[Senate Hearing 116-277]
[From the U.S. Government Publishing Office]
S. Hrg. 116-277
HOW PRIMARY CARE AFFECTS
HEALTH CARE COSTS AND OUTCOMES
=======================================================================
HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
ON
EXAMINING HOW PRIMARY CARE AFFECTS HEALTH CARE COSTS AND OUTCOMES
__________
FEBRUARY 5, 2019
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
_____
U.S. GOVERNMENT PUBLISHING OFFICE
41-389 PDF WASHINGTON : 2020
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
LAMAR ALEXANDER, Tennessee, Chairman
MICHAEL B. ENZI, Wyoming PATTY MURRAY, Washington
RICHARD BURR, North Carolina BERNARD SANDERS (I), Vermont
JOHNNY ISAKSON, Georgia ROBERT P. CASEY, JR., Pennsylvania
RAND PAUL, Kentucky TAMMY BALDWIN, Wisconsin
SUSAN M. COLLINS, Maine CHRISTOPHER S. MURPHY, Connecticut
BILL CASSIDY, M.D., Louisiana ELIZABETH WARREN, Massachusetts
PAT ROBERTS, Kansas TIM KAINE, Virginia
LISA MURKOWSKI, Alaska MARGARET WOOD HASSAN, New
TIM SCOTT, South Carolina Hampshire
MITT ROMNEY, Utah TINA SMITH, Minnesota
MIKE BRAUN, Indiana DOUG JONES, Alabama
JACKY ROSEN, Nevada
David P. Cleary, Republican Staff Director
Lindsey Ward Seidman, Republican Deputy Staff Director
Evan Schatz, Minority Staff Director
John Righter, Minority Deputy Staff Director
C O N T E N T S
----------
STATEMENTS
TUESDAY, FEBRUARY 5, 2019
Page
Committee Members
Alexander, Hon. Lamar, Chairman, Committee on Health, Education,
Labor, and Pensions, Opening statement......................... 1
Murray, Hon. Patty, Ranking Member, a U.S. Senator from the State
of Washington, Opening statement............................... 3
Witnesses
Umbehr, Josh, M.D., Atlas MD, Wichita, KS........................ 7
Prepared statement........................................... 8
Kripalani, Sapna, M.D., Assistant Professor of Clinical Medicine,
Division of General Internal Medicine and Public Health,
Vanderbilt University Medical Center, Nashville, TN............ 30
Prepared statement........................................... 31
Summary statement............................................ 35
Bennett, Katherine, A., M.D., Assistant Professor of Medicine,
Division of Gerontology and Geriatric Medicine, University of
Washington School of Medicine, Seattle, WA..................... 36
Prepared statement........................................... 37
Summary statement............................................ 44
Watts, Tracy, Senior Partner, National Leader for US Healthcare
Reform, Mercer, Washington, DC................................. 45
Prepared statement........................................... 46
Summary statement............................................ 51
HOW PRIMARY CARE AFFECTS
HEALTH CARE COSTS AND OUTCOMES
----------
Tuesday, February 5, 2019
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The Committee met, pursuant to notice, at 10 a.m., in room
SD-430, Dirksen Senate Office Building, Hon. Lamar Alexander,
Chairman of the Committee, presiding.
Present: Senators Alexander [presiding], Murray, Collins,
Cassidy, Roberts, Scott, Romney, Braun, Casey, Baldwin, Murphy,
Warren, Kaine, Hassan, Jones, and Rosen.
OPENING STATEMENT OF SENATOR ALEXANDER
The Chairman. Good morning. The Senate Committee on Health,
Education, Labor, and Pensions will please come to order.
Senator Murray and I will each have an opening statement and
then we will introduce the witnesses, and after the witnesses'
testimony, Senators will each have a five-minute round of
questions.
Dr. Lee Gross of Florida testified last year at this
Committee's fifth hearing on the cost of health care. He told
us that after 7 years as a primary care doctor, he had an
epiphany. Too many Government mandates and insurance companies
were getting between doctors and patients, and making primary
care more expensive than it needed to be.
In 2010 Dr. Gross created one of the first direct primary
care practices. Instead of working with insurance companies and
Government programs, his patients pay him a flat monthly fee
directly, $60 a month per adult, $25 a month for one child, $10
a month for each additional child.
Dr. Gross is one of more than 300,000 primary care doctors
in the United States. Most of us go to see such doctors for our
day-to-day medical care, vaccines, flu shots, annual physicals,
and managing chronic conditions like diabetes. It is also our
entry point to coordinate additional medical care if, for
example, we need to get our hip replaced, or an MRI to diagnose
a problem. We heard from Dr. Brent James of the National
Academies of Medicine on our second hearing that between 30 and
50 percent of what we spend on health care in this country is
unnecessary.
I have asked for specific suggestions on what the Federal
Government can do to lower the cost of health care for American
families, and this year I am committed to passing legislation
based on that input to create better outcomes and better
experiences at a lower cost. Senator Murray and I met with
Senator Grassley and Senator Wyden, who are the chairman and
ranking member of the finance committee, which has a good deal
of jurisdiction in the health care area as well, and we are
going to see if we can find one or two big things, and several
medium-sized or small things, that will help reduce health care
costs.
