation box 
at the front desk. This covers some of the $13 average cost per 
patient. Medications are handed out for free--donated by pharmaceutical 
companies, drug representatives, sample closets of fellow physicians, 
and some purchased wholesale. Often we will write for the $4 
prescriptions that the free market has made available to all. Every 
patient leaves with a grateful heart, as they know that people cared 
for them because they wanted to, not because it was their job. All are 
treated with respect, empathy and kindness.
    Some people are poor through no fault of their own, but many have 
made bad choices along the way. They need good advice, role models and 
people who will patiently encourage them to make changes that will 
empower them to be lifted out of poverty. Zarephath Christian Church 
has many programs that fill their social voids--men's breakfasts, 
women's luncheons, Bible studies, support groups for those who grieve, 
support groups for battered women, marriage ministries and other groups 
for all ages.
             who gets care at the zarephath health center?
    Let me give you some examples of actual patients we have seen:

     A 54-year-old gentleman, a carpenter with no work, came in 
with severe nasal obstruction from sinus polyps. He was on Medicaid but 
could not find an ENT surgeon who would operate for the amount Medicaid 
would pay. Why should a surgeon take on full liability for such a low 
fee? This man was asking me to fill out disability forms. Instead, I 
called an ENT friend and asked what he would charge. We agreed upon a 
fair amount and the surgery was done and we paid out of donations we 
had received. The very grateful patient came to a men's breakfast at 
the church where volunteer workers are spending their free time fixing 
up our new clinic facility. He wants to volunteer as well.
     A 34-year-old woman came in with palpitations and a tender 
thyroid. With no risk factors for heart disease, we gave her medicine 
to slow her heart and had her come back the next day where our 
volunteer retired cardiologist saw her and confirmed the diagnosis. She 
was 100 percent better. The charity system was saved probably $10,000, 
as a visit to the ER would have triggered that much in advanced cardiac 
testing.
     A 25-year-old gentleman walked in with a vial of an anti-
psychotic medication that was to be administered monthly. He had the 
paperwork, but no one to administer it. We did.
     A 15-year-old girl with no insurance came in with 
palpitations and shortness of breath. Our retired cardiologist 
diagnosed a cardiac conduction defect that would require a surgical 
ablation to cure. He called a colleague who was happy to take care of 
her for no charge. Her grateful mother comes in and volunteers to do 
clerical work at the clinic.
     A couple is overwhelmed with two severely autistic 
children. The church has developed a program whereby these children are 
given one-on-one supervision in Sunday classes and the parents can 
attend church services together. The parents are extremely grateful and 
the father, an air conditioning specialist has offered to maintain our 
system in our new facility.
     A 48-year-old woman came in showing all the signs of the 
disfigurement of acromegaly, a disease of the pituitary gland where 
growth hormone continues unchecked after puberty. This was diagnosed 10 
years ago, but she had no means to pay for care. She went to the 
Medicaid office where she was told that the only way to get Medicaid 
was to be on welfare. She argued that she wanted to work, but just 
needed help with medical bills. She was thus turned away and referred 
to us by the unemployment office.
     A 50-year-old woman with extreme weight loss and a breast 
mass was being worked up for cancer. When no cancer was found, she was 
referred to our clinic. It turns out that her very bad teeth were 
seeding her bloodstream and causing the abscesses. Antibiotics helped 
her gain weight and a dentist agreed to take care of her teeth for no 
charge.
     A 54-year-old man who had had a kidney transplant came in 
with no way to pay for his transplant rejection medicine. This was a 
true emergency. We called the township and asked if there was some type 
of charity fund for this type of thing. Fortunately, we were able to 
get him the medicine he needed.

    Today we see 300-400 patients per month and the church has made new 
space available for us. We will go from 900 to 4,000 square feet, with 
five exam rooms, three intake and counseling rooms, and a large 
classroom to teach classes on diabetes and other topics. Our new clinic 
will have a dental chair for dentists to volunteer. It is being built 
by builders, plumbers and electricians who are working at a reduced 
rate and many former patients who are volunteering to do the sheet rock 
and spackling. The township building inspector, so inspired by the 
stories, has agreed to put the first coat of paint on all the walls for 
free. Money is being donated for the work, and we will open in a month 
or so, completely debt free. The church has gone from an attendance of 
150 to 2,000 in the 7 years the clinic has been in existence. A culture 
of caring attracts people.
       who goes to the emergency rooms for non-urgent complaints?
     Many patients bring their emergency room reports with 
descriptions of their ear aches, sore throats or rashes. When we ask 
why they went to the ER for such minor illnesses, they tell that they 
would have come to our clinic, but we were not open. Because of lack of 
physicians who are able to volunteer, our clinic is only open 12 hours 
a week.
     Patients who are poor and without any assets have 
absolutely no restraint when it comes to going to the ER. They know 
that there is a physician there 
24/7 so do not bother to call an office or clinic to make an 
appointment. When I was a resident many years ago I remember one 
patient showing me her rash at 3 a.m. When I asked why she was coming 
for such a minor complaint at that hour, she said she figured it would 
be a good time because we wouldn't be busy. To her, this was a 
perfectly reasonable answer.
     Patients on Medicaid are twice as likely to visit the ER 
for non-urgent conditions than patients with no insurance at all. Their 
sense of entitlement, having that Medicaid card combined with their 
poor management of their own resources makes a warm, clean ER 
environment a pleasant place to spend an afternoon. Since they are not 
turned away, they continue to come. They have absolutely nothing to 
lose, as they will never see a bill. Any attempts to divert them are 
futile.
                the cost of providing care for the poor
    I note that on the description of today's hearing you claim that 
the cost to provide care in the emergency room is $1,000, which is 7 
times the cost of providing care in community health centers. This 
correlates with the information I have gathered where the costs in 
these centers are between $140-$280 per patient visit. Compare that to 
the cost of providing care in a non-government free clinic such as 
ours--$13, one-tenth to one-twentieth the cost of a federally qualified 
clinic. If there were an adequate number of non-government free 
clinics, the savings to the taxpayer by keeping people out of the 
emergency rooms would be 100 percent, and the cost to the charitable 
donors would be minimal.
    A federally qualified health center in the next town has a yearly 
budget of $14 million--all from taxpayer dollars. (from the IRS Form 
990). Ours is $58,000--none from the taxpayers. For the amount it costs 
to fund one FQHC, we could fund 250 clinics like ours, and I submit 
that the patients would get better, more personalized care.
    I do not like to disparage the work of others, but the following is 
an eyewitness account of someone who worked in one of those $14 million 
FQHCs:

          ``The bureaucracy was unbelievable. The administrators had no 
        clue how the care of patients worked. Tons of rules. Lack of 
        proper supplies. Poor quality of the staff working there, 
        mostly from the indigent areas. Patients had to wait hours to 
        go through the registration and verification process which was 
        very frustrating for them. A normal visit to the clinic took 
        over 2 hours for a patient. Patients came there not by choice 
        but because they had no place else to go. It was not a caring 
        atmosphere. The administration made everything very 
        difficult.''

    This is not really surprising, for when providing charity is a job 
instead of a voluntary giving of one's services for no compensation, 
the dynamics change. This is not a new concept. In 1853, Rev. William 
Ruffner noted that:

          ``Charity is a work requiring great tenderness and sympathy, 
        and agents who do their work for a price rather than love 
        should not be trusted to execute the wishes of donors. The 
        keepers of poor-houses fall into a business, unfeeling way of 
        doing their duties, which is wounding and often partial and 
        cruel to the objects of their attention.''

               the nj volunteer physicians protection act
    So the question is, ``What would it take to have thousands of non-
government free clinics scattered throughout the country?''
    The Zarephath Health Center is open only 12 hours per week as we 
have trouble finding physicians to volunteer. Physicians have many 
stresses and often struggle to meet all their obligations, suffering 
from ever-decreasing third party payments and ever-increasing 
administrative burden. Volunteering does not easily fit into their 
schedules. Even though the Federal Tort Claims Act (FTCA) gives us free 
Federal medical malpractice coverage for the work we do in the free 
clinic, it is still hard to find physicians.
    So we, in New Jersey, are working on a solution. Physicians and 
citizens have come together to propose the NJ Volunteer Physicians 
Protection Act, whereby physicians would volunteer to donate 4 hours 
per week in non-government free clinics. Instead of billing for our 
services, we are asking that the State extend the same medical 
malpractice coverage it now provides to the medical school attendings, 
residents and students, to the entire practices of the physicians who 
volunteer. The State could simply take the same paperwork used by the 
FTCA to identify those physicians who qualify for coverage.
    Medical malpractice coverage would be the physicians' only reward--
no claim forms, no CPT codes, no secretaries at either end, no money 
flowing from the government to care for the poor. Just liability 
protection. The rest of the clinic work would be done with at least 90 
percent volunteers, with minimal key paid staff, all funded by private 
donors, local fundraisers and corporate donations. From our experience, 
there would be no shortage of volunteer nurses and support staff. The 
baby boomers are poised to become a huge pool of volunteers with 
expertise and experience. There would be no avenue for fraud and abuse, 
as no money would be coming in from the government.
    An organization founded by a philanthropic couple in Texas called 
Echo Clinics (echoclinics.org) has the mission of facilitating the 
founding of 10,000 free clinics by the year 2030. We look forward to 
working with them here in NJ. They facilitate in identifying core 
directors, choosing a free clinic site, establishing the 501(c)3, and 
going through the FTCA application.
    Senator Bernie Sanders, you hail from the left, where you proclaim 
a deep concern for the poor and underprivileged. So I would think that 
our idea would appeal to you. Greater and more satisfactory access for 
the poor to see physicians of every specialty. This is universal 
access.
    Senator Rand Paul, as a member of the Tea Party movement, you hail 
from the right, which believes in freedom, smaller government and lower 
taxes. Our plan ought to appeal to you as the free clinics would 
operate with no tax dollars at all. This is limited government.
    The NJ State Medicaid budget is $10 billion in a total State budget 
of $28 billion. Half of that is for indigent elderly and half is for 
acute care. Of the $5 billion for acute care, $2 billion goes to 
Medicaid-managed care and $800 million goes to federally qualified 
clinics. (data from statehealthfacts.org) Assuming an average 20 
percent administrative cost, that means a total of $500 million of 
these two entities is paying administrators of the system--people who 
do not touch the patients. In the NJ Medicaid budget, $90 million goes 
directly to physicians. There is a bit of a disconnect in common sense 
here.
    Since the Medicaid office is currently directing frustrated 
patients to our free clinic, why do we need the middle man? Why would 
we need Medicaid managed care if we physicians are willing to manage 
the care of the patients for free? Who can argue with free? Since the 
State would not be purchasing medical malpractice policies, the only 
cost to the State taxpayer would be incurred if an actual lawsuit were 
brought. From the experience of the FTCA, these would be rare. It does 
not take too much accounting to realize that NJ would quickly save $2 
billion if this program were implemented, and the 50 States could save 
$100 billion per year.
    The Federal Government would be able to lower its Medicaid spending 
as well. An added benefit would be the reduction of the estimated 20-30 
percent cost of defensive medicine by the reduction of unnecessary 
testing done purely to avert potential lawsuits. This would reduce 
Medicare spending as well, another $200 billion in savings, according 
to studies done during the Bush administration.
    I am not suggesting that we dismantle the Medicaid program in one 
fell swoop--but give the patients in need a choice. If someone finds 
himself ill and with no insurance and no funds, he could go to a 
Medicaid office and spend time filling out forms where he might be 
rejected, or he could go to a nearby free clinic. Once the word got 
out, a well-staffed free clinic that is open for many hours a day would 
be a huge deterrent from inappropriate use of the emergency rooms. 
Also, each hospital could have several rooms set up where non-urgent 
cases could be seen by physicians who would donate their time there. 
The free clinics would not have to be free-standing.
    Instead of having an entitlement for what might be a temporary 
tough time, why not have a place to go for only the time that is 
needed? After patients have been helped and are back on their feet, we 
will encourage those who find work to access and pay for care at our 
practices. Poverty should be a temporary state, not a way of life.
    We have a Web site--NJAAPS.org. There physicians and citizens can 
read all about the NJ Volunteer Physicians Protection Act and sign up 
to voice their approval. So far we have 40 physicians who agree with 
the concept, and I do not believe that staffing these clinics will be 
difficult.
    We have a seminar coming up next month to teach church leaders and 
concerned citizens how they can organize and establish a free clinic in 
their area. Sometimes it is good to revisit ideas from the past. 
Providing medical care for the poor and uninsured is one of them.
    Thank you for this opportunity to address this committee.

    Senator Sanders. Thank you very much, Dr. Eck.
    Dr. Dana Kraus, and I apologize for mispronouncing your 
first name a moment ago, is a board certified family physician. 
She did her residency at Oregon Health Science University, went 
to medical school at Dartmouth Medical School and has a 
bachelors in comparative literature from Brown University.
    Dr. Kraus, thanks very much for being with us.

   STATEMENT OF DANA KRAUS, M.D., FAMILY PRACTICE PHYSICIAN, 
           NORTHERN COUNTIES HEALTH CARE, ST. JOHNS-
                            BURY, VT

    Dr. Kraus. I would like to thank everyone for the 
opportunity to come and speak. What I would like to talk about 
really is the transformation of the primary health care system 
that has occurred in my rural community in northern Vermont 
over the last 5 to 10 years.
    What we do now is provide comprehensive, proactive and 
integrated health care using three things: The Chronic Care 
Model, the medical home and our own innovative community health 
team. The Chronic Care Model demonstrated that in order to 
provide the best chronic care, the best care for patients with 
the--Chronic Care Model indicated that the way to provide the 
best care for patients with chronic illness was to have a 
prepared and proactive team interacting with an informed and 
activated patient.
    So it makes no sense to wait for a diabetic patient to come 
to the clinic with an infected toe that needs hospitalization 
and expensive IV antibiotics. So our patients with chronic 
illness, such as diabetes, are scheduled routine visits. Before 
they come in my staff knows to order their blood work a week 
before. My nurse knows to pull up a template for me so at the 
time of the visit I have all of the information that I need 
about that patient, their last lab work, their most recent 
visits with other specialists, so I can have a very efficient 
and very effective visit with that patient.
    Now, to get an informed and activated patient, someone who 
is really engaged in their care and willing to work to improve 
their care is much more difficult. Remember that for patients 
with chronic illness, we are asking them, for example, to take 
medication when they have absolutely no symptoms of their 
illness, we are asking them to give up their Ben & Jerry's and 
go for a walk at lunchtime. So in order to help us to motivate 
these patients we have developed our community health team.
    The community health team is staffed for care coordinators, 
by community health workers, people with social work 
backgrounds and by counselors and they become then an extension 
of the primary care providers. They are the people who connect 
our patients to services that already exist. They make sure 
that there is no duplication of services. They can help 
patients to get affordable medication, transportation to and 
from their visits to us or to the specialists. They can help 
patients get to their visits or to find daycare or respite care 
for their elderly parents.
    What is unique in Vermont is that this payment is mandated 
by the State and is shared by not just Medicare and Medicaid 
but also by the private insurers, so all are cooperating to pay 
for this system.
    We have aggressively recruited other primary care doctors 
who come, partly because of the system of support that we have 
to help them work. We have expanded our clinic hours. We 
accommodate many new patients. Our community health team 
reaches out to patients who are seen in the emergency room and 
can offer them a primary care provider if they don't have one, 
can help them get access to insurance if they do not have 
insurance and they can also provide education at the time of 
that outreach so that they can make sure that the patient is 
taking their medications, that the patient is understanding 
their instructions and that they are improving and can also 
educate them about the fact that we have same day appointments 
for which they can be seen and also to let them know that we 
have 24 hour service. They can always call a physician at any 
time to find out where the most appropriate time or place is 
for them to get care.
    We feel, very importantly, that patients who come to see us 
at the clinic get significant benefit over going to the 
emergency room. We understand their chronic conditions and know 
what medications they are on. We are less likely to repeat 
tests or order unnecessary tests. We can do screening for 
depression and substance abuse and refer to our counselor, if 
that is necessary, as such illnesses tend to increase the cost 
of caring for the patient. We can also do preventative health 
service. So a patient who comes to see us for a sore throat is 
very likely to go out with an updated tetanus vaccine and a lab 
slip to have their cholesterol and their blood sugar checked 
for preventative health.
    What have the outcomes been? In our community we have seen 
a significant decrease in ER visits and in hospitalizations. We 
have seen an 11 percent decrease in per member/per month costs 
based on private insurance claims data. We also feel very 
strongly that by providing improved control of chronic 
conditions and increased adherence to preventative care, that 
in the future we will be seeing significant cost savings. Thank 
you very much.
    [The prepared statement of Dr. Kraus follows:]
                 Prepared Statement of Dana Kraus, M.D.
                                summary
    I thank Chairman Sanders, Senator Paul, and members of the 
subcommittee for inviting me to come and give testimony about how we in 
my community have begun to lower ER visits, decrease healthcare costs, 
and improve the health of our patients.
    The Problem:

