[Senate Hearing 113-252]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 113-252

                 HEALTH CARE QUALITY: THE PATH FORWARD
=======================================================================

                                HEARING

                               BEFORE THE 

                          COMMITTEE ON FINANCE
                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 26, 2013

                               __________



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                          COMMITTEE ON FINANCE

                     MAX BAUCUS, Montana, Chairman

JOHN D. ROCKEFELLER IV, West         ORRIN G. HATCH, Utah
Virginia                             CHUCK GRASSLEY, Iowa
RON WYDEN, Oregon                    MIKE CRAPO, Idaho
CHARLES E. SCHUMER, New York         PAT ROBERTS, Kansas
DEBBIE STABENOW, Michigan            MICHAEL B. ENZI, Wyoming
MARIA CANTWELL, Washington           JOHN CORNYN, Texas
BILL NELSON, Florida                 JOHN THUNE, South Dakota
ROBERT MENENDEZ, New Jersey          RICHARD BURR, North Carolina
THOMAS R. CARPER, Delaware           JOHNNY ISAKSON, Georgia
BENJAMIN L. CARDIN, Maryland         ROB PORTMAN, Ohio
SHERROD BROWN, Ohio                  PATRICK J. TOOMEY, Pennsylvania
MICHAEL F. BENNET, Colorado
ROBERT P. CASEY, Jr., Pennsylvania

                      Amber Cottle, Staff Director

               Chris Campbell, Republican Staff Director

                                  (ii)




                            C O N T E N T S

                               __________

                           OPENING STATEMENTS

                                                                   Page
Baucus, Hon. Max, a U.S. Senator from Montana, chairman, 
  Committee on Finance...........................................     1
Hatch, Hon. Orrin G., a U.S. Senator from Utah...................     2

                               WITNESSES

McClellan, Hon. Mark B., senior fellow, The Brookings 
  Institution, Washington, DC....................................     4
Cassel, Dr. Christine K., president and CEO, National Quality 
  Forum, Washington, DC..........................................     6
Lansky, Dr. David, president and CEO, Pacific Business Group on 
  Health, San Francisco, CA......................................     8
McGlynn, Dr. Elizabeth A., director, Kaiser Permanente Center for 
  Effectiveness and Safety Research, Pasadena, CA................    10

               ALPHABETICAL LISTING AND APPENDIX MATERIAL

Baucus, Hon. Max:
    Opening statement............................................     1
    Prepared statement...........................................    35
Cassel, Dr. Christine K.:
    Testimony....................................................     6
    Prepared statement...........................................    37
Hatch, Hon. Orrin G.:
    Opening statement............................................     2
    Prepared statement...........................................    53
Lansky, Dr. David:
    Testimony....................................................     8
    Prepared statement...........................................    55
McClellan, Hon. Mark B.:
    Testimony....................................................     4
    Prepared statement...........................................    68
McGlynn, Dr. Elizabeth A.:
    Testimony....................................................    10
    Prepared statement...........................................    85

                             Communication

Wisconsin Health Information Organization (WHIO) et al...........    93

                                 (iii)

 
                         HEALTH CARE QUALITY: 
                            THE PATH FORWARD

                              ----------                              


                        WEDNESDAY, JUNE 26, 2013

                                       U.S. Senate,
                                      Committee on Finance,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 10:06 
a.m., in room SD-215, Dirksen Senate Office Building, Hon. Max 
Baucus (chairman of the committee) presiding.
    Present: Senators Wyden, Stabenow, Carper, Cardin, Casey, 
Hatch, Crapo, Thune, Burr, Isakson, and Toomey.
    Also present: Democratic Staff: Mac Campbell, General 
Counsel; David Schwartz, Chief Health Counsel; Tony Clapsis, 
Professional Staff Member; and Karen Fisher, Professional Staff 
Member. Republican Staff: Kristin Welsh, Health Policy Advisor.

   OPENING STATEMENT OF HON. MAX BAUCUS, A U.S. SENATOR FROM 
            MONTANA, CHAIRMAN, COMMITTEE ON FINANCE

    The Chairman. The hearing will come to order.
    The American statistician who also helped pioneer quality, 
especially in the automobile business worldwide, W. Edwards 
Deming, once said, ``Quality is everyone's responsibility.''
    In 1999, the Nation received a wake-up call about our 
health care system. The Institute of Medicine published a 
landmark report entitled, ``To Err is Human.'' It concluded 
that nearly 100,000 people die each year in hospitals due to 
preventable errors. That is more than die from motor vehicle 
accidents, breast cancer, or AIDS.
    High-quality care clearly needed to be more of a priority 
at every level: Medicare, Medicaid, insurance companies, 
doctors, hospitals, and for policymakers as well. Each group 
started focusing on quality. The largest hospital accreditation 
group, the Joint Commission, required hospitals to report 
performance data. Congress required Medicare providers to 
submit quality reports. Medicare created tools for 
beneficiaries to compare provider quality. Hospital boards 
incentivized their leadership to improve quality.
    We saw some early wins. Between 2001 and 2009, for example, 
central line IV infections dropped by more than half. This 
quality improvement saved $2 billion and, more importantly, 
27,000 lives.
    When we first started to focus on quality, we realized that 
we had a long way to go. We began by requiring providers to 
simply report their data. The Affordable Care Act moved 
Medicare to the next level, from 1.0 to 2.0. Instead of paying 
just for reporting, Medicare now pays for results.
    Under new programs, Medicare will pay hospitals and 
physicians for providing high-quality care more than those 
providing low-
quality care. These health reform programs will move Medicare 
closer to a system built around the value and not the volume of 
care.
    Let me provide a current example. From 2007 through 2011, 
nearly 1 in 5 Medicare patients admitted to a hospital returned 
within a month. For many of them, that readmission could have 
been avoided. In the Affordable Care Act, we gave hospitals 
incentives to reduce avoidable readmissions, and hospitals 
responded. They made sure that patients had follow-up visits, 
doctors spent more time talking with patients about their 
discharge plans and answering questions, and we are seeing 
results.
    I am proud to say that, from 2007 to 2012, Montana's 
readmission rate fell by 11 percent, the largest reduction in 
the country. Last year, Medicare saw 70,000 fewer beneficiaries 
readmitted to hospitals nationwide.
    The Affordable Care Act also worked to increase quality in 
Medicare Advantage plans. The law gives bonuses to plans with 
high quality ratings. Seniors use these ratings to pick the 
best plan. Tying payments to performance has made plans focus 
more on quality.
    Since the ``To Err is Human'' report, everyone has worked 
to improve quality. It is time for us now to do a gut check. 
What has been most effective? What can we do better? What are 
the right measures of quality? It is astounding that we do not 
have agreement on how to calculate, for example, the risk of 
dying in a hospital. Three different commonly used measures of 
mortality produced different hospital rankings, so, depending 
on the measure, a hospital could be at the top or the bottom of 
the list.
    Separately, Medicare uses 1,100 different measures in its 
quality reporting and payment programs--one thousand, one 
hundred. While we need to recognize the differences among 
providers, do we really need more than 1,000 measures? That is 
just Medicare. Medicaid programs and dozens of commercial 
insurance companies all pay differently and run their own 
quality programs. Providers are pulled in different directions 
by different payers, and they have a tough time finding the 
right way forward to higher quality.
    So let us identify the key measures, develop them faster, 
align these efforts across payers, and reduce the 
administrative burden on providers. We all have a stake in 
this; after all, quality is everyone's responsibility.
    [The prepared statement of Chairman Baucus appears in the 
appendix.]
    The Chairman. Senator Hatch?

           OPENING STATEMENT OF HON. ORRIN G. HATCH, 
                    A U.S. SENATOR FROM UTAH

    Senator Hatch. Well, thank you, Mr. Chairman. I am pleased 
that we are having this series of hearings addressing different 
parts of our health care system. Last week's hearing showed us 
that transparency goes beyond price to include quality as well. 
Indeed, the price-quality equation should help us determine the 
value of our health care.
    Currently, there is so much marketing around provider 
quality, particularly with regard to hospitals. Everyone seems 
to be claiming to be the best at something. Many of these 
claims are based on proprietary data, making it hard for 
consumers to have an accurate picture of our health care 
system. Perhaps quality is in the eye of the beholder.
    I hope that today's hearing will help us to better 
understand another very important part of our health care 
system. For years, providers, payers, and Federal programs have 
been consumed with measuring quality with an eye towards 
altering the payment system to reward better quality care. I 
understand how complicated it can be. My concern is that the 
system as it currently stands seems quite unorganized, focusing 
on far too many things. We need to be very mindful that the 
primary purpose of quality measurement is to promote quality 
improvement.
    To be clear, I think a focus on measurement is the 
appropriate first step in building a solid foundation for 
quality. However, I wonder whether we have the right tools in 
place to help clinicians learn how to improve rather than 
simply showing them how they compare to their peers.
    Assessing a starting point is important, but ultimately the 
goal should be to improve care for every patient. That means 
giving clinicians the necessary resources in terms of best 
practices and care management. It also means providing 
clinicians with clear and consistent definitions of clinical 
concepts.
    If our collective goal is to ensure that every patient 
receives the right care in the right place and at the right 
time, providers need to know how those are defined and 
determined. Because data will be determined by measurement, it 
is imperative that we get measurement right in the first place.
    Providers should have confidence in the data being used to 
assess their care and payment for that care. In addition, we 
need to remember that the job of a clinician is to provide care 
to patients, not spend an unreasonable part of their day 
inputting data for measurement purposes.
    It seems to me that in order for quality programs to be 
successful, the collection of data needs to be as streamlined 
as possible and simply be an outgrowth of routine clinician 
work flow. I have the good fortune to represent a State with 
some of the highest-quality health care providers in the 
Nation. They are constantly striving to do better, and I 
commend them for that.
    However, I am aware that some providers in this country are 
struggling to make improvements, and I think we need to 
understand and appreciate that resources vary greatly across 
this country and this has an impact on quality data.
    Sometimes quality scores might not truly reflect the care 
being given at an institution, but I want to be clear about 
this: efficient and high-quality care must be an expectation 
that we have, not merely a goal. We cannot accept providers not 
making quality a top priority.
    Our witnesses this morning will share with us all of the 
activities going on in the quality space today, both in the 
Medicare and Medicaid programs, as well as the private sector. 
With so much at stake and so many taxpayer dollars going into 
various reporting initiatives, I would encourage all of us to 
work together to ensure that the process is well thought out, 
streamlined, and moves us towards improving outcomes and care, 
which of course is the ultimate goal.
    And so, Mr. Chairman, I want to thank you once again for 
this hearing, and I look forward to hearing from our witnesses. 
It is great to see some of you back here again. Mark, we are 
very happy to see you again, and all of you as well. So, thanks 
for being willing to testify.
    Thanks, Mr. Chairman.
    The Chairman. Thank you, Senator. Thank you very, very 
much.
    [The prepared statement of Senator Hatch appears in the 
appendix.]
    The Chairman. Today we will hear from four witnesses: Dr. 
Mark McClellan, director of the Engelberg Center for Healthcare 
Reform at the Brookings Institution; Dr. Christine Cassel, 
president and CEO of the National Quality Forum; Dr. David 
Lansky, president and CEO of the Pacific Business Group on 
Health; and Dr. Elizabeth McGlynn, director of the Kaiser 
Permanente Center for Effectiveness and Safety Research.
    We will begin with you, Dr. McClellan. As I am sure you all 
know, your statements will automatically be included in the 
record. Do not worry about that. Second, we urge you to 
summarize your statements. I strongly urge you to tell it like 
it is; do not pull any punches. Let 'er rip. [Laughter.]
    All right. Dr. McClellan, you are first.

