[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
EXAMINING LEGISLATION TO IMPROVE HEALTH CARE AND TREATMENT
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
DECEMBER 9, 2015
__________
Serial No. 114-108
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COMMITTEE ON ENERGY AND COMMERCE
FRED UPTON, Michigan
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Chairman Emeritus Ranking Member
ED WHITFIELD, Kentucky BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
JOSEPH R. PITTS, Pennsylvania ELIOT L. ENGEL, New York
GREG WALDEN, Oregon GENE GREEN, Texas
TIM MURPHY, Pennsylvania DIANA DeGETTE, Colorado
MICHAEL C. BURGESS, Texas LOIS CAPPS, California
MARSHA BLACKBURN, Tennessee MICHAEL F. DOYLE, Pennsylvania
Vice Chairman JANICE D. SCHAKOWSKY, Illinois
STEVE SCALISE, Louisiana G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington KATHY CASTOR, Florida
GREGG HARPER, Mississippi JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey JERRY McNERNEY, California
BRETT GUTHRIE, Kentucky PETER WELCH, Vermont
PETE OLSON, Texas BEN RAY LUJAN, New Mexico
DAVID B. McKINLEY, West Virginia PAUL TONKO, New York
MIKE POMPEO, Kansas JOHN A. YARMUTH, Kentucky
ADAM KINZINGER, Illinois YVETTE D. CLARKE, New York
H. MORGAN GRIFFITH, Virginia DAVID LOEBSACK, Iowa
GUS M. BILIRAKIS, Florida KURT SCHRADER, Oregon
BILL JOHNSON, Ohio JOSEPH P. KENNEDY, III,
BILLY LONG, Missouri Massachusetts
RENEE L. ELLMERS, North Carolina TONY CARDENAS, California
LARRY BUCSHON, Indiana
BILL FLORES, Texas
SUSAN W. BROOKS, Indiana
MARKWAYNE MULLIN, Oklahoma
RICHARD HUDSON, North Carolina
CHRIS COLLINS, New York
KEVIN CRAMER, North Dakota
Subcommittee on Health
JOSEPH R. PITTS, Pennsylvania
Chairman
BRETT GUTHRIE, Kentucky GENE GREEN, Texas
Vice Chairman Ranking Member
ED WHITFIELD, Kentucky ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois LOIS CAPPS, California
TIM MURPHY, Pennsylvania JANICE D. SCHAKOWSKY, Illinois
MICHAEL C. BURGESS, Texas G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey DORIS O. MATSUI, California
H. MORGAN GRIFFITH, Virginia BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida KURT SCHRADER, Oregon
BILLY LONG, Missouri JOSEPH P. KENNEDY, III,
RENEE L. ELLMERS, North Carolina Massachusetts
LARRY BUCSHON, Indiana TONY CARDENAS, California
SUSAN W. BROOKS, Indiana FRANK PALLONE, Jr., New Jersey (ex
CHRIS COLLINS, New York officio)
JOE BARTON, Texas
FRED UPTON, Michigan (ex officio)
C O N T E N T S
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Page
Hon. Joseph R. Pitts, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 1
Prepared statement........................................... 2
Hon. Gene Green, a Representative in Congress from the State of
Texas, opening statement....................................... 3
Hon. Renee L. Ellmers, a Representative in Congress from the
State of North Carolina, opening statement..................... 5
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 6
Hon. Doris O. Matsui, a Representative in Congress from the State
of California, prepared statement.............................. 96
Witnesses
Chad Asplund, MD, MPH, FACSM, Director, Athletic Medicine and
Head Team Physician, Georgia Southern University............... 8
Prepared statement........................................... 11
Jonathan Reiner, MD, Director, Cardiac Catheterization
Laboratory, George Washington University Hospital.............. 18
Prepared statement........................................... 20
Anthony R. Gregg, MD, Professor and Chief Division of Maternal-
Fetal Medicine, University of Florida Department of Obstetrics
and Gynecology................................................. 31
Prepared statement........................................... 33
Ginger Breedlove, PhD, CNM, APRN, FACNM, President, American
College of Nurse Midwives...................................... 41
Prepared statement........................................... 43
Deborah E. Trautman, PhD, RN, FAAN, President, American
Association of Colleges Of Nursing............................. 51
Prepared statement........................................... 53
Ovidio Bermudez, MD, FAAP, FSAHM, FAEd, F.iaedp, CEDS, Chief
Clinical Officer and Medical Director of Child and Adolescent
Services, Eating Recovery Center Senior Board Advisor, National
Eating Disorders Association................................... 60
Prepared statement........................................... 62
Answers to submitted questions............................... 140
Submitted material
Mr. Pitts' submitted material
Statement of Congresswoman Jaime Herrera Beutler............. 97
Statement of the American Congress of Obstetricians and
Gynecologists.............................................. 99
Statement of the National Nursing Centers Consortium......... 106
Statement of the National Association of Clinical Nurse
Specialties................................................ 111
Statement of the Nursing Community coalition................. 114
Statement of the Society for Maternal-Fetal Medicine......... 119
Statement of the National Leaque for Nursing................. 122
Statement of the National Athletic Trainers' Association..... 127
Statement of the Perinatal Quality Foundation................ 129
Mr. Guthrie's submitted material
Statement of sports medicine coalition....................... 131
Statement of the American Association of Orthopaedic Surgeons 132
Statement of the American Medical Association................ 137
Statement of the American Osteopathic Association............ 138
Statement of sports leagues and organizations................ 139
EXAMINING LEGISLATION TO IMPROVE HEALTH CARE AND TREATMENT
----------
WEDNESDAY, DECEMBER 9, 2015
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 9:59 a.m., in
room 2322, Rayburn House Office Building, Hon. Joseph R. Pitts
(chairman of the subcommittee) presiding.
Present: Representatives Pitts, Guthrie, Shimkus, Murphy,
Burgess, Blackburn, Lance, Griffith, Bilirakis, Ellmers,
Bucshon, Brooks, Collins, Green, Engel, Capps, Schakowsky,
Castor, Matsui, Schrader, Kennedy, Cardenas, and Pallone (ex
officio).
Staff Present: Leighton Brown, Press Assistant; Rebecca
Card, Assistant Press Secretary; Karen Christian, General
Counsel; Peter Kielty, Deputy General Counsel; Carly
McWilliams, Professional Staff Member, Health; Katie Novaria,
Professional Staff Member, Health; Graham Pittman, Legislative
Clerk; Adrianna Simonelli, Legislative Associate, Health; Heidi
Stirrup, Health Policy Coordinator; John Stone, Counsel,
Health; Jen Brennan, Minority Press Secretary; Jeff Carroll,
Minority Staff Director; Waverly Gordon, Minority Professional
Staff Member; Samantha Satchell, Minority Policy Analyst; and
Arielle Woronoff, Minority Health Counsel.
OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Mr. Pitts. The subcommittee will come to order. The chair
will recognize himself for an opening statement.
Today's hearing will examine several different legislative
proposals that will address shortcomings in current law, and
reauthorize an important nursing training program.
H.R. 921, the Sports Medicine Licensure Clarity Act
sponsored by the Health Subcommittee vice chair, Brett Guthrie,
clarifies medical liability rules for athletic trainers and
medical professionals to ensure they are properly covered by
their malpractice insurance while traveling with their athletic
teams to other states.
H.R. 1209, the Improving Access to Maternity Care Act,
sponsored by another member of our Health Subcommittee, Dr.
Michael Burgess, requires the Health Resources and Services
Administration to designate maternity care health professional
shortage areas inside existing primary care health professional
shortage areas, and review these designations at least
annually. The Department of Health and Human Services would
also be required to collect and publish data on the shortage
areas to better ensure access to maternity care.
H.R. 2713, the Title VIII Nursing Workforce Reauthorization
Act, sponsored by Representative Lois Capps, reauthorizes the
current nursing workforce development programs to continue
nursing education at all levels and provide additional support
for nurses practicing in medically underserved communities.
H.R. 3441, the Accurate Education For Prenatal Screening
Act, sponsored by Representative Jaime Herrera Beutler, directs
the Centers for Disease Control and Prevention to develop,
implement, and maintain programs to educate patients as well as
healthcare providers on the purpose of cell-free DNA prenatal
screenings. The reasons for such screenings, what conditions
may be detected as well as the risk, benefits, and alternatives
to such screenings.
H.R. 4152, the Cardiac Arrest Survival Act, sponsored by
Representative Pete Olson, expands immunity from civil
liability related to the use of automated external
defibrillator devices.
H.R. 4153, the Educating to Prevent Eating Disorders Act of
2015, sponsored by Representative Renee Ellmers, yet another
Health Subcommittee member, establishes a pilot program to test
the impact of early intervention on the prevention, management,
and course of eating disorders.
We will hear from a panel of experts and stakeholders as to
their ideas and recommendations on these bills.
I now yield to Dr. Burgess.
[The statement of Mr. Pitts follows:]
Prepared statement of Hon. Joseph R. Pitts
The subcommittee will come to order.
The Chairman will recognize himself for an opening
statement.
Today's hearing will examine several different legislative
proposals that will address shortcomings in current law and
reauthorize an important nursing training program.
H.R. 921, the Sports Medicine Licensure Clarity Act,
sponsored by the Health Subcommittee Vice Chairman Brett
Guthrie (KY) clarifies medical liability rules for athletic
trainers and medical professionals to ensure they are properly
covered by their malpractice insurance while traveling with
their athletic teams to other states.
H.R. 1209, the Improving Access to Maternity Care Act,
sponsored by another Member of our Health Subcommittee Dr.
Michael Burgess (TX) requires the Health Resources and Services
Administration (HRSA) to designate maternity care health
professional shortage areas inside existing primarily care
health professional shortage areas, and review these
designations at least annually. The Department of Health and
Human Services would also be required to collect and publish
data on these shortage areas to better ensure access to
maternity care..
H.R. 2713, the Title VIII Nursing Workforce Reauthorization
Act, sponsored by Rep. Lois Capps (CA) reauthorizes the current
Nursing Workforce Development programs to continue nursing
education at all levels, and provide additional support for
nurses practicing in medically underserved communities.
H.R. 3441, the Accurate Education for Prenatal Screenings
Act, sponsored by Rep. Jaime Herrera Beutler (WA) directs the
Centers for Disease Control and Prevention to develop,
implement, and maintain programs to educate patients as well as
health care providers on the purpose of cell-free DNA prenatal
screenings, the reasons for such screenings, what conditions
may be detected, as well as the risks, benefits, and
alternatives to such screenings.
H.R. 4152, the Cardiac Arrest Survival Act, sponsored by
Rep. Pete Olson (TX) expands immunity from civil liability
related to the use of automated external defibrillator devices.
H.R. 4153, the Educating to Prevent Eating Disorders Act of
2015, sponsored by Rep. Renee Ellmers (NC), yet another health
subcommittee member, establishes a pilot program to test the
impact of early intervention on the prevention, management, and
course of eating disorders.
Today we have two panels, including. Additionally, we will
hear from a panel of experts and stakeholders as to their ideas
and recommendations on these bills.
I will now yield to Dr. Burgess.
Mr. Burgess. Thank you, Mr. Chairman.
I just want to comment on the bill we have before the panel
today. Across the country, women with the greatest need for
maternity care services lack access to providers of such care.
This bill introduced with Representative Capps will help place
more maternity providers where they are needed and to improve
access to maternity care and advance the health of mothers and
babies. The National Health Service Corps provides for student
loan repayment to physicians and other health professionals in
exchange for our commitment to provide care in a designated
health professional shortage area.
The program has been effective in reducing provider
shortages by inspiring new providers to start where they are
needed the most. Maternity care providers currently participate
in the program based on a determination in an area that is a
primary care shortage area. This bill would more effectively
allocate maternity care providers based on an area or
population's specific needs.
In other words, a maternity care provider will continue to
be able to participate, but their participation will be based
on a designation of a maternity care shortage area, not just
simply a primary care shortage area. We are continuing to work
with HRSA to ensure that this narrow targeted provision will
improve access to mothers and the care that they and their
babies need.
And thank you, Mr. Chairman. I will yield back.
Mr. Pitts. The chair thanks the gentleman. The chair now
recognizes the distinguished ranking member of the Health
Subcommittee, Mr. Green, from Texas, 5 minutes for opening
statement.
OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS
Mr. Green. Thank you, Mr. Chairman. Today we are here to
review six bills aimed at improving our healthcare system. But,
first, and since this is, hopefully, our last hearing of the
year, I want to start by thanking all of my colleagues on the
Health Subcommittee, Ranking Member Pallone, Chairman Upton,
and, of course, Chairman Pitts, for all of their work that went
into the bills that comprise our shared success. It has been an
incredibly productive year, and this subcommittee serves as an
example of what we can accomplish when we work together on
behalf of the American people.
From the 21st Century Cures Act, which passed with
overwhelming support in the House last summer, to the Medicare
Access and CHIP Reauthorization Act, which repealed and
replaced the SGR and extended funding for the CHIP program in
community health centers to dozens of public health bills
signed into law, to ongoing efforts along the salient issues
such as regulation of laboratory developed tests, the success
of undertakings of this subcommittee are numbered in
significance. None of this would have happened without the
strong leadership on both sides of the aisle and the commitment
to bipartisanship and a tireless dedication of staff, House
legislative counsel and advocates, including the
administration. I want to thank all of you and look forward to
seeing what we can accomplish in the coming year.
Now to our bills today. H.R. 921, the Sports Medicine
Licensure Clarity Act, will promote the safety of our athletes
by ensuring that sports teams' physicians and athletic trainers
who treat their athletes while outside their home state can
treat their patients regardless of whether they are home or
away. Many medical liability insurance carriers do not offer
coverage for care provided outside of the State in which the
provider is licensed, making it difficult for team physicians
to maintain adequate coverage while traveling throughout a
sport season. This legislation would clarify certain aspects of
the medical liability and malpractice insurance for those
providers to address this issue in a targeted manner.
H.R. 4152, the Cardiac Arrest Survival Act, aims to
increase the deployment of automated external defibrillators,
or AEDs, by providing a baseline protection from civil
liability for persons who own or use AEDs and doing a good-
faith medical emergency. Numerous studies have demonstrated the
value of prompt use of AED during an out-of-hospital cardiac
arrest as the likelihood of survival decreases by 7 or 10
percent for every minute delayed until defibrillation.
H.R. 3441, the Accurate Education for Prenatal Screening
Act, aims to advance the use of cell-free DNA prenatal
screening. The development and delivery of genetic and genomic
health care will continue to transform the practice of medicine
and improve the diagnosis, prevention, and treatment of
disease. While I thank the bill sponsors for their commitment
to the promise of genetics and the improving care for women
with high-risk pregnancies, I have some concern that this
legislation is overly prescriptive and premature and that
information surrounding these tests is not evaluated by the FDA
for their clinical or analytical validity.
H.R. 1209, Improving Access to Maternity Care Act, was
introduced to increase access to maternity care services by
creating a new designation within primary care health
professional shortage areas, HPS designation--HPSA. As someone
who represents an underserved area, I appreciate the bill
sponsors, Representative Mike Burgess and Lois Capps, for their
commitment to targeting gaps in access and ensuring women can
obtain vital maternity care services.