     Many unnecessary ER visits
     High proportion of medical expenditures to treat 
complications of chronic illnesses

    Some of the Causes:

     Medical system designed for providing acute, reactive care
     Shortage of primary care providers
     Patients lack adequate insurance, thus avoid preventive 
care
     Poor patient understanding of proper ER use
     Changing behavior is difficult: taking medications, proper 
diet, exercising

    Background Information:

     Northern Counties Health Care is a Federally Qualified 
Health Center (FQHC)
     Located in rural Northeastern Vermont
     25-bed critical access hospital serves 30,000 people, 45 
ER visits per day

    Our Solutions:

     Provide comprehensive, integrated care using:

          Chronic Care Model, Medical Home, Chronic Care Team

     Increase access to primary care providers
     Improve access to health insurance
     Patient education about proper ER use

    Integrating The Chronic Care Model:

     Prepared proactive practice team
          Scheduled appointments with tests done and available
          Medical data in organized format
          Guideline recommendations embedded in the EMR
          EMR used to identify patients overdue for care

     Informed activated patients

          Self-management goals set and reviewed with patients
          Written care plans provided and reviewed with 
        patients

    Expansion To The Medical Home:

     National Committee for Quality Assurance (NCQA) 
Certification
     Preventive health maintenance
     Improved access to primary care provider
     Improved coordination of care
     Continuous quality improvement

    The Community Health Team (CHT):

     Key to our success!
     An extension of the primary care providers
     Connects patients to existing local services and 
coordinates care
     Staffed centrally at the hospital and within the Medical 
Home clinics
     One-stop services, ``wrap services around the patient''
     Sets self management goals with patients
     Helps to identify and manage most high-risk patients
     Provides behavioral health within the medical home clinics
     Funded by all insurers

    Increased Access to Primary Care Providers:

     Aggressive provider recruitment
     Expanded clinic hours
     Accommodate new patients
     Increased availability of acute, same day slots
     CHT identifies ER patients without primary care provider, 
offers one

    Increased Access to Insurance:

     CHT works with uninsured patients to access appropriate 
programs

    Patient Education:

     CHT provider post-ER phone calls
     Proper use of ER addressed with patient at next clinic 
appointment

    Additional Benefits of Seeing a Primary Care Provider:

     Chronic conditions/medications known
     Less likelihood of repeating tests or ordering unnecessary 
tests
     Screening done for depression and substance abuse
     Preventative health issues are addressed and implemented

    The Outcomes:

     Decreased ER visits
     Decreased inpatient admissions
     Decreased PMPM costs
     Improved care of chronic conditions should lead to future 
cost savings
     Improved preventive care should lead to further cost 
savings
                                 ______
                                 
    I would first like to thank Chairman Sanders, Senator Paul, and 
members of the subcommittee for inviting me to come and give testimony 
about how we in my community have begun to lower ER visits, decrease 
healthcare costs, and improve the health of our patients.
    My name is Dana Kraus. I am a board-certified family physician 
working at the St. Johnsbury Family Health Center in Vermont. The 
clinic is one of six Federally Qualified Health Centers run by Northern 
Counties Health Care (NCHC). NCHC has been operating Federally 
Qualified Health Centers since 1976. NCHC provides care for over 18,000 
patients in three hospital catchment areas in rural northern Vermont, 
and also runs two dental clinics and a Home Health and Hospice Agency. 
As a Federally Qualified Health Center we offer a sliding scale fee 
program so that no one is denied care, and also a low-cost prescription 
drug program.
    Four of the six clinics are in and around the town of St. 
Johnsbury, with a service area of 30,000 people. NCHC provides 40-50 
percent of the primary care for this catchment region. Another 40-50 
percent is provided by a clinic owned and run by the local hospital, a 
25-bed critical access hospital. Our ER currently sees on average 45 
patients per day.
                           chronic care model
    The four NCHC St Johnsbury based clinics, in collaboration with the 
local hospital, have been participating as a pilot site in the Vermont 
Blueprint for Health since 2005 (See Attachment 1). This initial pilot 
brought the Chronic Care Model (See Attachment 2) of care to our area, 
transforming our care delivery system from a reactive model designed 
for acute care, to a proactive model designed to improve the care of 
patients with chronic conditions. We have made some fundamental changes 
in the way that we see patients with chronic illness. All these 
patients are given regular followup visits. Labs and tests are 
scheduled prior to the followup visit so that they are available for 
review at the time of the visit. We use templates and charts embedded 
within our Electronic Medical Record (EMR) to remind providers of 
guideline-recognized goals for each chronic condition. We are able to 
identify those patients who are overdue for a visit, and are proactive 
in contacting them and bringing them back up to date with routine care. 
We set self-management goals with patients, and provide written care 
plans.
    It is known that a large proportion of our health care expenditure 
is spent on patients with chronic conditions. Since implementing the 
Chronic Care Model, we have seen significant improvements in short-term 
outcome measures of our patients with chronic illnesses. For example, 
our diabetics have better control of their sugars and blood pressure, 
have more frequent preventive eye and foot exams, and are taking 
medications known to decrease complications more regularly. Under this 
program greater proportion or our hypertensive patients have well-
controlled blood pressure, and more of them are taking aspirin, known 
to decrease the risk of heart attacks and strokes.
                    ncqa medical home certification
    Late in 2008 we became one of the first two Vermont Medical Home 
pilot sites. All participating clinics underwent National Committee for 
Quality Assurance (NCQA) certification for Medical Home status and all 
four NCHC clinics, as well as the hospital run rural health center, 
qualified at the highest level (level 3). This certification indicates 
among other things that a clinic provides enhanced access to and 
continuity with a primary care provider, and has a robust electronic 
medical record that can be used for population management and 
performance feedback. A medical home also emphasizes and promotes 
patient self-care and referrals to community resources, and can track 
and coordinate care. (See Attachment 3). The Medical Home expands upon 
the concept of the Chronic Care Model by addressing preventative health 
maintenance, improved access, and continuous quality improvement.
                       the community health team
    Key to our success as a high functioning Medical Home is our 
Community Health Team (CHT). Our CHT is made up of a hospital-based 
program called Community Connections, and Chronic Care Coordinators and 
Behavioral Health Providers that are imbedded within the clinics.
                community connections, one-stop services
    The Community Connections piece has its origins back in 2002 with a 
grant from the Health and Human Services Bureau of Women's Health. A 
group of primary care providers and community resource representatives 
sat down to discuss how to improve the health of women in the 
community. What we found was that we had many existing services, but 
there was poor coordination and communication between the various 
agencies, and health care providers had trouble referring to and 
patients had trouble accessing the existing resources. Thus began the 
Women's Resource Center, which in 2006 was expanded to include men and 
children, and was renamed Community Connections. Care coordinators and 
community health workers staff Community Connections. They work to 
connect patients with whatever services they need. Our director loves 
to say that they ``wrap services around the patients.''
    The key to Community Connections is that it provides ``one stop 
services,'' so that providers and patients do not have to negotiate the 
complexities of existing disparate agencies. Community Connections 
staff work very closely with all of the existing State and private 
agencies so as not to duplicate resources. For example, they help 
patients get insurance coverage and access to affordable medications. 
They help patients get childcare, transportation, and respite care for 
elderly family members. They help patients to connect with local health 
education programs, such as diabetes or asthma education, or local 
exercise programs. They help patients do their grocery shopping, or go 
with patients to their provider visits to be sure that the patient 
understands instructions.
                       chronic care coordinators
    The Chronic Care Coordinator works closely with providers to 
identify and manage high-needs patients with chronic illness. These are 
the patients for example with poor control of their diabetes, asthma, 
or heart failure who are at high risk for expensive ER visits and 
hospitalizations. They meet with patients during scheduled provider 
visits, or separately, and do a lot of phone outreach. They help with 
the handoff of patients to Community Connections. They do panel 
management using reports pulled from the EMR to identify patients 
overdue for health maintenance, such as mammograms, or pneumonia 
vaccines, or those patients with diabetes or asthma or hypertension who 
are poorly controlled, at high risk of complications, or overdue for a 
visit.
                      behavioral health providers
    Our Behavioral Health Specialists are counselors who work within 
the primary care clinics. They focus on crisis intervention, or short-
term counseling, in order to keep their schedules open at all times for 
new patients. For those patients who need long-term counseling, they 
help them find a ``good match'' with a community-based counselor. 
Depression is known to frequently co-exist with chronic illness, and 
treatment of depression has been shown to improve outcomes. Now that we 
have easy access to a counselor, we are screening all patients for 
depression. Patients with depression often present to their primary 
care provider as well as to the ER with multiple complaints, and these 
complaints typically decrease significantly once the underlying 
depression is treated.
    Behavioral Health Providers help patients with true mental illness 
and substance abuse, and also those patients who are having trouble 
motivating to care for themselves and their chronic illness. For 
example they help patients start exercising, begin a weight loss 
program, or more reliably take their medications. Such interventions 
lead to better disease control, which eventually means fewer 
complications, fewer ER visits and hospitalizations, and decreased 
costs.
             funding for the community healthy teams (chts)
    An important point about our CHT is that Vermont's major private 
insurers and Vermont Medicaid fund it as a shared resource. This is an 
obligation that is mandated by State law. The State has also been 
paying for the share of the CHT belonging to Medicare as well as for 
the per-patient-per-month payments to the practices for Medicare 
beneficiaries. Vermont was recently chosen as one of eight States to 
participate in the CMS Multi-payer Advanced Primary Care Demonstration, 
enabling Medicare to be a part of the payment reform in the same 
manner. The CHT and Medical Home Clinics provide care for all patients, 
regardless of their insurance status.
    Under the current payment system, all insurers have their own 
separate chronic care management programs, which often provide care via 
the phone from distant sites. It is our vision that the local CHTs will 
eventually take over much of this redundant and expensive care. We feel 
strongly that providing face-to-face care, by people who work in 
conjunction with primary care providers and who are intimately familiar 
with the local resources, culture and climate will provide more 
effective care. For example, rather than recommending an outdoor 
walking program during a typical northern winter, our care coordinators 
know that there is a daily walking group at the Mall, several Strong 
Living classes for seniors, and a diabetic exercise class through the 
local hospital.
                        evidence of success/data
    Recent data gathered from hospital statistics have shown a 
significant downward trend in both ER visits and hospitalizations in 
the last 2 years compared to the 2 years prior to the Medical Home 
Pilot. It was anticipated that the ER visit rate would be 60 visits per 
1,000 patients, and instead it was 40 visits per 1,000 patients, a 33 
percent decrease. Similarly, for inpatient hospital admissions, it was 
expected to be just below 10 admissions per 1,000 patients, and instead 
was only 7.5 admissions per 1,000 patients, a 24 percent decrease. (See 
attachment 4) The decrease in ER visits is due to both avoiding illness 
exacerbations that would have led to necessary ER visits, and to 
decreasing non-urgent ER visits. Just in a 1-year period between 2008 
and 2009, there was a 11.5 percent decrease in per member per month 
(PMPM) expenditures in our pilot population, based on private insurance 
claims data.
                      evidence of success/examples
    We have endless stories of how the chronic care team has helped our 
patients. Daily there are patients who get better care because they 
have help applying for health insurance so that they can afford 
preventive services, help finding a more affordable medication, help 
accessing a counselor for their longstanding depression, or help 
getting transportation to their appointments. We anticipated that many 
of these interventions would improve the outcomes of patients with 
chronic illness and provide cost savings many years down the line. I 
think that even we here in our community are surprised and thrilled to 
see how quickly our interventions have led to more immediate cost 
savings, with decreased ER visits and hospitalizations.
    For example, among my patients is a 30-year-old single mother of 
three who has asthma and chronic pelvic pain, which lead to frequent ER 
visits. She is functionally impaired, and had great trouble affording 
and taking her medications. She met regularly with the CHT. She now has 
her medications ``blister packed'' at the pharmacy, and has 
successfully been taking birth control pills, which have taken care of 
her pelvic pain, and now that she is regularly taking her asthma 
medications she has had neither ER visits nor even acute clinic visits 
for her asthma. Another provider had a gentleman who visited the ER 18 
times in 2010 for chest pain. Since being connected with the CHT, it 
was discovered that he was not able to afford his medications, and that 
depression was contributing to his symptoms. He now has regular care 
with his primary care provider, a counselor, and his cardiologist. He 
also has insurance to pay for his medications, and has had only one ER 
visit in the last 6 months.
                    addressing non-urgent er visits
    There are several components of the Medical Home and Community 
Health Team that specifically target reduction of non-urgent ER visits. 
These involve (1) assigning primary care providers to those without 
one, (2) helping patients access existing insurance options (3) 
following up with ER patients to ensure that they are improving and 
have proper followup (4) improving access to primary care providers (5) 
educating patients about appropriate ER use.
1. Efforts to Increase Patients With Access to a Primary Care Provider
    A member of the CCT looks at the ER roster daily. Initially there 
were multiple patients each day that did not identify a primary care 
provider. These patients were contacted, and whenever possible they 
were connected with a primary care provider at one of our Medical Home 
Clinics. The Medical Home Clinics have worked very hard to accommodate 
new patients. We have had aggressive recruitment of new physicians and 
mid-level providers in our community. Two years ago most practices had 
very limited new patient appointments. At my clinic alone in the last 
12 months we saw over 650 new patients. Just this week I saw a 
gentleman who spends 6 months in Vermont and 6 months in Florida. He 
and his wife are well-educated, and have health insurance. His wife had 
several ER visits last year for what turned out to be giardia. I saw 
him as a new patient with similar GI complaints, and he was so 
thankful. ``Last year we tried and tried to get in to see a primary 
care doctor, and were told there were none available, so we had to use 
the ER any time that we needed care.''
2. Efforts to Increase Insurance Coverage
    The number of patients without a Primary Care provider has 
decreased to such an extent that the CHT now has the time and resources 
available to also contact those ER patients without insurance, to work 
with them to obtain insurance. Patients with insurance are more likely 
to access primary care and preventive services, rather than using the 
ER for their care.
3. Followup
    At the Medical Home Clinics our Chronic Care Coordinators provide 
phone followup with most patients who have been to the ER, or have been 
discharged from the hospital. They insure that the patient understands 
and is following the instructions that they were given. They also 
ensure that they have the medications they were prescribed, that they 
are improving, and that they have appropriate followup.
4. Extended Hours and Acute Slots
    We have extended hours at our sites, opening several mornings per 
week at 7:30, and staying open until 7 p.m. some evenings. We try to 
keep ``acute time'' open slots daily at each site. We have a policy at 
my clinic that the support staff or triage nurse can refer no pediatric 
patient to the ER without consulting a provider. Often these visits are 
appropriate for the clinic, and usually we can find a spot in even a 
``full'' schedule, or assess the situation and determine that having 
the child seen the next day would be appropriate. We are hoping to 
extend this policy to adults. We have recently implemented a system 
whereby if one of our local health centers is full, an appointment is 
found at one of the other clinics, instead of sending the patient to 
the ER.
5. Education
    During ER followup phone calls, in the case of non-urgent ER 
visits, the Chronic Care Coordinators remind patients that we are 
available to see patients on a same-day basis. They also remind 
patients that there is always an after-hour physician on call to help 
determine if ER care is required. They stress the importance of using 
the Medical Home Clinic rather than the ER whenever possible. As part 
of our nursing intake, every patient is asked about recent ER visits, 
and those reports are brought to the provider to review. This gives the 
provider a chance to discuss the appropriate use of the ER when the 
visit was not urgent.
                benefits of seeing primary care provider
    We believe very strongly that patients get the best care for most 
semi-urgent conditions when they receive care consistently at their own 
health center, and preferably by their own primary care provider. That 
is where their chronic conditions and current medications that may 
impact the acute illness are known. There is no need to repeat labs or 
studies that have been done recently, as that information is typically 
available at the health center. We screen every patient regularly for 
depression and substance abuse. Every visit with a primary health 
provider is an opportunity to be sure that all health maintenance and 
preventive measures are taken care of. Many a patient comes in with a 
``cold'' or a ``sore shoulder'' and leaves with a referral to a smoking 
cessation program, an updated tetanus vaccine, or a lab slip to check 
fasting cholesterol and blood sugar levels.
    Using the Medical Home Model, and with the unique help of our 
Chronic Health Team, we feel that we have made a significant change in 
the way we provide care in our community. We believe it is through a 
combination of improved access and improved care management, along with 
ongoing patient education, that we have begun to significantly decrease 
ER use. We expect that in the years to come we will see further 
significant decreases in the expenses for chronic illness complications 
as we continually assist our patients in improving their health.
       Attachment 1.--From the Vermont Blueprint for Health 2010 
                     Annual Report, January 2011\1\
                         Background and History
                              legislation
    The Douglas administration formally launched the Vermont Blueprint 
in 2003. The goal at the time was to address the increasing costs of 
caring for people with chronic illnesses, with an early emphasis on 
diabetes management in response to the overwhelming projected burden of 
morbidity and resource utilization. The transition to a more broadly 
defined Health Reform agent of change has occurred over time. 
Throughout the Blueprint's history, the Legislative and Executive 
branches have been critical in its support and development as follows:
---------------------------------------------------------------------------
    \1\ Full report available at: http://hcr.vermont.gov/sites/hcr/
files/final_annual_report_01_
26_11.pdf.