    STATEMENT OF HON. MARK B. McCLELLAN, SENIOR FELLOW, THE 
             BROOKINGS INSTITUTION, WASHINGTON, DC

    Dr. McClellan. All right. Thank you, Mr. Chairman. With 
that challenge, Chairman Baucus, Ranking Member Hatch, and 
members of the committee, I very much appreciate your 
leadership in focusing the Nation's attention on improving 
quality. As you all pointed out in your opening statements, we 
have been making progress with measurement and with improvement 
of quality, but the measures keep showing us that big gaps 
remain, leading to worse health outcomes and avoidable health 
care costs.
    I have four recommendations for the committee that are 
discussed in more detail in my written testimony. First, and 
most importantly, we need to take further steps to transition 
payment systems in public programs to case- and person-level 
payments. The quality problem is not just or mainly a problem 
of quality measurement, it is a problem of providers and 
patients getting support for better care at the person level 
through our financing and our regulations.
    Fee-for-service payments for specific services and quality 
measures for processes of care undertaken by particular 
providers are important, but they have not been sufficient to 
fundamentally improve care. And they are growing more out of 
step with health care that should be increasingly personalized 
to the needs of each patient based on their genomics, their 
preferences, and other characteristics when they increasingly 
involve wireless technologies, wellness initiatives, home-based 
services, and other approaches that are just not covered by 
traditional fee-for-service insurance.
    Recently, along with a bipartisan group of health care 
leaders and experts, I authored a report on ``Person-Centered 
Health Care Reform: A Framework for Improving Care and Slowing 
Health Care Cost Growth.'' We proposed directing more of our 
health care resources to getting better care at the person 
level through moving to more person-level payments and outcome-
oriented measures of quality.
    Other recent reports all agree that the most important 
thing that policymakers can do now to improve health care 
quality is to make feasible changes in health care payments and 
benefits so that they can better support patient-centered care.
    Building on recent reforms like bundled payments and 
accountable care payments in the private sector and public 
insurance programs, Medicare should take further steps to move 
away from fee-for-service and transition to greater use of 
these person- and 
episode-based payments. This could be enacted this year as part 
of legislation to address the physician SGR problem, as well as 
in post-acute care and other systems that are paid primarily on 
volume and intensity.
    This would build on ideas like the primary care medical 
home where primary care physicians get some of their payments 
based on providing better care for a patient, not based on 
specific services. Some oncologists are implementing an 
oncology home for their cancer patients where they can devote 
more effort to tracking their patients' care and helping them 
avoid pain and other costly complications.
    Cardiologists and cardiac surgeons have proposed 
collaborative heart teams to care for complex heart patients. 
These could all be supported by case-based payments. I want to 
emphasize that these are shifts in payments away from fee-for-
service, not additional payments, because better coordination 
and better quality should mean fewer unnecessary services and 
lower health care costs.
    The second step is to take further steps to implement case- 
and person-level quality measures in public programs. A growing 
set of case- and patient-level measures are becoming available 
or could transition into more widespread use. The payment 
reforms I have described would accelerate the development and 
use of such measures, but more must be done.
    Further funding for quality measurement activity should 
require a clear path for the development and use of patient 
experience measures and patient outcomes through Medicare's 
payment systems. For example, instead of using quality measures 
like whether or not a patient was screened for body mass index, 
an outcome-
oriented measure like a patient's overall risk for 
cardiovascular disease could be tied to the collection of data 
for quality improvement, reporting, and eventually become a 
component of payment.
    This emphasis on key outcomes and experience measures could 
help drive both alignment of performance measures, as you all 
have emphasized is a key goal, and also better outcomes. They 
would also reinforce efforts that many, many clinical 
organizations and quality improvement organizations are taking 
today to develop better data and underlying measures to help 
drive improvements and outcomes.
    Third, there needs to be more support for the NQF, along 
with a streamlined process for developing, endorsing, and 
incorporating more meaningful quality measures in the public 
programs. You will hear more about the National Quality Forum 
from Dr. Cassel on my right.
    Once again, this core set of common measures should focus 
on patient experience and engagement, outcomes related to care 
coordination like readmissions, and measures of important 
safety complications. And measures of population and preventive 
health should also include outcome measures relevant to 
particular conditions. These measures should be prioritized, 
and they should be the basis for, first, alignment, because 
they can be used across multiple programs to reduce 
administrative burdens and achieve greater impact.
    Finally, I have some proposals in my written testimony for 
supporting collaborations to implement quality measures using 
existing and emerging electronic data systems along the lines 
that, Senator Hatch, you suggested, to make these a routine 
part of care provided in a way that supports clinicians in 
taking steps to improve care.
    Thank you all very much for the opportunity to join you 
today.
    The Chairman. Thank you very much, Dr. McClellan. That is 
very interesting.
    [The prepared statement of Dr. McClellan appears in the 
appendix.]
    The Chairman. Dr. Cassel? Since he introduced you, you may 
proceed.

   STATEMENT OF DR. CHRISTINE K. CASSEL, PRESIDENT AND CEO, 
             NATIONAL QUALITY FORUM, WASHINGTON, DC

    Dr. Cassel. Thank you. Mr. Chairman and Minority Leader 
Hatch, first I want to commend your leadership and actually 
that of the entire committee, because, after all, it was your 
action that established so many of these initiatives--public 
reporting, value-based purchasing, delivery reform--intended to 
improve our Nation's health care. These efforts all rely on 
quality measures.
    I joined the National Quality Forum--this is actually my 
first official week on the job--because I understand the power 
of good quality measures. We need the good quality measures to 
create information that patients need and, as you pointed out, 
to enable hospitals, doctors, and nurses to know how to 
improve.
    For those who are not aware, NQF is a nonprofit, 
nonpartisan organization with 440 organizational members, 
including physicians, nurses, hospitals, business leaders, 
patients, insurance plans, and accrediting and certifying 
bodies, all of which collectively embody NQF's public service 
mission.
    Over the last few months, I have been reaching out to 
dozens of people to listen to their ideas about what is needed 
to accelerate quality. The goal of this listening tour has been 
to identify ideas to make NQF more responsive to a shared 
urgent imperative that you are going to hear from all of us 
today: to more swiftly and effectively drive performance 
improvement.
    What I have heard from all these people is that we need 
measures that matter to clinicians, measures that are 
meaningful to patients and families, and a process that is 
transparent, efficient, flexible, and responsive. We also need 
measures so that policymakers like yourself can tell whether 
innovative public programs like medical homes and Accountable 
Care Organizations enhance patient care and reduce costs.
    If everyone agrees on the same basic measures, then we are 
all rowing in the same direction. That is where NQF comes in. 
NQF has two distinct and complementary roles: (1) endorsing 
measures based on rigorous scientific criteria; and (2) 
convening diverse stakeholders to gain agreement about measures 
and about priorities, as Mark just mentioned, that we all need 
to agree on for improvement.
    Since NQF started endorsing performance measures a decade 
ago, much has been accomplished. Hundreds of endorsed measures 
are now publicly available. We are constantly evaluating them 
to stay up with the science and to reduce burden and bring 
higher impact measures into play. Last year, for example, we 
retired more measures than we added.
    Most of the measures now are focused on clinical care and 
patient safety, but, as you heard, we are at work on patient- 
and 
family-centered care measures, affordability, and population 
health, with all of them focusing more on outcomes.
    We are also looking at how to improve our own work. Last 
year we reduced our measure endorsement time by half, and this 
year we want to launch a better open pipeline approach for 
reviews. Here are a few examples of how NQF-endorsed quality 
measures have improved care and reduced costs. Chairman Baucus 
mentioned the almost 60-percent decrease in some hospital 
bloodstream infections, saving thousands of lives and billions 
of dollars. In obstetrics, the reduction of inappropriate early 
elective deliveries before 39 weeks is resulting in healthier 
babies, fewer ICU days, and lower costs. Improvements using our 
measures in Medicare's End-Stage Renal Disease kidney failure 
program have produced reduced hospitalizations and deaths in 
this very sick and very vulnerable population. There are many, 
many such examples in many, many very good systems around the 
country, but there are not nearly enough of them.
    What will it take to accelerate improvement? One, we need 
more strategic and coordinated measure development that is 
tightly focused on filling serious gaps in order to reduce 
duplication and facilitate the use of new medical knowledge in 
easy-to-use and -understand measures.
    Two, NQF must work on making measurement information more 
understandable for consumers and policymakers.
    Three, we must all foster public and private alignment, 
public and private payers using the same measures. This would 
provide great clarity to both consumers and providers.
    Four, electronic systems need to live up to their promise 
to make it easier to derive measures from clinical practice, 
not add more clerical work for busy doctors.
    Five, NQF's current review process must expand to meet 
changing needs and progress in data sources, for example, by 
setting standards for measurement systems like physician 
registries so that they can be available for accountability 
programs. To make this happen, we need support from both the 
public and private sectors for all of this work.
    The bottom line is that mistakes, poor care, and 
complications hurt people and increase costs to workers, 
families, businesses, and taxpayers. We can, and must, do 
better, and with your help I am confident we will. I thank you 
for your past support and for the opportunity to speak to you 
today. Our challenges are solvable, but only if we all work 
together. Thank you.
    The Chairman. Thank you, Dr. Cassel.
    [The prepared statement of Dr. Cassel appears in the 
appendix.]
    The Chairman. Dr. Lansky, you are next.