H.R. 2713, the Title VIII Nursing Workforce Reauthorization
Act, will extend successful advanced nurse--education nursing
grants to support clinical nurse specialist programs. The Title
VIII nursing workforce development programs have a long history
of success and bipartisan support in Congress. Continued
investment in these programs will ensure we have an adequate
nursing workforce in the future. I want to thank Congresswoman
Capps, the bill's sponsor, an unwavering champion for her work
to reauthorize these critical programs, for her long history of
working to improve nursing workforce demand, education,
practice, recruitment, and retention.
H.R. 4153, the Educating to Prevent Eating Disorders Act,
will create a pilot program through the Agency on Healthcare
Research and Quality to test the efficiency of early
interventions on eating disorders. According to the NIH, eating
disorders frequently present during teens and early adulthood,
affect as many as 25 million Americans.
I look forward to hearing from our witnesses and learning
more about the merits of each legislative proposal before the
subcommittee.
And I thank you, and I yield back my time.
Mr. Pitts. The chair thanks the gentleman.
And now, in lieu of the chairman, Mr. Upton, the chair
recognizes the gentlelady from North Carolina, Mrs. Renee
Ellmers, 5 minutes for opening statement.
OPENING STATEMENT OF HON. RENEE L. ELLMERS, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF NORTH CAROLINA
Mrs. Ellmers. Thank you, Mr. Chairman.
And thank you to our panelists for being here today for
this subcommittee hearing today. Through my experience as a
nurse, I recognize and have witnessed the serious implications
that stem from eating disorders.
These disorders impact a person's emotional and physical
health. So it is all the more important that we put in
evidence-based programs in place to better understand the early
warning signs of the disease. Our legislation, H.R. 4153,
creates a pilot program within middle schools to begin
educating school counselors, teachers, nurses, and parents
about the signs and symptoms typically associated with these
disorders.
Education is a critical first step, if we hope to prevent,
identify, manage, and intervene on behalf of the struggling
adolescent. It is my hope that this legislation provides school
officials and healthcare professionals with the education and
resources they need to help thwart this mental illness from
taking root. Thirty million Americans will struggle with an
eating disorder at some point in their lives.
H.R. 4153 aims to amend the Public Health Service Act to
establish a pilot program to test the impact of providing
students with interventions to prevent, identify, intervene,
and manage eating disorders. The bill would establish a 3-year
pilot program to provide grants to eligible schools for eating
disorder screening, which would be implemented based on best
practices recommendations from experts in the field of eating
disorders. The pilot program would also include educational
information and seminars on eating disorders developed by
experts in the field for teachers, and parents, and eligible
schools.
The intent of H.R. 4153 is to detect risk factors and
symptoms so that young people can be directed to help when it
is most effective. H.R. 4153 could be the most important
proactive piece of legislation for the early intervention and
prevention of deadly eating disorders.
I look forward to beginning this important discussion
today, and thank you, again.
I yield back the remainder of my time.
Mr. Pitts. The chair thanks the gentlelady.
Is anyone else on this side of the aisle seeking
recognition?
The chair thanks the gentlelady, and I now recognize the
distinguished ranking member of the full committee, Mr.
Pallone, 5 minutes.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Mr. Chairman. This morning we will
be discussing a wide variety of bills. The first, H.R. 921, the
Sports Medicine Licensure Clarity Act, stipulates that if a
team doctor or athletic trainer crosses State lines for a game,
any care provided at the out-of-State event will be treated as
if it were a home game for the purpose of medical licensure and
liability.
The second bill, H.R. 4152, the Cardiac Survival Act,
expands civil liability protections related to the usage of
automated external defibrillator devices, or AEDs. This bill
would offer broad protections for both the owners of AEDs and
any lay person that may use it. While I strongly support the
intended goal of this bill, I do have some concerns surrounding
State law preemption, especially as itmay relate to various
State AED training laws.
Third is H.R. 3441, the Accurate Education for Prenatal
Screenings Act, would direct CDC to develop patient and
provider education programs and materials to inform them about
the use of cell-free DNA prenatal screening tests for genetic
conditions such as Down syndrome. These screenings are intended
to provide patients with genetic information regarding their
pregnancy. However, these screenings are not regulated by FDA
and have a history of false positives and false negatives.
Further, these tests are often misunderstood by both patients
and providers. More must be done to ensure that the information
provided about these tests is accurate and truthful to ensure
that patients and providers can better understand these
screenings and their limitations.
The fourth bill, H.R. 1209, the Improving Access to
Maternity Care Act, as introduced by Representatives Burgess,
Capps, and Duckworth, would make changes to the National Health
Service Corps definition of a primary care health professional
shortage area by creating a subcategory specifically for
maternity care providers. This would allow the National Health
Service Corps to better target maternity care providers towards
the areas with the most need.
And then we have H.R. 2713, the Title VII Nursing Workforce
Reauthorization Act as introduced by Representative Capps and
Joyce, would reauthorize the Title VIII nursing workforce
programs which provide valuable training to our Nation's
nursing workforce through 2020. It also provides technical
updates that more accurately reflect the current state of the
nursing profession.
And, finally, H.R. 2153, the Educating to Prevent Eating
Disorders Act, as introduced by Representatives Ellmers, Clark,
and Castor, creates a pilot program to test new approaches to
early interventions for eating disorders.
I would like to yield the remainder of my time to Mrs.
Capps.
Mrs. Capps. I thank my colleague for yielding.
And I thank you, Mr. Chairman and Ranking Member Green, for
holding this hearing. I am particularly pleased that two pieces
of legislation I have worked on for a long time are also
included in this discussion. Each would help strengthen our
healthcare workforce and improve access to care for patients
across the Nation.
H.R. 1209, the Improving Access to Maternity Care Act,
would help identify and fill gaps in maternity care through the
National Health Service Corps. My colleague from Texas has
already described this, but I want to underscore the fact that
the National Health Service Corps is one of our most effective
programs to improve access to care in underserved areas.
Maternity care professionals are already included in the
program, but their placement is based on data looking at
primary care access shortages, not maternity care data. And
this bill would make this more efficient by allowing these
professionals to serve in areas with shortages in maternity
care access, not just those with primary care deficiencies. It
may seem like a small thing, but it is actually pretty
significant.
I am pleased to have also co-authored this legislation with
Dr. Burgess, and I want to highlight the work of our colleague,
Representative Roybal-Allard on this issue over the years.
Quality maternal care is vitally important for both the health
of women and their future children, and it is our interests to
do all we can to break down barriers to access for this care.
I am also very pleased that we are considering H.R. 2713,
the Title VIII Nursing Workforce Reinvestment Act--Workforce
Reauthorization Act. Sorry. Title VIII is the primary program
our Nation has to strengthen and grow the nursing workforce.
Title VIII has supported the recruitment, retention, and
distribution of the highly educated professionals who comprise
our Nation's nursing workforce and have been doing so for over
50 years through Title VIII. These programs bolster nursing
education at all levels, from entry-level preparation through
graduate study, and they provide support for institutions that
educate nurses for practice in rural and medically underserved
communities. Moreover, these programs are designed to address
specific needs within the nursing workforce and America's
patient population. The Nursing Workforce Reauthorization Act
would ensure that these critical programs are available for
years to come.
I want to thank my nursing caucus co-chair, Representative
David Joyce, for coauthoring this legislation and the over 50
nursing groups that we have worked with to move this
reauthorization forward. It is a great day.
So, again, thank you for including these bills in today's
hearing.
And with that, I yield back to my colleague, but I don't
think there is any time. Thank you.
Mr. Pitts. The chair thanks the gentlelady.
As usual, all written opening statements of the members
will be made a part of the record.
I have a UC request. I would like to submit the following
documents for the record: Statements from Representative
Herrera Beutler, from the American Congress of Obstetricians
and Gynecologists, from National Nursing Centers Consortium,
from the National Association of Clinical Nurse Specialists,
from the Nursing Community Coalition, from the Society for
Maternal Fetal Medicine, from the National League for Nursing,
and the National Athletic Trainers' Association. Without
objection, these will be made a part of the record.
[The information appears at the conclusion of the hearing.]
Mr. Pitts. I will now introduce the panel. We have six
witnesses today. I will introduce them in the order of their
testimony.
First of all, Dr. Chad Asplund, Director, Athletic
Medicine, Head Team Physician for Georgia Southern University,
and Dr. Jonathan Reiner, Director, Cardiac Catheterization
Laboratory, George Washington University Hospital, and Dr.
Anthony Gregg, Professor and Chief, Division of Maternal Fetal
Medicine, University of Florida, Department of Obstetrics and
Gynecology.
Dr. Ginger Breedlove, President, American College of Nurse
Midwives; Dr. Deborah Trautman, President and CEO of American
Association of Colleges of Nursing, and Dr. Ovidio Bermudez,
Chief Clinical Officer and Medical Director of Child and
Adolescent Services Eating Recovery Center, Senior Board
Adviser, National Eating Disorders Association.
Thank you, each, for coming today. Your written testimony
will be made a part of the record. You will each be given 5
minutes to summarize your testimony. You have a little series
of three lights; green for the first 4 minutes, yellow for the
last minute, red when your time has expired. So thank you for
coming.
And at this point, Dr. Asplund, you are recognized 5
minutes for your summary.
STATEMENTS OF CHAD ASPLUND, MD, MPH, FACSM, DIRECTOR, ATHLETIC
MEDICINE AND HEAD TEAM PHYSICIAN, GEORGIA SOUTHERN UNIVERSITY;
JONATHAN REINER, MD, DIRECTOR, CARDIAC CATHETERIZATION
LABORATORY, GEORGE WASHINGTON UNIVERSITY HOSPITAL; ANTHONY R.
GREGG, MD, PROFESSOR AND CHIEF DIVISION OF MATERNAL-FETAL
MEDICINE, UNIVERSITY OF FLORIDA DEPARTMENT OF OBSTETRICS AND
GYNECOLOGY; GINGER BREEDLOVE, PHD, CNM, APRN, FACNM, PRESIDENT,
AMERICAN COLLEGE OF NURSE MIDWIVES; DEBORAH E. TRAUTMAN, PHD,
RN, FAAN, PRESIDENT, AMERICAN ASSOCIATION OF COLLEGES OF
NURSING; AND OVIDIO BERMUDEZ, MD, FAAP, FSAHM, FAED, F.IAEDP,
CEDS, CHIEF CLINICAL OFFICER AND MEDICAL DIRECTOR OF CHILD AND
ADOLESCENT SERVICES, EATING RECOVERY CENTER SENIOR BOARD
ADVISOR, NATIONAL EATING DISORDERS ASSOCIATION
STATEMENT OF CHAD ASPLUND
Dr. Asplund. Thank you, Mr. Chairman, Ranking Member Green,
members of the committee. Thank you for inviting me here to
discuss H.R. 921, the Sports Medicine Licensure Clarity Act. My
name is Chad Asplund. I am a family medicine, sports medicine
physician, and I am the head team physician at Georgia Southern
University.
I graduated from the United States Coast Guard Academy,
completed medical training at the University of Pittsburgh,
family medicine residency at DeWitt Army Community Hospital at
Fort Belvoir, and my sports medicine fellowship at Ohio State
University. Additionally, I completed a master's of public
health degree at the University of Florida.
In my experience as a sports medicine physician, I have had
the opportunity to take care of athletes at all levels;
Olympic, professional, NCAA division 1, 2, and 3, as well as
recreational and high school athletes. I am here today
representing the American Medical Society for Sports Medicine,
the largest organization of team physicians in the world, which
I serve as its chair of the practice and policy committee. I
would not be here also without the support of the National
Athletic Trainers' Association, the American Academy of
Orthopedic Surgeons, and many others.
Nearly every day in this country, athletic teams travel
across state lines to compete in their contests. Every day
those athletes are out on the field they are subject to danger
and to harm. And because of this, physicians and athletic
trainers are there to ensure their safety. In the United States
there are approximately 14,000 athletic trainers and physicians
that are dedicated to team care, and each week in America 300
to 500 of these professionals travel across state lines to
provide care to the teams that they support.
What you may not realize is that in many cases by doing
this, by crossing state lines to perform their jobs, they are
risking their professional licenses and personal assets to make
sure that those athletes have the best care by the medical
professionals who know them best.
H.R. 921 would protect medical professionals that keep
these athletes safe. H.R. 921 has three main components. First,
to ensure medical professionals' licenses are valid when
crossing state lines when they travel with their teams for
sanctioned events as long as the care they provide is within
the confines of the bill.
Second, to ensure that the Medical Practice Act in the
medical professional's home state dictates their scope of
practice, licensure requirements, laws, rules, and regulations
governing their actions. And third, to ensure that a medical
professional's medical malpractice and liability coverage can
and will cover them while they were traveling to support their
teams.
As you are aware, it is college football bowl season. Many
teams will travel across state lines to play football, which at
times can be a violent and dangerous sport. Athletic trainers
and physicians travel with these teams in order to ensure their
safety. I would like to share a personal story of an incident
that happened to us.
During this football season, during a game at Troy
University, one of our Georgia Southern football players
received a hit to the head and was laying unconscious, face
down on the football field. Our medical team ran onto the
field, and upon finding him, he was found to be unconscious and
unresponsive. It was determined that he would need to be spine
boarded and transported to the nearest emergency medicine
facility.
The complex choreography of stabilizing the cervical spine,
managing the remainder of the spine while rolling the patient
and placing him on a backboard is something that takes lots of
training and lots of practice between physicians and athletic
trainers that work together all the time. Our athlete was
placed on a spine board and was transported to EMS. Thankfully,
his further evaluation was all negative. He was diagnosed with
a concussion, and has since made a full recovery.
At the beginning of this incident, the Georgia Southern
University medical team provided the medical care to this
patient, which was then transferred to the emergency medical
services when he was placed in the ambulance. Had there been an
adverse event and a lawsuit had been filed, the protection of
those members that provided that care would be uncertain. Their
medical licenses and their personal assets would be at risk.
But there is no need to put medical professionals at risk.
Today you can take a significant step to solve this problem.
You can choose to protect athletes and medical professionals by
supporting and passing H.R. 921. I urge you, again, to support
and pass this bill. And thank you very much for your time
today.
[The statement of Dr. Asplund follows:]
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Mr. Pitts. The chair thanks the gentleman.
And, Dr. Reiner, you are recognized 5 minutes for your
summary.
STATEMENT OF JONATHAN REINER
Dr. Reiner. Mr. Chairman, Ranking Member Green, members of
the committee, thank you for the opportunity to testify on
behalf of the Cardiac Arrest Survival Act and the many
thousands of lives this bill has the potential to save. I am a
professor of medicine and cardiologist at the George Washington
University, and I have spent most of my adult life treating
people with heart disease. This is a topic I care about deeply.
Every year approximately 350,000 Americans experience an
out-of-hospital cardiac arrest. Sudden cardiac arrest, or SCA,
is a condition that results most often from the abrupt onset of
a heart rhythm abnormality called ventricular fibrillation.
This extremely rapid and chaotic arrhythmia causes the heart to
quiver, effectively blocking its ability to pump. With no heart
function, blood pressure drops to zero, breathing stops, and
organs, most quickly the brain, begin to die. Without immediate
measures, the victim has just a few minutes to live. SCA is a
supremely lethal event that results in the death of about 90
percent of those it afflicts.
Sudden cardiac arrest is an equal opportunity killer. It
kills the young and the old, the rich and the poor, those
suffering from chronic heart disease, and those who have never
before been sick. It kills our husbands and our wives, our
parents, and our partners, our friends, and neighbors, and our
children. The annual death toll from sudden cardiac arrest is
about twice the number of those who die from breast cancer,
lung cancer, and HIV-AIDS combined.