     2006--The Blueprint officially became law when the Vermont 
Legislature passed Act 191, sweeping Health Care Reform that also 
created Catamount Health to provide coverage to uninsured Vermonters. 
The Act included language that officially endorsed the Blueprint and 
expanded its scope and scale.
     2007--The Legislature further defined the infrastructure 
for administering the Blueprint with Act 71 and mandated ``integrated'' 
pilot projects to test the best methods for delivering chronic care to 
patients--based on the Patient Centered Medical Home model and multi-
disciplinary locally based care coordination teams (Community Health 
Teams). The original pilot sites were chosen through competitive 
request for proposals processes in 2007 and 2008 from communities that 
had been actively involved in Blueprint quality improvement 
initiatives. Voluntary payment reform to support these innovations in 
health care delivery was introduced. This transition ultimately led to 
the Advanced Primary Care Practice model now being implemented 
statewide.
     2008--Act 204 further defined the Integrated Pilots and 
officially required insurer participation in their financial support, 
which covered approximately 10 percent of the State population.
     2009--Launch of the Vermont Accountable Care Organization 
Pilot (ACO)--A project led by the Vermont Health Care Reform Commission 
(HCRC) to investigate how ACOs might be incorporated into the State's 
comprehensive health reform program.

     2010--Act 128 updates the definition of the Blueprint for 
Health as a ``program for integrating a system of health care for 
patients, improving the health of the overall population, and improving 
control over health care costs by promoting health maintenance, 
prevention, and care coordination and management.'' It also requires 
the Commissioner of the Department of Vermont Health Access to expand 
the Blueprint for Health to at least two primary care practices in 
every hospital services area no later than July 1, 2011, and no later 
than October 1, 2013, to primary care practices statewide that wish to 
participate.
 advanced primary care practice model and blueprint integrated health 
                            service program
    The Advanced Primary Care Practice model (the basis for the 
original Blueprint Integrated Pilots and subsequent expansion to the 
Integrated Health Service program) is characterized by seamless 
coordination of care. It stresses the importance of preventive health--
engaging people when they are well, as well as giving patients the 
tools to keep existing conditions from worsening. Patients are 
encouraged to become active partners in their own care, and practices 
become effective and efficient teams.
    As one of the requirements of recognition as a Blueprint IHS APCP, 
practices must meet a set of criteria for Patient Centered Medical 
Homes, established by the National Committee for Quality Assurance 
(NCQA), a non-profit organization dedicated to improving health care 
quality. Using the NCQA Physician Practice Connection--Patient Centered 
Medical Home (PPC-PCMH) recognition rubric, practices are scored on 
their compliance meeting standards related to areas such as access and 
communication, patient tracking and registry functions and advanced 
electronic communications. These evolved practices create internal 
teams, maximizing the effectiveness of their staff and expanding the 
definition of their roles within the site and beyond.
    Another key IHS requirement is to form Community Health Teams 
(CHTs)--locally based groups of multi-disciplinary practitioners that 
support patients who receive care in the associated APCPs. The teams 
are designed at the local level, informed by community-wide assessments 
of local resources and gaps, to help patients with and without chronic 
conditions adhere to preventive health guidelines.
                        payment reform figure 1
    Vermont's Integrated Health System APCP model includes two 
components of payment reform, which are applied consistently to all 
participating public and commercial insurers. Currently, fee-for-
service methodology remains intact, with the reforms below in addition.
1. Enhanced Payments to Advanced Primary Care Practices
    All insurers pay each recognized APCP an enhanced provider payment 
above the existing fee-for-service payments--calculated on a per 
patient per month (PPPM) basis--and based on the quality of the health 
care they provide as defined by the NCQA PPC-PCMH standards. In order 
to calculate payment, each insurer must count the number of their 
beneficiaries that are attributed to a practice, and multiply that by 
the PPPM amount.
2. Community Health Team Payments
    The Vermont Blueprint emphasizes that the excellent and challenging 
work of an APCP must be supported by more than just the NCQA PPC-PCMH-
triggered payments. A dedicated Community Health Team (CHT) provides 
this essential range of services. Insurers currently share the costs of 
CHTs equally. This support allows the services of a CHT to be offered 
free of charge to patients and practices, with no co-pay or prior 
authorization. Insurers provide a total of $350,000 per full CHT 
annually, which serves a general population of 20,000, with shares paid 
to a single existing administrative entity in each HSA. This combined 
funding covers the salaries of the core team, allowing for barrier-free 
access to the essential services provided. While this ``core'' CHT 
often works one-on-one with patients to meet a wide range of needs, the 
``functional'' team may be much larger, including members of other 
local individuals and organizations who work in partnership with the 
CHT and the APCP.
    Planning and refining these elements are achieved through consensus 
in the Blueprint Expansion Design and Evaluation Committee, and the 
details of implementation at the Blueprint Payment Implementation Work 
Group. Both groups are well represented by a wide variety of 
stakeholders and serve to advise the Blueprint Executive Director. (See 
Appendix II for Blueprint advisory committee membership.)
                         community health teams
    The Blueprint's cutting edge payment reforms allow for the 
innovative Community Health Teams (CHTs) to provide services free of 
charge to the APCP patients. The multidisciplinary CHT partners with 
primary care offices, the hospital, and existing health and social 
service organizations. The goal is to provide Vermonters with the 
support they need for well-coordinated preventive health services, and 
coordinated linkages to available social and economic support services. 
The CHT is flexible in staffing, design, scheduling and site of 
operation, resulting in a cost-effective, core community resource which 
minimizes barriers and provides the individualized support that 
patients need in their efforts to live as fully and productively as 
possible. The CHTs function as extenders of the practices they support, 
and their services are available to all patients (no eligibility 
requirements, prior authorizations or co-pays).
    To ascertain the local Health Service Area's specific needs, the 
local IHS workgroup identifies current health services and existing 
gaps for patients and providers in participating primary care practices 
and the surrounding community. Based on the information obtained, the 
group will build the foundation of the CHT by working together to 
determine how existing services can be reorganized and what new 
services are required.
    The overall design of the Blueprint Integrated Health Services 
model provides patients with seamless and well-coordinated health and 
human services. This includes transitioning patients from patterns of 
acute episodic care to preventive health services. Well structured 
followup and coordination of services after hospital-based care has 
been shown to improve health outcomes and reduce the rate of future 
hospital-based care for a variety of patient groups and chronic health 
conditions (e.g. reduce emergency department visits, hospital inpatient 
admissions, re-admissions). CHT members, hospital staff, and other 
community service providers work closely together to implement 
transitional care strategies that keep patients engaged in preventive 
health practices and improved self-management. A goal of the Blueprint 
model is seamless coordination across the broad range of health and 
human services (medical and non-medical) that are essential to optimize 
patient experience, engagement, and to improve the long term health 
status of the population.
    The Community Health Team serves as the central locus of 
coordination and support for patients.
                            self-management
    A central part of the Blueprint's self-management efforts has been 
the Healthier Living Workshop (HLW), Vermont's version of the evidence-
based Stanford Chronic Disease Self Management program, offered 
throughout the State since 2007. The original workshops are not 
specific to any chronic disease, but rather teach patients self-
management skills and provide a peer-support network for individuals 
with chronic conditions. HLWs empower individuals as self-managers 
through education, support and skill-building exercises, notably, goal-
setting and problem-solving.
    This year, the workshops have been expanded to more specifically 
target common problems including diabetes and chronic pain. Successful 
pilots have paved the way for broader spread statewide. Plans are also 
underway to pilot an online Healthier Living Workshop program in 
partnership with the Stanford program and the National Council on 
Aging.
    The Blueprint also helps provide clinical practices with the skills 
and resources needed to create a self-management infrastructure--and in 
conjunction with the Jeffords Center for Quality at Fletcher Allen 
Health Care, offers educational sessions that train coaches and 
practice facilitators to assist individual practices with self-
management support. This educational effort has successfully trained 
clinic-based practice coaches (``local talent'') to complement the 
EQuIP personnel.
                    health information architecture
    The Blueprint works closely with the Vermont Information Technology 
Leaders (VITL)--the State-sponsored Health Information Exchange (HIE)--
to develop infrastructure that supports the meaningful use of health 
information. The core of this infrastructure is the Blueprint's 
centralized registry and Web-based clinical tracking system: DocSite-
Covisint. The registry is used to produce visit planners that guide 
individual patient care, and to produce reports that support population 
management, quality improvement, program evaluation and comparative 
benchmarking.
    Data from the IHS APCP sites are sent to DocSite from the point of 
care, either entered manually into the Web-based portal or via 
interfaces and direct feeds. It is a major goal to facilitate the entry 
of data at the point of care while minimizing any disruptions to the 
work flow of the practice. This is a major improvement process at the 
practice level, facilitated by the EQuIP and internal practice teams.
    All aspects of the Blueprint's information architecture are 
designed to meet strict guidelines concerning data access and privacy 
protections.
   Attachment 2.--From the Improving Chronic Illness Care Web site: 
                      www.improvingchroniccare.org


                         delivery system design
Assure the delivery of effective, efficient clinical care and self-
        management support
     Define roles and distribute tasks among team members.
     Use planned interactions to support evidence-based care.
     Provide clinical case management services for complex 
patients (2003 update).
     Ensure regular followup by the care team.
     Give care that patients understand and that fits with 
their cultural background (2003 update).

    Improving the health of people with chronic illness requires 
transforming a system that is essentially reactive--responding mainly 
when a person is sick--to one that is proactive and focused on keeping 
a person as healthy as possible. That requires not only determining 
what care is needed, but spelling out roles and tasks for ensuring the 
patient gets care using structured, planned interactions. And it 
requires making followup a part of standard procedure, so patients 
aren't left on their own once they leave the doctor's office. More 
complex patients may need more intensive management (care or case 
management) for a period of time to optimize clinic care and self-
management. Health literacy and cultural sensitivity are two important 
emerging concepts in health care. Providers are increasingly being 
called upon to respond effectively to the diverse cultural and 
linguistic needs of patients.
                            decision support
Promote clinical care that is consistent with scientific evidence and 
        patient preferences
     Embed evidence-based guidelines into daily clinical 
practice.
     Share evidence-based guidelines and information with 
patients to encourage their participation.
     Use proven provider education methods.
     Integrate specialist expertise and primary care.

    Treatment decisions need to be based on explicit, proven guidelines 
supported by clinical research. Guidelines should also be discussed 
with patients, so they can understand the principles behind their care. 
Those who make treatment decisions need ongoing training to stay up-to-
date on the latest evidence, using new models of provider education 
that improve upon traditional continuing medical education. To change 
practice, guidelines must be integrated through timely reminders, 
feedback, standing orders and other methods that increase their 
visibility at the time that clinical decisions are made. The 
involvement of supportive specialists in the primary care of more 
complex patients is an important educational modality.
                      clinical information systems
Organize patient and population data to facilitate efficient and 
        effective care
     Provide timely reminders for providers and patients.
     Identify relevant subpopulations for proactive care.
     Facilitate individual patient care planning.
     Share information with patients and providers to 
coordinate care (2003 update).
     Monitor performance of practice team and care system.

    Effective chronic illness care is virtually impossible without 
information systems that assure ready access to key data on individual 
patients as well as populations of patients. A comprehensive clinical 
information system can enhance the care of individual patients by 
providing timely reminders for needed services, with the summarized 
data helping to track and plan care. At the practice population level, 
an information system can identify groups of patients needing 
additional care as well as facilitate performance monitoring and 
quality improvement efforts.
                        self-management support
Empower and prepare patients to manage their health and health care
     Emphasize the patient's central role in managing their 
health.
     Use effective self-management support strategies that 
include assessment, goal-setting, action planning, problem-solving and 
followup.
     Organize internal and community resources to provide 
ongoing self-management support to patients.