   STATEMENT OF DR. DAVID LANSKY, PRESIDENT AND CEO, PACIFIC 
          BUSINESS GROUP ON HEALTH, SAN FRANCISCO, CA

    Dr. Lansky. Thank you. Good morning.
    The Chairman. Good morning.
    Dr. Lansky. My name is David Lansky, and I am the president 
and CEO of the Pacific Business Group on Health--we call it 
PBGH. Thank you, Chairman Baucus and Ranking Member Hatch, for 
letting me present the purchaser's view of health care quality 
today.
    PBGH represents large health care purchasers who are 
working together to improve the quality and affordability of 
health care in the United States. Our 60 member organizations 
provide health care coverage to over 10 million people, and 
they spend over $50 billion each year. They include a wide 
range of familiar companies like Wells Fargo, Target, Intel, 
Boeing, and public purchasers like the California Public 
Employees' Retirement System (CalPERS).
    These companies believe that care will improve when 
providers compete on value, on quality, and cost, as each of 
them must do in their own industries. They are looking for 
meaningful transparency on price and quality, and neither is 
available today. Our large employer members believe that 
providers should be required to measure and report the outcomes 
that American families and employers care most about: 
improvements in quality of life, functioning, and longevity.
    After a patient has a knee replacement, is her pain 
reduced? Can she walk normally? Can she return to work? When a 
child has asthma, can he play school sports? Can he sleep 
through the night? Unfortunately, the measurements we use today 
leave us unable to make many of these vital judgments about the 
quality of doctors, hospitals, or health care organizations.
    When I asked our members last week how they would describe 
the value of our national quality measurement efforts to their 
own companies, they responded with one word: abysmal. Still 
today, the only information large employers have to 
differentiate hospitals, clinics, or doctors in most 
communities is their reputation, not their true price nor their 
likelihood of obtaining good results.
    There are three areas where we believe that Federal action 
can help put us on the right path: developing useful measures, 
building out a national data infrastructure, and making use of 
performance information for payment and public reporting.
    First, PBGH companies see that the quality measures 
available today will not create a successful health care 
market. We know the kind of quality data that is needed, and we 
look to the public agencies to ensure that the needed 
information becomes available.
    Congress should direct CMS to identify and adopt useful 
standardized measures that address consumer and purchaser 
concerns far more quickly. CMS could either continue to rely on 
a multi-stakeholder consensus process under a new and more 
stringent mandate, or take on this responsibility directly in 
order to expedite action.
    Continued funding of the measurement enterprise should be 
tied to stronger decision-making roles for those who experience 
and pay for health care; rapid adoption of outcome measures 
already in widespread use, such as those for total knee 
replacement and depression in Minnesota; and collaboration with 
publishers so that the results of measurement can be rapidly 
distributed to the public through generally accessed channels.
    If we make quickly available measures that can 
differentiate high-performing providers from others, then the 
employers involved with PBGH and many others will be able to 
change their payment policies, reconfigure their health care 
networks, and create consumer incentives to encourage the 
people that they cover to get care from the high-performing 
organizations. This is the critical market signal needed to 
drive improved quality and affordability.
    Second, PBGH member organizations see that we still do not 
have a national data infrastructure to support a continuously 
improving health care enterprise or the ability for people to 
make informed decisions about their care. While purchasers 
applaud the important progress made in the adoption of 
electronic health records since 2009, it is time now to jump-
start a new era of technology standards and interfaces that 
take advantage of the global explosion in cloud computing, 
mobile technology, and the Internet.
    CMS and the Office of the National Coordinator for Health 
IT should develop and quickly implement a framework that will 
allow for evaluation of a patient's care over time, including 
the appropriateness of care decisions, their outcomes, and the 
total resources consumed.
    This data infrastructure should also permit Congress and 
the public to assess whether new models of care, such as 
episode payment, ACOs, and even the new insurance marketplaces, 
are contributing to improved health.
    Such a data infrastructure will also allow employers to 
evaluate the performance of physicians and health care 
organizations across settings and across time, and support 
continued innovation in the care models that they offer to 
their employees.
    Third, and most importantly, PBGH members are concerned 
that Medicare, as the largest purchaser of all, continues to 
send financial signals to providers that reward volume over 
value and leave millions of beneficiaries and the general 
public with no useful information on the quality of care they 
receive. Congress should require the Secretary to imbed the 
most useful outcome and efficiency measures into platforms like 
Physician Compare and into all Federal recognition and payment 
programs within 24 months.
    In particular, the current interest in replacing the 
Sustainable Growth Rate mechanism with a value-based payment 
update could tie positive incentives to the collection and 
reporting of measures of appropriateness, patient outcomes, 
care coordination, and efficiency.
    PBGH companies believe that a health care marketplace where 
providers compete based on their ability to improve health and 
manage resources efficiently will prove to be sustainable and 
will improve the health of all Americans. But time is short. 
Such a system must be based on meaningful performance 
information available in the public domain.
    Just as we created the SEC and fuel efficiency ratings and 
nutrition labels to drive successful markets, we must create a 
flow of information that consumers and purchasers can use to 
make critical health decisions. You have the opportunity to 
direct Federal resources to address this vital national 
interest, and you will have the support of major employers in 
accelerating this agenda.
    Thank you for considering the purchasers' perspectives in 
your deliberations.
    The Chairman. Thank you, Dr. Lansky. That was very 
interesting, very thoughtful.
    [The prepared statement of Dr. Lansky appears in the 
appendix.]
    The Chairman. Dr. McGlynn?

    STATEMENT OF DR. ELIZABETH A. McGLYNN, DIRECTOR, KAISER 
   PERMANENTE CENTER FOR EFFECTIVENESS AND SAFETY RESEARCH, 
                          PASADENA, CA