Defibrillation with an automated external defibrillator, an
AED, is the only effective treatment for sudden cardiac arrest.
An AED is a small device, about the size of a lunch box, that
can deliver a therapeutic shock to essentially reset the
electrical circuitry of the heart. Contemporary AEDs, the type
you see throughout airports and here in the hallways of the
Capitol, have algorithms that automatically determine whether a
shock is indicated and step-by-step audio prompts that guide
the rescuer through the surprisingly simple process of saving a
life.
This is time-tested technology designed for use by people
who have had no prior medical training. In the late 1990s, when
clinical studies proved unequivocally that public access to
defibrillation saved lives, states began to enact AED laws.
Over the next several years, all 50 states and the District of
Columbia passed such legislation. Unfortunately, the unintended
consequence of this effort was that the enacted AED measures
were all different, creating a confusing patchwork of
regulatory requirements and liability provisions.
The American Heart Association has stated that the
variations and complexities of state laws have complicated
efforts to disseminate AEDs around the country. For example,
more than 30 states require the registration of AEDs with local
authorities, a process that is different in each state and can
be quite cumbersome. Despite the fact that AEDs are designed to
be used by lay rescuers, several states still prohibit AEDs by
untrained operators.
Forty states require oversight of an AED program by a
licensed physician. Although all 50 states have enacted some
form of Good Samaritan protection for AED responders, the laws
differ as to who in particular is eligible for immunity.
Collectively, the varied state laws create a confusing series
of bureaucratic hurdles that must be crossed before an AED
program can commence. While individual state laws make the
process of instituting a single AED program cumbersome, state-
to-state regulatory heterogeneity and differences in Good
Samaritan protections create an air of liability uncertainty
for national corporations considering enterprise-wide AED
programs.
The Wall Street Journal, noting that hotels around the
United States have been reluctant to deploy defibrillators,
describe their liability concerns as the, quote, ``no good deed
goes unpunished exposure.'' American retail stores have been
similarly reluctant to deploy defibrillators. For example, you
can purchase an AED from Walmart for about $1,000, however,
should you experience a cardiac arrest while shopping in most
stores, resuscitation will have to wait until the paramedics
arrive.
To facilitate the placement of AEDs in businesses and
public places across the United States, there must be a single
unambiguous nationwide platform of liability protections. This
is what the Cardiac Survival Act of 2015 does. The bill
essentially decouples liability protection from the very state
requirements for AED implementation, and in so doing, creates a
national uniform baseline of civil liability protection for
Good Samaritan rescuers and the entities that own the device.
Reducing the current uncertainty surrounding AED acquisition
and use will encourage the deployment of additional AEDs across
the Nation and ultimately, this will save lives that otherwise
that would have been lost.
In conclusion, Mr. Chairman, the current jumble of state
AED provisions creates great uncertainty regarding liability
exposure and has become a virtual speed brake on the
dissemination of the simple, irreplaceable, decades-proven
therapy. Congress has the ability to remedy this problem with
the passage of the Cardiac Arrest Survival Act. Thank you.
[The statement of Dr. Reiner follows:]
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Mr. Pitts. The chair thanks the gentleman, now recognizes
Dr. Gregg, 5 minutes for your summary.
STATEMENT OF ANTHONY GREGG
Dr. Gregg. Good morning, Mr. Chairman, members of the
subcommittee. I am Anthony Gregg, professor and chief of the
Division of Maternal-Fetal Medicine at the University of
Florida. I am board certified in obstetrics and gynecology,
maternal-fetal medicine, and clinical genetics. I have been in
practice for over 20 years specializing in high-risk
pregnancies. I am here today as a representative of the
American College of Medical Genetics and Genomics.
ACMG is a specialty society representing U.S. clinical and
laboratory medical geneticists, who are certified by the
American Board of Medical Genetics and Genomics. There are
nearly 2,000 ACMG members, including genetic counselors,
nurses, and public health geneticists. Delivery of genetic and
genomic health care is an exciting area that has transformed
and continues to alter the practice of medicine.
Medical genomics refers to the knowledge of human DNA
organization and structure along with an appreciation of the
environmental impacts that lead to health and disease. Medical
genomics is now applicable in the delivery of prenatal and
postnatal patient care, including fetal and neonatal screening
for genetic conditions.
I am also here today in the capacity as lead author of the
May 2013 ACMG policy statement on noninvasive prenatal
screening for fetal aneuploidy. The genetics and genomics world
is fast moving. Noninvasive prenatal screening, NIPS, using
cell-free DNA was introduced clinically in the United States
about 4 years ago. The ACMG statement on this technology
outlines test limitations and major issues to consider with
regards to test limitations. It emphasizes the screening nature
of this test and states clearly that false positive and false
negative results occur. In fact, ACMG introduced the name,
noninvasive prenatal screening, NIPS. The S in the acronym is
meant to emphasize the screening nature of this test.
The ACMG document addresses the importance of clear
language when conveying laboratory test results and recommends
that laboratories offering this testing adhere to accepted
standards and guidelines for practice. Uniquely, the statement
includes a number of information resources available to
patients and providers.
ACMG supports H.R. 3441, the Accurate Education for
Prenatal Screenings Act. H.R. 3441 recognizes that NIPS is
unique. It has better screening test metrics than any
technology which has preceded it and any other currently in
use. It is a technology that is easy to implement. It is
noninvasive, which means it requires only a blood draw from a
patient's perspective. These features within a rapidly changing
genetics and genomic medical practice environment creates
challenges for many patients and providers of obstetric care.
NIPS has seen rapid uptake by providers and their patients,
and it is increasingly offered to a large proportion of
pregnant women. This has caused a paradigm shift in the way
prenatal genetic screening takes place. Every aspect of
screening is impacted, including pretest counseling, sample
collection and shipping, laboratory testing, and post-test
counseling, and follow-up.
Counseling patients is at the heart of the clinical utility
of NIPS. Nondirective, but informed counseling requires
training and skill. Patient aids, literacy level, spoken
language, and baseline anxiety varies among patients. Medical
geneticists are uniquely trained to address patient
heterogeneity. ACMG agrees with the goal of H.R. 3441.
Clinicians are going to provide patients with both pretest and
post-test counseling when offering NIPS in order to avoid any
potential harm or confusion.
There are nearly 4 million U.S. births annually, and it is
imperative that obstetric care providers, including
obstetricians, family medicine doctors, nurse midwives, and
practitioners have access to accurate educational materials
that ensure patients receive accurate pretest counseling.
Pretest education and counseling leading to informed
decisionmaking are critical components of any genetic screening
process. The great majority of normal results are communicated
to patients by the provider or their designee that counseled
and offered the test. However, abnormal results may not be easy
for nongenetics trained professionals to interpret. Sometimes
these must be put into the context of personal and medical
family history in order for patients to receive accurate
information. A deep understanding of genomic medicine is
required.
We applaud Congressmen Herrera Beutler and Roybal-Allard
for including provisions in H.R. 3441 that emphasize the
importance of both pretest education and counseling as well as
the need for accurate and patient-specific follow-up when
results point to a possible fetal genetic condition.
Mr. Chairman and members of the committee, thank you for
focusing on this important issue for women and families. ACMG
looks forward to working with you to ensure access to accurate,
reliable, and up-to-date information. Thank you.
[The statement of Dr. Gregg follows:]
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Mr. Pitts. The chair thanks the gentleman and now
recognizes Dr. Breedlove, 5 minutes for your summary.
STATEMENT OF GINGER BREEDLOVE
Dr. Breedlove. Chairman Pitts, Ranking Member Green, and
members of the subcommittee on Health, it is truly my honor to
be with you today to discuss the status of maternity care in
the United States and the need for Congress to work with
maternity care providers, including midwives, to improve a
woman's access to these essential services.
I am a certified nurse-midwife with 37 years of clinical
experience and a professor of graduate nursing and nurse-
midwifery at Shenandoah University in Winchester, Virginia.
Today I join you as president of the American College of Nurse-
Midwives.
ACNM is the professional organization for certified nurse-
midwives and certified midwives, and our vision is a midwife
for every woman. Our mission is to support midwives and advance
the practice of midwifery in order to achieve optimal health
for women through their lifespan with expertise in well-women
and gynecologic care promoting optimal pregnancy, physiologic
birth, postpartum care, and care of the newborn through the
first 28 days of life. CNMs are licensed, independent
healthcare providers with prescriptive authority in all 50
states, the District of Columbia, American Samoa, Guam, and
Puerto Rico.
Medicare, Medicaid, and all other Federal programs provide
access to midwifery services. Approximately 82 percent of CNMs
have a master's degree, and as of 2010, a graduate degree is
required to entry into our practice. As president of ACNM, I am
proud to fully support the Improving Access to Maternity Act,
H.R. 1209, as authored by Representative Michael Burgess and
Representative Lois Capps. I thank them for championing this
important public health initiative on behalf of women in rural
and urban areas experiencing shortages of qualified maternity
care providers.
I also wish to thank the American College of Obstetricians
and Gynecologists, which has been a strong partner supporting
this legislation along with numerous nursing and maternal
health groups.
H.R. 1209 would establish a maternity care shortage
designation within existing designated health professional
shortage areas. The goal of this legislation is to identify
areas in the U.S. experiencing significant shortages of full
scope professionals, including midwives. Such information will
enable Congress and the administration to better understand and
address needs of women of child-bearing age and allow
appropriate resources to be focused on those unique needs.
ACNM believes enabling access to maternity care
professionals in underserved areas can reduce overall maternity
care costs by ensuring women have access to necessary prenatal
and delivery options. For example, we know nearly half of the 4
million annual births in the U.S. each year are covered by the
Medicaid program. Thus, both Federal and state governments have
a clear financial stake in ensuring high-quality care is being
provided at a reasonable cost. Too many of these births require
expensive interventions that could double the cost of a birth
and, in fact, increase a woman's risk for maternal mortality.
The CDC reports that the rate of maternal mortality has more
than doubled in the past few decades.
Today, women giving birth in our country are at a higher
risk of dying than those giving birth in China or Saudi Arabia.
This tragedy must be addressed. While there are several causes,
one solution is better access to maternity care providers,
including midwives, who can monitor a woman's pregnancy,
provide prenatal care, adequate postnatal care, and promote a
healthy transition to parenthood without complications.
Research shows that in 2011, some 40 percent of counties
had neither a certified nurse midwife nor an OB-GYN to provide
direct patient care services. For millions of women, shortages
in maternity care providers can result in long waiting times
for appointments, and long travel times to their prenatal care
or site of their birth. We know inadequate prenatal care is
associated with increased risk of prematurity, stillbirth, and
neonatal death.
H.R. 1209 will ensure policymakers have necessary
information on maternity care shortage areas. Midwives and OB-
GYNs are already full participants in the National Health
Service Corps, which places practitioners in underserved areas,
yet, no maternity care shortage designation exists. Allowing
the National Health Service Corps to place them where their
unique skills are most needed will benefit the women of our
country.
Thank you for your consideration of this legislation today.
[The statement of Ms. Breedlove follows:]
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Mr. Pitts. The chair thanks the gentlelady, now recognizes
Dr. Trautman, 5 minutes for your summary.
STATEMENT OF DEBORAH E. TRAUTMAN
Ms. Trautman. Good morning. My name is Deborah Trautman,
and I am the chief executive officer for the American
Association of Colleges of Nursing. I want to thank the
chairman for hosting this important meeting today, also
recognizing Ranking Member Green and the opportunity to speak
to you all about a very important issue for our Nation's
health.
On behalf of H.R. 2713, Title VIII Nursing Workforce, I
would also like to extend my gratitude to Representatives Capps
and Joyce for introducing this legislation and for their work
as the nursing caucus. Both of them are fierce champions for
the nursing profession and for improving health in our Nation.
Additionally, I wish to thank House Energy and Commerce
Committee members who have cosponsored this legislation,
including Representatives Castor, Kennedy, Loebsack, Matsui,
Schrader, and Yarmuth. AACN, as you may know, represents 781
schools of nursing across the country in all 50 States and the
District of Columbia. Our membership extends to 475,000
individuals, 18,000 full-time faculty, 457,000 nursing
students, and deans who lead these institutions.
Healthcare delivery models are not static, as you know,
neither is nursing education. This legislation would modernize
the Title VIII nursing workforce development programs, thus
creating alignment with transformational efforts underway in
nursing and health care. With over 3 million licensed
providers, registered nurses are the largest healthcare
workforce in America and essential members of the healthcare
team.
As we continue to ensure that all communities have access
to care, it is essential that Title VIII nursing workforce
development programs be reauthorized. This will ensure a
continued pipeline of support for providers who spend the most
time with patients, our Nation's nurses.
AACN, along with 51 other nursing organizations,
collaborated with Representatives Capps and Joyce to identify
four technical changes. The mutually agreed-upon changes
promote the clinical nurse specialist role, which employs
expertise to specific patient populations, nurse managed health
clinics, which provide essential primary care, and the clinical
nurse leader role, which is vital to care coordination.
Title VIII programs have supported the nursing profession
for over five decades. In 2015, the Title VIII programs awarded
1,166 new and continuing grants. These grants bolster the
nursing workforce, address nursing workforce diversity, improve
and increase nursing faculty, improve quality, promote inter-
professional education and training, and help meet the needs of
our aging population.
Today, regional demands for nurses reflect some of the
barriers to recruitment and retention, particularly in areas of
nursing shortage. One Title VIII program, the advanced
education nursing traineeship, helps us address this. In a
study HRSA did recently, this program supported 5,650 students,
of which 56 percent of these students received training in
medically underserved areas, and 48 percent received training
in primary care settings.
One future nurse, who is a recipient of this traineeship,
Britney Keplera, a doctor of nursing practice student at the
University of Pittsburgh, students like Britney are prime
examples of how this program reaches those who provide care to
the underserved. Britney, as others, look forward to serving
their local community, and Title VIII funding allows students
to prioritize their future practice settings over choosing an
area where salary will help offset their loans.
Another nurse, Lisa Van Cleave, a Ph.D. student at Hardin-
Simmons University in Abilene, Texas, is supported through the
nurse faculty loan programs. Lisa states that this financial
aid will assist her in becoming a doctorally prepared faculty
member. There is a critical demand for doctorally prepared
faculty across the country.
Each year, hundreds of students like Britney and Lisa share
with AACN how the nursing workforce development programs have
provided them financial opportunity to work towards their
ultimate career goal, providing high-quality, cost-effective
care, and for many of them that includes becoming the faculty
of the future who will teach tomorrow's nurses.
I thank the subcommittee for the opportunity to share the
tremendous impact that Title VIII programs have had and how its
recipients and their careers have and will continue to improve
the health of our Nation.
I applaud the subcommittee for bringing H.R. 2713 to a
hearing, as it is the necessary legislative step to support
America's patients, their families, and the communities in
which they live.
AACN is dedicated to working with this subcommittee and
Congress to advance this legislation.
Thank you for the opportunity to comment.
[The statement of Ms. Trautman follows:]
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Mr. Pitts. The chair thanks the gentlelady, now recognizes
Dr. Bermudez, 5 minutes for your summary.
STATEMENT OF OVIDIO BERMUDEZ
Dr. Bermudez. Thank you, Mr. Chairman, and members of the
Subcommittee on Health for the opportunity to testify before
you today to support H.R. 4153, the Educating to Prevent Eating
Disorders Act of 2015.