    All patients with chronic illness make decisions and engage in 
behaviors that affect their health (self-management). Disease control 
and outcomes depend to a significant degree on the effectiveness of 
self-management.
    Effective self-management support means more than telling patients 
what to do. It means acknowledging the patients' central role in their 
care, one that fosters a sense of responsibility for their own health. 
It includes the use of proven programs that provide basic information, 
emotional support, and strategies for living with chronic illness. 
Self-management support can't begin and end with a class. Using a 
collaborative approach, providers and patients work together to define 
problems, set priorities, establish goals, create treatment plans and 
solve problems along the way.
     Attachment 3.--From The NCQA Web Site, at http://www.ncqa.org
    NCQA's initial Physician Practice Connections--Patient-Centered 
Medical HomeTM (PPC-PCMH) program reflects the input of the 
American College of Physicians, American Academy of Family Physicians, 
American Academy of Pediatrics and American Osteopathic Association and 
others in the revision of Physician Practice Connections to assess 
whether physician practices are functioning as medical homes. Building 
on the joint principles developed by the primary care specialty 
societies, the PPC-PCMH standards emphasize the use of systematic, 
patient-centered, coordinated care management processes.
    NCQA's Patient-Centered Medical Home (PCMH) 2011 is an innovative 
program for improving primary care. In a set of standards that describe 
clear and specific criteria, the program gives practices information 
about organizing care around patients, working in teams and 
coordinating and tracking care over time. The NCQA Patient-Centered 
Medical Home standards strengthen and add to the issues addressed by 
NCQA's original program.
    The Patient Centered Medical Home is a health care setting that 
facilitates partnerships between individual patients, and their 
personal physicians, and when appropriate, the patient's family. Care 
is facilitated by registries, information technology, health 
information exchange and other means to assure that patients get the 
indicated care when and where they need and want it in a culturally and 
linguistically appropriate manner.
    There are six PCMH 2011 standards, including six must pass 
elements, which can result in one of three levels of recognition. 
Practices seeking PCMH complete a Web-based data collection tool and 
provide documentation that validates responses.



   Attachment 4.--From the Vermont Blueprint for Health 2010 Annual 
                        Report, January 2011 \2\


      
---------------------------------------------------------------------------
    \2\ Full Report available at: http://hcr.vermont.gov/sites/hcr/
files/final_annual_report_01_
26_11.pdf.



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

    Senator Sanders. Thank you very much, Dr. Kraus.
    If it is OK with Senator Paul, I would like to turn the mic 
over to Senator Whitehouse to make a comment and ask questions, 
if you would like.

                    Statement of Senator Whitehouse

    Senator Whitehouse. I would love to followup a little bit 
with Dr. Kraus. First of all, I hope you enjoyed your time at 
Brown University in wonderful Rhode Island.
    Senator Merkley. And at OHSU.
    Senator Whitehouse. I'm sorry?
    Senator Merkley. And at OHSU.
    Senator Whitehouse. I wanted to ask you a little bit more 
about your experience with electronic health records and 
integrating them into your practice, how effective have they 
been, have you been able to integrate your electronic health 
record with the local pharmacy, the local hospital, and other 
local specialists. Have you been able to begin to exchange any 
data? Just sort of give us an update on how that is going.
    Rhode Island is doing a pretty good job. We are hoping that 
we will have an actual health information exchange set up 
shortly that can do that, we already have a health information 
exchange operating on a trial basis. But I know Vermont has 
done a lot of work and as a practitioner who works with it 
every day I would love to hear your thoughts.
    Dr. Kraus. We, for a small rural town, have a very advanced 
integrated electronic medical system. All except one private 
practitioner of our practices use an electronic health record. 
We have an electronic record at the hospital and we have data 
that is automatically downloaded from the hospital labs and x-
rays and specialists that come directly into our electronic 
health medical record.
    We are working on and have recently started inputting our 
data to an entire statewide information center. From that we 
are now able to pull very helpful patient management reports. 
So, I send all my lab work, my blood pressures, my foot exams, 
my eye exams and at the touch of a finger I can immediately get 
a report of what percentage of my patients who have diabetes 
are meeting targets; I can run a list of those patients who are 
overdue for a retinal exam; I can run a list of those patients 
who are at poorest control so that we can case manage them. So 
our electronic health record system is working very efficiently 
at this time.
    As I mentioned, using the electronic health record allows 
us to, at every visit, have the essential information about the 
patient at our fingertips and also it can take a patient who 
has multiple medical issues, diabetes and asthma and heart 
disease, and the system knows that they have all those issues 
and can highlight to us, this patient is overdue for a eye exam 
and for a flu shot and for an echocardiogram, all within one 
system. So it is very efficient and has been very helpful.
    Senator Whitehouse. In terms of the finances of your 
practice, how is this paid for? Did you get support from the 
Federal Government in the Recovery Act? Does Vermont have a 
program that supports this? Does your insurance company help 
with it or did you do this on your own?
    Dr. Kraus. I work for a federally qualified health center, 
so it has been through the----
    Senator Whitehouse. So it goes through the community health 
center?
    Dr. Kraus. There have been grants in the State to help 
clinics to improve their use of electronic medical records. We 
bought the system ourselves but there has been some help to 
improve the way that we use it and to integrate it with the 
State information system.
    Senator Whitehouse. Do you have a private practice outside 
or do you practice through the community health center?
    Dr. Kraus. I guess I would like to make clear, I work for a 
federally qualified health center.
    Senator Whitehouse. Yes.
    Dr. Kraus. We provide 40 to 50 percent of care in my 
community, the other 40--there is another clinic that is a 
rural health center that is also funded that provides 40 to 50 
percent of care in my community. We have about 50 to 60 percent 
of our patients in our community who have Medicare or Medicaid, 
about 40 percent of our patients are private. So my private 
practice is my Federal health center, that is the way--I see 
patients who are poor and have no insurance, I also see 
bankers, I see lawyers. I take care of everybody. We are the 
community health center for everybody.
    Senator Whitehouse. Understood. Let me just close, my time 
is running out. I want to thank Senator Sanders for holding 
this very important hearing. He has shown a lot of leadership 
in this area.
    I just want to add that in Rhode Island our experience has 
also been that there has been really considerable leadership 
shown by these community health centers in terms of developing 
an electronic health record system and utilizing the 
efficiencies that it allows, as well as the improvements in 
patient care, and the improvements in doctor awareness of 
medical information. Although it was a chore for them to get 
through the initial adoption process, if you go to the 
Thundermist Health Center in Woonsocket which is probably one 
of our leaders on this, and you tried to take away their health 
information technology, you would have a war on your hands. 
They really see the value of it.
    Senator Sanders. You would need emergency care treatment, 
is what you are saying?
    Senator Whitehouse. You would need emergency care 
treatment, exactly.
    [Laughter.]
    Senator Sanders. OK.
    Senator Whitehouse. Thank you very much, Doctor.
    Senator Sanders. Thank you very much.
    Senator Merkley.

                      Statement of Senator Merkley

    Senator Merkley. Thank you, Mr. Chair. Dr. Kraus, do you 
have any plans to go to Kentucky?
    Dr. Kraus. I am quite happy in Vermont. Thank you.
    Senator Merkley. I am just struck by the fact that you have 
been at Oregon Health Sciences University and then--did I catch 
that right?
    Dr. Kraus. Yes.
    Senator Merkley. And then at Brown University, now serving 
in Vermont, so----
    [Laughter.]
    Senator Merkley [continuing]. Only one stop left for this 
panel.
    When you mentioned the same-day appointments, I thought, 
that is certainly different than the stories I hear from folks 
every day about the challenge of getting in the front door of 
the health care system where they may call with a concern and 
find that the only appointment they can get is months out, 
which could drive them to seek care in an emergency room, 
potentially.
    How have you been able to accomplish that kind of 
flexibility and capacity?
    Dr. Kraus. It can be a dilemma for this, in fact, we are 
struggling at this point to convince our administration to keep 
our same day appointments, because what happens is if you leave 
appointments and they aren't filled, then that is not very good 
for the bottom line. So there always has to be a very careful 
balance to book enough patients.
    But we, for example, we have a policy in my clinic that no 
child ever goes to the emergency room without that being run by 
a provider. So if a triage nurse takes a call or a front staff 
person takes a call about a kid, they are either offered an 
appointment today, whether we have space or not, and if the 
staff feel that there is no space it is run by a provider and 
we can often make a decision that we know the family, we know 
the child, they can be seen tomorrow or we will say, just bring 
them in. It is usually a quick visit, we don't want our kids to 
go to the emergency room. We are trying to extend that to 
adults as well, that we would never say to a patient we cannot 
see you today.
    Senator Merkley. I certainly applaud that vision and the 
fact that you have been able to make it work on the ground.
    I also wanted to ask you, on your community health teams, 
do you have a changing role in terms of the types of 
responsibility nurses and nurse practitioners carry or any kind 
of insights there that would be helpful to us?
    Dr. Kraus. Our nurse practitioners have and always have 
really had an independent practice. I know that in some 
practices everybody has to have a primary care doctor and then 
if they have an acute illness or they have a physical and they 
don't have complicated issues, then they see the nurse 
practitioner. Our nurse practitioners in our clinic have their 
own complex panels of patients. If they have a patient that 
they feel has so many complexities and they are feeling 
overwhelmed, they will transfer the care to a physician, but 
they really work equally with us. They certainly ask us 
questions about our patients.
    Senator Merkley. When someone calls needing an appointment, 
how is it determined, internally, whether this person should go 
to a nurse practitioner or to a doctor, for example?
    Dr. Kraus. We are all primary care providers, that is why I 
don't use the term primary care physician, I use the term 
primary care provider. My kids see my nurse practitioner as 
their primary care provider. The first option is always to have 
an appointment made with the patient's primary care provider, 
if possible. If that person is not available, then with one of 
the others of us.
    Senator Merkley. So there is a provider assigned to each 
patient?
    Dr. Kraus. Absolutely. We all have our separate panels but 
we have access to each other's notes and certainly are able to 
see each other's patients if the opportunity is needed. But we 
try and have patients see their own provider as much as 
possible.
    Senator Merkley. Thank you.
    Now Dr. Cunningham, you noted that sometimes hospitals 
resist shifting care out of emergency departments, as I 
gathered because of financial reasons. That suggests that 
perhaps the high cost at an emergency room is probably related 
to the structure and the services provided but partly just 
related to a pricing structure within the institution, in which 
case shifting folks out of an emergency room we may be 
overstating the savings. Is that a possibility?
    Mr. Cunningham. I think some of the estimates about the 
savings on a per visit basis may be a little bit high because 
it is hard to compare on an apples to apples basis, because the 
intensity of visits in an emergency room tend to be higher. I 
think the studies that have really tried to make an apples to 
apples comparison have shown that it is maybe two to three 
times higher in an emergency room. But then you also have to 
consider the downstream cost savings that if you get people 
into a medical home and you get better continuity of care there 
could be additional savings down the road, so it is kind of 
hard to estimate exactly what the total cost is. But, you know, 
it is difficult even on a per visit basis to do so.
    Senator Merkley. I want to thank you all for the work you 
are doing and I am out of time, but Dr. Eck, I will be 
interested in following up to understand better, if the law was 
changed, how much expansion of volunteer time you think would 
occur and the overall impact it might have. Thank you all.
    Senator Sanders. OK. Thank you, Senator Merkley.
    Senator Paul.
    Senator Paul. Thank you. Miss Draper, are you familiar with 
the Hyde amendment?
    Ms. Draper. No, sir, I am not.
    Senator Paul. The Hyde amendment is an amendment that has 
been around since the 1970s that prohibits Federal money from 
being spent on abortions. According to the Alliance Defense 
Fund, which I would like to insert the comments from them into 
the record, there is evidence that money for community health 
centers is actually going to abortion providers.

    [The information referred to above can be found in 
additional material.]