    Dr. McGlynn. Thank you, Chairman Baucus, Ranking Member 
Hatch, and members of the committee, for inviting me here 
today. I am Dr. Elizabeth McGlynn, director of the Kaiser 
Permanente Center for Effectiveness and Safety Research. I am 
testifying today as a health care quality measurement expert 
and also on behalf of the National Kaiser Permanente Medical 
Care Program, which is the largest integrated health care 
delivery system in the United States.
    My experience at Kaiser Permanente over the last 2\1/2\ 
years has deepened my understanding of the challenges of 
measuring and providing high-quality care on the delivery 
system front lines.
    My written testimony makes five points. First, we are 
making progress on quality, but we cannot declare victory yet. 
When I started studying health care quality in 1986, most 
people thought it was not a problem in the United States. But 
in 2003, my colleagues and I found that American adults were 
receiving just 55 percent of recommended care for the leading 
causes of death and disability.
    Along with the IOM reports that you referred to, Senator 
Baucus, measurement demonstrated that we had a problem and 
provided the motivation to fix it. The question that you are 
asking now is, how can we do this better? That in itself 
indicates progress. The conversation has changed.
    We know it is possible to deliver on the promise of high 
quality. Within Kaiser Permanente, for example, we used our 
electronic health records to evaluate our performance on a 
range of preventive care interventions, such as mammography 
screening. We set goals for improvement and used all of the 
tools in our integrated system to ensure that our patients got 
the right care at the right time, every time. Now our rates are 
among the best in the Nation, and our patients benefit, but 
this is not true everywhere. Making progress is hard work. It 
requires team problem-solving, robust and timely information, 
effective leadership, and rewards for doing better, not just 
doing more.
    Second, we must be clear about what we are trying to 
achieve and what measures will allow us to track progress. A 
decade ago, Dr. Cassel and I were members of the Strategic 
Framework Board, which recommended to the National Quality 
Forum a goal-oriented, broad-based vision for a national 
quality measurement system. That vision remains relevant today 
and has yet to be fully implemented.
    Goals for U.S. health care should be audacious and engage 
the public, on par with landing a man on the moon. What if we 
set out to make obesity a rare event or cut the number of 
people with diabetes in half? Without clear, quantifiable goals 
and a commitment to reach them, measurement becomes a separate 
enterprise rather than a purpose-driven tool for change.
    Third, we must make sure that we have the right set and 
number of quality measures. This requires robust development 
processes closely linked to established goals. Too many 
measures used today represent outdated technology created when 
the goal was simply to raise awareness about quality deficits.
    Delivery system and payment reforms were not yet a major 
focus, and claims data were all we routinely had. Times and 
health care realities have changed. We need to invest in 
developing measures that help us achieve our health outcomes 
goals. Measures should also encourage development of innovative 
delivery systems, support payment reforms, and take advantage 
of the increasing availability of clinical and patient-reported 
data.
    Fourth, new quality measures should anticipate the future. 
With the advance of electronic health records, information 
technology is becoming a real tool in health care, providing 
new opportunities to drive measures from richer clinical data.
    Consumer mobile devices can enable real-time data feedback 
into quality improvement programs. The explosion of apps for 
health care represents valuable technology that we are just 
beginning to learn how to harness.
    The need for delivery system improvement should foster 
integrated models as the norm, not the exception. Payments 
should reward quality, and we should engage the public and 
providers broadly in achieving major advances in the country's 
health.
    This vision differs from the Nation's current enterprise by 
moving away from sole reliance on old data sources. It would be 
sufficiently flexible to work as systems and payment designs 
change. It would accelerate the rate at which improved health 
is realized. If we cling to the past in our measurement 
strategy, we will stifle important innovation in all these 
domains.
    Finally, the Federal Government can, and should, lead by 
bringing the right stakeholders together to have honest 
dialogue about goals. The government should facilitate, as well 
as participate in, actions to achieve those goals. The 
government should promote and reward innovation.
    By tying payment to quality standards, programs like the 5-
star quality rating system for Medicare Advantage plans are 
already altering the value equation, and we have recent 
evidence that consumers are acting on this information by 
choosing higher-value plans.
    The Federal Government can also lead by educating the 
public about health care value through clear, easily 
accessible, reliable information about quality. Consumers are 
both beneficiaries and drivers of quality improvement when they 
can make educated choices about the care they receive.
    Thank you for the opportunity to talk with you today.
    The Chairman. Thank you, Dr. McGlynn.
    [The prepared statement of Dr. McGlynn appears in the 
appendix.]
    The Chairman. Let me ask you, Dr. Lansky, you named--if I 
understood you correctly--a few different recommendations to 
develop useful measures and some kind of national data entry 
structure, and then somehow--well, then another, third 
recommendation.
    I am wondering, tied in with Dr. McClellan's ideas of more 
patient-centered efforts to determine quality and outcomes, are 
those the kind of measures that you are talking about in your 
first recommendation or not?
    As I heard you: better reporting, everybody reporting both 
price and quality in the ideal world, then payers such as 
yourself can decide, companies can decide, patients can decide, 
where to go. But those measures that you would like to see 
reported, do they include items mentioned by Dr. McClellan, 
that is, patients' experiences and outcomes? What should be 
available to people?
    Dr. Lansky. My answer is ``yes.'' I will let Dr. McClellan 
answer and see if he agrees. I think we have advocated for a 
long time that patients are able to report on the outcomes, 
many of the outcomes, of care that they receive.
    Tracking the experience of a patient's care over time, 
seeing a number of doctors in a number of settings, we might 
think of that as an episode of care or managing a condition for 
a year, diabetes or another problem. It needs to be assessed 
comprehensively.
    We can ask patients after a knee replacement--and there are 
very systematic ways of doing this--whether they can walk 
better, whether they can climb stairs, whether they can go back 
to work, whether their pain has been relieved. Those kinds of 
measures are what the employers want to know and what the 
patient, of course, wants to know.
    If the patient is about to choose a surgeon or a hospital, 
they want to know which of those surgeons or hospitals is most 
likely to get them back to successful functioning and get them 
back to work. There have been a number of health systems around 
the country and around the world that have done this, and they 
do see significant variations in the ability of teams, 
hospitals, and surgeons to get people--in this example--back to 
high levels of functioning.
    So we want to help people get into the hands of the best 
doctors and hospitals that will help them be most successful 
and recover most quickly from these treatments. So yes, I 
think, to me, the two dimensions of patient-centeredness are 
capturing the patient's experience over time, not in specific 
slices of process, and second, asking the patient, are you 
doing better at the end of the treatment you have been 
undergoing?
    The Chairman. What measures are your companies taking? 
Companies want to do the best for their employees. So how are 
they determining price, but more importantly for the sake of 
this hearing, quality? How are they determining that?
    Dr. Lansky. They are frustrated. They are relying on the 
measures that are publicly available for the most part, or 
those that are provided by their health plans, the carriers 
that provide their network of services. The measures that are 
available to them today are not adequate to answer the kinds of 
questions you were raising a minute ago.
    So they are using what is available, but they frankly feel 
that they are being brought into a process of choosing networks 
based on cost, because that is all there is. They cannot really 
determine whether those networks are high-quality, and they 
cannot with confidence say to the employee, if you go to this 
hospital or this doctor, we have evidence that they are going 
to get you a better result. That is what they want to be able 
to do. One of the reasons they are reluctant to steer employees 
into certain networks is they cannot with confidence say that 
those networks are actually better.
    The Chairman. Let me just ask all of you a basic question: 
what do you recommend that we do? What should Congress do? One 
of you tried to answer that question, but I would like to 
briefly ask each of the four of you just, bottom line, what 
should we do? Dr. McClellan?
    Dr. McClellan. Mr. Chairman, you cannot do everything. But, 
as I think you have heard from all of us, there is a lot of 
support for being clear about incorporating measures that have 
outcomes, that have patient experience, that have these key 
features that patients really care about, incorporated in the 
payment system. For the Finance Committee, I know this hearing 
is first and foremost about quality, but how you pay, as you 
have heard from all the people on the panel, matters.
    The Chairman. So this could be part of reforming SGR?
    Dr. McClellan. It could be, yes.
    The Chairman. All right.
    Dr. Cassel, what do we do?
    Dr. Cassel. Thank you. I have two suggestions. One is, 
support for measurement development. Actually, there was 
funding authorized in the ACA for measurement development, but 
it has not been appropriated. That money could help develop--
the kind of measurement development that Dr. Lansky is 
referring to does not just happen by snapping your fingers.
    There are smart scientists like Dr. McGlynn who know this. 
It takes testing, it takes getting the right people together, 
the right kinds of data, et cetera. So, specialists in this 
area are at work trying to do this and have been doing it with 
sort of a hodgepodge of support. If we really had a major man-
to-the-moon kind of effort that you heard about to get these 
right measures, that would be very helpful
    The Chairman. My time is expiring.
    Dr. Cassel. Can I mention one other thing?
    The Chairman. All right. Sure.
    Dr. Cassel. One other thing is to have the public/private 
sector entities and the multi-stakeholder groups like NQF help 
us push for alignment between the public and private sector 
payers. One of the reasons that the employers cannot get the 
information they need is that the private insurance companies 
often use different measures or proprietary measures.
    The Chairman. My time is expiring, but how do we push for 
alignment? How do we do that?
    Dr. Cassel. Well, one thing would be to push us, that is to 
say the stakeholder groups----
    The Chairman. We are pushing right now. [Laughter.]
    Dr. Cassel [continuing]. To do more in this area.
    The Chairman. You have just been pushed. [Laughter.]
    Dr. Cassel. Thank you. Thank you.
    The Chairman. All right. My time has expired.
    Senator Hatch? We will get to you later, Dr. Lansky--next 
round. Senator Hatch?
    Senator Hatch. Well, thank you. I hope you do not feel 
badly about being pushed like that. [Laughter.]
    Now, Dr. Lansky, you and other experts acknowledge that 
there has been a proliferation of measures, and yet much more 
work needs to be done to improve outcomes. If that is the case, 
can you help us identify gaps where improvements could be made 
to deliver better outcomes, and should we allocate resources 
differently? Is some of this our fault?
    Dr. Lansky. My own view is that--and I think my members are 
reluctant to describe how providers should alter their care to 
achieve better results--if the market rewards them for better 
results because we measure and expose outcomes, they will be 
brilliant in finding the best ways to achieve those results.
    Many of the breakthroughs in care recently have not been 
with new technology, but with deploying the right kinds of 
people to the bedside, to the home, through the Internet. We 
want to encourage people to be innovative in how they achieve 
good results, but we want to see that they are producing those 
results. So my answer, Senator, would be to have the 
measurement requirements be stringent, demanding, 
understandable to the public, and then let the providers do 
what they need to do to be successful.
    Senator Hatch. Well, let me ask this of all of you. Have 
any of you seen reports that have estimated how much providers 
are spending to collect and report quality measures? Let me 
start with you, Dr. McClellan.
    Dr. McClellan. There have been a number of reports, and 
also a number of surveys of clinicians who feel quite burdened 
by the quality reporting effort. I think one indication of that 
is the participation rates in Medicare's physician quality 
reporting systems are much lower than I think what many of us 
would like. They are high in some specialties, low in others.
    I think this goes to, Senator Hatch, your point earlier 
about trying to make quality reporting a consequence of 
delivering care, not a separate set of activities that needs to 
be done on top of everything else that clinicians are already 
doing.
    Dr. Lansky emphasized that outcome measures and patient 
experience are things that providers really care about, and 