My name is Dr. Ovidio Bermudez, and I serve as chief
clinical officer and medical director of child and adolescent
services for the Eating Recovery Center, a treatment facility
in Denver, Colorado.
I also serve as senior advisor for the board of the
National Eating Disorders Association, which is a not-for-
profit organization that supports both families and individuals
who have been impacted by eating disorders.
I applaud this subcommittee for their consideration of this
legislation, and in particular Congresswoman Ellmers for her
leadership in championing this very important cause. As a
medical doctor working in the field of eating disorders now for
over 25 years, I would like to emphasize the importance of
screening and early recognition and intervention in the
prevention of eating disorders.
Over the last two and a half decades, I have treated
thousands of children and adolescents suffering from eating
disorders and have learned a few things about them that I would
like to share with you. First, those who suffer from an eating
disorder and their families bear a heavy burden of disease.
However, many of the personality characteristics that have
rendered them at risk for the development of these illnesses
also render them productive members of society once they have
recovered from their illness.
Second, those in touch with the daily lives of young
people, meaning parents and school personnel, specifically
teachers, are in the best position for early detection. There
are attitude changes in a young person that often precede the
development of eating related pathology and behaviors, and thus
can clue us into the needs for assessment and further
intervention.
Third, eating disorders are curable mental illnesses, but
the later the diagnosis and the institution of appropriate
intervention, the harder the course of illness and worse the
outcome. So early recognition and early intervention are
essential to improve treatment outcomes and avoid the
chronicity and early death often associated with eating
disorders.
In the U.S., 20 million women and 10 million men suffer
from a clinically significant eating disorder at some point in
their lives, including anorexia nervosa, bulimia nervosa, or
binge eating disorder. Eating disorders are real; they are
complicated, complex, and devastating conditions and can have
serious consequences for health, productivity, and
relationships. They are not a fad. They are not a phase. They
are not a lifestyle choice. In fact, they are not a choice at
all.
Eating disorders are serious, potentially life-threatening
conditions that affect a person's emotional and physical health
and can impact every organ of their body, including the brain.
If left untreated they can damage the brain, the liver,
kidneys, gastrointestinal tract, teeth, skin, hair, bones, and
heart. They can result in serious medical conditions such as
retarded growth, osteoporosis, kidney problems,
gastrointestinal dysfunction, and heart failure.
In fact, eating disorders have the highest mortality rate
of any mental illness, yet, due to the lack of awareness and
education about them, many people do not receive the treatment
they need and deserve. Due to this lack of information, eating
disorders are often not recognized or diagnosed until the
physical health of an individual is compromised, at which point
irreversible damage may have already occurred. But the good
news is that eating disorders are treatable conditions. Early
recognition may prevent the development of eating disorders and
subsequent chronic physical and mental conditions, including a
high risk of suicide.
Studies have demonstrated a link between early intervention
and better treatment outcomes. The American Academy of
Pediatrics has recommended the screening questions about eating
patterns and body image be asked of all preteens and
adolescents to detect the onset of eating disorders early and
halt their progression. The cost of treating a full-blown
eating disorder is quite expensive, and so prevention really
pays.
H.R. 4153 aims to amend the Public Health Act to establish
a pilot program to test the impact of early intervention
through screenings, under-prevention management, and course of
eating disorders that would establish a 3-year pilot program to
provide grants to eligible schools for eating disorders
screenings. The screenings would be implemented based on best
practices from recommended experts in the field of eating
disorders.
To me, the reality is, is that this is an important
opportunity to protect one of the most valuable sectors of our
population, which is young people.
So I want to thank you for hearing this testimony and for
the consideration of supporting H.R. 4153 to improve the health
and well-being of youth across our Nation by helping to prevent
eating disorders. Thank you.
[The statement of Dr. Bermudez follows:]
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Mr. Pitts. The chair thanks the gentleman. That concludes
the oral presentations of the witnesses. We will now begin
questioning.
I will recognize myself 5 minutes for that purpose.
Dr. Asplund, has your organization discussed H.R. 921 with
any medical malpractice insurers, and if so, what are their
thoughts on the need to clarify lines of jurisdiction when a
team physician or trainer is providing care for an athlete
outside the state which they are licensed or insured?
Dr. Asplund. Thank you for the question. A group of
colleagues from the American Medical Society for Sports
Medicine contacted 20 of the Nation's largest medical
malpractice providers and asked them the question, would you
cover a team physician practicing across state lines?
Approximately 25 to 30 percent said that they would
regardless of the place where care was covered, 45 to 50
percent said it would depend, and 30 percent outright said that
they would not cover that medical professional who provided
that care outside of the state. So there is a potential for
anywhere from 30 to 80 percent of medical providers who may not
be covered by their malpractice, simply for traveling with
their team and doing their job.
Mr. Pitts. Thank you.
Dr. Reiner, you mentioned in your testimony that all 50
states have passed legislation, including the liability
protection for citizens that use a defibrillator on someone
during the course of an apparent medical emergency, and for
businesses that have defibrillators installed for such
purposes. Can you speak to how these laws vary and the impact
such variation is having on increased deployment of lifesaving
devices? And how would H.R. 4152 lead to more widespread
deployment, and how many lives could they save?
Dr. Reiner. Mr. Chairman, in Pennsylvania, for instance, if
a business wants to institute an AED program, they can do so,
but they are required to train their employees in the use of
the device.
Mr. Green, in Texas, there is no such training requirement.
In Virginia, there are no requirements at all. So if you want
to purchase a defibrillator for your coffee shop or your
hardware store, you can buy one on Amazon and put it on the
wall.
So the essential problem is that although all states have
enacted some form of legislation, the legislation differs from
state to state. So if you are a national corporate entity that
wants to do business around the United States, you have the
problem of getting 50 different state laws correct. And they
differ just enough to create an uncertainty in your mind that,
if I don't get this right, then this is my problem.
Imagine if you have a hotel and your state requires a
trained employee on duty 24/7, and that night someone dies in
your hotel and somehow the resuscitation doesn't go well. Well,
now, that is potentially your problem. And the owner of the
hotel might say, gee, it might have been better for me just not
to have a defibrillator at all.
So simply what this bill does is decouple all of the state
provisions, training, supervision. If the states find an
interest in those, that is great. But it just decouples those
different training and supervision requirements from liability
protection. If you have a working defibrillator that is kept in
good order, you are protected from liability.
Mr. Pitts. Thank you.
Dr. Gregg, does the training OB-GYNs receive in genetics
prepare them to interpret cell-free DNA prenatal screening
results and communicate them effectively to patients?
Dr. Gregg. I think this is the fundamental problem and
probably what brings this bill to this body today. The
obstetrician, gynecologist can certainly read a report where
the report says normal and can read a report that says the
patient has an abnormal test result. What follows is a detailed
discussion on post-screening test results in the context of
what does an abnormal test result really mean.
Patients have taken that test result to mean that they
definitely have a child that has Down Syndrome, and in some
cases due to time constraints, fear has led them in directions
that, as we have heard through the lay press, were directions
that weren't what they would have expected.
The problem, then, becomes in understanding that this is a
screening test and what types of tests need to follow. In
addition, understanding the positive and negative predictive
value of the results at hand.
Mr. Pitts. The chair thanks the gentleman. My time is
expired. The chair recognizes the ranking member, Mr. Green, 5
minutes for questions.
Mr. Green. Thank you, Mr. Chairman.
Dr. Trautman, we appreciate you joining to discuss the
Title VIII nursing workforce programs. Title VIII programs have
long enjoyed bipartisan support, and I am glad that it has
continued with the introduction of H.R. 2173. The Title VIII
Nursing Workforce Reauthorization Act by Representative Capps
and Joyce, like many, I am concerned about the nursing shortage
facing the U.S. and baby-boomer generations further
exaggerating the great need for more healthcare providers.
According to a report, the United States registered nurse
workforce report card and shortage forecast published in the
American Journal of Medical Quality in January of 2012, the
shortage of registered nurses is projected to spread across the
country to 2030 with the most intense shortages in the South
and the West. I understand that one of the contributing factors
in the shortage of nursing facilities. In fact, in 2012,
nursing undergraduate and graduate programs turned away 80,000
qualified applicants due to the lack of capacity.
Doctor, could you elaborate on the difficulty in attracting
students and professionals entering in the nursing faculty
workforce?
Ms. Trautman. Yes, thank you, Chairman. That is a very good
question. And I want to thank you, again, for the support that
has occurred over the decades that has allowed us to attract
individuals to nursing programs.
We have a strong desire to continue to advance those who
are interested in not only the sciences but in caring for
individuals to join the nursing profession. And we have done
more with respect to these programs and recognizing that it is
important to get to our youth earlier and speak to them about
the profession, educate them.
Title VIII funding, as you know, has been targeted
recently, some of the advance practice work in serving the
underserved areas. As you mentioned, it is correct that the
nursing workforce, like the American public is aging, so while
our past efforts have been successful, we must do more. A part
of doing more, which Title VIII supports, is advancing doctoral
education for nursing because we need doctorally prepared
nurses to be faculty to teach the future nurses. It is an
extraordinary profession, and we will continue to work with our
colleagues in Congress and outside to educate others about the
benefits of being a member of the nursing profession.
Mr. Green. OK. Since we had so many applicants, qualified
applicants who couldn't get in, does this legislation help in
that lack of capacity?
Ms. Trautman. Yes, it does. It helps in two regards. The
problem is primarily related to either clinical placements and/
or faculty. Although, again, there is regional variation, some
areas of the country have no problem. But in those areas that
do, Title VIII helps support, as well as some other programs,
but it helps support, again, preparing doctorally prepared
faculty. And the clinical placements are not a part of Title
VIII, but the nursing community and other stakeholders
recognize the importance.
The nurse managed clinics, though, which are in Title VIII,
do provide an opportunity for additional clinical settings, and
that will help us accept more students.
Mr. Green. OK. Great, thank you.
We also have all heard about the difficulty in accessing
maternity care services in certain areas and where there is
certain populations. It is surprising that we do not have good
data to understand the problem.
Dr. Breedlove, what do we know about the existing shortage
in maternity care providers?
Dr. Breedlove. We know there is an increasing shortage of
OB/GYNs graduating from residency programs. And ACOG has
supported data on the critical workforce shortage of OB/GYNs, I
believe, in their testimony. We also know that 40 percent of
counties in our country have no maternity care provider,
whether that be an OB/GYN or a midwife. So it is astounding
that so much of the geographic region of our country can
provide services through the National Health Service Corps
through primary care providership, which both these professions
are a part of. However, the specialty they provide often is not
identified in the primary care shortage definition. So a
physician, OB, or midwife may go to one of these primary care
shortage areas but not be able to deliver the services they are
uniquely trained for.
Mr. Green. OK.
Will H.R. 1209, Improving Access to Maternity Care, help us
collect that information?
Dr. Breedlove. Absolutely. This directs HRSA to create
definitions and collect data that can help us place
particularly new graduates in these professions and setting
where they are most needed.
Mr. Green. OK.
Thank you, Mr. Chairman. I yield back.
Mr. Pitts. The chair thanks the gentleman and now
recognizes the gentleman from Illinois, Mr. Shimkus, for 5
minutes for questions.
Mr. Shimkus. Thank you, Mr. Chairman.
Welcome. This is a great panel, great issues. The challenge
of health care is apportionment of costs because everyone is
really there to serve the public. And it is just a great aspect
of being on this committee. I just have two--I think, Dr.
Reiner, so in the 108th Congress, we passed the Adam's Memory
Act, which allowed emergency auxiliary defibrillators to be
placed throughout in public areas. And it was based upon an act
of young boy who got hit in the chest with a baseball at a
diamond and went down. And just, fortunately, there was a
policeman there and had one in the truck of the car. And that
caused us to move a year or two later to help place these
throughout open-access areas. And they have changed quite a bit
since technologically. So I think a good way to really kind of
reinforce the language of this bill is to just have one here
because they tell you what to do. It is like: Open the case;
grab these little wires; put them here; press start. Right? So
that is what you basically need, to be able to follow
instructions and listen to them to use one of these auxiliary
emergency defibrillators today. Isn't that correct?
Dr. Reiner. That is right, sir. The devices were really
made to be used by people with no training. And the favored
study that I point to is a study that compared sixth grade
kids, basically 12-year-olds, to trained paramedics. So they
set up a mock cardiac arrest. And they told the kids outside
the room--who had never seen a defibrillator--that all you have
to do is open it because, as you said, there are audio prompts
that talk you through. And, importantly, the device cannot
deliver a shock to a person who would not benefit from it. So
they compared 20 kids to 20 paramedics. And, obviously, the
paramedics knew how to do it. And the paramedics beat the kids
by only about 20 seconds, 20 seconds. Every kid could do it.
Every kid did it properly. Every kid did it right the first
time.
But the laws are confusing, and they are intimidating. I
travel through O'Hare from time to time. And signage on the
defibrillators is terrifying. The signage says ``to be used
only by trained responders.'' Well, why should it say that? The
devices are designed to be used by anyone, trained or
untrained. It says that because there is a piece of Illinois
law that makes that necessary.
So all that this bill says is if you have a working
defibrillator and it is used with good intent to try and save
the life of somebody, that the owner of the defibrillator is
protected, as is the Good Samaritan. It doesn't change the
requirements that some States may have for training or
supervision. It simply says that whatever the State rules are,
if you are using it with good intent and you have a working
device, everyone is protected.
Mr. Shimkus. Excellent. Thank you.
And I will just finish up with Dr. Gregg. And I appreciate
this bill too. There is going to be a continued debate, I mean,
between those who consider ourselves pro-life and believe life
begins at conception and should be protected and then the
challenges that we face under medical ethics, under genomic
testing, and then decisions that are made because of that which
may not sometimes--as you pointed out, we need to make sure
that they are an accurate as possible description to inform the
family of what may or may not be. If you want to comment on
that, you can. That is a challenge that I think the healthcare
community has to work on.
Dr. Gregg. Sure. Let me just say that noninvasive prenatal
screening, or NIPS, has the best test metrics for screening
available today, better than anything we have used over the
last 30 years, the best positive predictive value, negative
predictive value, sensitivity, and specificity. In a New
England Journal of Medicine paper published last spring, this
best testing metrics was confirmed across all reproductive age
groups, so not just what is classically defined as advanced
maternal age patients, but all reproductive age groups.
Having said this, it is imperative that patients and the
providers understand that it is still a screening test and that
there is a need for follow up.
As far as women and their reproductive choices, I will say
that the American College of Medical Genetics and Genomics has
as a fundamental ethics tenet that counseling is performed in a
nondirective fashion. And screening takes place today. This is
not adding screening to a healthcare system that doesn't
already have it, but it is trying to refine the educational
piece. And, to me, that is what this bill does. It brings the
educational piece to the forefront, not screening or not what
women do with the screening.
Let me say that the false positive rate with this
particular test is less than 1 percent--in fact, in some
studies, less than a half a percent. Other screening tests that
have been in play now for now more than 25, 30 years have a
false positive rate of 5 percent. That brings more people to
the high-risk obstetrician with anxiety. And it brings more
people potentially to diagnostic procedures that have some
small but real measurable risk associated with them.