    The specific example they bring up is the Institute for 
Family Health in New York City which gets millions of Federal 
dollars but also is listed by NARAL as a pro-choice abortion 
site of recommendation by NARAL in New York City. I think it is 
illustrated by Dr. Kraus' testimony that there is not really a 
distinction between community health centers and private 
practice. Her private practice and her community health center 
are located in the same venue. I am not saying she does, but it 
sounds like there are people around the country who are using 
that money basically to provide for a center that also performs 
abortion. I think the division between what is private practice 
and what is community center is very hard to delineate and 
separate and I find it troubling that I think this goes against 
the spirit and actually probably the letter of the law with 
regard to the Hyde amendment.
    I was wondering if the GAO has any mechanism for looking 
into whether Federal funding is being used in community health 
centers for abortions.
    Ms. Draper. We have not looked at that, as far as I know. 
This particular study was looking at strategies that health 
centers have implemented to really divert the non-urgent use of 
emergency departments.
    Senator Paul. Can you look into that for me and give me an 
answer as to whether or not Federal funding is going to pay for 
abortions at community health centers?
    Ms. Draper. We can talk about that after the hearing if 
that works for you.
    Senator Paul. Yes, I would like to have that information 
and if the GAO could send that to me.
    Another question for Miss Draper is that it looks like when 
you look at the statistics on these community health centers, 
72 percent of the patients arriving at them have insurance, 
Medicare, Medicaid and private insurance. So we are looking at 
38 percent that you are helping that have no other venue. My 
question is, it seems to me that you have a 72 percent 
duplication rate with other providers who would be providing 
these services. Many other doctors are taking Medicare, many of 
them are taking Medicaid, many of them are taking private 
insurance, so once again, when we look at a budget that is $2 
trillion over budget, do we really need to be duplicating 
services that are available in the private sector?
    Ms. Draper. According to a 2009 UDS--Uniform Data System--
data from HRSA, about 80 percent of the patients that are seen 
in community health centers, overall, are either uninsured or 
have Medicaid. The remaining 20 percent are Medicare or 
privately insured.
    Senator Paul. I guess that contradicts data that we have 
from the government, from the Health and Human Resources that 
shows 72 percent being Medicaid, Medicare or other private 
insurance and that only about 38.2 percent are uninsured. The 
other thing is that a lot of this can be siphoned off, in a 
sense Dr. Kraus gives a perfect example of what is part of her 
clinic and what is not part of her clinic. The patients she 
sees with insurance are not part of the clinic and the ones 
that are, so it would look like she would have a very high 
percentage in that case. But, according to the statistics from 
the Health and Human Resources, 72 percent of these people have 
insurance of one form or another and it would appear to me that 
we are duplicating a process where there is also a private 
sector alternative.
    I would like to take the remainder of my time to thank Dr. 
Eck for coming today. I think her story is incredible. I think 
that we really have gotten to the point in our society where we 
do not differentiate between charity of the heart, really 
giving voluntary, and people who are simply working for the 
government. Those who would give of their time voluntarily, I 
think earn a great deal of respect and deserve our respect and 
admiration. Also really the idea that a lot of this could be 
done through the private world. We have had government crowding 
out charity now for decades and the idea that this can be done, 
I know it from firsthand in my experience with the Lions Eye 
Clinic in my practice, and I commend Dr. Eck and thank you very 
much for coming.
    Senator Sanders. Thank you very much, Senator Paul.
    Let me just, for the record, pick up on a point that 
Senator Paul raised. The Hyde amendment simply prohibits 
abortions being performed by facilities that receive Federal 
funding. To my understanding there have been a number of 
studies which suggest that FQHC's, which do receive--community 
health centers, which do receiving Federal funding, do not 
perform abortions. Period. That is my understanding.
    Let me go to Dr. Kraus, because she comes from the State of 
Vermont. Why not.
    [Laughter.]
    I would like to mention to folks that the area that she and 
her clinic are in is one of the lowest income areas in the 
State of Vermont, it is the northeastern part of our State, we 
call it the Northeast Kingdom. A lot of folks there are working 
at low wage jobs. There is an agency there, an FQHC, one of the 
very first in the State of Vermont, started by the gentleman 
behind me, David Reynolds, who now works for me.
    One of the interesting things, and Dr. Kraus correct me if 
I am wrong, is that in one of the poorest parts of a rural 
State because of the FQHC's there, and I think you have what, 
six locations now? Six locations in small towns. They have gone 
a very long way to solve the crisis of primary health care 
access which exists in many parts of the country. Is that a 
fair statement, Dr. Kraus?
    Dr. Kraus When you look at our quality measures compared to 
other places across the country they are improved. If you look 
at our ER visits and our hospitalization rates, they are 
declining whereas in areas of the State that have not 
instituted the sort of changes that we have made they are 
raising or staying stable. We have more advanced use of the 
electronic health record than in most parts of the State and 
the country.
    Senator Sanders. But what I am getting at, if we were to 
talk about that region of the State of Vermont, called the 
Northeast Kingdom, people would tell you there are a lot of 
problems that exist. Right? We don't have enough jobs, wages 
are too low, etc. Probably people would not say that access to 
primary health care is one of the major issues, despite the 
fact that it is one of the lowest income areas of the State. Is 
that a fair statement?
    Dr. Kraus. I think we do a wonderful job of trying to get 
patients in to see their primary care providers.
    Senator Sanders. So the point here is that in a rural area, 
in a low-income area we have gone a long way through the 
establishment of six satellite programs to provide quality, 
cost-effective health care to the people of that area.
    I know Senator Paul mentioned before, I think picking up on 
a point that Dr. Eck made about smiles when somebody walks in 
the door. I have been to every one of the clinics in the 
Northeast Kingdom, and you know what, they smile there too. I 
don't think Dr. Kraus sees herself as a government worker. I 
think she is working very hard along with the other physicians 
and nurses and medical personnel there who have great spirit. I 
have been to all of the clinics and they do a great, great job.
    Dr. Kraus, I want to ask you one brief question. I want to 
get to Dr. Eck in a second. Talk a little bit, because in a 
sense the thrust of the hearing today is how we provide quality 
care and try to save money, both for taxpayers as well as the 
overall system, in terms of keeping people out of the hospital. 
I know the hospital up there, my son was born there 42 years 
ago, so I know the hospital in St. Johnsbury. How are you doing 
that and is it working?
    Dr. Kraus. When you look at the outcomes, the numbers--for 
example, there was a study looking at Medicaid patients 
specifically and in our community, as well as in the other 
pilot community that has had a medical home and a community 
health team, there has been a significant bending of the curve. 
There was a steady increase in costs taking care of Medicaid 
patients. When we looked at our two communities there was a 
significant decrease in that steady increase. That was seen 
also, but not as too much of an extent, in the one community 
that has only had this grant for 1 year. When they looked at 
nonpilot sites across the State, the Medicaid costs continued 
on the same projection. So there was evidence that what we have 
been doing started to significantly decrease the costs of care, 
at least for Medicaid patients.
    In the private sector they did a per member/per month 
analysis and showed that we had an 11 percent decrease in the 
per member/per month costs of caring for patients. This was a 
$48 cost--$48 decrease per member in the communities where we 
had this team. It costs the State about $4 per member/per team 
in running the community health team and in extra reimbursement 
that we get at the pilot sites per member/per month. So they 
got a $48 saving for a $4 investment. This is the private 
insurers.
    We feel that our community health team that really helps 
patients to navigate the system so that they are able to 
decrease barriers to getting excellent health care has really 
helped, so that we are decreasing emergency room, both non-
urgent emergency room costs by being open and also by keeping 
people healthier so they are no longer needing to use the 
emergency room or the hospital.
    Senator Sanders. OK, thanks.
    Let me ask Ms. Draper and then maybe Dr. Cunningham. I want 
to get to Dr. Eck in one second. I am going to give the mic 
over to Senator Paul when I am finished.
    Is it fair to say that honest people can have differences 
of opinion ascertaining what is, in fact, utilization of 
emergency rooms, whether it is for a true emergency or not? In 
other words, we can agree that if somebody got shot it is an 
emergency. If somebody has a common cold, it is not an 
emergency. But there is a lot of gray area in between that.
    The report, the GAO report that we looked at suggested that 
maybe 8 percent, as I recall, of utilization in emergency rooms 
were nonemergent. I have heard statistics which go as high as 
50 percent. Is it fair to say that there may be some 
differences of opinion as to the extent of nonemergency use of 
emergency rooms?
    Ms. Draper. I think that is fair to say. The non-urgent 
classification is really someone who needs to be seen within 2 
to 24 hours. It is not that the care that they receive in the 
emergency room--it is not inappropriate care, but they may have 
been able to be seen somewhere else at a more cost-effective 
setting.
    Senator Sanders. OK. Dr. Cunningham, did you want to 
comment on that?
    Mr. Cunningham. Yes, I would agree. I think about 15 
percent of visits are visits that need to be seen, either 
immediately or within 15 minutes. The emergency----
    Senator Sanders. What are your--I'm sorry, 15 or 50?
    Mr. Cunningham. Fifteen percent----
    Senator Sanders. Fifteen, yes.
    Dr. Cunningham [continuing]. Are true emergencies in that 
sense. So yes, there is a whole range of visits that fall into 
the urgent and the semi-urgent category. I think probably where 
you see the differences in terms of the estimates or where 
people say that it is appropriate or not--or inappropriate, 
probably reflects that group. I think furthermore, whether it 
is appropriate or inappropriate probably depends on whether 
there is other resources in the community for people to go to. 
If it is 3 a.m. on a Sunday morning and there is no other place 
to go, well I don't think it would--most people would say it is 
inappropriate to go to the ER for maybe a semi-urgent problem.
    Senator Sanders. OK. Thanks.
    Let me just ask Dr. Eck a question. First of all, thank you 
very much for what you do. Your volunteer activities are much 
appreciated.
    Let me ask you this, in a sense, philosophical question. We 
have gone a little bit into philosophy today. I believe, many 
people in my own State believe that health care is a right, R-
I-G-H-T, regardless of income. That every American has the 
right to the best quality health care that the system can 
offer, regardless of income. That if you are a low-income kid, 
or you are a wealthy kid, you have the same opportunity to 
access the health care system. Do you believe that?
    Dr. Eck. I believe that every person ought to get good 
health care. The Hippocratic Oath says that I would provide 
health care regardless of whether the person pays me or not. I 
definitely believe that people need health care. The question 
is how do we do that.
    Senator Sanders. If I may? I will give you a chance to 
respond. We all know people do need health care when they get 
sick. But is it a right? Should all people, regardless of 
income, have access to the same quality system or should we 
have a two-tier or three-tier system, in your judgment?
    Dr. Eck. If health care is a right then so is food care and 
shelter care and clothing care. Food, clothing and shelter I 
think are at least as important as health care and yet we don't 
expect the government to provide food, clothing and housing to 
everybody.
    Senator Sanders. Not to everybody we don't, but we do have 
a food stamp program which does provide to low-income people.
    Dr. Eck. When you call something a right--it is different 
to have a right--a freedom to act and to do what is best for 
one's family in a free America, it is another thing to have 
your rights impose obligations on other people. That is a whole 
different philosophy, and I am not so sure that is what the 
Constitution guarantees.
    Senator Sanders. OK. Let me ask you this, and I have gone 
on too long, I am going to give it over to Senator Paul.
    Again, I applaud you for your free services and your 
volunteer efforts, but don't you think it is a little bit 
apples to oranges to say that, if somebody does something for 
nothing obviously the cost is going to be lower than somebody 
who is paid. A physician is usually paid, nurses are paid, 
surgeons are paid. Two questions--I mean isn't that basically 
true? Second of all, it is one thing to run a primary health 
care free clinic, as important as that is. Somebody walks into 
your office, they are diagnosed with cancer, they have to go to 
a hospital for an extensive number of tests and treatments 
which could run up tens of thousands of dollars. How does that 
person pay for that in a free clinic environment?
    Dr. Eck. In the United States you will notice people aren't 
dying on the street. People are taking care of patients and 
people are coming down with cancer, have no insurance, they are 
getting medical care. The hospitals absorb it, the oncologists 
take care of them for free. That is already being done. It is 
not as bad as it sounds.
    What we are suggesting though is what we have in this 
country is patients are taking on the liability of patient--or 
physicians are taking on the liability of taking care of 
patients who are not paying them, and yet the liability is 
huge. And that is why the whole idea of the malpractice 
coverage in exchange for free care.
    I have spoken with physicians, informally and I have done 
internal polls. I will send out an email--Survey Monkey--and 
ask them, would you do this, would you provide 4 hours a week 
of free care in a nongovernment free clinic where you get no 
compensation. Every specialty says yes, they would do it in a 
heartbeat. I am suggesting that neurosurgeons maybe do two 
cases a month, maybe an obstetrician do two deliveries a month 
for free and that would account for their post-op time. They 
all say that they would be happy to do that.
    So we are talking no money, we are not going to--it is 
free. How can you argue with free? And it is universal access. 
How can you agree with that? It sounds like something on your 
side of the alley.
    Senator Sanders. OK. Thanks very much.
    I have gone over my time. I am going to give the mic over 
to Senator Paul.
    Senator Paul. Thank you very much.
    With regard to the idea of whether or not you have a right 
to health care, you have to realize what that implies. It is 
not an abstraction. I am a physician, that means you have a 
right to come to my house and conscript me. It means you 
believe in slavery. It means that you are going to enslave not 
only me but the janitor at my hospital, the person who cleans 
my office, the assistants who work in my office, the nurses. If 
you have a right to their services basically once you imply a 
belief and a right to someone's services, do you have a right 
to plumbing, do you have a right to water, do you have a right 
to food, you are basically saying that you believe in slavery. 
You are saying you believe in taking and extracting from 
another person.
    Our founding documents were very clear about this. You have 
a right to pursue happiness, but there is no guarantee of 
physical comfort, there is no guarantee of concrete items. In 
order to give something concrete or someone's service, you have 
to take it from someone. So there is an implied threat of 
force.
    If I am a physician in your community and you say you have 
a right to health care, do you have a right to beat down my 
door with the police, escort me away and force me to take care 
of you? That is ultimately what the right to free health care 
would be. If you believe in a right to health care you are 
believing in basically the use of force to conscript someone to 
do your bidding.
    Now just because it is a noble thing to believe that we are 
obligated, as Christians, we are obligated through the 
Hippocratic Oath, we have always done this. Since the beginning 
of modern medicine we have always provided 100 percent access. 
I do it in exchange for privileges. I do it because I believe 
in the Hippocratic Oath, but my hospital also says to me, ``You 
can only operate in this hospital if you agree to see everyone 
coming through the emergency room.'' I always have. We have 
always treated. We have always had 100 percent access through 
our emergency room. Those were for emergencies, they are not 
the best place for primary care, we all agree with that, but we 
have always had 100 percent free access.
    Going back to one specific question with Dr. Kraus, do you 
receive, personally, more money because you work in a Federal 
clinic? Do you get higher Medicare and Medicaid reimbursements 
to you personally for working in a health clinic?
    Dr. Kraus. Me personally, I think I get well below the 
national average for an annual income of a primary health 
provider.
    Senator Paul. But do you specifically get more from 
Medicare and Medicaid because you have a health clinic?
    Dr. Kraus. Me, personally?
    Senator Paul. When you have billed--do you, as a physician, 
get a higher rate because you work in a health clinic? I 
believe the answer is yes.
    Dr. Kraus. I am paid by a salary. The health center is 
reimbursed at a higher rate, but me as a salaried position is 
given the same salary that I would--I also would note, that I 
was taught to be self-sufficient and hardworking, that is how I 
was brought up. When I look at our budget and I see that there 
is a big component of my budget coming as a grant from the 
Federal Government, that doesn't make me happy. The reason that 
I am getting that grant, however, is because the current health 
care system is not reimbursing primary care adequately in the 
first place. If there was adequate reimbursement for primary 
care physicians in the first place, then we wouldn't require 
the extra funding for a federally qualified health center.
    Senator Sanders. This is going to be an interesting year, I 
will tell you that.
    [Laughter.]
    I think it is fair to say that Senator Paul and I have some 
slight philosophical differences.
    All right. My profound question to Dr. Kraus is, do you, as 
an employee at a federally qualified health center consider 
yourself as a slave?
    [Laughter.]
    Dr. Kraus. I love my job. I chose there. I do not feel like 
a slave. Thank you.
    Senator Sanders. Ms. Draper, the implication, again from my 
friend Senator Paul, is that we have kind of solved the problem 
of health care access in America, that any place in the 
country, I guess anybody who has a problem, if you are on 
Medicaid, if you have no health insurance, maybe if you have 
health insurance, you can just walk in the door tomorrow and 
find a doctor to treat you. Is that true, in your judgment?
    Ms. Draper. There is a huge body of literature that 
discusses the difficulties, particularly Medicaid beneficiaries 
have to finding a physician. There are many physicians who are 
unwilling to accept Medicaid patients and also for those who 
are uninsured face equally challenging or maybe more so 
challenging access issues.
    I think you can look at the experience in Massachusetts 
with reform and, the issue there is that wait times have 
increased for people who have already had insurance and even 
more so for those who are newly insured. I think I saw one 
study where the wait times had doubled from 17 days to 30-some 
days for people that are with reform.
    There are some lessons learned. I think there is a Kaiser 
Family Foundation study that talked about some lessons learned 
from the Massachusetts' experience and a couple of those are 
that, when you have insurance coverage initiatives, that there 
will be a higher demand for primary care services--particularly 
from low-income and underserved communities and also that there 
needs to be an investment in primary care. We see in many parts 
of the country that there are major shortages of primary care 
physicians. Those are some of the lessons from the 
Massachusetts' experience.
    Senator Sanders. All right. My last question is for Dr. 
Kraus, again picking up on Senator Paul's comment. As you know, 
Vermont is moving toward a Medicare for all single payer 
approach. Are you worried that if we consider health care as a 
right in the State of Vermont that the St. Johnsbury Police 
Department, in the middle of the night, is going to break down 
your door and force you to treat a patient. Is this an 
immediate concern of yours?
    Dr. Kraus. No.
    Senator Sanders. OK. Thank you.
    I want to thank Senator Paul for being here. It was a 
provocative, interesting discussion. I want to thank mostly the 
panelists for being here. I think we are discussing an issue of 
great important. Again, thank you all for your participation.
    The meeting is now adjourned. The record is open for 10 
days for any additional comments.
    Thank you. The meeting is adjourned.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