having some measures that could be developed from their 
clinical record systems, from their patient registries, would 
be very helpful and would help them improve their care. The 
problem is that the way that they are paid today does not 
really give providers much support to do those kinds of things.
    There are examples, I think, in every single specialty. I 
mentioned a few in my testimony, for example, in oncology 
where, if oncologists are only paid based on the volume and the 
intensity of chemotherapy drugs that they administer, and not 
paid for things like setting up a registry for their patients 
so they can track how each patient is doing and whether they 
are getting the latest 
evidence-based care and spending extra time, maybe hiring a 
nurse to help their patients who are having pain or other 
complications so that they do not end up in the emergency room 
or the hospital, you cannot do those things under current fee-
for-service payments and still stay in business. So it is very 
frustrating and burdensome for doctors, but it is a problem 
that I think could be addressed with feasible legislation.
    Senator Hatch. Well, thank you.
    Dr. Cassel?
    Dr. Cassel. Thank you, Senator. I wanted to add to Dr. 
McClellan's point that there are, around the country--and you 
pointed out, in your own State--examples of excellent systems 
that actually invent their own measures and use their own 
measures to drive their own improvement. They do not see 
themselves as measure developers who are submitting measures to 
NQF for endorsement to be used more broadly.
    What I am going to be doing at NQF is a kind of 
prospecting, going out there and looking for, what are the good 
systems doing and how could we then take advantage of some of 
those and make them available so that they would make sense to 
clinicians and lower the burden on clinicians?
    The other point related to this, of course, is really 
accelerating some of the new electronic technologies so that 
the physicians themselves do not have to report these measures.
    I just want to say, though, that currently some of those 
are compliance provisions that are put in place because of 
concerns about fraud and other things to make sure that the 
doctor is the one who is doing it, so we have to somehow get to 
a technological place where we can relieve the clinician of 
that burden. I completely agree.
    Senator Hatch. All right.
    Dr. Lansky, then Dr. McGlynn. We only have a few more 
seconds.
    Dr. Lansky. Just two other points. I think we have 
demonstrated in California, with a joint replacement registry 
that we have developed, that we can collect almost all the data 
from electronic systems in the hospital and the doctor's office 
with very little additional data burden, so it can be done with 
new technology.
    Second, I would draw the distinction that, I think a lot of 
the process measures that are very burdensome, we do not need 
to require as a national strategy. The national interests 
should be in the outcomes. Let the providers innovate with the 
processes they want to monitor, measure, and approve. That is 
not really necessarily a matter of public scrutiny.
    Senator Hatch. Dr. McGlynn?
    Dr. McGlynn. I will add two things to what has been said. 
The first is, I think we have over-promised on some of what is 
possible out of the current technologies in electronic health 
records. I think there ought to be--and Dr. Lansky and I were 
talking about this before the hearing--a real push to upgrade 
those technologies. They are not really optimized for the kind 
of quality measurement systems we are talking about today. So, 
that is one thing we should look at.
    The second is, I think you ought to think about some 
innovation zones. There are systems in this country that have 
demonstrated, across a large number of areas, consistent high 
performance. One possibility is to relieve them from the burden 
of current reporting so that they can be part of moving some of 
this measurement forward.
    But I think in many cases to do better, we have to stop 
doing something so that there is sort of time and energy. I 
think integrating measurement into clinical care delivery is 
the place that we need to go, and we certainly talk to our 
clinicians a lot about how to make that happen.
    You really have to understand how measurement fits into the 
clinical work flow so that, both the data that are produced are 
the ones that you are interested in, and so that you are 
actually having providers focus on the things that are 
important to them and to their patients.
    I just think there are real opportunities here, but we need 
investments to make that possible, and we need kind of 
everybody--it needs to be an all-in process with all of the 
kinds of people whom we represent here today engaged in that. 
Now is the time to do it.
    Senator Hatch. Thank you. Thank you all.
    The Chairman. Thank you, Senator.
    Senator Cardin, you are next.
    Senator Cardin. Thank you, Mr. Chairman. Thank you for 
holding this hearing.
    Quality is an extremely important subject. We were trying 
to get to a cost-effective quality health care system and how 
we maintain it, and we have been talking about this for some 
time. I want to follow up on the questioning, but to deal with 
it from the point of view of the consumer for one moment. We 
have talked about how the user of health care can be more 
informed on making a choice on quality.
    If they make a choice on quality, that can drive the system 
to a much more cost-effective system. I find that, if you have 
a choice in health care, you want to go to the provider that 
will offer you the best care. Cost is also a factor, but you 
are seeking health care in order to achieve a result.
    I have heard you talk about all the different information 
we are trying to make available on quality, but, if you had an 
opportunity to move forward on a tool that would be available 
to the end-user in order to make judgments on quality, what is 
the tool and what do we need to do in order to accomplish that? 
How do we make the consumer a better consumer on judging 
quality?
    One last preface to that. In Maryland, we have quality 
indexes that are available for different providers. It has 
worked well in long-term care. Consumers do look at these 
guides. It does make a difference. But there are hundreds of 
thousands of providers out there in the Medicare system alone. 
What can we do to empower consumers to make better choices on 
quality?
    Dr. McClellan. The examples that you gave, I think, 
highlight how to do it. In areas like long-term care, there are 
some States, including yours, that have meaningful measures of 
outcomes that people care about--is the care there safe?--and 
measures of experience of care that patients have and 
caregivers have as well. That is clearly what patients care 
about.
    There are lots of examples of tools around the country: 
some that have been developed by the private sector, some that 
Dr. Lansky's employers are using, some that States are 
developing. The challenge is often, as you have heard from the 
panel, getting the right information into those tools that the 
patients can understand and that they really do care about. And 
that I think brings us back to the theme that you have heard 
throughout this hearing, which is making sure that there are 
relevant outcome measures available for each of these many 
different areas of care, just like we are starting to have for 
long-term care. For example, for ophthalmologic surgery, the 
surgeons have developed measures of visual acuity after 
procedures, something that patients----
    Senator Cardin. Dr. McClellan, MedPAC tells us there are 
close to 600,000 physicians in the Medicare system alone 
receiving payment. How do you develop that in a cost-effective 
way for CMS?
    Dr. McClellan. There are some efforts under way for 
identifying a core set of these meaningful measures for 
patients. They include things like patient experience for every 
single one, almost, of these provider types. They interact with 
patients, and there are effective ways of measuring patients' 
experience with care.
    It is true that different clinical areas have different 
outcomes that matter to patients, but in each clinical area 
there are some clear places to start, like operative outcomes 
for knee replacement and patients' functional status down the 
road. Each of these clinical areas is working on meaningful 
ways of measuring these outcomes.
    So, it is a daunting task, but I want to emphasize that we 
are not talking about hundreds or thousands of measures, we are 
talking about a few key places to start on outcomes and 
experience in each of these major clinical areas.
    Senator Cardin. Now, as you know, I represent Maryland. CMS 
is located in Maryland. So, if we are talking about doubling 
the size of CMS, it might be good for my State. But they 
already have an incredible burden over there, as you know. Are 
we creating really a workable system? Can it be done?
    Dr. McClellan. I think it can be done. I would like to let 
some of the rest of the panel comment on this too.
    Senator Cardin. All right.
    Dr. Cassel. Senator Cardin, thank you for that question. It 
is a really important question. I just want to add a couple of 
things. First of all, to the issue of over-promising, we cannot 
have perfect, complete measures for everything that you value 
about health care. As an internist, a big part of what people 
want is to make sure they get the right diagnosis. We have no 
measures that tell you that.
    All the measures we now have, you assume the patient comes 
in the door with the diagnosis on their forehead, but that is 
much more complex and much more difficult to get. If we get to 
overall outcomes and well-being and performance of systems, 
then we will have a better shot at including within that 
doctors making the right diagnosis and having the right 
information.
    But that also gets to the point that CMS is hampered by the 
fact that it pays doctors individually, and it pays them by 
fee-for-
service. Often the outcomes that you want are outcomes by teams 
and by groups of physicians, groups of providers, whole systems 
of care. So we also need to move to more system-level outcomes. 
I know that many of the professionals within CMS agree with 
this, so some of these payment reforms, I think, will help with 
that.
    Senator Cardin. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator.
    Senator Casey, you are next.
    Senator Casey. Mr. Chairman, thank you, and thanks for this 
hearing. We appreciate the panel, your testimony, and your 
willingness to be here to answer these questions. I know it is 
a difficult set of issues for us. I wanted to concentrate on 
two areas, and first and foremost, children and how some of 
these issues relate particularly to our kids.
    A lot of the advocates around the country who fight every 
day on behalf of kids often remind us that, in the health care 
context, children are not small adults. You cannot just--and 
you know this better than I--somehow impose a course of 
treatment or a health care strategy that might make sense for 
an adult on a child; there are a whole other set of challenges 
there.
    The Senate, for almost a generation now, has come together, 
led by both the chairman and the ranking member, on children's 
health insurance, a great advancement for the country. 
Pennsylvania really led the way on that. There is, despite the 
debates we have here, I think a fairly strong consensus about a 
part of the Medicaid program that works very well, the so-
called EPSDT, Early Periodic Screening, Diagnosis, and 
Treatment. That whole program or that whole effort over time 
has been, I think on the whole, very successful. It could be 
improved. So we have had a number of efforts that focused 
specifically on children.
    I wanted to ask you, in light of this discussion of trying 
to link quality to payment reform, trying to link quality to a 
whole other set of measures, how do we do this in the context 
of making sure that programs that are providing children's 
health insurance now are in fact doing an even better job 
because we are focused on these issues, particularly in the 
context of kids? We can go left to right or right to left. Dr. 
McGlynn?
    Dr. McGlynn. Thanks for that question. I am involved right 
now with an effort that was funded through CHIPRA to develop 
new measures for the CHIPRA program, but also that would be 
applicable to kids in any----
    The Chairman. I am sorry. What is the CHIPRA program?
    Dr. McGlynn. Oh, I am sorry. The Children's Health 
Insurance Program Reauthorization Act.
    The Chairman. Not SCHIP?
    Dr. McGlynn. Well, SCHIP is--CHIPRA is the legislative 
acronym for the reauthorization of SCHIP. Sorry.
    The Chairman. All right.
    Dr. McGlynn. Here I am in Washington. I thought we all 
spoke acronyms. I am sorry. [Laughter.]
    But in that legislation, the Congress put money into 
measure development with a recognition that quality measurement 
for kids was really undeveloped relative to adults, and so I am 
part of one of the teams that is working on measures in that 
area, and I will just sort of highlight two things about that.
    One is, it has taken very much this approach we have all 
talked about, which is a multi-stakeholder approach. So our 
team, for instance, has at the table parents of kids who have 
particularly complex needs as we are developing measures, and 
so we are talking to them about, what is meaningful to you?
    Part of what we have learned--and this has been a very 
helpful process--we have looked at the scientific literature 
about what we know clinically and we have talked to parents, 
and ultimately what we decided in the areas of continuity of 
care, coordination of care, is, we really need to hear from the 
parents.
    We need to hear whether their needs are being met, because, 
frankly, they vary from individual to individual. So we have 
developed a set of measures that we are in the field testing 
right now that rely heavily on asking the people who are most 
important whether they are getting the kind of care they need.
    So, two points: the multi-stakeholder process gives us 
different measures than we would have gotten otherwise; and 