So it is these educational aspects--I will just say one
more thing, that this is becoming an increasingly complex
testing environment as we move from common aneuploidies, Down
syndrome being one of the most commonly talked about, to now
other aspects of genomics. Other aspects where small pieces of
DNA are deleted or duplicated, we are now able to identify
these. These have a different positive and negative predictive
value. And different things are done in response to these test
results. And that is the educational piece, not sort of the
simpler aneuploidy piece. I think that can be done in a
paragraph. But it is how to keep in front of the evolution of
this technology as it comes forward.
Mr. Shimkus. Thank you.
Thank you, Mr. Chairman.
Mr. Pitts. The chair thanks the gentleman.
I now recognize the ranking member of the full committee,
Mr. Pallone, for 5 minutes for questions.
Mr. Pallone. Thank you, Mr. Chairman.
I want to ask Dr. Trautman some questions and then, if I
have time, Ms. Breedlove.
Dr. Trautman, as you know, there are four advanced practice
registered nurse roles: Nurse practitioner, certified
registered nurse anesthetist, certified nurse midwife, and
clinical nurse specialist. And I am interested in learning more
about the role of the clinical nurse specialist. Could you
explain the role of the clinical nurse specialist within the
healthcare system, and what are the education and training
requirements of clinical nurse specialists?
Ms. Trautman. Thank you. As you have described, there are
four advanced practice roles in nursing. The clinical nurse
specialist is a role that is focused on a specialty, so a
specialty area. The education for a clinical nurse specialist
is a graduate degree. There are master's prepared clinical
nurse specialists. And there are increasingly more doctorally
prepared clinical nurse specialists.
Mr. Pallone. OK. Now, the advanced nurse education grant
program supports projects that develop and test innovative
academic practice partnership models for clinical training and
prepare primary care and advanced practice registered nurses to
provide safe, quality care. Can you explain why this program is
important to supporting the nursing workforce?
Ms. Trautman. Certainly. Thank you. That is an excellent
question. Academic practice partnerships are critically
important. Gone are the days where the academic community can
be separate from the practice community. As we as a Nation move
forward in all of our efforts to improve health and health
care, those partners and leaders and practitioners in practice,
as well as our educators, must come together. And when we do,
we benefit from the expertise of both of those very important
disciplines to not only advance the profession, but we have had
significant examples in the VA and in other settings of how we
improve the experience of care for individuals and their
families.
Mr. Pallone. OK. Now, currently only three of the four
advanced practice register nurse roles are eligible for this
program. Could you elaborate on why it is important to include
the clinical nurse specialists in the advanced nursing
education program?
Ms. Trautman. Certainly. The request for the change, the
technical change in the reauthorization, is to allow us to
standardize, as you have just mentioned, across all advanced
practice nursing roles. And because the education, as I have
shared, is similar, at graduate level and above, the
competencies of the clinical nurse specialist, it will, by
making this technical change, it allows us to create parity
within all of the advanced practice roles.
Mr. Pallone. OK. Thank you.
So let me go to Ms. Breedlove, I wanted to ask some
questions about the increase in maternal mortality. According
to the CDC, the rate of maternal mortality has more than
doubled in the past few decades, increasing from 7.2 deaths per
100,000 births in 1987 to 17.8 deaths per 100,000 births in
2011. Could you explain some of the reasons leading to this
increase?
Dr. Breedlove. Absolutely. Thank you for the opportunity to
comment.
Just this morning, the World Health Organization released a
statement related to maternal mortality with a specific focus
on issues related to pre and postnatal care. Most specifically,
contributors include preeclampsia, lack of early diagnosis,
post partum hemorrhage, and post partum infection. And when you
think about the provider shortage challenging the ability for
pregnant and postdelivery women to access immediate care for
evaluation and referral to appropriate services, particularly
in rural areas of our country, we know there are ways to
address this. But we have to have providers who are accessible
to the women who need that care.
Mr. Pallone. And specifically how would the creation of the
maternity care health professional shortage areas help reduce
maternal mortality?
Dr. Breedlove. By placing the most qualified providers of
the unique services to women during the childbearing years in
the areas where the need is more clearly defined. Right now, we
have no ability to designate maternity shortage areas under the
Health Service Corps definition, nor do we have any idea what
that shortage area percentage might be. But we are aware from
many stories and the poor outcomes that we are facing that
health care is needed in those areas. So it would be a very
simple way to introduce a new definition without changing those
who already exist in the Health Service Corps.
Mr. Pallone. Thank you very much.
Mr. Pitts. The chair thanks the gentleman.
I now recognize the gentleman from Pennsylvania, Dr.
Murphy, 5 minutes for questions.
Mr. Murphy. Thank you, Mr. Chairman.
And thank you to the panel for being here.
Dr. Breedlove, let me continue on with some of those areas
that Mr. Pallone was asking. With regard to the number of OB/
GYNs available, do we have any idea of the cost we would
encounter from having them involved in this?
Dr. Breedlove. There would not be additional costs. We are
talking about providers who already qualify in the National
Health Service Corps. So what we are talking about in this bill
is enabling the right provider to be at the right place at the
right time.
Mr. Murphy. But it comes out of the funding for the medical
corps, medical service that is existing. So does that mean it
takes away from the current areas designated for shortage are
primary care, dental care, and mental health care. So it would
pull from the same amount of money, not additional?
Dr. Breedlove. I am not exactly sure how to answer your
question, other than these provider types which we currently
have already fulfill the primary care opportunities.
Mr. Murphy. I am just trying to think in terms of funding.
There is a certain block of money. So we add them to that list,
and then they all pull from that same list. Am I correct in
terms of----
Dr. Breedlove. I am not able to answer your question.
Mr. Murphy. That is OK. All right. I just want to make sure
because given that--I don't know what the cost savings would be
and maybe you could get us some estimates. I know we went to
Dr. Tom Insel here, the immediate past head of the National
Institute of Mental Health. He said the current cost in our
mental health system is $444 billion. That does not include the
justice system, which is probably another $50 billion to $100
billion, so half a trillion dollars per year. I just want to
make sure we are not cutting other services for a group that we
already have a massive shortage on. But I agree with you; we
need to do this part too.
Dr. Bermudez, welcome. I want to ask you about some of the
aspects you brought out about eating disorders. And thank you
for talking about that. You said that there are perhaps tens of
millions of mostly women and some men who are affected by this.
But in your testimony, you really emphasized the role of the
family and the role of teachers to early identification and
facilitate treatment. And toward the end of your testimony, you
also said basically once an eating disorder takes hold, it is
very difficult to reverse. The physical, emotional, and
financial toll it takes on families is devastating.
I am a psychologist by training so that you know. And in
this, would you say--and I have seen this in other studies too,
first of all--that a person who has an eating disorder can
sometimes be so deeply involved in their psychiatric problems
that they may resist treatment, true?
Dr. Bermudez. True.
Mr. Murphy. And under those circumstances, I read another
study that says whether a person is involuntarily or
voluntarily committed, that the outcome is good if you get them
in treatment. It is much better if they are in treatment versus
not in treatment. Is that correct?
Dr. Bermudez. The data is clear on that.
Mr. Murphy. OK. That is very important because sometimes
people say, ``Well, we shouldn't involuntarily commit
someone,'' but a person's mind may be so disturbed from the
psychiatric illness, they are not cognitively aware of what
they need. Further, some people with eating disorders may also
be in the category of severe mental illness--schizophrenics,
bipolar--so they have dual diagnoses on top of that, which
makes it even more complicated. Am I correct?
Dr. Bermudez. Absolutely.
Mr. Murphy. So in this getting a family member involved,
one of the big dilemmas that oftentimes occurs are HIPAA laws,
where if you are treating someone with bulimia or anorexia and
the issue is if they are not even going to their appointments
and the family member doesn't even know their diagnosis or the
treatment plan or where they are supposed to go or a change in
appointment or the medication, very often providers say, by
HIPAA laws, I am not even allowed to tell you information to
facilitate treatment. Am I correct?
Dr. Bermudez. So what I wanted to tell you is that I agree
with that for adults. Now, that is part of the beauty of the
opportunity here is that we are talking about a group of
illnesses that generally presents in early adolescence and
toward the latter part of adolescence. So the opportunity of
the involvement of the family at a very meaningful level is
clearly there, in spite of HIPAA laws and wanting to work and
respect----
Mr. Murphy. And during that time, a provider could
certainly build a relationship with family members and
understand who to trust, who is part of the team. So even when
that person turns 18, for example, severe mental illness, 50
percent of severe mental illness emerges by age 14; 75 percent
by age 24. It is a critical time. They are no longer in school.
They are past 18. HIPAA dynamics change. But from what I hear
you saying, from your testimony, it is very important that, for
the prognosis of that person, to keep the family member
involved and find ways to make sure the HIPAA law doesn't get
in way so that person can be involved. Would that be fair to
state?
Dr. Bermudez. That is a fair statement. And we have clearly
shifted as a field in our understanding of eating disorders and
moving away from really blaming families to really partnering
with families. Families are critical as agents of change, not
only to be aware early on and recognize in a timely fashion and
bring their loved ones to care, which secures better outcomes,
but I think, at the same time, to remain involved and continue
the appropriate followup of these illnesses. As you know, from
a psychological perspective, these are not things that change
overnight. And, therefore, involvement of a support system--
i.e., the family--is critical in the success of treating these
illnesses.
Mr. Murphy. Thank you. I appreciate it.
I yield back.
Mr. Pitts. The chair thanks the gentleman.
I now recognize the gentlelady from California, Mrs. Capps,
5 minutes for questions.
Mrs. Capps. Thank you, Mr. Chairman.
Thank you all for your testimony.
And before I begin, Dr. Trautman, I would like to ask my
first question of you. But I want to clarify, my colleague, Mr.
Murphy, just raised an issue about funding for maternal-child
health. And I just want to clarify this money is already being
spent, to my colleague. Mr. Murphy?
Mr. Murphy. I am sorry?
Mrs. Capps. I just want to clarify something to you as I
started because of the statement that you made regarding
funding and allocations coming. This is money that is already
now being spent. So there are no new providers being added or
taken into the program for maternal-child health or for any of
these nursing programs. It would just help to drill down within
the existing programs for primary care designations to place
these maternity care professionals where they are needed most.
Mr. Murphy. I understand.
Mrs. Capps. I just want to make sure----
Mr. Murphy. Make sure we are robbing from Peter to pay
Paul. We need to do more. Not less.
Mrs. Capps. Exactly. So, Dr. Trautman, as you well know
more than most of us, the Institute of Medicine's 2010 Future
of Nursing Report is a landmark study for our profession. In
it, the IOM laid out the current state of our nursing workforce
and a roadmap of what needs to happen to prepare for the
healthcare system of the future. Just last week, IOM's
evaluation committee released a followup report reviewing the
progress made on the Future of Nursing's recommendations. One
of their recommendations was an increased focus on nursing
workforce diversity. Title VIII Nursing Workforce Diversity
program has supported increasing diversity. No one is arguing
with this.
So, Dr. Trautman, can you discuss what progress you see
being made in nursing school enrollments regarding diversity?
And how does the title VIII program, for all of us to
understand it better, how does this program support this goal?
Ms. Trautman. Thank you very much, Representative Capps.
And thank you again for your fierce, strong commitment to the
profession and what ultimately again is going to improve the
health of our Nation. Thank you.
The importance of diversity in all health professions, most
certainly in nursing, is clearly understood. And title VIII has
been very effective in helping us make improvements. In the
years, looking at the data, from 2010 to 2014, we have improved
the diversity of the nursing student population at all levels.
At the baccalaureate, at the master's, and at the doctoral
level, we are now at 30 percent of those students represent
diversity. And while that is significant progress, it is not
yet enough. Much more needs to be done. Some of that, most
certainly, has within the past been directly related to title
VIII and so will the future in these programs that are
specifically targeted to help us not only to bring diverse
individuals into the profession but, as you know, equally
important that we are serving areas of the country most in
need.
Mrs. Capps. Yes.
Ms. Trautman. So that is very important. We will also do
other things beyond the law, the legislation, the changes that
are proposed in the health professions. One example that you
are aware of, I know, is this holistic review, which is an
approach to looking at individuals who enter the profession,
and it includes the individual as a whole. So we look at
personal attributes, in addition to the academic metrics that,
in the past, most health professions had solely relied upon.
Mrs. Capps. I appreciate that. Thank you very much.
Switching gears here, the goal of the Improving Access to
Maternity Care Act is to better target the maternity care
professionals to the communities that need it most. We know
that prenatal care is so critical to pregnant women. But far
too many women are not getting the recommended care, as you
know.
So, Dr. Breedlove, from your perspective as a certified
nurse midwife--I am big supporter of that program, of course--
and an educator of midwives, what impact does proximity to
prenatal care--that, I think, is something we really want to
zero in on--and post partum care, maternity care have on the
quality of a pregnancy for a woman and for the child?
Dr. Breedlove. Thank you so much for your fierce support of
our profession but also of access to prenatal care for women in
our country. The issue really is around whether or not there
can be adequate screening, which we have heard a little bit
about today, whether there is an opportunity to assess women
for potential risk, could be preconception, early pregnancy, as
well as routine prenatal visits, which we know have a huge
impact on the ability to diagnose early signs of preeclampsia,
again, one of the problems of maternal mortality in our
country. So it really is critical that if women are driving,
you know, an hour and an hour and a half to find prenatal care,
the likelihood of her having routine care and not missing
visits, in addition to driving even longer than that for the
birth facility is a very challenging thing for our families and
really is clearly evident of some of the challenges that we
have in all women in our country having in the prenatal care
they need in a timely fashion.
Mrs. Capps. Thank you very much both of you.
And I yield back my time.
Mr. Pitts. The chair thanks the gentlelady.
I now recognize the gentleman from Texas, Dr. Burgess, 5
minutes for questions.
Mr. Burgess. Thank you, Mr. Chairman.
And, Ms. Breedlove, forgive me, Dr. Bucshon had eclipsed
you temporarily.
Thank you, Doctor. You are so kind to me.
Let me ask you a question because, I mean, because in your
statement, your testimony, the suggestion that the maternal
mortality rate has increased over the last 10 to 12 years'
time, can you give us--I know you have been asked this
previously--but can you give us the breakdown of where those
deaths have occurred?
Dr. Breedlove. We are collecting data under the guidance of
CDC and the Maternal Mortality Commission. I attended an all-
day workshop at the ACOG annual meeting in San Francisco last
year. It is very clear that not only is it based on prenatal
and postnatal adequacy of care but also in systems of care
within the hospital setting itself so that there are clearly
defined clinical pathways and the management of women who are
at risk of stroke, who are at risk for hemorrhage, and who are
at risk for hypertension that is poorly managed. So there are a
variety of projects that are interdisciplinary in nature going
on around the country, developing we call them bundles for care
that are collaborative in nature and codeveloped by all the
disciplines within healthcare maternity services.
So we know more about some of the challenges. But we also
are keenly aware that if you have no one available to help
diagnose and early screen and provide services prior to
hospital admission, you have increased risk of those families.