     Prepared Statement of Matthew S. Bowman, Esq., Legal Counsel, 
                      Alliance Defense Fund (ADF)
    I write to discuss the occurrence of abortions and illegally 
compelled participation in services such as abortion at Federally 
Qualified Community Health Centers (hereinafter FQHCs) that receive 
Federal funding from section 330 of the Public Health Service Act as 
well as from various other Federal sources.
              1. fqhcs can perform abortions, and some do
    Despite some public comments to the contrary, FQHCs can and do 
perform abortions. For example, the Institute for Family Health in New 
York, NY is an FQHC and its cluster of clinics have received millions 
of Federal dollars annually for many years. The abortion advocacy 
organization NARAL Pro-Choice New York lists the Institute for Family 
Health Sidney Hillman Family Practice and Phillips Family Practice as 
performing surgical and medical abortions.\1\ The Institute for Family 
Health's Web site also indicates that one ``Sidney Hillman'' clinic 
doctors works at Planned Parenthood.\2\
---------------------------------------------------------------------------
    \1\ See http://prochoiceny.org/boc/sect3_4.shtml (last viewed on 
May 6, 2011).
    \2\ See http://www.institute2000.org/health/manhattan/hillman.htm 
(last viewed May 6, 2011).
---------------------------------------------------------------------------
    This is merely one example. Another abortion advocacy group, the 
Reproductive Health Access Project, provides detailed guidance on the 
ways in which FQHCs can perform abortions while working around some 
restrictions relating to their Federal funding.\3\ FQHCs have many 
referral and other connections with abortion providers, such as in 
South Carolina, where Planned Parenthood boasts that the founder of 
PP's Aiken County clinic, Margaret Weston, went on to found local FQHCs 
under the name of the Margaret J. Weston Community Health Centers.\4\
---------------------------------------------------------------------------
    \3\ See http://www.reproductiveaccess.org/getting_started/faq.htm 
(last viewed on May 6, 2011).
    \4\ See http://www.plannedparenthood.org/health-systems/history-
28077.htm (last viewed May 6, 2011).
---------------------------------------------------------------------------
    2. fqhcs might be using federal money for abortions and related 
                                services
    Several Federal law loopholes apparently allow FQHCs to use Federal 
funds to pay for abortions and related services, and FQHCs may already 
be doing so. For example, the above-mentioned Institute for Family 
Health in New York has already received Federal funding under the 
``Affordable Care Act Teaching Health Center (THC) Graduate Medical 
Education (GME) Payment Program.'' Nothing in the Patient Protection 
and Affordable Care Act of 2010 (PPACA) prohibits the funds directly 
appropriated under PPACA from being used for abortions. Such 
restrictions on PPACA appropriated funds were proposed but rejected in 
the legislative process.
    The Hyde amendment, an annual Labor/HHS appropriations rider,\5\ 
prohibits using funds from that appropriations package on any abortion 
or on health coverage that includes coverage of abortion. But the Hyde 
amendment does not apply to funds appropriated directly to PPACA 
including $11 billion that PPACA directly appropriates for FQHCs. 
(Although the Hyde amendment does apply to any funds in the same trust 
fund as Hyde-applicable funds, PPACA creates a separate trust fund for 
its FQHC funds. PPACA, 10503.) And even if an entity gets funds to 
which the Hyde amendment does apply, such as section 330 funds, the 
amendment does not prohibit the entity from performing abortions--it 
only prohibits the entity from expending Hyde-applicable funds on any 
abortion.
---------------------------------------------------------------------------
    \5\ See, e.g., Omnibus Appropriations Act, 2010, Div. D, tit. V,  
507.
---------------------------------------------------------------------------
    President Obama's Executive Order 13535 issued in connection with 
PPACA does not fix this loophole. The order states, ``I hereby direct 
the Secretary of HHS to ensure that program administrators and 
recipients of Federal funds are aware of and comply with the 
limitations on abortion services imposed on CHCs by existing law.'' But 
in ``existing law,'' the Hyde amendment does not restrict PPACA-
appropriated funds.
         3. fqhcs claim to be violating federal conscience laws
    A leading FQHC advocacy organization recently told the Department 
of Health and Human Services that its FQHCs are apparently forcing 
their employees to assist abortion-related activities and other 
practices in violation of longstanding Federal conscience statutes.
    The National Association of Community Health Centers (NACHC), whose 
Web site claims to represent at least 1,250 CHCs around the country, 
sent a letter in September 2008 asking that HHS not require its FQHCs 
to comply with Federal statutes that are applicable to them. Those laws 
require FQHCs not to force their employees to violate their 
conscientious beliefs. NACHC declared that if the centers were actually 
made to comply with these Federal statues, patients would be deprived 
of ``access'' to services that their FQHCs are providing.\6\
---------------------------------------------------------------------------
    \6\ See http://www.nachc.com/client/documents/
Provider%20Conscience%20Role%20Comments
%209.25.08.pdf (last accessed on May 6, 2011).
---------------------------------------------------------------------------
    For example, FQHCs, by virtue of their receipt of funds of section 
330 and/or Title X of the Public Health Service Act, must comply with 
42 U.S.C. 300a-7(d), which prohibits the FQHCs from requiring any 
``individual'' to ``perform or assist in the performance of any part of 
a health service program . . . funded in whole or in part'' by the HHS 
funds, ``if his performance or assistance in the performance of such 
part of such program or activity would be contrary to his religious 
beliefs or moral convictions.'' Moreover, by virtue of the Weldon 
amendment (attached to Labor/HHS appropriations at 508), FQHCs that 
participate in Federal programs funded by HHS cannot ``subject[] any 
institutional or individual health care [professional] to 
discrimination on the basis that the health care [professional] does 
not provide, pay for, provide coverage of, or refer for abortions.''
    Nonetheless, at pages 4 and 5 of its letter to HHS, NACHC 
specifically objected to its centers being required to comply with this 
exact statutory language that applies to them. NACHC even specifically 
objected that its centers must not be forced to follow the law 
prohibiting them from forcing employees to ``refer for abortions'' in 
violation of the Weldon amendment.
    Despite the fact that 42 U.S.C. 300a-7(d) says no employee of a 
FQHC can be required to even assist in ``any part'' of a program even 
partially funded by HHS, NACHC opined that disaster would follow if HHS 
actually enforced this language against FQHCs, because it would cause a 
``substantial negative impact'' on the services that FQHCs already 
deliver.
    It is necessarily true that if FQHCs are presently providing a 
service, and if their being made to comply with conscience-respecting 
statutes would reduce their provision of that service, then the FQHCs 
must be presently discriminating against present or prospective 
employees who conscientiously object to assisting in those services. 
The NACHC letter is therefore an admission that FQHCs are engaged in 
widespread violation of Federal conscience statutes.
    NACHC lamented that its FQHCs must be able to force individuals to 
assist in the performance of parts of their federally funded programs 
against their religious beliefs, including ``a vast array'' of services 
that FQHCs perform themselves, and a ``wide'' practice of referring and 
counseling patients to obtain ``services that the health center does 
not (or cannot) provide'' from ``a wide network of community 
providers.''
    NACHC objected that centers should not be required to follow 
Federal statutes that prohibit them from forcing individuals to assist 
in morally objectionable federally funded programs, because ``if health 
care personnel and support staff are allowed to ``opt-out'' of 
performing services which they find objectionable, effectively health 
centers will be unable to meet their statutory and regulatory 
obligations to furnish required services to all residents of their 
service area.''
    In other words, even in NACHC centers that do not perform abortions 
themselves, the FQHCs use Federal money to counsel and refer patients 
for abortions at locations such as nearby Planned Parenthood centers 
(the ``wide network of community providers''), and the FQHCs do commit 
other potentially objectionable practices, but they claim they will not 
be able to do such things unless they are allowed to force employees to 
participate in violation of Federal law.
                                 ______
                                 
          American College of Emergency Physicians,
                                                       May 8, 2011.
Hon. Orrin Hatch,
104 Hart Senate Office Building,
Washington, DC 20510.

    Dear Senator Hatch: On behalf of the American College of Emergency 
Physicians (ACEP), I am writing to share with you information about the 
Nation's emergency departments that I believe will be very useful in 
preparation for your hearing on Wednesday. Based on the title of the 
hearing, ``Diverting Non-urgent Emergency Room Use: Can It Provide 
Better Care and Lower Costs,'' ACEP wants to be sure that the members 
of your subcommittee have all of the relevant facts at their disposal 
when discussing this significant issue.
    First, the Center for Disease Control and Prevention's (CDC) 2008 
study states that of the nearly 124 million annual patient visits to 
emergency departments, only 8 percent have non-urgent (``needing care 
in 2 to 24 hours'') conditions. By comparison, the number of non-urgent 
patients in 2005 was 14 percent. Furthermore, the CDC states that the 
term ``nonurgent'' does not imply unnecessary.
    Second, it is important to understand that all services provided in 
the emergency department, including physician services, account for 
less than 2 percent of the Nation's health care costs. According to the 
Agency for Healthcare Research and Quality (AHRQ), total spending on 
emergency care in the United States was $47.3 billion in 2008. However, 
total health care expenditures were estimated at $2.4 trillion in 2008.
    Third, while it may cost more for patients to visit an emergency 
department than to obtain services at a physician's office or community 
health center, the comprehensive care available in the emergency 
department, due to our access to diagnostic imaging, lab tests, other 
physician services, etc., is unequaled. Unlike most other health care 
providers, our services are available 24 hours a day, 7 days a week, 
and 65 percent of emergency department patients arrive after normal 
business hours. Emergency departments are prepared to diagnose and care 
for the most complex medical conditions, and physicians regularly refer 
their patients to us. In a poll ACEP recently conducted, 97 percent 
reported that patients are referred daily to their emergency 
departments by primary care physicians.
    Emergency physicians and their departments are essential to the 
Nation's health care delivery system. They are truly America's health 
care safety net and many emergency physicians dedicate their lives to 
injury prevention and educating the public about how to prevent medical 
emergencies. However, the reality of the Nation's population 
demographics, as well as physician shortages and an analysis of those 
seeking emergency care, show that dissuading patients from using 
emergency departments is not likely to be an effective strategy. In 
addition, the nature of emergencies, which are unscheduled events, and 
the needs of patients must be taken into account as policymakers and 
health care stakeholders develop new paradigms for how health care will 
be provided in the future. We look forward to working with the HELP 
Committee and the Primary Health and Aging Subcommittee as it works to 
balance health care costs and the need to maintain a vibrant emergency 
care system.
            Sincerely,
                             Sandra Schneider, M.D., FACEP,
                                                         President.
                                 ______
                                 
       U.S. Government Accountability Office (GAO),
                                      Washington, DC 20548,
                                                    April 11, 2011.
Hon. Tom Harkin, Chairman,
Committee on Health, Education, Labor, and Pensions,
U.S. Senate.

Hon. Bernard Sanders, Chairman,
Subcommittee on Primary Health and Aging,
Committee on Health, Education, Labor, and Pensions,
United States Senate.

Subject:  Hospital Emergency Departments: Health Center Strategies That 
May Help Reduce Their Use

    Hospital emergency departments are a major component of the 
Nation's health care safety net as they are open 24 hours a day, 7 days 
a week, and generally are required to medically screen all people 
regardless of ability to pay.\1\ From 1997 through 2007, U.S. emergency 
department per capita use increased 11 percent.\2\ In 2007, there were 
approximately 117 million visits to emergency departments; of these 
visits, approximately 8 percent were classified as nonurgent. The use 
of emergency departments, including use for nonurgent conditions, may 
increase as more people obtain health insurance coverage as the 
provisions of the Patient Protection and Affordable Care Act (PPACA) 
are implemented.\3\
---------------------------------------------------------------------------
    \1\ In order to participate in Medicare, hospitals are required to 
provide a medical screening examination to any person who comes to the 
emergency department and requests an examination or treatment for a 
medical condition, regardless of the individual's ability to pay. 
Social Security Act 1866(a)(1)(I), 1867 (codified at 42 U.S.C. 
1395cc(a)(1)(I), 1395dd). Medicare is the Federal health program that 
covers seniors aged 65 and older, certain disabled persons, and 
individuals with end-stage renal disease.
    \2\ 1n 1997, there were an estimated 35.6 emergency department 
visits per 100 people compared to 39.4 visits in 2007. See P. Nourjah, 
``National Hospital Ambulatory Medical Care Survey: 1997 Emergency 
Department Summary,'' Advance Data, no. 304 (1999), and R. Niska, F. 
Bhuiya, and J. Xu, ``National Hospital Ambulatory Medical Care Survey: 
2007 Emergency Department Summary,'' National Health Statistics 
Reports, no. 26 (2010).
    \3\ For purposes of this report, we refer to the Patient Protection 
and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119, as amended 
by the Health Care and Education Reconciliation Act of 2010, Pub. L. 
No. 111-152, 124 Stat 1029, as PPACA. According to estimates from the 
Congressional Budget Office (CBO), an additional 32 million individuals 
are projected to obtain health insurance coverage by 2019; CBO also 
estimates that gaining insurance increases an individual's demand for 
health care services by about 40 percent. See D. Elmendorf, Director, 
CBO, ``Economic Effects of the March Health Legislation'' (presentation 
at the Leonard D. Schaeffer Center for Health Policy and Economics, 
University of Southern California, Los Angeles, CA, Oct. 22, 2010).
---------------------------------------------------------------------------
    Some nonurgent visits are for conditions that likely could be 
treated in other, more cost-effective settings, such as health 
centers--facilities that provide primary care and other services to 
individuals in communities they serve regardless of ability to pay. 
Care provided in an emergency department may be substantially more 
costly than care provided in a health center. The average amount paid 
for a nonemergency visit to the emergency department was seven times 
more than that for a health center visit, according to national survey 
data.\4\ While there are many reasons individuals may go to the 
emergency department for conditions that could also be treated 
elsewhere, one reason may be the lack of timely access to care in other 
settings, possibly due to the shortage of primary care providers seen 
in some areas of the country.\5\
---------------------------------------------------------------------------
    \4\ According to estimates from the 2008 Medical Expenditures Panel 
Survey (MEPS), the average amount paid for a nonemergency visit to an 
emergency department was $792, while the average amount paid for a 
health center visit was $108. Similarly, the average charge for a 
nonemergency visit to an emergency department was 10 times higher than 
the charge for a visit to a health center--$2,101 compared to $203. 
MEPS is a set of large-scale surveys of families and individuals, their 
medical providers, and their employers across the United States.
    \5\ In 2009, we reported that patients' lack of access to primary 
care services was one factor that may contribute to emergency 
department crowding. The report, which provided a followup to a 2003 
report on emergency department crowding, also noted that crowding 
continued to occur in hospital emergency departments and that some 
indicators of emergency department crowding--such as the amount of time 
patients must wait to see a physician--suggested that the situation may 
have worsened. See GAO, Hospital Emergency Departments: Crowding 
Continues to Occur, and Some Patients Wait Longer than Recommended Time 
Frames, GAO-09-347 (Washington, DC: Apr. 30, 2009), and Hospital 
Emergency Departments: Crowded Conditions Vary Among Hospitals and 
Communities, GAO-03-460 (Washington, DC: Mar. 14, 2003).
---------------------------------------------------------------------------
    Health centers may serve as a less costly alternative to emergency 
departments, particularly for individuals with nonurgent conditions. 
Like emergency departments, the nationwide network of health centers is 
an important component of the health care safety net for vulnerable 
populations, including those who may have difficulty obtaining access 
to health care because of financial limitations or other factors. 
Health centers, which are funded in part through grants from the 
Department of Health and Human Services' (HHS) Health Resources and 
Services Administration (HRSA), provide comprehensive primary health 
care services--preventive, diagnostic, treatment, and emergency 
services, as well as referrals to specialty care--without regard to a 
patient's ability to pay. They also provide enabling services, such as 
case management and transportation, which help patients access care. In 
2009, more than 1,100 health center grantees operated more than 7,900 
delivery sites and served nearly 19 million people. With increased 
funding from PPACA--projected to be $11 billion over 5 years for the 
operation, expansion, and construction of health centers \6\--health 
center capacity is expected to significantly expand, with the National 
Association of Community Health Centers estimating that health centers 
could more than double their capacity to 40 million patients by 
2015.\7\
---------------------------------------------------------------------------
    \6\ Specifically, PPACA appropriated $9.5 billion for fiscal years 
2011 through 2015 to a new Community Health Centers Fund to enhance 
funding for HRSA's community health center program. It also provided 
$1.5 billion over that same time period for the construction and 
renovation of community health centers. Pub. L. No. 111-148, 10503, 
124 Stat. 119, 1004 (2010); Pub. L. No. 111-152, 2303, 124 Stat. 1029, 
1083.
    \7\ National Association of Community Health Centers, Expanding 
Health Centers Under Health Care Reform: Doubling Patient Capacity and 
Bringing Down Costs (Bethesda, MD, June 2010).
---------------------------------------------------------------------------
    Given the increased use of emergency departments, concern over 
adequate access to primary care, and increased Federal support for 
health centers, you requested that we examine how health centers may 
help reduce the use of emergency departments. In this report, we 
describe strategies that health centers have implemented that may help 
reduce the use of hospital emergency departments.
    To conduct our work, we interviewed officials from 9 health centers 
about strategies that they have implemented that may help reduce 
emergency department use. We selected health centers to provide 
geographic variation and to ensure that health centers serving rural 
and urban areas were represented. We based our selection on our review 
of relevant literature published in the past 5 years and interviews 
with officials from HRSA and experts, specifically representatives from 
the National Association of Community Health Centers and individuals 
who have conducted research on health centers and emergency department 
utilization. We also e-mailed all State and regional primary care 
associations--private, nonprofit membership organizations of health 
centers and other providers--to identify specific health centers in 
their jurisdictions that had implemented strategies that may have 
reduced emergency department use.\8\ (Enc. I provides selected 
characteristics of the individual health centers interviewed.) To gain 
additional insights and perspectives on the information obtained from 
the nine individual health centers, we also conducted group interviews 
with officials from multiple health centers operating in three 
States.\9\ In our interviews, we asked health center officials to 
describe the strategies they have implemented that may help reduce the 
use of emergency departments for conditions that might also be treated 
in other care settings, such as health centers. We also asked health 
center officials to describe key factors contributing to the 
strategies' success and any challenges to implementation. Additionally, 
we requested any data or evaluations the health centers had on the 
effectiveness of each strategy implemented. We also collected 
information about health centers' strategies from the literature and 
our interviews with agency officials and experts.
---------------------------------------------------------------------------
    \8\ We received responses from 21 of 52 regional and State primary 
care associations we contacted.
    \9\ Specifically, we conducted group interviews with officials from 
6 health centers in Colorado, 13 health centers in Pennsylvania, and 9 
health centers in Wisconsin. Similar to our individual health center 
selection, these States were selected to provide geographic variation 
and to ensure that health centers serving rural and urban areas were 
represented.
---------------------------------------------------------------------------
    We conducted this performance audit from November 2010 through 
April 2011 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives.
                            results in brief
    Health centers have implemented three types of strategies that may 
help reduce emergency department use. These strategies focus on (1) 
emergency department diversion, (2) care coordination, and (3) 
accessibility of services. For example, some health centers have 
collaborated with hospitals to divert emergency department patients by 
educating them on the appropriate use of the emergency department and 
the services offered at the health center. Additionally, by improving 
care coordination for their patients, health centers may help reduce 
emergency department visits by encouraging patients to first seek care 
at the health center and by reducing, if not preventing, disease-
related emergencies from occurring. Finally, health centers employed 
various strategies to increase the accessibility of their services, 
such as offering evening and weekend hours and providing same-day or 
walk-in appointments--which help position the health center as a 
convenient and viable alternative to the emergency department. Health 
center officials told us that they have limited data about the 
effectiveness of these strategies, but some officials provided 
anecdotal reports that the strategies have reduced emergency department 
use. Health center officials described several challenges in 
implementing strategies that may help reduce emergency department use, 
such as the difficulty in changing the behaviors of patients who 
frequent the emergency department. HHS provided a technical comment on 
a draft of this report, which we incorporated.
                               background
    Emergency department visits are often made at night and on weekends 
by patients with varying sources of payment and levels of severity. Not 
all emergency department visits may be necessary; some visits may be 
handled in less costly settings or even avoided altogether through 
better management of chronic conditions. Lack of awareness of other 
sources of care, lack of access to primary care and other providers, 
and financial barriers can contribute to emergency department use, 
including use for nonurgent conditions. Health centers, which are 
required to serve patients regardless of ability to pay, are an 
important safety net provider for financially or otherwise vulnerable 
populations.
Emergency Department Use
    There were an estimated 116.8 million emergency department visits 
in 2007, according to the most recent publicly available report from 
HHS's National Center for Health Statistics (NCHS).\10\ For a majority 
of these visits (about 65 percent), patients arrived in the emergency 
department on weekdays from 5 p.m. to 8 a.m., and on the weekends.
---------------------------------------------------------------------------
    \10\ NCHS is an agency within HHS's Centers for Disease Control and 
Prevention that compiles statistical information to guide actions and 
policies to improve health. Annually, NCHS collects data on U.S. 
hospital emergency department utilization using a nationally 
representative survey, the National Hospital Ambulatory Medical Care 
Survey.
---------------------------------------------------------------------------
    Emergency department visits were made by patients with varying 
sources of payment. Individuals with private insurance coverage 
represented the largest percentage of emergency department visits 
followed by those with health insurance coverage through Medicaid or 
the State Children's Health Insurance Program (CHIP).\11\ (See table 
1.) Research indicates that Medicaid patients have a disproportionately 
higher share of emergency department use compared to patients with 
other sources of payment.\12\
---------------------------------------------------------------------------
    \11\ Medicaid is a joint Federal-State program that finances health 
care for certain low-income adults and children. CHIP is a joint 
Federal-State program that finances health care coverage for children 
in families with incomes that, while low, are above Medicaid 
eligibility requirements.
    \12\ See, for example, Committee for the Future of Emergency Care 
in the United States Health System, Hospital-Based Emergency Care: At 
the Breaking Point (Washington, DC: National Academies Press, 2007).