two--and this is consistent with things we have said--we need 
to really ask the end-users whether they are getting the kinds 
of information they need and whether they feel like they can 
make the choices that are right for their child, whether they 
are supported in doing that. That information can be rolled up 
then to produce a sense at the State level and at systems 
levels about where the best care is going on.
    Senator Casey. Dr. Lansky, you have a difficult task: there 
are 23 seconds left. We have the lightning round.
    Dr. Lansky. Well, two points. There are a number of 
measures out there that have been developed that segment the 
child population: some with special needs, adolescents, and so 
on. And second, this is actually a great opportunity for 
alignment that was raised earlier, because our members are 
certainly very concerned about their kids' care, as it takes 
people away from the workplace and all the rest, and Medicaid 
programs in particular have a huge child population to take 
care of, so I think there is a chance for dialogue between the 
commercial purchasers and the public programs to sort this 
problem out.
    Senator Casey. I am 6 seconds over now. Our last two 
witnesses, if you could provide 30-second answers, I think the 
chairman might allow that.
    The Chairman. Take as long as you want.
    Dr. Cassel. It raises the issue of people with multiple 
conditions, interacting conditions, and any other area of 
complexity where we really need major investment, whether it is 
for children or my area, geriatric care. Same issue.
    Senator Casey. Thank you.
    Dr. McClellan. For the minority of kids who have very 
serious health problems, these kinds of initiatives are very 
important. For most kids, the most important thing is 
establishing good habits, education, staying in good health, 
staying up with preventive care and services. There are ways to 
measure that.
    Kind of analogous to what many employers are doing about 
the bottom line of health is, how well is it translating into 
your life? Maybe some measures like some school systems are 
doing about health measures that track how well kids are 
staying in school--this is especially true for young kids in 
preschool programs. Think outside just the health care box for 
what really matters to kids.
    Senator Casey. Thank you.
    The Chairman. Thank you, Senator.
    Senator Toomey?
    Senator Toomey. Thank you, Mr. Chairman. Thanks to the 
witnesses as well.
    I am just trying to understand a little bit better, and I 
am a little bit confused. I thought I was hearing a consensus 
about a lot of progress that has been made in recent years 
about measuring quality and measuring outcomes, but then I 
heard something that caused me to really pause.
    I think it was Dr. Cassel who might have said this. Did I 
understand you to say that we do not have good information 
about the quality of diagnoses, that that is an area in 
particular where we are lacking good information?
    Dr. Cassel. That is an area where there are not good 
outcome measures, quality measures, the same way we have if we 
know what the patient's diagnosis is.
    Senator Toomey. Quality in the sense of measuring the 
quality of the diagnosis itself?
    Dr. Cassel. Of the process, of the clinician, the 
physician, or the team that is involved in making the 
diagnosis.
    Senator Toomey. All right.
    Dr. Cassel. And misdiagnosis is probably 15 to 20 percent 
of what we would consider errors. The experts in the area of 
patient safety use that number from the studies that they have 
done.
    Senator Toomey. And does everybody else agree that this is 
an area where there is a particular level of difficulty and a 
particular problem?
    Dr. McGlynn. Yes. It is a challenging area to measure. Our 
current approaches, measurements that work well in other areas, 
are not particularly adequate for assessing this aspect of 
quality.
    Senator Toomey. Because it strikes me that we could have a 
real problem measuring the final outcome of a patient's care if 
we do not know how well we got the diagnosis straight in the 
first place. It seems like that is the necessary precondition. 
I am not a doctor, I have no expertise here, but I am not sure 
how I would analyze outcomes if I was not sure whether we got 
the diagnosis right in the first place.
    Dr. Cassel. Senator, this gives me an opportunity to say a 
few words about some of the other approaches to quality that 
are going on in the private sector. The organization I just 
recently came from, the American Board of Internal Medicine, 
represents certifying boards for all the major medical 
specialties.
    They have kind of a simulation for ``Can You Get the Right 
Diagnosis,'' which is an examination, a very highly developed, 
secure examination that physicians take every 10 years in which 
you have to figure out the right diagnosis to a patient case. 
So it is not real patients in front of you, but it does sort of 
tell you, has that person got what they need to be able to make 
the right diagnosis?
    Should they have the information electronically, decision 
support, and other kinds of things that they need? But in terms 
of actual quality measures, I think it is necessary to have a 
high-level group getting together--and I hope we can do this at 
NQF--to ask this question: is this appropriately handled in the 
traditional way we think about quality measures now, or are 
there different ways that we can assure the public in this 
area?
    Dr. McClellan. I would like to add a point, that there are 
common diagnostic problems out there and there is no question 
that there are misdiagnoses that lead to worse outcomes, and 
that does need to be addressed through the kinds of approaches 
that Dr. Cassel has described. But there are common problems, 
like people with chest pains who do not have any known heart 
disease, or people with back pain, or people who have a very 
bad headache, that end up getting treated very differently.
    Senator Toomey. Right.
    Dr. McClellan. And I think you can take the same approach 
that Dr. Lansky and really all of us have emphasized on kind of 
a patient- or person-centered approach to care and then a focus 
on how different providers are working together to solve those 
problems.
    Senator Toomey. All right.
    Dr. McClellan. On the chest pain problems, the 
cardiologist, the surgeons, and the primary care doctors have 
an approach that would do this.
    Senator Toomey. All right. Yes, I appreciate that. That is 
an interesting challenge that we have.
    I just briefly wanted to get back to a point that Dr. 
Lansky made, which is, it seems to me there is also a gap 
between the information that we do have, the measurements we 
are making about quality and outcome, and that which is 
available to consumers. There is a gap there.
    What is the main reason for that gap? Is there a reluctance 
on the part of some providers to provide information? Like, 
obviously not everybody is above average. Is there a problem on 
the part of those who might rather not have the information 
readily available to consumers?
    Dr. Lansky. Yes. There are very specific cases where 
provider organizations refused to share their data with efforts 
to aggregate and publish results, so I think there are several 
elements of this pipeline that are all problematic. One is, 
getting the primary raw data, and sometimes organizations 
withhold it. Second, once you have it, you have to massage it 
and make it understandable to people. There are pretty good 
ways of doing that now.
    But third, we have a platform. Physician Compare is in the 
legislation, the Affordable Care Act, already, and it should be 
a platform where everyone in the country can access the kind of 
information that we do have. The Qualified Entity Program that 
was also in the bill, where CMS is putting its data into the 
hands of regional centers, is a platform where you can very 
quickly spin out measures of individual doctor quality under 
collaboration with CMS and other private payers. So, I think 
the mechanism is in place.
    The Chairman. I am afraid I am going to have to enforce the 
5-minute rule here. There are going to be several votes 
starting at 11:30, and there are four or five Senators who have 
yet to ask questions. I am sorry, but we are going to have to 
start enforcing the 5-minute rule so everybody can get their 
questions in.
    Senator Stabenow, you are next.
    Senator Stabenow. Thank you very much, Mr. Chairman, for 
this hearing. Welcome to everyone.
    It strikes me as we are listening to this that we have had 
these conversations before, important conversations on health 
reform. We have in the legislation, in health reform, at least 
the beginning of tools in this area that I hope we would double 
down on in many cases and really fund.
    I mean, we have been for years moving on electronic medical 
records but need to move faster. We need to make it simpler, 
more user-friendly, and so on, the value-based purchasing 
efforts, the Accountable Care Organizations.
    Dr. McClellan, when you are talking about how we ought to 
be providing payments, it reminds me of a conversation I had 
way back in the beginning with someone, the CEO of a Detroit 
hospital, who said, ``Just remember that payments drive the 
system.''
    So, if you want to pay for more collaborative work or 
preventative work or physicians having more time on the front 
end to spend with people, whatever, then the system has to be 
designed that way to be able to pay for that. So I hope that 
that is something that at least was begun, and we need to do a 
whole lot more of, because it seems to me we know what needs to 
be done in many ways. Not everything certainly, but in many 
ways we just need to do it.
    I want to talk about maternity care for a minute, which is 
a very big issue and concern for me, not only for the obvious 
reason in terms of quality of moms and babies, but in saving 
dollars as well. Senator Grassley and Senator Cantwell and I 
and others have a bill called the Quality Care for Moms and 
Babies Act that would push for higher-quality care, and we 
basically do two things.
    We ask CMS to consider including the National Quality Forum 
quality measures in CHIP and Medicaid quality reporting 
programs as they are needed, and we provide some initial start-
up funds for quality collaboratives.
    I wonder, Dr. Cassel, you mentioned the success in reducing 
elective deliveries before 39 weeks. We have certainly seen 
this in Michigan. The Keystone Quality Collaborative, which is 
really, if not the first, certainly one of the very, very first 
to really focus on quality. The Michigan Hospital Association 
has done a great job with this. But the OB project there has 
certainly been very successful, saving lives, saving dollars.
    I am wondering if you can discuss the role you see for 
quality collaboratives like Keystone, as well as any particular 
changes in CHIP or Medicaid quality programs that would provide 
better maternity care outcomes.
    Dr. Cassel. Thank you. Well, first, I congratulate you on 
this important proposed legislation. I think that Keystone is a 
marvelous example. It gets to this point I made about 
prospecting, that there are places out there that are really 
ahead of the game in terms of everyone else and that we should 
be going to, looking for what measures they use to really get 
the best outcomes for their members or their patients. Kaiser 
is another one. NQF, with your support, can do that.
    I also think that, here is a place where, in so many cases, 
it is the private sector. Yes, Medicaid is a really big payer 
and an important one for kids, and all the issues that Dr. 
McClellan mentioned are very important there. But we also need 
to have the private sector aligned here, and particularly 
employers and purchasers. So much of workplace productivity has 
to do with the health of moms and the health of their babies 
when they go through that process.
    So I think here is another place where perhaps a part of 
what your leadership could do is help push us, as Chairman 
Baucus said, in this public/private alignment sector. I think 
this is a very ripe area for that.
    Senator Stabenow. Does anyone else want to comment on that 
particular thing, on maternity care? Yes, Dr. Lansky?
    Dr. Lansky. I would just endorse Dr. Cassel's point. Our 
members are working very closely with a group in California 
called the California Maternal Health Quality Collaborative, 
and Stanford University is the intellectual hub of this group. 
They are providing feedback to doctors in the State, and the 
employers see a very tight alignment with the goals of 
improving maternity care with Medicaid and other programs.
    Senator Stabenow. Thank you. I would just say in 
conclusion--I know my time is up--I know there are some very 
important issues that we have to deal with around SGR. We need 
your input. I ultimately am trying to figure out the way we 
should be looking at the physician quality reporting system and 
modifying that or changing that completely. So my time is up, 
but I would like very much in follow-up to know what your 
recommendations are on that. Thank you.
    The Chairman. Thank you, Senator, very much.
    Senator Burr?
    Senator Burr. Thank you, Mr. Chairman. Thank you to all of 
our witnesses.
    I think I have heard all of you agree that we sort of need 
best-in-class measurements. We need quality measurements, we 
need usable measurements. I have to share with you that I am a 
little bit concerned how often we change measurements.
    I do not say that from the perspective of the providers or 
the consumers, because I think, on both ends, they are smart 
enough to figure out how to use that. I am very concerned about 
government's ability to change, to recognize the value of 
something.
    So let me turn to you, Dr. Cassel, if I can, because you 
noted in your testimony that NQF is in the process of 
streamlining measures to ensure that only the best in class are 
on the market. As a result, last year you retired certain 
measurements. Of that, some of them had been adopted by CMS and 
HHS.
    My question to you is, are you seeing CMS and HHS begin to 
adjust those programs to reflect NQF's thinking, and to your 
knowledge are there measures that NQF has retired that CMS and 