Mr. Burgess. I think that is the lesson we are in danger of
overlooking when we have this discussion. The drop in maternal
mortality, not just in this country but worldwide, was
dramatic. And it occurred about 1937. It is important to me
because my grandfather was an academic obstetrician at the
Royal Victoria Hospital in Montreal. So he was part of that
generation of doctors. These are doctors who practiced before
antibiotics were widely available, before anesthesia was as
reliable or survivable as it is today. Certainly the same could
be said about blood banks. If you were fortunate enough to get
a blood transfusion, the likelihood that you would survive it
was certainly problematic before modern blood banking
techniques emerged. And all of that coalesced around 1937, and
the numbers dramatically dropped. So it is the presence of a
trained attendant at birth that really probably has made more
difference in maternal mortality than anything else, which is
why your testimony intrigued me because we shouldn't forget the
lessons of the past. So one of the things that this will do,
with all deference to my friend from Pennsylvania, we are not
taking his money, but we are trying to make certain that the
money that is available in the primary care space goes where it
is most needed. And the other thing that, interestingly enough,
has been found over the years is that doctors tend to go or
stay, rather, where they train. We are not terribly
imaginative, as it turns out. And so we don't wander far from
where it is that we took our--generally our residency training,
perhaps subspecialty training. We tend to marry people who are
in that area. And, as a consequence, we don't move from there
unless our spouses give us permission. We tend to establish
referral patterns: who you can trust, who you can't. So the
degree of professional comfort is greatest in the area in which
you train. It certainly was true for me and a great number of
my cohort. The significance there is if we can bring to the
medically underserved from a maternal standpoint, if we can
bring practitioners to the medically underserved area, the
likelihood that they will then populate those areas is higher
than if we try to entice them with other inducements. So that
is why this change in designation, although it is really not
more money and we are not taking money from someone else, this
is really an important thing to accomplish and why I am
grateful that Representative Capps has partnered and that we
are now having the legislative hearing, and we are working on
getting it done.
And, Dr. Gregg, I just want to say to you--and thank you
for your testimony--we are struggling--I shouldn't say ``we''
are struggling. I am struggling--the committee seems, everyone
else seems comfortable with letting the FDA have further
regulatory ability over what are called laboratory-developed
tests. And I am nervous about that. And people on this
committee know that. But I was encouraged by some of your
comments. A screening test is a screening test. No one takes
someone to the operating room because of a screening test. You
do the confirmatory test.
Now, it is one of the idioms or one of the axioms of
medicine that the confirmatory test will always be equivocal.
But, nevertheless, you don't start a clinical action based on a
screening test. So I appreciate your testimony on that very
much.
Mr. Chairman, thank you. I will yield back.
Mr. Pitts. The chair thanks the gentleman.
I now recognize the gentleman from Oregon, Dr. Schrader, 5
minutes for questions.
Mr. Schrader. Thank you, Mr. Chairman.
A question on the Cardiac Survival Act for Dr. Reiner. I am
familiar with the use of the devices. And you indicated in the
testimony some of the queries that anyone can pretty much use
those. So the device discerns between like atrial fibrillation
and ventricular fibrillation. So it is not up to the individual
using the device?
Dr. Reiner. That is right. And, in fact, there is really no
way to deliver a shock to someone who doesn't have what is
programmed into the system as a, quote, shockable rhythm, which
is basically ventricular fibrillation or a very fast
ventricular tachycardia. So if someone has just passed out, for
instance, but they don't have one of those rhythms, you cannot
actually deliver a shock.
Mr. Schrader. OK. Good to know.
For Dr. Gregg, I guess, on the cell-free DNA testings,
screenings, those can be ordered by anybody, anywhere, any
time? It is not through a physician?
Dr. Gregg. It can be, these can be ordered by advanced
practice nurses, yes, sir.
Mr. Schrader. I mean, just laypeople.
Dr. Gregg. No.
Mr. Schrader. OK. OK.
Dr. Gregg. You would have to have an MPI number.
Mr. Schrader. And there is a concern that advanced practice
nurses and physicians are unclear about how to interpret the
results on these and, therefore, would advise people perhaps
incorrectly?
Dr. Gregg. On the pre-test side, there is a concern that
patients may not and are not getting the adequate information
to understand well the tests that they are having done and what
that test is actually doing.
Mr. Schrader. But if that is done in concert with the
physician or advanced nurse practitioner, wouldn't that take
care of that potential problem?
Dr. Gregg. Again, the concern here is that the advanced
practice nurse and/or physician does not have the depth of
knowledge to completely understand what it is they are
ordering. And then when results come back, this becomes an even
more complex problem when the result is abnormal. When the
result is abnormal, it is not simply reading an abnormality is
here, and then there is an algorithmic next step. In
interpreting abnormal results, there are many subsequent steps
that should take place following.
Obstetric care, as you know, is provided by people that
range in their knowledge base. Midlevel providers provide
obstetric care under the direction of physicians and so forth.
Midwives provide obstetric care independently.
Mr. Schrader. Would they be interpreting these results too?
Is that what you are----
Dr. Gregg. That is exactly right, that there is a wide
variety of people interpreting these results.
Mr. Schrader. OK. I understand.
Then, I guess, for Dr. Breedlove, if I may, on the
Maternity Care Act, my understanding from some of the
information we have gotten is that primary care shortage areas,
of which this is one, is already recognized. And the reason for
this is to draw even more attention to it? Or I am not exactly
clear why it is called that.
Dr. Breedlove. Actually, no. The maternity care designation
is not listed under the primary care scope. So what we are
asking is that there be a definition within primary care.
Mr. Schrader. OK. Great. I misinterpreted that then. And
then, I guess, last but not least our nursing person here, talk
a little bit about title VIII and how we can develop the next
generation of nursing educators so critical to improving the
number of nurses out there and why there is such a shortage.
Ms. Trautman. Well, thank you very much. Title VIII has
made a contribution already. We have improved significantly the
number of doctorally prepared nurses. We now have had in both
the research doctorate as well as the practice doctorate an
increased number of enrollees that is unprecedented. What we
now also need to do beyond quantity is also start earlier in
the nurse's career. And so we have begun to create programs
that facilitate earlier attainment of the knowledge and skills
that are necessary for one to be competent and practice at the
doctoral level. So it is a very exciting time and unprecedented
in our Nation's history how the schools across the country are
responding to assure that we have quality, high standards in
education programs but that we facilitate ease of access and
progression.
Mr. Schrader. Thank you, Doctor.
With that, I yield back, Mr. Chairman.
Mr. Pitts. The chair thanks the gentleman.
I now recognize the gentleman from Virginia, Mr. Griffith,
5 minutes for questions.
Mr. Griffith. Thank you very much, Mr. Chairman.
I appreciate all of you being here today. I want to start
with Dr. Asplund and just say I am a cosponsor of the bill. I
think it is a good concept. My reading of the bill, and I think
it goes in a good direction, but my reading of the bill
indicates this would also apply not only to college and
professional athletes, but it would also apply to those folks
who have trainers with high school teams if they are competing
in a nationally sanctioned or sponsored event, something that
some national organization puts on. Is that your understanding
of the reading as well?
Dr. Asplund. Thank you for your question. So with the
National Federation of High Schools being a sanctioning body of
all high school athletes, it was the intent in our language for
high school athletes to be covered by this bill as well. As
many people are aware, there are far more high school athletes
in America than at any other time. There are far more contests
across state lines in the high school level. I live in Augusta,
Georgia. We frequently cross the river to South Carolina pretty
much weekly to do that and, as such, are crossing into a state
where many of my colleagues do not have licensure. So, yes,
high schools were intended to be included through the line with
the national sanctioning body being the National Federation of
High Schools.
Mr. Griffith. I represent a district that borders four
other states. And we have lots of high school competition going
on. So I appreciate that. And I think that is a very good
aspect of the bill. And I do appreciate that.
Dr. Reiner, I have got concerns about the AEDs or the bill
at least. I think that the Federal policy does need to be
looked at just simply because the good news is the bill that
was passed in 2000, one of the criteria was you notify the
local EMS. I think that at the time that made a lot of sense.
Today, those AEDs are in a lot more places than they were in
2000. I think now it is impractical, in fairness, to notify
local EMS for a lot of the small businesses that have these.
Which EMS do they notify? Our area is all generally referred to
where I live as the Roanoke Valley--but you have the city of
Salem, the city of Roanoke, and Roanoke County, all of which
are completely separate and have separate fire, police, and
rescue squad folks. Some are paid. Some are volunteer. And so
it might be difficult. I think we do need to look at that
policy.
But that being said, one of your examples kind of struck
something that--my friends who are trial lawyers have raised an
issue, and that is, it appears that when you look at the actual
lawsuits, there are more lawsuits for not having the AED on
premises than there are for having it but using it improperly.
In fact, they can't find a whole lot of cases where that has
been the case based on the existing law. And I was concerned
because one of your examples was Walmart sells them, but they
may not have them. And I actually think that is a bigger
liability issue for whatever retail establishment, whether it
be Walmart, Kmart, whomever, if they are selling the device but
they don't have one charged up ready to go, that is probably a
bigger liability issue than having one prepared and then having
somebody who is doing the best they cannot use it properly.
What do you have to say to that? Because I am trying to decide
what to do on this bill, and I think both sides have some merit
to their arguments.
Dr. Reiner. So it is important to know that the bill leaves
State laws alone. So any provision in a State law that the
folks in that State feel is important as it pertains to
training or registration or supervision, any of those
provisions remains in force. All that this bill says is that if
you have a working defibrillator, you are protected. So that
entities like Walmart or Target can know that, look, they are
going to do the best they can to get all these local ordinances
right. But it is important for them to protect their community
and their employees. And they are going to do the best they
can. But they need to know that if their defibrillator is in
working order, they are protected.
So it doesn't create new law. It doesn't cost industry a
cent. It doesn't cost the government a penny. But there are a
lot of people who die from this. I see folks who come to my
hospital in two conditions: One person has had an out-of-
hospital cardiac arrest, and they have been in close proximity
to a defibrillator, and if they have been shocked pretty
quickly, that person goes home to their family. The second
patient has been someplace; it has taken a while for paramedics
to get there. And they come to my place in a different
circumstance, and they go to the morgue.
Mr. Griffith. And I appreciate that. I think we want to get
that policy right. I apologize for cutting you off. But my time
is up, and I have to yield back.
Thank you, sir. I appreciate your testimony today.
Mr. Pitts. The chair thanks the gentleman.
I now recognize the gentlelady from Florida, Ms. Castor, 5
minutes for questions.
Ms. Castor. Good morning. Thank you, Mr. Chairman, for
calling this hearing. And thanks to all the witnesses for being
here today, especially for including H.R. 4153, the Educating
to Prevent Eating Disorders bill, and H.R. 2713, the Title VIII
Nursing Workforce Reauthorization Act. And I want to thank my
colleague, Representative Lois Capps, for introducing the Title
VIII Nursing Workforce Reauthorization Act. I am a proud
cosponsor of this bill, which would reauthorization critical
nursing workforce initiatives that are so desperately needed.
And I hear from Dianne Morrison-Beedy, the dean of the
College of Nursing at the University of South Florida in Tampa,
and her excellent team there, some of the most passionate
advocates for a strong nursing workforce. That is one reason
why USF's College of Nursing was ranked as one of the top, the
best graduate schools this year on the national ranking. I am
very proud of them. Ensuring that we have qualified registered
nurses and advanced practice nurses is critical to meeting our
Nation's healthcare needs.
I would also like to thank my colleagues and friends,
Representative Renee Ellmers and Yvette Clarke, for introducing
H.R. 4153, Educating to Prevent Eating Disorders. We filed this
bill last week. It is an important bill that is aimed at
reducing eating disorders with early intervention.
Specifically, our bill would create a 3-year pilot initiative
which would provide grants to schools, serving middle-school-
aged children to test the impact of providing students with
interventions to prevent, identify, intervene, and manage
eating disorders. We will help the pilot schools hire a
healthcare provider who will administer the initiative. The
schools participating in the pilot will submit a report
detailing the process they used and the outcomes that they
achieved. And it will be posted on the Agency for Healthcare
Research and Quality Web site. There is a huge desire for
accurate, up-to-date information on these challenges. And we
have got to do more to prevent young people from suffering from
an eating disorder. I am a mother of two teenage girls. And we
know some of their friends who have struggled with these
issues. And, oftentimes, families just don't know where to
turn. There are not resources out there to help them deal with
this. And as Representative Ellmers knows and has championed,
you have got to intervene early. So I am grateful to all of
you.
I want to thank Dr. Bermudez for being here. And I would
like to ask you, could you briefly discuss the different types
of eating disorders and the serious health consequences they
cause and whether or not we have seen a rise in the number of
individuals impacted by an eating disorder?
Dr. Bermudez. Sure. Glad to. Thank you.
The main eating disorders that we are really talking
about--anorexia nervosa, bulimia nervosa, and binge eating
disorder--now, an important characteristic here to distinguish
is that these are not fads. These are serious mental illnesses.
You can't tell somebody who has an eating disorder by looking
at them. And this is no longer an illness of Caucasian,
privileged young women. This is an illness that affects all
genders, all races, all ethnicities, all social economic
statuses. And that is important to come at it from.
Anorexia nervosa really constitutes a caloric restriction
with loss of weight. These are people that when the disease is
advanced, you can see them and you can recognize them as people
who are alarmingly underweight.
In the case of bulimia, these people often binge eat, which
means that they consume a very large amount of calories in a
short period of time and then feel very guilty and tend to
induce some form of purging, most of the time by vomiting,
inducing vomiting, or abusing laxatives. But there are other
forms as well.
And binge eating disorders are people who will binge
recurrently and not engage in the compensatory mechanisms that
include the purging behavior.
So that is really what we are talking about, the
opportunity for early identification and appropriate early
intervention I think would save many, many, many, lives.
Ms. Castor. Does the data show that the number of cases is
increasing? Has it stayed level?
Dr. Bermudez. So the data shows that the number of cases,
number one, is increasing. But also that the presentation, the
clinical presentations of the cases are also increasing. So we
are seeing some what is called demographic drifts. We are
seeing younger and younger children involved in eating
disorders, as young as 7 and 8 years of age. That was unheard
of a few years ago. More mature people in midlife, more women
than men but men also in midlife, people from different races,
and different ethnicities. So the protective factors that
certain groups, like African Americans on Asian Americans or
Hispanic Americans, had, those protective factors have eroded.
And we are seeing more men represented across the spectrum of
eating disorders, from anorexia to bulimia to binge eating
disorder.
Ms. Castor. Thank you very much.
I yield back my time.
Mr. Pitts. The chair thanks the gentlelady.
I now recognize the gentleman from Indiana, Dr. Bucshon,
for 5 minutes for questions.
Mr. Bucshon. Thank you, Mr. Chairman.
I was a cardiovascular and thoracic surgeon for 15 years
prior to coming to Congress. So I want to comment primarily on
the defibrillator issue.
I recently helped distribute defibrillators to a couple of
the counties for law enforcement and other businesses based on
grants through the Lugar Center, former Senator Lugar, and our
state has a grant program that helps with these type of things.
And H.R. 4152 is a necessary step in furthering the
dissemination of AEDs.
Let me give you some personal experience. You commented,
Dr. Reiner, about the two situations, that you see patients.
And I have seen some also that have survived but have not
survived in a state which is consistent with their pre-arrest
state. I have specifically two patients that I ended up doing
surgery on that have long-term brain injury that changed their
lives dramatically and the lives of their family. And I have
also been consulted on many patients who are in the ICU who
were found to have coronary disease. But I ultimately ended up
not treating that patient with surgery because of a very severe
brain injury for which they never woke up essentially and did
not recover.
My two patients that had brain injuries had cardiac arrest
at work. They had colleagues who were trained in BLS, basic
life support, almost immediate CPR, no defibrillator available,
5 to 10 minutes' time before a defibrillator became available.
They survived but had injury. So this is really important.