    Table 1.--Emergency Department Visits by Source of Payment, 2007
------------------------------------------------------------------------
                                                   Number of
                                                    visits    Percentage
                Source of payment                     (in      of visits
                                                  thousands)
------------------------------------------------------------------------
Private insurance...............................      45,580          30
Medicaid \1\....................................      29,379          25
Medicare........................................      20,133          17
No insurance \2\................................      17,926          15
Unknown \3\.....................................      10,484           9
Other \4\.......................................       4,587           4
------------------------------------------------------------------------
Source: GAO analysis of National Center for Health Statistics data.
Note: There were 116.8 million emergency department visits in 2007.
  Because more than one expected source of payment may be reported per
  visit, the total number of visits by source of payment exceeds 116.8
  million and the sum of the percentage of visits by source of payment
  exceeds 100 percent.
\1\ Medicaid includes visits where the payment source was the State
  Children's Health Insurance Program.
\2\ `The National Center for Health Statistics defines no insurance as
  having only self-pay, no charge, or charity as payment sources.
\3\ `Unknown includes visits where the payment source was either unknown
  or blank.
\4\ Other includes visits where the payment source was workers'
  compensation or other.

    Patients present to the emergency department with illnesses or 
injuries of varying severity, referred to as acuity level.\13\ Each 
acuity level corresponds to a recommended timeframe for being seen by a 
physician--for example, patients with ``immediate'' conditions should 
be seen within 1 minute and patients with ``emergent'' conditions 
should be seen within 1 to 14 minutes. In 2007, urgent patients--
patients who should be seen by a physician within 15 to 60 minutes--
accounted for the highest percentage of visits to the emergency 
department. Nonurgent patients--patients who should be seen within 2 to 
24 hours--accounted for 8 percent of visits. (See fig. 1.)
---------------------------------------------------------------------------
    \13\ NCHS developed time-based acuity levels based on a five-level 
emergency severity index recommended by the Emergency Nurses 
Association.


    Studies have shown that some emergency department visits may have 
been avoided through the use of appropriate and timely primary care and 
preventive care.\14\ Additionally, better management of chronic 
conditions, such as diabetes, asthma, and congestive heart failure, 
could also reduce the need for emergency department visits.
---------------------------------------------------------------------------
    \14\ For a review of literature on emergency department 
utilization, including utilization of the emergency departments for 
potentially preventable conditions, see D. DeLia and J. Cantor, 
Emergency Department Utilization and Capacity, Research Synthesis 
Report No. 17 (Princeton, N.J.: The Robert Wood Johnson Foundation, The 
Synthesis Project, July 2009).
---------------------------------------------------------------------------
    There are a number of factors that contribute to the use of 
emergency departments. Some patients may believe the emergency 
department provides more convenient, comprehensive, and better quality 
care than care provided in other settings. In addition, some patients 
may be unaware of alternative sources of care available within their 
community or may experience difficulty accessing primary or specialty 
care. Specifically, patients may have difficulty finding providers 
willing to accept new patients; patients with certain types of health 
coverage, such as Medicaid; or patients who are uninsured. There may 
also be difficulty finding providers with available and convenient 
appointment times. For example, studies have found that emergency 
department utilization is higher in areas with fewer primary care 
providers, including areas with fewer health centers, and that growth 
in emergency department visits among patients with mental health 
conditions has coincided with reductions in the general availability of 
mental health service providers.\15\ Finally, some patients may 
perceive the emergency department to be an affordable source of care, 
as emergency departments generally provide medical screenings to 
patients regardless of their ability to pay.
---------------------------------------------------------------------------
    \15\ See, for example, P. Cunningham, ``What Accounts for 
Differences in the Use of Hospital Emergency Departments Across U.S. 
Communities? '' Health Affairs, vol. 25, no. 5 (2006), and P. 
Cunningham, K. McKenzie, and E. Taylor, ``The Struggle to Provide 
Community-Based Care to Low-Income People with Serious Mental 
Illness,'' Health Affairs, vol. 25, no. 3 (2006).
---------------------------------------------------------------------------
HRSA's Health Center Program
    To increase access to primary care services for the medically 
underserved, HRSA provides grants to health centers nationwide under 
Section 330 of the Public Health Service Act.\16\ Health centers 
participating in HRSA's Health Center Program are private, nonprofit 
community-based organizations or, less commonly, public organizations 
such as public health department clinics. Health centers are required 
to have a governing board, the majority of which must be patients of 
the health center.\17\
---------------------------------------------------------------------------
    \16\ 42 U.S.C.  254b.
    \17\ 42 U.S.C.  254b(k)(3)(H). Under certain circumstances, the 
requirement for a governing board may be waived, such as for centers 
funded to serve only one or more of the following: homeless, migrant, 
or public-housing populations.
---------------------------------------------------------------------------
    Health centers also are required to provide comprehensive primary 
health care services, including preventive, diagnostic, treatment, and 
emergency services. Moreover, they are required to provide referrals to 
specialty care and substance abuse and mental health services. Health 
centers may use program funds to provide such services themselves or to 
reimburse other providers.\18\ A distinguishing feature of health 
centers is that they are required to provide enabling services that 
facilitate access to health care, such as case management, translation, 
and transportation. Additionally, HRSA requires health centers to 
provide services at times and locations that ensure accessibility and 
meet the needs of the population to be served, and to provide 
professional coverage for medical emergencies during hours when the 
center is closed. Health center services, which may be offered at one 
or more delivery sites, must be available to all individuals in the 
center's service area with fees adjusted based on an individual's 
ability to pay. Uninsured individuals are charged for services based on 
a sliding fee schedule that takes into account their income level.
---------------------------------------------------------------------------
    \18\ Health centers funded to serve homeless individuals are 
required to provide substance abuse services.
---------------------------------------------------------------------------
    Health centers primarily serve low-income populations in medically 
underserved areas. According to HRSA data, in 2009, the majority of 
health center patients whose family income was known had income at or 
below the Federal poverty level.\19\ In addition, 38 percent of health 
center patients were uninsured and 25 percent spoke a primary language 
other than English, the latter of which could indicate a potential 
barrier in accessing primary care at other settings that do not offer 
translation services. In 2009, half of all HRSA-funded health centers 
were located in rural areas.
---------------------------------------------------------------------------
    \19\ Family income was known for approximately 75 percent of health 
center patients.
---------------------------------------------------------------------------
    Research has shown that the annual health care expenditures for 
patients receiving care at health centers were lower than those for 
other patients. For example, one study showed that average health care 
expenditures for a person who received care at a health center were 
$3,500 compared to $4,594 for a similar person who did not receive care 
at a health center.\20\
---------------------------------------------------------------------------
    \20\ The study, which compared 2006 annual medical expenditures of 
people who received care at health centers and those who had not, made 
adjustments for an array of factors, including age, gender, income, 
insurance coverage, and health status. See L. Ku, P. Richard, A. Dor, 
E. Tan, P. Shin, and S. Rosenbaum, ``Strengthening Primary Care to Bend 
the Cost Curve: The Expansion of Community Health Centers Through 
Health Reform,'' Geiger Gibson/RCHN Community Health Foundation 
Research Collaboration, Policy Research Brief No. 19. (Washington, DC: 
The George Washington University School of Public Health and Health 
Services, June 30, 2010).
---------------------------------------------------------------------------
health centers have implemented three types of strategies that may help 
                    reduce emergency department use
    Health centers have implemented three types of strategies that may 
help reduce emergency department use, namely strategies for (1) 
emergency department diversion, (2) care coordination, and (3) 
increasing the accessibility of services, according to our interviews 
with experts and health center officials. Our review of the literature 
also identified similar types of strategies.

     Emergency Department Diversion. Health centers' emergency 
department diversion strategies are intended to encourage certain 
emergency department patients to use a health center as an alternative 
to emergency department care. Such diversion strategies, which 
generally are implemented in collaboration with a hospital, focus on 
educating emergency department patients on the appropriate use of the 
emergency department; informing them about the services offered at the 
health center; and arranging appointments at, or referrals to, the 
participating health center. Emergency department diversion strategies 
may be targeted at patients whose visits are nonurgent, who lack a 
regular source of care, who are uninsured or who have Medicaid, or who 
are frequent users of the emergency department.\21\ According to the 
health center officials we interviewed, their diversion strategies most 
commonly focused on preventing future visits to the emergency 
department, typically involving health center or hospital officials 
interacting with patients after those patients were seen by emergency 
department physicians. However, a Colorado health center's program 
refers emergency department patients triaged with less acute conditions 
to walk-in appointments for treatment at the health center's site, 
located less than a mile from the hospital. (See table 2 for other 
examples of emergency department diversion strategies implemented by 
selected health centers.) According to health center officials, for an 
emergency department diversion strategy to be successful, there must be 
good communication between the health center and the hospital and buy-
in from the hospital's administration and emergency department staff. 
Such buy-in is essential because, according to experts and health 
center officials we interviewed, hospitals and emergency department 
physicians may face financial disincentives to divert patients.\22\
---------------------------------------------------------------------------
    \21\ Health center officials we interviewed provided varying 
definitions of frequent users, ranging from individuals with 2 or more 
visits per year to individuals with 12 or more visits per year.
    \22\ Officials from one health center stated that some emergency 
department physicians are paid based on volume and, therefore, may be 
less willing to divert patients. Additionally, experts and health 
center officials indicated that hospitals may have an incentive to only 
divert uninsured patients, who may provide no payment to the hospital 
or health center.

Table 2.--Examples of Emergency Department Diversion Strategies Used  by
                         Selected Health Centers
------------------------------------------------------------------------
                                              Description of emergency
           Health center (State)                department diversion
                                                      strategy
------------------------------------------------------------------------
Baltimore Medical System (MD).............  The health center works with
                                             a local hospital to link
                                             eligible patients--
                                             specifically, Medicaid and
                                             uninsured patients with two
                                             or more emergency
                                             department visits in the
                                             previous year--to a primary
                                             care provider at the health
                                             center.

Brockton Neighborhood Health Center (MA)..  The health center works with
                                             two local hospitals to
                                             develop treatment plans for
                                             health center patients
                                             identified as having 12 or
                                             more emergency department
                                             visits within a year.

LifeLong Medical Care (CA)................  As a participant in a
                                             countywide initiative, the
                                             health center collaborates
                                             with other providers in the
                                             community to provide
                                             linkages to services and
                                             manage care for frequent
                                             emergency department users,
                                             defined as patients who had
                                             10 or more visits in 12
                                             months, or 4 or more visits
                                             in each of 2 consecutive
                                             years.

------------------------------------------------------------------------
Source: GAO analysis of information obtained through communications
  with, and documents provided by, officials from selected health
  centers.