HHS currently still embrace?
    Dr. Cassel. Thank you for that question. It is a very 
important part of this streamlining and progress towards more 
outcome measures. So sometimes measures are retired because 
science changes and the medical world changes, and then it is 
very appropriate to retire a measure, and I am sure that CMS 
will follow suit on those issues. That requires a real ongoing 
maintenance.
    There are also times to retire measures when everybody is 
performing at such a high level that it does not distinguish 
between them anymore. Thankfully, we have a few examples of 
that, particularly in cardiac care, where we have actually 
retired measures that NQF has endorsed or that the National 
Committee for Quality Assurance or other accreditors use, 
because everybody is above average and functions at above 90 or 
95 percent.
    Then there is this other issue of getting away from process 
measures towards more outcome measures. There are times when it 
might be appropriate for one user to retire a measure of 
process because you have a better measure for outcome, but 
sometimes CMS, for example, is not able to use that outcome 
measure because the payment or legislative requirements for 
Physician Compare do not allow that. So it is very important 
that there be alignment with all of these efforts and that CMS 
really be allowed to be more flexible in that way.
    Senator Burr. Well, Mark, let me ask you, is there a risk 
of developing too many quality measures and reporting 
requirements for providers? How do we strike the right balance?
    Dr. McClellan. There is a risk. As you heard earlier, there 
are a lot of measures out there that are now being used in 
Medicare payment systems. Unfortunately, as Dr. Lansky 
mentioned in his testimony, most of them are either just 
oriented to specific processes of care or they are not used 
consistently across all physicians.
    I think it would help for CMS to be able to focus more on 
some really important person-oriented, outcome-oriented 
measures, like measures of patient experience with care, like 
some of the outcomes that we have talked about before. As you 
have heard, those are tough to fit into current fee-for-service 
payments.
    They involve doctors and other providers working together, 
or at least spending their time on things that they do not 
traditionally get paid for, like answering e-mails or doing 
other things that really can help a patient get to a better 
outcome and that you do not want to really micromanage from a 
Federal standpoint.
    So I think this movement from CMS away from just paying for 
specific services and focusing at the same time on some key 
outcome-oriented measures and patient experience-oriented 
measures would be the best way to help simplify this 
proliferation, help the providers focus on what is important.
    Senator Burr. Dr. McGlynn, you said in your testimony that 
you cautioned that measures should not be overly proscriptive. 
I guess my question is, do you believe that today's measures 
are resulting in a one-size-fits-all approach to the delivery 
of care?
    Dr. McGlynn. I think we have a number of examples of that 
across different kinds of measurement programs. I think that is 
just something to be on the lookout for. I would say, even in 
the outcomes measure area, this could happen. If you think 
particularly about patients who have multiple chronic 
conditions, one of the things--and I was just at a set of 
meetings where we had some examples of better approaches to 
measurement that allow us to incorporate patient preferences.
    That is, if patients have multiple conditions, they could 
choose a set of outcome preferences that make sense for their 
life that might not mean that they would do as well on all 
kinds of measures. But as long as it is tailored for their 
preferences--and I think there are ways to do this kind of 
measurement--then I think we all win. It just takes a lot more 
nuance than we have been able to apply today.
    Senator Burr. Thank you very much.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator.
    Next we have Senator Isakson.
    Senator Isakson. Thank you, Mr. Chairman.
    Dr. McGlynn, in your testimony--I think I heard this right. 
You said we are making progress on quality outcomes, and you 
immediately referred to preventative care as one of the reasons 
we are doing that. Am I correct?
    Dr. McGlynn. Yes.
    Senator Isakson. Here is my question. We have talked about 
everybody reporting everything except the patient. In the 
private sector, in the last 15 to 20 years, corporations have 
put incentives in their health benefit plans for their 
employees to incentivize wellness and disease management: 
managing their blood sugar, their heart rate, blood pressure, 
all those types of things.
    Is there any way we can engage the patients' adherence to 
the doctors' recommendations on wellness and health care as a 
part of that measurement of quality? Because, if a patient is 
not paying attention to the doctor's prescriptions, not taking 
care of their own health, you are going to have a lousy outcome 
with no fault of the doctor.
    Dr. McGlynn. So, at Kaiser we are trying a sort of 
interesting experiment, and I do not have the results of this 
yet, but this is in conjunction with our labor partners. We 
have an incentive program that is put in place that 
incentivizes the group of patients to achieve improvements in 
outcomes across the group. So, rather than holding an 
individual patient accountable, because we know there are 
different struggles, we try to incentivize the group as a whole 
to have better health.
    So this is like a population health concept, but focused on 
a group of employees. The idea is to really encourage our 
employees to support each other in making health improvements 
and in that way be responsive to these physician 
recommendations, but to kind of engage the larger group 
support.
    So we have lots of examples of how we are trying to do that 
in a way that does not make an individual patient bad, but that 
says, we know this is a tough road for many people, how can we 
collectively support you in doing that? But it incentivizes the 
group so everybody will benefit if the health of the group 
improves. So, sort of stay tuned for the results on this. This 
is just something we are trying out as, I think, a pretty 
innovative strategy.
    Senator Isakson. I will be interested in hearing about it.
    I will ask one more quick question then go to future 
chairman and ranking member, one way or another, Ron Wyden, 
who, after the chairman retires, I think is next in line. But 
let me ask you the question about coordinated care. Ron Wyden 
has worked a lot, and I have tried to help him some, with this 
idea of getting care coordination as reimbursable under CMS and 
Medicare, because a lot of times people have multiple 
conditions and multiple physicians, and, without coordination 
in care, you can sometimes have an unintended consequence of a 
medical error, an over-prescription, or conflicting 
prescriptions one way or another. Would that help, to focus on 
coordinated care for seniors, in terms of producing better 
outcomes and lowering costs?
    Dr. McGlynn. I absolutely think it would. I have to say, 
just as a person who has moved from not being in integrated 
care to integrated care, it is sort of priceless, the value of 
having a system that has the ability to see all those things 
together. So I think that kind of coordinated care is 
absolutely critical, particularly for people who have more than 
one thing going on, which in this country is an increasingly 
large portion of the population.
    I would say that the other thing is really--and I think all 
of us are emphasizing this need to be more person-focused--
people need different kinds of help in getting coordination. 
Not everybody, even with the same clinical conditions, has the 
same coordination needs.
    So I think we also have to find ways to assume that one 
size does not fit all in terms of what good coordination looks 
like, but that we are hearing from patients about whether they 
feel that their care is adequately coordinated. That is kind of 
one of the approaches that we have been taking to measurement 
that I think will be much more meaningful than saying, this is 
kind of the only way to coordinate care.
    Senator Isakson. Thank you very much.
    The Chairman. Thank you, Senator.
    Next is Senator Thune.
    Senator Thune. Thank you, Mr. Chairman.
    I want to thank our panelists today for sharing your 
thoughts on this very important subject. I wanted to ask this 
question. This one, I think anybody can respond to. But there 
are stakeholders who have proposed using the electronic health 
records as a mechanism for measuring and reporting quality 
metrics.
    We have a lot of providers and a lot of hospitals across 
the country that are participating in the electronic health 
care record incentive program, and ideally it would be a way in 
which we might be able to get at this whole issue of measuring 
quality.
    And so I guess I am just thinking about what the advantages 
and disadvantages might be of using electronic health records 
as a mechanism for that and perhaps get your thoughts on that. 
Mark?
    Dr. McClellan. Just a couple of thoughts. Electronic health 
records do hold the promise of supporting exactly the kind of 
quality improvements and then reporting on quality improvements 
that you describe. I think in practice there have been a few 
challenges for providers.
    First of all, many of the traditional electronic record 
systems have not been very well designed to put together data 
from lots of different sources and enable you to track your 
particular patients in the way that you really need to in order 
to improve their care, and a lot of providers are doing add-ons 
or modifications to systems to help make that happen now.
    Second, from the standpoint of the meaningful use payments, 
so far most of those payments have been tied to whether or not, 
basically, you have electronic record systems that are capable 
of doing things like tracking a patient over time and maybe 
potentially reporting in on quality measures, but not actually 
doing it.
    One way to better align the payments that providers are 
receiving and further the goals of getting better quality 
information out, especially around outcomes and improving 
quality, would be to move towards meaningful use payments and 
other payments that really do support doctors in using their 
systems to put these data together and then report on it from 
their electronic record systems.
    Now, there are some concerns that that may be too big of a 
leap, but if you do not, as I think Senator Stabenow said 
earlier, focus the payments and the goals of your financing 
systems in Medicare and other programs on what you really want 
to get, it is awfully hard to get there.
    Dr. McGlynn. And I would agree that the promise is there. 
Actually, larger systems invest quite a bit of money in 
wresting value and information out the back end of these 
electronic health records. So I think that there needs to be 
more work to make them readily usable, so, for physicians in 
individual practice, I think it is a much harder climb because, 
frankly, they are not optimized for this use right now.
    I think that is very possible, and I think there are ways 
that we can push to make that more the case and not only 
possible in large systems that can make these additional 
investments. Half of my center's budget goes to making our data 
usable for research and for clinical decision support, and that 
is just not something everybody can afford to do.
    Senator Thune. Let me just, if I might--Dr. McClellan, if 
you want to respond to this, or others as well--there are also 
the stakeholders out there who believe that CMS has developed 
too many different measures. In quality improvement programs, 
you have things like value-based purchasing, physician quality 
reporting systems, electronic health records that we just 
mentioned, a meaningful use program, and the list goes on and 
on. I am wondering if you agree with that statement and, if so, 
what should or could be done to create a more strategic 
approach to enhance quality.
    Dr. McClellan. So there are an awful lot of measures out 
there, as we have said, and as I am sure you have heard from 
your constituents. I think I am going to maybe over-simplify 
things a bit, but one way of viewing what CMS is doing with all 
these multiple measurement systems is trying to put the same 
measures into each one.
    So in, for example, the Physician Meaningful Use Payments 
and in what CMS is planning for the value-based modifier, we 
are seeing some of the same measures coming together. 
Unfortunately, it is a very long list of measures, and it is 
not really the smaller set of the very important outcome-
oriented patient experience types of measures that really 
matter for patients. I think with good support in terms of 
financing reforms, it would be easier for providers to figure 
out their own best ways.
    Dr. Lansky said there is a lot of innovation going on in 
health care delivery, and clinicians are really interested in 
having more resources that they can use to support better care. 
So, if you not only tried to align the measures across these 
different programs but tried to simplify them down to the 
measures that are really important for patients, I think it 
could support a lot of efforts and reduce the burden of 
reporting for clinicians.
    Senator Thune. Thank you.
    Mr. Chairman, my time has expired.
    The Chairman. Thanks, Senator.
    Senator Wyden?
    Senator Wyden. Mr. Chairman, first of all, thank you for 
holding this special hearing on quality. It reminded me of some 
of the discussions that we had during health reform. There were 
always scores of articles about costs, and it always seemed 
that quality got short shrift. You said we ought to be going 
after that, and I think this is another indication that, when 
people have these debates, we ought to not just consider the 
quality issue an after-thought. You started talking about that 
a long time ago, and I appreciate it.
    All of you have given excellent presentations. I am just 