The other thing is--and I am going to ask you to comment on
this--education of the public in the use and importance of
these is critical. Employees and businesses, school children,
as is pointed out by your study, it is very important. And I
think for the future we probably need to start training school
children, I would think, in their health class or something
just about this because one of the biggest barriers to use,
even if they are available, is fear. And I had a colleague of
mine in an airport traveling to Washington who saw a person
that had an arrest. There were people standing around. And he
was a physician. And he said: Is there a defibrillator
available?
Of course, there was. And they used it. And that patient
survived and, subsequently, had heart surgery and is normal.
But had he not been there as someone who was available to
overcome his fear because of his training, that may not have
happened. So there are some barriers.
So, in combination with availability, can you comment on
what your thoughts are also on the importance of education and
helping people overcome their fear?
Dr. Reiner. I think that is a wonderful point, Congressman.
The biggest issue is that people don't know that they can do
this. We took a defibrillator out to the Verizon Center a
couple years ago and filmed people as they walked down the
street. We said: Hey, do you want to try and use a
defibrillator? These were folks who had never used it. And they
all could do it. They could do it very quickly. And the
universal response: Oh, now I won't hesitate to use it if I
ever have to.
But this kind of uncertainty is not just for the general
public, but it exists for corporations. They are afraid of
being sued if they get it wrong. All this bill says is if you
have a defibrillator that works, you are protected from
liability. It is a simple bill. But once national organizations
start educating people about the bill, then I agree; we need to
educate everyone how to use these devices. Imagine having a
fire extinguisher in the corner that had labels on it that said
``for use by trained rescuers only.''
Mr. Bucshon. Right. Right.
Dr. Reiner. This is a fire extinguisher that talks to you.
Mr. Bucshon. I agree with that. And that is why I have a
real issue when trial lawyers, for example, have questions
about people using things in good faith that save people's
lives. And as a physician, my personal view is it is really sad
that they would consider the financial benefits of suing people
doing things in good faith. I really take offense to that,
honestly.
Dr. Gregg, you commented on your screening test. Are they
better than an amniocentesis?
Dr. Gregg. That is the point. An amniocentesis is the
diagnostic test.
Mr. Bucshon. I guess the reason I am asking is because at
some point, when did the screening test supplant a more
invasive study and become the standard?
Dr. Gregg. Screening tests have been in place for more than
30 years. The initial screening test was age alone. You will
remember that age 35 was what rattled people's cage a little
bit. Today, we recognize that the detection rate of age alone
is not better than about 30 percent, just using age as a marker
to go to the amniocentesis, as you are implying.
Over the last decades, multiple other screening paradigms
have been put into place. Today, with noninvasive prenatal
screening, we are at a 98-percent detection rate from that 30
percent for advanced maternal age. The followup test is the
amniocentesis or the chorionic villus sampling.
Mr. Bucshon. I guess my point is, at some point, a
screening test becomes a standard of care for the test, and it
supplants a more invasive test. My time is up.
Dr. Gregg. An EKG doesn't replace what you do.
Mr. Bucshon. Understood. Fair point.
I yield back.
Mr. Pitts. The chair thanks the gentleman.
I now recognize the gentleman from California, Mr.
Cardenas, 5 minutes for questions.
Mr. Cardenas. Thank you very much, Mr. Chairman.
Thank you Doctor, Doctor, Doctor, Doctor, Doctor, Doctor,
and all of the people here who are on the panel giving us their
expertise and also my colleagues who have practiced as well.
Thank you so much for shedding light on many of these issues.
I am not a doctor, nor do I play one on TV. But I do care
about the state of health care for our country and certainly
now that a new chapter in my family's life has begun, as our
daughter and her husband announced to us very nonchalantly that
they are pregnant and our first grandchild is on the way. And
that being the case, it leads to my first question having to do
with prenatal screenings.
An article late last year in Disability Scoop discussed
some limitations of cell-free DNA prenatal screenings and
suggested that the need for quality control needs to be
improved. So my first question is to Dr. Gregg. Are you aware
of any noninvasive prenatal tests that are regulated by the
FDA?
Dr. Gregg. No.
Mr. Cardenas. No? OK. Some companies that make these tests
have made claims about the high accuracy of their results or
have made claims of very few false positives. Do any Federal
agencies, such as the FDA, evaluate the claims that these
companies are making to ensure that they are valid and
supported by clinical data?
Dr. Gregg. Currently, the FDA does not regulate this
particular LDT.
Mr. Cardenas. So those claims, where and how are they
validated by third parties today?
Dr. Gregg. By third parties?
Mr. Cardenas. Yes.
Dr. Gregg. I am not aware that they have been validated by
third parties.
There have been a significant number of peer-reviewed
publications, large international trials, that validate the
test metrics of these particular tests.
Mr. Cardenas. Is that, do you feel that that suffices to
ensure the public that that accuracy is in line with what the
claims are? Or could we possibly enlist some kind of agency to
go ahead and help us understand that accuracy and have more, at
least more appreciation for that accuracy?
Dr. Gregg. I am satisfied with the claims. I would say that
an involvement of a Federal agency has value. We think there
should be some oversight of these laboratories. CLIA and CAP
currently provide this oversight. To me and to ACMG, one of the
principal values of FDA oversight would involve labeling and
marketing aspects. Clinical validity has been established for
other types of prenatal screening for aneuploidy. These out-of-
the-box kits are probably regulated already but not molecular-
based testing in this way.
Mr. Cardenas. Yes. What can Congress possibly do to assure
the quality of these tests and that the tests are providing
accurate and reliable information to providers and specifically
pregnant women?
Dr. Gregg. Well, the tests already provide accurate
information. The laboratories themselves do currently have CLIA
and CAP oversight. So that is already in place.
Mr. Cardenas. So, right now, as you see it, Dr. Gregg, the
environment is at least satisfactory for those assurances and
understanding by not only the practitioners but also the
patients?
Dr. Gregg. No, I don't think it is satisfactory as far as
it relates to practitioners or patients. And that is what H.R.
3441 proposes to do, is put in place the educational
initiatives so that they are detailed, indepth, and provide for
a balanced and accurate information as the technology evolves.
Currently, the technology has expanded beyond simple
aneuploidies or common aneuploidies. As I said earlier, there
are genomic changes that the technology is now being used to
report screening results to. There is a need for more studies.
And what we haven't talked about here is the underlying
bioinformatics that follows what happens in the laboratory. The
bioinformatics is a big piece. It is proprietary. And at some
level, there probably needs to be some digging into that black
box to make sure that we can validate the bioinformatic pieces.
The companies sure can play a better role in disclosing the
data that they have access to. I think they probably with a
nudge would be willing to do that. But that is the type of
oversight I think that needs to be in place on the laboratory
side.
Mr. Cardenas. One last point, if you will allow me, Mr.
Chairman, I think that, unfortunately, proprietary information
should not preclude us from making sure that what is going on
out there is safe. And I think the government can play a
protective role in protecting that proprietary information and
bringing a better semblance of the environment for what is
going on. Thank you so much.
Thank you, Mr. Chair.
Mr. Pitts. The chair thanks the gentleman.
I now recognize the gentleman from Florida, Mr. Bilirakis,
5 minutes for questions.
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it so
very much.
And I want to thank all of the sponsors of these really
good bills.
And thanks for agenda-ing the bill today, Mr. Chairman,
having the hearing.
Dr. Bermudez, the subject of eating disorders has been of
great importance to several of my constituents. They have come
to my office, both in D.C. but also locally. In October, I met
with a group of advocates and heard their personal stories
about how they or their loved ones were affected by these
debilitating mental illnesses. What are some of the biggest
challenges to identifying the early signs of an eating
disorder?
Dr. Bermudez. So eating-related pathology has an
interesting characteristic, which is that people tend to not
want to be discovered, right. So people in other areas of
medicine want to seek the help and want others to know because
that is the path to accessing help. In eating disorders, that
is not the case. There is a lot of secretiveness in the
clinical presentations of an eating disorder. So imagine a 14-
year-old, who learns about some of this on the Internet or may
have some friends that have been affected. They talk about it,
and she sort of begins to change her behavior through
restriction and dieting and exercise. Well, she doesn't want
anybody to know. That is one of the biggest challenges. This is
not a child who is going to come to the parents and say: Mom,
Dad, I am struggling; I have a problem. This is a child that is
going to work hard not to be discovered. Hence, the importance
of educating those in the front lines, those individuals that
really, day to day, are interacting with children.
Mr. Bilirakis. So which are they--I know you brought it up.
I hate to interrupt. What should we look for, our loved ones
look for, a parent look for? How can we detect this?
Dr. Bermudez. We should look for change. We should look for
signs that are telling us that something is really changing in
the way this individual views themselves and is trying to
project themselves and fit into the world around them. So when
a young person starts to make self-deprecating statements about
their size, their weight, their appearance, their desirability;
when a young person starts to make excuses to not eat; when a
young person is losing weight and stops participating in the
normal activities that they had interest in and love,
especially social aspects of them, then I think families need
to sort of pick that up and become concerned and seek
appropriate assessment.
Mr. Bilirakis. Thank you. What are the most effective early
intervention treatments?
Dr. Bermudez. So formalizing the diagnosis becomes very
important. So after a screening test that raises a level of
suspicion or parental familial concern, a thorough assessment
becomes really important. And that assessment includes looking
for medical complications of the eating disorder behaviors and
psychiatric complications of the eating disorder behaviors.
Once that diagnosis is made, then you can sort of assess the
level of severity: Where is the illness in the spectrum of
severity of the illness? Because that may determine where we
start the treatment process. And so the different levels of
care, including medical stabilization, psychiatric
stabilization, outpatient services that are age-appropriate,
disease appropriate, intensive outpatient programs, partial
hospitalization, residential treatment, and inpatient eating
disorder specialized efforts are all in the armamentarium, and
so that assessment helps guide the family in making the
decision as to where is the appropriate place to start.
Mr. Bilirakis. How many millions of people are affected by
this disorder?
Dr. Bermudez. About 30 million people, so about 20 million
women and 10 million men at some point in their lives will be
affected by an eating disorder in the United States.
Mr. Bilirakis. Not just teenagers? All ages?
Dr. Bermudez. All ages.
Mr. Bilirakis. OK. Thank you.
Thank you, very much, doctor.
Dr. Asplund, thank you for your testimony, again, today. As
an avid sports fan and an attorney, the issue of athletes being
able to receive medical attention from their team physician
while across State lines has been of interest to me for a very
long time, even when I was in the legislature in Florida.
You mentioned that merely exempting team physicians from
the State's licensure requirements would not be sufficient
because there is still a risk of a lawsuit. Can you explain how
this complicates or hinders your ability to provide the best
possible care for athletes?
Dr. Asplund. Thank you for your question. I am not sure
that the language of the bill or the law hinders an ability to
provide health care. What it does, though, is it takes away
protection for the athletic trainer or the physician after they
have provided that health care in case something were to go
wrong.
As I testified earlier, many medical malpractice carriers
tie that malpractice coverage to that licensure link. And so of
the major malpractice carriers that we surveyed, almost 30
percent said they wouldn't cover someone out of state
regardless of licensure if they were out of state; 50 percent
said they would cover them out of state only if they had a
license in that second state; and there is 25 percent that
wouldn't cover them regardless of what state they were in. So
having the licensure piece overlooked or not married up will
put physicians and athletic trainers and other providers that
provide that care at potential great malpractice risk.
Mr. Bilirakis. Teams are having trouble hiring physicians
for these positions because of the risk of lawsuits?
Dr. Asplund. I am not aware of any difficulty in hiring
providers. It is nearly the provision of care and then the risk
that that may involve.
Mr. Bilirakis. Very good. Thank you so much.
Dr. Asplund. Thank you.
Mr. Bilirakis. I appreciate it.
And I yield back, Mr. Chairman.
Mr. Pitts. The chair thanks the gentleman.
I now recognize the gentleman from New York, Mr. Engel, 5
minutes for questions.
Mr. Engel. Thank you very much, Mr. Chairman.
Dr. Breedlove, before I came, Mr. Pallone asked you a
question about the rate of maternal mortality. I am wondering
if we could come back to that because I wasn't quite sure--we
were listening on the TV. I wasn't quite sure what the answers
are.
The statistics I have is that it increased from 7.2 deaths
per 100,000 births just in 1987, and it is more than double
today, 17.8 deaths per 100,000 births in 2011. What is the
reason for that? That is really alarming, or it seems alarming.
What is the reason for that, and are other developed countries
experiencing the same thing in mortality rates?
Dr. Breedlove. I think from the data that is being
collected by the CDC and the collaborative work groups related
to maternal mortality in our country, we are finding that some
of it does have to do with access to prenatal care and early
assessment, the risk criteria during pregnancy, but some of it
also has to do with care provision in the hospital systems
themselves, whether that is the level of care provided, that
the appropriate providers are in the right place for crisis
management, or that those who are in hospital facilities have
adequate training and resources to provide the provisions they
need for critical high-risk patients.
So, unfortunately, there are many variables, including the
rising rate of cesarean section and the complications that come
with that. So the effort that is occurring by many
collaboratives, including ACOG, Society for Maternal-Fetal
Medicine, AWHONN, the nursing organization, is to begin to
implement care bundles that are hospital-based but also to
define levels of maternal care which will have the right
providers at the right facility for the need of the patient.
Mr. Engel. Is part of it that older women are having more
babies than they were 30 years ago, or does that have nothing
to do with it?
Dr. Breedlove. I am not sure I could answer that question.
Perhaps my colleague, Dr. Gregg could, in terms of advanced
maternal age and increased risk. Certainly, the increase in
multiples can play a part in that, but I would defer to Dr.
Gregg.
Mr. Engel. OK.
Dr. Gregg.
Dr. Gregg. I actually co-chair the Florida maternal
mortality committee, which is recognized as one of the most
thorough maternal mortality committees in the country. We
review every maternal death in the state that has specific
criteria.
Let me just say that a couple of things have happened. The
way data on maternal mortality is ascertained has changed. So I
heard somebody say there was a drop and somebody else say it is
increasing. So all of that relates to who is obtaining the
data. There were two entities within CDC both obtaining data,
and now it is obtained across more states than ever before. So
we are seeing what appears to be an increase in numbers are due
to better ascertainment. And when that is compared worldwide,
it looks like the U.S. does poorly. We have to remember that,
worldwide, many countries don't collect any data or have very
spotty data-collection capabilities. So I just want to put that
out there.
There are increasingly--women of advanced maternal age are
getting--not 35; to me, it is much higher than that--are
getting pregnant. They have other associated medical conditions
that go along with advanced age.
We have more women getting pregnant that in times past
couldn't get pregnant because they had underlying medical
conditions that did not support pregnancy well. We have
interventions to help them get pregnant. So now we are seeing
sicker patients enter pregnancy, and we are having to manage
sick patients in a pregnancy that challenges their physiology,
so----
Mr. Engel. Thank you. It makes sense. Since I have you, let
me ask you another question not related to this, but I
understand that, as drafted, the patient and provider education
campaigns, including in H.R. 3441, would need to be funded
using existing resources. So has any analysis been done to
determine what the cost of these campaigns might be or where
the funding might be pulled from to finance them?
Dr. Gregg. I am not aware of a financial analysis or
financial analysis report and don't have the data on that. I
apologize.
Mr. Engel. OK. Thank you.