     Care Coordination. By coordinating the care of their 
patients, health centers may help reduce emergency department use by 
working to ensure that patients first seek care at health centers 
instead of emergency departments and by focusing on the prevention of 
disease-related emergencies. Care coordination may include establishing 
a plan of care that is managed jointly by the patient and the health 
care team, anticipating routine needs, and actively tracking progress 
toward patient care plan goals. Health center officials we spoke with 
described two types of care coordination strategies--the medical home 
model and chronic care management. The medical home model uses a care 
team led by a physician who provides continuous and comprehensive care 
to patients with the aim of maximizing health outcomes.\23\ Chronic 
care management focuses on monitoring and managing chronic conditions, 
such as diabetes, asthma, and heart disease, through preventative care, 
screening, and patient education on healthy lifestyles. (See table 3 
for examples of care coordination strategies implemented by selected 
health centers.) Some health center officials we interviewed noted the 
importance of including mental health services and patient education as 
key components to the success of care coordination. They also noted 
that health centers' electronic medical records, especially when 
compatible with hospital systems, are helpful in coordinating care but 
that acquiring the technology can be expensive.
---------------------------------------------------------------------------
    \23\ Under the medical home model, the care team is responsible for 
providing for all of a patient's health care needs or appropriately 
arranging for care with other qualified professionals. This includes 
the provision of preventive services and treatment of acute and chronic 
illness.

   Table 3.--Examples of Care Coordination Strategies Used by Selected
                             Health Centers
------------------------------------------------------------------------
                                                 Description of care
           Health center (State)                coordination strategy
------------------------------------------------------------------------
Health West (ID)..........................  The health center
                                             coordinates care for
                                             patients with chronic
                                             diseases, such as diabetes
                                             and cardiovascular disease,
                                             by proactively scheduling
                                             appointments for care. The
                                             health center's physicians
                                             indicate when patients need
                                             to come in for their next
                                             visits. The information is
                                             recorded in the health
                                             center's electronic medical
                                             records and a report is
                                             generated each week
                                             identifying patients due
                                             for appointments. Health
                                             center staff then contact
                                             each patient to schedule an
                                             appointment.
Lincoln Community Health Center (NC)......  The health center has
                                             education and support
                                             groups for patients with
                                             certain chronic conditions,
                                             including diabetes and
                                             hypertension. The groups
                                             include patient education,
                                             such as food and nutrition
                                             instruction provided by a
                                             dietician; social support,
                                             such as a walking club to
                                             encourage exercise; and
                                             medication management and
                                             guidance on prescription
                                             compliance. In addition,
                                             health center staff work to
                                             coordinate care for all
                                             patients by, among other
                                             things, following up on
                                             missed appointments and
                                             scheduling appointments to
                                             coincide with patients'
                                             needs for prescription
                                             refills.
Northern Counties Health Care (VT)........  Through its medical home
                                             model, the health center's
                                             primary care physicians are
                                             responsible for
                                             coordinating all levels of
                                             patient care, including
                                             referring patients to
                                             specialty care, and
                                             connecting patients to
                                             community services. The
                                             primary care physicians
                                             work with a team of
                                             providers, including
                                             behavioral health
                                             therapists and chronic care
                                             coordinators, to ensure
                                             that patients receive
                                             necessary care. For
                                             example, patients may be
                                             referred to the behavioral
                                             health therapist for
                                             smoking cessation or
                                             assistance managing drug
                                             and alcohol dependence.
------------------------------------------------------------------------
Source: GAO analysis of information obtained through communications
  with, and documents provided by, officials from selected health
  centers.

     Accessible Services. Health centers employ various 
strategies to make their services accessible and to raise community 
awareness of the services they offer, which can help position the 
health center as a convenient and viable alternative to the emergency 
department. Such strategies include expanding health center hours to 
include evenings and weekends; providing same-day or walk-in 
appointments; providing transportation to health center locations; and 
locating health center sites in convenient places, such as in or near 
hospitals, schools, and homeless shelters. Health centers also use 
strategies to provide care to patients outside of the health center, 
such as through telemedicine, home visits, and mobile clinics, and may 
use translators to reduce linguistic and cultural barriers to care. In 
addition, health centers may engage in outreach activities to increase 
awareness of their services. For example, a health center in Wisconsin 
works with individuals at local community agencies that serve the poor 
and uninsured, including public health workers, clergy, and social 
workers, to encourage them to refer individuals to the health center 
for services. (See table 4 for other examples of strategies health 
centers have implemented to increase the accessibility of their 
services.)

   Table 4.--Examples of Strategies Used by Selected Health Centers to
              Increase the Accessibility of Their Services
------------------------------------------------------------------------
                                              Examples of strategies to
           Health center (State)              increase accessibility of
                                                      services
------------------------------------------------------------------------
Access Community Health Network (IL)......  The health center has
                                             several strategies to help
                                             ensure that its services
                                             are accessible and that the
                                             community is aware of the
                                             services offered. For
                                             example:

Community Health Centers (OK).............  To increase access to its
                                             services, the health
                                             center:

United Neighborhood Health Services (TN)..  To increase access to its
                                             services, the health
                                             center:

------------------------------------------------------------------------
Source: GAO analysis of information obtained through communications
  with, and documents provided by, officials from selected health
  centers.

    Health center officials told us that they had limited data about 
their strategies' effectiveness at reducing emergency department use 
and indicated that because health centers often implemented multiple 
strategies, evaluating the effectiveness of any one would be 
challenging. Officials from one health center we spoke with did have an 
evaluation of the countywide emergency department diversion program it 
participated in, which found that emergency department visits for 
participating patients decreased by 63 percent 1 year after patients 
enrolled in the program. Other health center officials provided 
anecdotal reports of the impact of various strategies they implemented. 
For example, health center officials from Pennsylvania reported that 
offering extended hours did help reduce the use of the emergency 
department. Additionally, officials from a health center that provides 
care coordination indicated that they have seen an increase in routine 
visits, which they believe is helping to prevent some emergency 
department visits.
    Health center officials described several challenges in 
implementing strategies that may help reduce emergency department use. 
Specifically, officials noted that some services, such as those 
provided by case managers, are generally not reimbursed by third-party 
payers, but instead must be funded in total by the center.\24\ Another 
challenge, according to health center officials, is that health centers 
do not benefit from any cost savings resulting from reductions in 
emergency department visits. Additionally, health center officials 
noted that it is difficult to change the care-seeking behaviors of 
certain patients who frequently use the emergency department, including 
those who are homeless or have substance abuse and mental health 
problems. Finally, some health center officials noted challenges with 
recruiting the necessary health providers to serve their patients. 
Given that the demand for services may increase as more individuals 
gain health insurance coverage as a result of PPACA, several health 
center officials we spoke with reported that they have applied for, or 
expect to apply for, additional health center funding from HRSA to 
expand services (such as by hiring new providers), open new sites, or 
renovate existing sites.
---------------------------------------------------------------------------
    \24\ We previously reported that care coordination services are 
generally not covered by health insurance. See GAO, Health Care 
Delivery: Features of Integrated Systems Support Patient Care 
Strategies and Access to Care, but Systems Face Challenges, GAO-11-49 
(Washington, DC: Nov. 16, 2010).
---------------------------------------------------------------------------
                            agency comments
    We provided a draft of this report to HHS for review and comment. 
HHS provided a technical comment that we incorporated.
    As agreed with your office, unless you publicly announce the 
contents of this report earlier, we plan no further distribution of 
this report until 30 days after its issue date. At that time, we will 
send copies of this report to the Secretary of Health and Human 
Services, and other interested parties. In addition, the report will be 
available at no charge on GAO's Web site at http://www.gao.gov.
    If you or your staff have any questions, please contact me at (202) 
512-7114 or [email protected]. Contact points for our Offices of 
Congressional Relations and Public Affairs may be found on the last 
page of this report. GAO staff members who made key contributions to 
this report are listed in enclosure II.

                                           Debra A. Draper,
                                             Director, Health Care.
                              Attachment I

                                             Characteristics of Individual Health Centers Interviewed, 2010
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                        Latest                Number of    Percentage of patients by coverage status in
                                                             Number    weekday     Saturday    patient                       2009 \2\
                   Health center (State)                       of      closing    hours \1\   visits in  -----------------------------------------------
                                                             sites     time \1\                  2009     Uninsured \3\  Medicaid \4\  Medicare  Private
--------------------------------------------------------------------------------------------------------------------------------------------------------
Access Community Health Network (IL)......................       58      10 p.m.       Yes       799,065           32             55          4        9
Baltimore Medical System (MD).............................       12       7 p.m.       Yes       168,552           20             48         11       21
Brockton Neighborhood Health Center (MA)                          2       8 p.m.       Yes       100,586           31             60          5        4
Community Health Centers (OK).............................        4       7 p.m.        No        49,768           73             18          4        5
Health West (ID)..........................................        6    6:30 p.m.        No        23,000           47             17         12       24
LifeLong Medical Care (CA)................................        9       9 p.m.       Yes       170,098           28             35         26       11
Lincoln Community Health Center (NC)......................        7       8 p.m.       Yes       139,694           80             12          6        3
Northern Counties Health Care (VT)........................    8 \5\       7 p.m.        No        76,250            8             26         22       44
United Neighborhood Health Services (TN)..................       16      10 p.m.       Yes        89,454           51             34          4       11
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: GAO analysis of information obtained through communications with, and documents provided by, officials from selected health centers.
\1\ Evening and Saturday hours may not be available at all of a health center's sites and evening hours may not be available all weeknights.
\2\ The totals may not add up to 100 percent because of rounding.
\3\ Uninsured also may include self-pay patients, those who paid out-of-pocket.
\4\ Medicaid may also include people enrolled in the State Children's Health Insurance Program.
\5\ The health center also offers a home health and hospice program, which provides services 24 hours a day, 7 days a week.

         Attachment II.--GAO Contact and Staff Acknowledgments
GAO Contact

Debra A. Draper, (202) 512-7114 or [email protected].

Staff Acknowledgments

In addition to the contact named above, key contributors to this report 
were Michelle B. Rosenberg, Assistant Director; Jennie F. Apter; 
Matthew Gever; Carolyn Feis Korman; Katherine Mack; Margaret J. Weber; 
and Jennifer Whitworth.
                                 ______
                                 
New Jersey Primary Care Association, Inc., (NJPCA),
                                              May 12, 2001.
Hon. Bernard Sanders, Chairman,
Primary Health and Aging Subcommittee,
Committee on Health, Education, Labor, and Pensions,
428 Senate Dirksen Office Building,
Washington, DC 20510.

    Dear Chairman Sanders: Thank you for allowing the New Jersey 
Primary Care Association to submit testimony on the subject of 
``Diverting Non-urgent Emergency Room Use: Can It Provide Better Care 
and Lower Costs?'' We understand that there was a hearing on this topic 
on May 11, 2011 and the Federally Qualified Health Centers (FQHCs) have 
a great deal of experience with this subject.
    New Jersey has 20 FQHCs that serve approximately 430,000 patients a 
year with over 1.3 million patient visits. These health centers have 
seen tremendous growth over the years with a 124 percent jump in their 
uninsured patients from 2002-9. New Jersey, unfortunately, was one of 
the States that had many distressed hospitals. Twenty-four have closed 
since 1992. In many cases, it was the FQHC who stepped up to ensure 
that the community still had access to good quality health care. FQHCs 
expanded services, sites, and providers and at present have 103 sites 
in 19 of the 21 counties. In addition the State of New Jersey 
recognizes that FQHCs are low cost, are comprehensive, and that they 
provide good quality care. As such, the State, through a bipartisan 
effort, has ensured that State funding flows to these centers so that 
thousands have access to primary and preventive care. The FQHCs in New 
Jersey average $1.17 per day for care which is far lower than the cost 
of getting care in an emergency room.
    New Jersey FQHCs have worked in partnership with hospitals to 
conduct emergency room diversion programs for quite some time. Timely 
use of primary and preventive care services reduce the need for 
episodic care that patients receive in hospital emergency rooms (ERs) 
when medical conditions go undetected and untreated. It is widely 
acknowledged that when patients have a regular source of care or a 
health care home, they are more likely to be in better health and less 
likely to be hospitalized for preventable conditions.
    Many New Jersey health centers have collaborative relationships 
with their area hospitals to reduce inappropriate ER usage by their 
patients. One New Jersey health center, North Hudson Community Action 
Corporation (NHCAC), has been recognized in a NACHC publication as 
having a successful medical home delivery model that focuses on 
reducing ER usage by their patients. NHCAC, located in northern Hudson 
County has been a federally qualified health center since 1994. It 
serves about 70,000 patients annually via nine sites and one mobile 
center. The broad array of services provided by the center includes 
adult medicine, pediatrics, dental, prenatal and obstetrics and 
gynecology, mental health, and substance abuse treatment. Services are 
available 6 days a week with many sites open until 7 p.m. on weekdays 
and for extended hours on Saturdays. The main site is open until 10 
p.m. on 4 days of the week and on Sunday for at least 6 hours. In an 
effort to provide health care that is easily accessible, continuous, 
timely, and comprehensive, NHCAC, in collaboration with Palisades 
Medical Center, has initiated an Emergency Department (ED) diversion 
program. Under this program, health center doctors provide care within 
the hospital through a 24 hours a day, 7 days a week with on-call 
service for pediatrics and OB/GYN. The program seeks to address the 
health care needs of NHCAC's uninsured and underinsured patients who 
may be frequent users of the ED. Once a patient is seen by an on-call 
doctor at the ED, patients are given appointments at the health center 
for their timely followup care. The health center reserves 
approximately five appointment slots a day from 1-3 p.m. for these 
followup visits at the health center. The primary goal of this program 
is to improve and establish continuity of care for patients. Since the 
program's inception, both Palisades Medical Center and NHCAC have 
reported decreased overcrowding in the ED and improvement in receipt of 
continuous primary care by patients.
    Two other centers are also working hard to promote timely use of 
primary and preventive care services and reduce unnecessary ER visits 
for their patients. In 2008, two New Jersey FQHCs, the Monmouth Family 
Health Center (MFHC) and the Newark Community Health Center (NCHC) 
received funding from CMS through the New Jersey Office of Medicaid to 
collaborate with two partnering hospitals to implement an ER Diversion 
project. The project titled ``Community Partnership for ED Express Care 
and Case Management'' is focused on identifying Medicaid patients who 
present at the ERs of the two collaborating hospitals for primary care 
conditions; treating and educating them on the proper use of the ER 
services; educating the patients on the benefits of having a primary 
care home; and setting them up for followup visits at the partnering 
health centers; and tracking patient care at the partnering health 
centers to evaluate the impact of the project. The focus of this 
project is on reducing inappropriate ER usage, educating patients on 
the benefits of having a health care home, and in the process improving 
the overall health status of the patients that show up in the ERs. As 
of December 2010 both Express Pilot EDs have handled 8,718 project 
patients and 7,596 of those patients have been referred to the 
partnering health centers for followup care. Another key component of 
this project was the ability of the hospital to use a terminal to pull 
up the appointment system of the FQHC to set up an appointment while 
the patient was still at the hospital.
    Health centers in New Jersey are very focused on the use of 
Electronic Medical Records (EMR) and adoption of Health Information 
Technology (HIT) to ensure better quality and safety in patient care 
and reduce costs. More than half of New Jersey FQHCs have implemented 
their systems and are now linking with hospitals and with State 
agencies for seamless care. In addition, 95 percent of the health 
centers have used or are still using chronic disease patient 
registries. Health information technology can help providers improve 
quality of care, reduce medical errors, increase efficiency, reduce 
duplicative services, provide timelier patient/provider interactions 
and in the process provide significant savings in the delivery of 
healthcare services.

                                     Katherine Grant-Davis,
                                                 President and CEO.

    [Whereupon, at 11:30 a.m., the hearing was adjourned.]