going to ask Dr. Cassel a question or two, not just because, in 
Oregon, we claim her as ours. As you probably know, she was the 
first female dean at Oregon Health and Science University, but 
she was also one of the premier gerontologists that I remember 
reading articles about and using for the various issues that we 
were tackling at home.
    So, Dr. Cassel, you really, I think, hit on an extremely 
important issue that is just now beginning to get some 
attention, and that is chronic care. Back when you were looking 
at some of the first geriatric research in Oregon and we were 
picking up on it in the Gray Panthers, we remember that 
Medicare was a very different program. There was a lot less 
cancer, a lot fewer strokes, a lot less diabetes. It was not 
the kind of chronic care challenge that it presents today.
    What Senator Isakson was alluding to is that he, I, and 
Senator Casey, a big group of Senators, Democrats and 
Republicans, are very interested in this issue. I was struck by 
your comment that, among the challenges with respect to chronic 
care is that you think the quality measures with respect to 
chronic care are coming up short.
    I was wondering what you could tell us about why that is 
the case. You mentioned challenges with respect to sharing data 
and maybe the providers in the plans are not communicating, but 
what is the challenge so that we can build into these 
bipartisan discussions on chronic care your thoughts on getting 
at quality, which frankly, because of Chairman Baucus, we have 
a chance to do this morning. I mean, nobody else is really 
digging into it, so I think it is a perfect time to hear your 
thoughts on chronic care and quality.
    Dr. Cassel. Well, thank you, Senator Wyden. Thank you for 
your leadership in this. I do remember those days with the Gray 
Panthers, and I was a fellow in geriatrics at the VA in Oregon. 
I remember that I had patients who had come in on a 3-hour bus 
ride, trying to figure out what was going to be their chief 
complaint, because they were only allowed one. As soon as we 
opened the geriatric clinic, they loved it because they could 
have more than one medical problem, which was the reality for 
many of these very elderly veterans.
    Now, of course, as you point out, there are more and more 
people in our country, because people are living longer, which 
is a good thing, who are facing this issue. The quality 
measurement science and movement, if you want to call it that, 
has understandably focused initially on high-prevalence, high-
yield conditions like diabetes, hypertension, heart disease. So 
they have looked at this one disease at a time across the 
spectrum and have not put as much investment into composite 
measures or the aggregate of a patient's outcome overall, and 
often these individual quality measures, as Dr. McGlynn 
mentioned, kind of backfire because what you might want for 
diabetes in somebody who does not have any other problems could 
be very different with a patient who also has Alzheimer's 
disease and is suffering from two or three malignancies and 
other kinds of issues, perhaps in a nursing home.
    So really we need an investment in this area of aggregating 
information and having it all be patient-centered, all be 
around the individual patient and their function and their 
values.
    In order to do that, if that were not challenging enough 
scientifically, we also need to get the data together from 
sectors outside of hospitals and doctors' offices, the 
traditional area that we are looking at right now--and the 
long-term care and community providers whom you are so familiar 
with have to be part of this picture as well. So I think that 
is doable, but I think it just needs to be lifted up and be 
made a higher priority.
    Senator Wyden. I still have a few seconds. Do any of your 
colleagues want to add to this?
    Dr. McGlynn. So I would just add that quality measurement 
follows in the wake of clinical science. Frankly, clinical 
science has not really figured out conceptually or practically 
how best to deal with patients with multiple morbidities. So I 
think that this is something we need to do together, to figure 
out how to think about that.
    The clinical science is pretty siloed itself, and I do not 
think just adding up the individual siloes is going to get us 
where we need to go. So these examples of engaging patients to 
set goals for themselves and then to measure how well the 
system is delivering against those preferences is an area I 
think we really need to explore for this population.
    Senator Wyden. Let us do this. Chairman Baucus has been 
good enough to let me do this, and we have a vote on the floor. 
Would any of you like to make additional contributions on the 
question of chronic care and quality? Dr. McClellan has also 
been very interested in this for years. For any of you four--
this has been a terrific panel. Again, Mr. Chairman, I really 
appreciate your doing this.
    The Chairman. You bet. Thank you, Senator, very much.
    The vote has begun, but we have a couple of minutes here. 
There are a couple of people who are not at this table. First, 
there are no doctors here, or any practicing doctors. 
[Laughter.]
    Second, CMS is not at the table. We have a lot of other 
groups that are not at the table. Let us just start with CMS. 
What would you tell Marilyn Tavenner if she were here, and what 
would she say back to you after you told her that? [Laughter.]
    Anybody? We have about 3, 4, 5 minutes.
    Dr. Lansky. I would ask her to move as rapidly as possible 
to use the tools she already has. She has publishing tools, she 
has value payment tools that can use the kinds of measures we 
have talked about today. That signal is the most important 
signal that the country needs.
    The Chairman. Anybody else?
    Dr. Cassel. I would ask, and I have actually done this 
already, for greater flexibility in the support that CMS gives 
for measure development, including to NQF and groups like us 
that get away from fee-for-service measure development to more 
of an open pipeline so that we can be more rapid and more 
adaptive.
    The Chairman. Are they not trying to do that?
    Dr. Cassel. They are trying to do that, but that would 
really be my urgent----
    The Chairman. All right.
    Dr. McClellan. We have talked some about changes in focus 
to measures that are outcome-oriented and simplifying and 
aligning all the different Medicare payment initiatives that 
physicians and everybody else have to face around these key 
measures and goals.
    Beyond that, I do think she could use some legislative help 
in the payment systems, especially those that are completely 
fee-for-
service-based now, like physician payment to some extent, post-
acute care payment, having a piece of those payments go to 
something else, more flexibility for doctors to work across 
specialties, to work with other providers to tie those to some 
of these very important outcome measures that we have 
described. And that would take legislation.
    The Chairman. So when we update SGR----
    Dr. McClellan. It could be done with part of----
    The Chairman. Part of that.
    Dr. McClellan. A step in this direction could be done as 
part of even a short-term SGR bill.
    The Chairman. All right.
    Senator Carper, an extremely valuable member of this 
committee, has just arrived, and we do not have much time left. 
Senator Carper, it is all yours.
    Senator Carper. Thanks. Thanks so much, Mr. Chairman.
    To our witnesses, welcome. It is nice to see you all. It is 
especially nice to see Mark. I enjoyed working with him over 
the years, wearing a number of different hats. But thank you 
all for coming. We have a bunch of things going on outside of 
this room today, as you know, and are trying to make some 
progress on those.
    I want to talk a little bit about Medicare Advantage plans, 
if I could. If this has been asked by others, I apologize. But 
as you know, Medicare Advantage plans are currently judged on a 
variety of quality measures. I think they use a star rating 
system. From what you said, these quality measures seem to be 
effectively driving Medicare beneficiaries to choose higher-
quality insurance plans.
    On the other hand, Medicare fee-for-service programs to 
allow beneficiaries to compare quality among hospitals and 
providers appear to be, at least to us, outdated and used 
rather infrequently by seniors and by their families.
    So my question is, do you think that the Medicare Advantage 
quality measurement system is effective for seniors? What kind 
of lessons should we draw from this quality system for the 
Medicare fee-for-service system in the private health insurance 
market? Please.
    Dr. Cassel. Let me start this out, but Dr. McGlynn has much 
more experience with the 5-star program. But I think a big part 
of it, Senator, is about this issue of making the measurements 
understandable to consumers and patients, putting the 
information in a broad enough framework that they can 
understand.
    They are not going to go, or very rarely, and check 
individual quality measures on individual providers, and 
frankly that is a lot of what CMS has right now in terms of 
Physician Compare. The reason 5-star is successful is because 
it is understandable to everybody. You have four stars and five 
stars, and five stars is better than four stars.
    So, if we had ways of describing the other parts of our 
quality enterprise that were as accessible as that, but that 
allowed you to dig down if you wanted to to get more detail 
about it, I think that would be hugely helpful.
    Senator Carper. Good. Thank you.
    Others? Please.
    Dr. McGlynn. I agree. That is actually consistent with a 
lot of research that has been done, which is to find ways to 
separate the details of measurement, from, are we measuring the 
right things to, how do we communicate that to different 
audiences?
    The Medicare 5-star--I think what is nice about it is it 
produces understandable information for consumers, and, as you 
said, we see evidence now that there is some use for that 
information and it aligns incentives. And I will say at Kaiser 
Permanente we pay a lot of attention to the 5-star ratings in 
terms of driving through our system improvements that are 
consistent with those measures. The advantage is, with those 
bonuses, they go back to member benefits, so everybody wins.
    The challenge is, how do you do that in a non-system? But I 
think that, in terms of the information, the communication 
aspect, absolutely that is the way to go. There are lots of 
systems out there, hotels, restaurants, et cetera, that use 
these very simple rating systems that are a roll-up of a much 
more complex under-the-hood measurement, and absolutely 
Medicare fee-for-service fits that model.
    Senator Carper. Thank you. Let me just ask of Mark and Dr. 
Lansky--I had one more question I wanted to ask. Are you in 
general agreement with what our first two witnesses said?
    Dr. McClellan. Two really quick comments.
    Senator Carper. Sure.
    Dr. McClellan. It would be nice if there were more outcome-
oriented components of the Medicare Advantage measures. 
Unquestionably, people are paying attention to them. I think 
you can still build in that same kind of outcome focus in 
Medicare fee-for-
service. Let us move those in the same direction. In fact, a 
lot of Medicare Advantage plans like Aetna are now supporting 
fee-for-service providers and coordinating care and doing 
better on these patient-level results.
    Senator Carper. All right. Good. Thanks.
    The second question. As a recovering Governor, I often 
think of States as good laboratories of democracy to test and 
perfect new ideas. You mentioned, I think, maybe Minnesota's 
and California's quality reporting and measurement systems as 
potential examples of more effective quality rating systems.
    My question is, what are the lessons and best practices 
that Medicare should draw from the quality measurement and 
reporting programs in those two States, and maybe other States? 
Do Medicare and Medicaid have sufficient statutory authority to 
create similar quality reporting programs? If you can just be 
very, very brief. Dr. Lansky?
    Dr. Lansky. Minnesota is really a very good example, as is 
Wisconsin and other States. So I do think you are right: there 
is an opportunity to cull the best practices, especially those 
that are used utilizing patient-reported measures and outcome 
measures, which is being done in a number of the States. So I 
think that is an opportunity. There is no reason Medicare could 
not implement the same mechanisms across the country.
    Senator Carper. All right.
    Dr. McClellan. Let me just add that it is not an accident 
that those systems are best-developed in Minnesota and 
California. Those States have done a lot of activities and 
leadership around payment reform to focus more at the person 
level rather than just on fee-for-service payments.
    One thing that Medicare really needs to do that really 
could help providers is moving their payment systems away from 
fee-for-
service, otherwise you are telling people, construct these 
measures, work at the patient level, but you are not paying 
them in a way that helps them do that.
    Senator Carper. All right.
    I have to run. A vote is under way. This is great. I have 
been trying to get on your dance card, Mark, for a more 
fruitful conversation, so hopefully we can do that and I will 
learn even more than we have learned today.
    Thank you very much for your testimony today. Thank you.
    The Chairman. Thank you, Senator. Thank all four of you. 
Earlier on I mentioned the Edwards Deming quote that quality is 
the responsibility of everyone, and then I pushed you a little 
bit, Dr. Cassel, who said we have to push. Well, I think, 
frankly, that we all need to be pushed: you all, CMS, 
providers, everybody, including this panel.
    So let us just all agree to, not only understand that 
quality is everybody's responsibility, but pushing all of this 
is our responsibility too, because this is very important. 
Thank you so much. You have added a lot to this subject. Thank 
you.
    The hearing is adjourned.
    [Whereupon, at 11:45 a.m., the hearing was concluded.]
                            A P P E N D I X

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