Let me ask Dr. Reiner. In your testimony, you discuss the
patchwork of laws that exist across 50 States with respect to
liability for those who own or deploy automatic external
defibrillators. And I would be interested to know what kinds of
laws exist with regard to training and storage for these
defibrillators. And the reason I am asking this is, while I
take your points concerning liability, it occurs to me that we
really should also be considering how we can enhance awareness
and skill around these defibrillators. Obviously, they save
lives. The usage rates might improve if defibrillators had to
be stored, say, in permanent locations, and I know state laws
vary. So if you could perhaps shed some light on how they vary
in this respect. If you can----
Dr. Reiner. Thank you for the question, Mr. Engle. I
completely agree. Defibrillators work best when they are
located in places where people congregate. And in a building
like this, they are easy to find. But in other parts of busy
cities, they are not. So part of the solution is education to
the business community, community at large, educating people
that these are easy to use, teaching kids--I love the idea to
teach kids how to use these while they are in middle school and
high school. But the other piece of this is removing the
concern for liability, what I think is the unnecessary concern
for liability that business owners do have for acquiring this
technology. An AED cost about the same as a MacBook. It is
cheap. This is decades-proven technology, but businesses are
afraid of it.
Mr. Engel. Thank you. I want to just say in concluding that
I always like when there are a bunch of doctors in the room, so
I feel if anything happens to me, we can get good care.
Thank you all for testifying today. We really appreciate
it.
Mr. Pitts. The chair thanks the gentleman.
I now recognize the vice chairman of the subcommittee, Mr.
Guthrie, 5 minutes for questions.
Mr. Guthrie. Thank you very much. I appreciate all of you
being here, but I want to focus on the Sports Medicine
Licensure Clarity Act. That is the one that I am the sponsor
of. I have a friend who is an emergency room physician, but he
also is--I don't know if he is a team doctor or designated
doctor. He is one of the doctors who travel with Auburn
University. So I remember when I first came across this issue
and got interested in it because of his experience, I said: Do
you realize when you were at the BCS game in California and the
Rose Bowl, as much fun as you were having, enjoying it, you
were probably there with--you are unclear what your liability
coverage would be if you are there?
And I know one of my colleagues was--I don't know where
they were going with it--but talked about being a lawyer. This
isn't preventing opportunities for people to bring malpractice
suits. It just makes sure you are covered, your insurance is
covered, so it is not taking away anybody's ability to move
forward. It is just making sure that doctors have the surety
that they are being covered.
And, also, I would just like to compliment Georgia
Southern. I got to see you guys play a couple of years ago at
Georgia Tech. I was there for a game. My son is there. And it
was a closer game than some thought, and I think there was a
controversial overturn that changed the game for Georgia Tech's
behalf, and so a lot of fans get upset. But I remember walking
out and going: Wow, Georgia Southern handled everything with
class and a lot of--great program, a lot to be proud in that
program. And I know you are going to Mobile, so you are going
to have to go to Alabama without a license, right, practicing
license.
So that is the thing that we are trying to fix is that, you
have got Western Kentucky University. You are playing Bowling
Green. We are from Bowling Green. A lot of people think we are
playing you guys, but we are Western Kentucky University, and
we are going to Miami. And so I remember, last year, we
actually went to the Bahamas Bowl, and it is amazing how many
18- to 22-year-old young men do not have passports. So my
office actually spent about a month trying to get everybody
cleared to go. So when these games happen and it is a single
game somewhere, you just can't do paperwork for every scenario
that you are moving forward.
So we just want to fix it. I think it just makes it
smarter. I think everybody agrees that the team physician
should be able to travel with the team--who knows the young men
and women, and knows there may be a previous injury, what they
are favoring. So instead of bringing a local physician there
who doesn't know the history of each kid, it is important to do
so.
So I just want to ask you about the licensing process for
sportsmen and professionals at the state level, and I know it
would be very expensive and cumbersome and maybe even
impossible, from the time you get a full bid until you are
ready to play a ball game, to get licensed as a sports
professional in a state. So what is kind of the process
currently to be licensed as a sports professional in Georgia or
any other state you are familiar with?
Dr. Asplund. Mr. Guthrie, thank you for the question, and
thank you for the support of our bill.
You are correct. All 50 states and territories have
differing requirements or processes to get a medical license.
They generally look at your educational background, your
malpractice claims, your continuing medical education, and then
they issue a license. And while each state has sort of an
underlying--they are all similar, but yet they are different.
And so we have been to Alabama twice, and we are going to go
back a third time. And had I known with enough time to get a
temporary 14-day license--which, according to the State of
Alabama, would cost $500 and would only last for 14 days. So on
our initial trip to south Alabama, I could have paid $500,
gotten 14 days of coverage. Two months later, when we went to
Troy, I would have to pay another $500 to get 14 days of
coverage and, now that we are returning to Mobile, another $500
for this 14 days of coverage. So the temporary medical
licensing may work on occasion when you know that you have--
when you know where you are going.
Mr. Guthrie. But even if you are licensed there, there is
no guarantee that your malpractice insurance recognizes that,
right? That is what we are trying to clarify as well.
Dr. Asplund. That is correct. And in a study that we talked
about, malpractice carriers sometimes tie their coverage to
your state of license. So each state is different. The process
is costly, anywhere from $150 to $900 per state, and the
timeframe on that is anywhere from 2 to 6 months until that
paperwork can process.
Mr. Guthrie. I want to get to a couple of other questions.
So the bill doesn't restrict what you can do. You couldn't have
gone to Troy hospital--or if you went to Montgomery or wherever
you went or Birmingham--and performed an orthopedic surgery on
a player that was hurt?
Dr. Asplund. Correct.
Mr. Guthrie. And it does restrict what you can do. So
pretty much what we understand is on-the-field coverage?
Dr. Asplund. Yes. It restricts it to on-the-field or in-
the-training-room type coverage. Any coverage that would occur
in a medical facility, like a hospital or a clinic, would not
be covered by this bill. It is typical stuff that you would do
on the sidelines, in the training room, underneath the stadium.
Mr. Guthrie. And why is that important? I have got just a
couple of seconds, so I want to make sure. Why is it important?
Because I know my friend was telling me that, you know, this
person has a sore ankle; this person has done it before; if he
hurts it again in the game, I know where to go. Why is it
better to have--I guess I am answering it--but why is it better
to have you with your team than just hire a local doctor to
come cover the game?
Dr. Asplund. Well, you highlight some of the concerns with
the orthopedic issues, but we are seeing more and more young
people with complex medical issues that are playing sports at
the highest level. We have several asthmatics, several
diabetics. We have two athletes who have no colon at all. And
so there are complex medical issues that also come into play.
The example I highlighted in my testimony of a spinal cord
care, that process is practiced and rehearsed weekly with our
team, and so if a new doctor were just to fall in on our team,
there may be some miscommunication and a potential catastrophic
injury if the neck was turned too soon or the back was turned
too soon, rendering an athlete paralyzed.
Mr. Guthrie. Are you employed by the school, or are you a
private physician who travels with the team?
Dr. Asplund. In this particular job, I am employed by the
school and, hence, the state, and so would likely be covered by
the Georgia Tort Act for performing my job, but when I was at
Ohio State, I was a private practice contract.
Mr. Guthrie. That is what my friend is. So you would be in
the same situation, so not everybody is covered?
I am running over time.
Dr. Asplund. Correct.
Mr. Guthrie. So it is important that we do this. And I
appreciate being involved in it.
Dr. Asplund. Thank you very much.
Mr. Guthrie. Thank you.
Mr. Pitts. The chair thanks the gentleman.
I now recognize the gentlelady from North Carolina, Mrs.
Ellmers, 5 minutes for questions.
Mrs. Ellmers. Thank you, Mr. Chairman.
Again, thank you to our panel. This has been a very good
subcommittee hearing, and the testimony has been wonderful.
Dr. Bermudez, my questioning is primarily for you on our
bill, on our eating disorders bill. And I would just like to
ask you, you mentioned some of the myths that are associated
with eating disorders. Can you just expand a little bit on what
some of those myths are?
Dr. Bermudez. Absolutely, and thank you. The reality is
that eating disorders affect everybody. Everybody is at risk.
Mrs. Ellmers. It is not just young females.
Dr. Bermudez. Yes. If you have sons and daughters and if
you have nieces and nephews and if you have grandchildren, they
are all at risk in a societal context like ours. So the key is
to take it away from the concept of choice, such as people
choose to do this and this is about lookism, and take it into
the context of this is a brain-based mental illness that
profoundly affects the lives of not only the person who is
identified with the illness but all of those affected and
surrounding them as well. So that is one important shift.
The other important shift is it is everybody's disease,
every gender, every race, every ethnicity, every socioeconomic
status, and so that no one is exempt because of who they are or
what they look like. Those are, I think, the two important
distinctions in dispelling the myths.
Mrs. Ellmers. Now, as far as the most common eating
disorders, I know we talked a little about anorexia. We talked
about binge eating, which certainly, we know that that is part
of the bulimia nervosa. Do you also consider, kind of along the
line of the binge eating, those who are overweight and eating
disorders associated with, maybe not the binge side of it but
the eating--we know that we have kind of an epidemic in this
country of obesity. Would you consider that part of this too or
no?
Dr. Bermudez. So I think we need to make some distinctions
and highlight some similarities. I think the main distinction
that is really important, I think, for the public to understand
is that obesity is a real problem in our country, but obesity,
in and of itself, is not a mental health illness.
Mrs. Ellmers. Correct. And that would be one of the
clarifications that would be made in the process of treatment?
Dr. Bermudez. Absolutely.
And so the other distinction that, to me, is really
important, though, is that there are similarities. There are
potential advantages here. There is potential value to better
understand and address some of the issues with obesity because
at the end of the day, in a stressful living situation, in a
complex society likes ours, which really means that kids grow
up with significant perceived stress, we tend to either eat too
little or eat too much. The reality is that the relationship
between our developmental stance, our constant concept of self
or self-view, and our relationship with food are integrally
tied. So as we learn about prevention, as we better understand
how to do early intervention and teach the front line, parents,
teachers, about what to recognize and the steps to take to
secure more adequate next-step assessments, not only would we
be protecting the most vulnerable, but we will learn a whole
lot about the resiliency factors that keep those that stay
well. So we may very well learn how to keep them well. And
along those lines, we may very well learn what happens when the
eating goes not just toward bingeing or purging or anorexia but
simply eating too much and ending on the side of obesity.
Mrs. Ellmers. Which leads to its own set of----
Dr. Bermudez. Right.
Mrs. Ellmers. You did mention that we have seen this in
children as young as 7 or 8. So I have a very basic question.
We are looking at middle school as starting the pilot program.
Do you think maybe we should rethink that and maybe start it
earlier?
Dr. Bermudez. I think, based on the information we know,
the demographics of eating-related pathology that we know
today, middle school is a critical place to start.
Mrs. Ellmers. OK.
Dr. Bermudez. It is a vulnerable time of life. It is a time
when, in the normal process of separation, individuation, kids
are beginning to sort of find their own path. Peer influence
and cultural influences sort of are highlighted. So it is
really a vulnerable time of life. Statistically speaking, I
think this is really where the payoff is.
Mrs. Ellmers. The best----
Dr. Bermudez. But we should not ignore the fact that
younger children may also be affected.
Mrs. Ellmers. Very good.
And I have one last question with 30 seconds left. I want
to target where we were going with the eating disorder and
early intervention and possibly not being able to make the
goals that we want and leading to some of the physical
illnesses that end up happening. And I know, in your testimony,
you basically said eating disorders are serious, potentially
life-threatening conditions that affect a person's emotional
and physical health. And it goes on to say that it could affect
your organs, going on to heart, brain, other vital organs,
retarded growth, osteoporosis, kidney problems,
gastrointestinal dysfunction, and even heart failure.
With that in mind--and one of our biggest challenges here
in Washington is being able to put forward legislation with
funding, moving forward so that we can actually show that there
is going to be progress made into the future, which will
eventually lead to fiscal savings when we are talking about
things like Medicaid, Medicare coverage. Now, I know you are in
eating disorders, and that is your specialty. But in your
medical background, would you not say that if we could prevent
this and keep this person healthier as a result of
intervention, that this will help to save that person from
having lifelong or end-of-life issues that would affect them
and the cost of health care?
Dr. Bermudez. Representative Ellmers, I think that is a key
point of H.R. 4153. We are talking about not just saving lives
and saving people from suffering, but this is an area in which
an ounce of prevention is worth many, many, many pounds of
cure. So these are expensive illnesses to treat. These take a
significant toll on a very important sector of our society,
which is our bright, otherwise healthy young people. And my
sense is that what we will learn from this pilot program is
that this is really where the future is to say: Let's get ahead
of the curve here and not just continue to sort of do the
remedial care that we have been focused on.
Mrs. Ellmers. Yes. Focus on prevention.
Well, thank you, again, so much.
And, again, thank you to our panel. This has been a very,
very good subcommittee hearing, but I have learned a lot as
well. So thank you.
Mr. Pitts. The chair thanks the gentlelady.
We have a UC request?
Mr. Guthrie. Thank you, Mr. Chairman.
I do have a unanimous consent to add into the record or put
into the record several letters, one from a coalition of
healthcare providers supporting the bill, a letter of support
from the American Association of Orthopaedic Surgeons, a letter
of support from the American Medical Association, also from the
American Osteopathic Association, from the National Athletic
Trainers' Association.
And I know we were discussing how this affects college
football more than anything because of your role, but this is
also one from Major League Baseball, the NBA, the NCAA, NHL,
NFL, and the Olympic and Paralympic Committees. And I will ask
unanimous consent they be put into the record.
Mr. Pitts. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Pitts. That concludes our time of questioning.
I will have some followups, so I will send those to you in
writing. We ask that you, please, respond promptly.
I remind members that they have 10 business days to submit
questions for the record. Members should submit their questions
by the close of business on Wednesday, December 23.
Really a very, very excellent hearing, very informative,
very high-quality testimony. Thank you very much for coming and
speaking to the subcommittee today.
Without objection, the subcommittee stands adjourned.
[Whereupon, at 12:26 p.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
Prepared statement of Hon. Doris O. Matsui
Thank you, Mr. Chairman for holding this hearing today. I
look forward to hearing from each of the witnesses about the
targeted public health problems we are aiming to address, and
your thoughts on the best solutions to these challenges.
In particular, I would like to highlight my support for the
Nursing Workforce Reauthorization Act, and I thank my colleague
Representative Capps for her leadership on that issue.
Additionally, I would like to thank my colleague,
Representative Ellmers for her work on the eating disorders
legislation we are discussing today.
As many as 30 million Americans suffer from an eating
disorder, but only 1 in 10 ever receives treatment. Eating
disorders can have severe consequences and medical
complications such as heart failure, organ failure,
malnutrition, and suicide.
That is why I support the Anna Westin Act, which I have
worked on with my colleague Representative Lance as well as the
coauthors Representatives Deutch and Ros-Lehtinen.
The Anna Westin Act would train doctors and teachers to
recognize at-risk behaviors in order to ensure earlier
diagnosis and treatment, and it would clarify mental health
parity for eating disorders so that insurers can't pick and
choose mental disorders to exclude from coverage.
The pilot project in the legislation we are discussing
today would test the impact of early intervention on the
prevention, management, and course of eating disorders in
grades 6 through 8. This is certainly a project that we should
undertake.
I encourage support of this legislation, and I also
encourage the Committee to take our work on eating disorder
prevention a step farther by reviewing the Anna Westin Act as
well. Thank you.
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