Dr. Gross practice is one of about a 1,000 similar clinics
in the United States, and it is a good example of how a primary
care doctor can help reduce costs. The first way Dr. Gross does
this is by helping with his patients' wellness. For $60 a
month, Dr. Gross can do EKGs and cortisone injections, manage
chronic conditions like diabetes, asthma, and hypertension,
remove minor skin cancers, right in his office.
The second thing he can do to reduce cost is keeping his
patients out of the emergency room. For $60 a month, patients
have unlimited office visits. They can also email, text, call,
use an app to contact his office any time, day or night. So, if
you have a stomach pain at 11 p.m., you could text Dr. Gross,
who knows that it might just be a side effect of a new medicine
that he had prescribed for you.
Third, primary can help reduce health care costs because it
is patients' access point to more advanced care. When Dr. Gross
refers people for additional care, he is able to provide cost
and quality information about the different options, so his
patients can choose the best option. For example, one of his
patients with rheumatoid arthritis was quoted $1,800 for blood
work. Dr. Gross was able to find a laboratory that offered the
blood test for under $100.
This echoes what Adam Boehler, who leads the Center for
Medicare and Medicaid Innovation, recently told me. He
estimated that primary care is only 3 to 7 percent of health
care spending, but affects as much as half of all health care
spending. And as Dr. Roizen of the Cleveland Clinic has said
before this Committee, regular visits to one's primary care
doctor along with keeping your immunizations up to date,
maintaining at least four measures of good health such as a
healthy body mass index and blood pressure, will help avoid
chronic disease about 80 percent of the time. This is important
because according to Dr. Roizen over 84 percent of all health
care spending is on chronic conditions like asthma, diabetes,
and heart disease.
I believe we can empower primary care doctors, nurse
practitioners, and physicians assistants to go even a step
further. At our fourth hearing, we heard about how the cost of
health care is in a black box. Patients have no idea how much a
particular treatment or test will end up costing. Even if the
information on the cost and quality of health care is easily
accessible, patients still have trouble comparing different
health care options. For example, earlier this year hospitals
began to post their prices online as required by the Center for
Medicare and Medicaid Services, but to the average consumer,
this information has proven to be incomprehensible.
But while the data may be incomprehensible today, it is a
ripe opportunity for innovation for private companies, like
Healthcare Bluebook, a Tennessee company that testified at our
hearing last fall, and non-profit organizations to arrange that
data so primary care doctors, nurse practitioners, and
physicians assistants can help their patients have better
outcomes and better experiences at lower cost.
There are other ways to lower health care cost through
expanded access to primary care. Dr. Gross direct primary care
clinic is one example. Another is community health centers,
which we talked about at our last hearing. They serve 27
million Americans for their primary care. And employers are
increasingly taking an active role in their employees' health
and in the cost of health care. One of our new Committee
Members, Senator Braun, was an employer of 1,000 people and was
aggressive about helping his employees reduce health care
costs. Like primary care doctors, more good data could help
employers, like Senator Braun, more effectively lower those
costs.
Employers are also employing a doctor onsite so employees
do not have to take time off work to see a primary care doctor.
On-site primary care makes it easier to keep employees healthy
by helping to manage a chronic condition or get a referral to a
specialist. Today, I am interested in hearing more about
specific recommendations to improve access to affordable,
primary care.
Senator Murray.
OPENING STATEMENT OF SENATOR MURRAY
Senator Murray. Thank you Mr. Chairman, and thank you to
all of our witnesses for joining us as we look at the role
primary care can play in addressing skyrocketing health care
costs and improving health outcomes.
Families across the country want quality health care to be
accessible and affordable no matter where they live, or how
much money they make, or what health challenges they indeed
face. They want to know that breaking a bone is not going to
break the bank, and that a high fever will not come with a high
cost. That filling a prescription will not mean emptying a
savings account. That managing a chronic illness will not mean
having to travel prohibitively long distances or manage
exorbitant costs. And when it comes to keeping families healthy
and care affordable, how we approach primary care is a key
piece of this puzzle.
Experts in Washington State have known this for years, and
have been a driving force for models that work to make primary
care more accessible, affordable, and effective. Like Dr. Ed
Wagner at the MacColl Center in Seattle, who helped advance the
idea of the Patients-Centered Medical Home. It is a delivery
model where care is coordinated through primary care teams for
better efficiency and better health outcomes.
Having these primary care teams quarterback care in this
way means giving them a clearer view of the field, a patient's
holistic health needs, a roster of their teammates to the
patient's other health care providers, and the power actually
to call plays, tools for coordinating care or end treatment
decisions across the health system. In practice, that means
that primary care providers can better understand how to keep
all the different specialists and providers on the same page
about which treatments, and prescriptions, and approaches are
best for a patient's needs, and how to prevent treatments that
are redundant, or worse, counterproductive when used together.
And they can better understand what barriers, barriers like
cost, or distance, or language, might prevent a patient from
getting the care they need and how to overcome them. The result
is care that brings down costs, not just by giving patients
better, efficient care while they were ill, but also by doing
more to keep them healthy.
This promising delivery model was not only advanced in
Washington State by the MacColl Center, it was put into
practice by one of our state's largest employers, Boeing.
Boeing found that by delivering care that was more coordinated
and personalized not only lowered costs for patients by one-
fifth by preventing expensive care like hospital admissions,
they also increased access to care and improved their
employees' health outcomes.
Our state has continued to lead the way in implementing new
ideas to improve primary care for patients across the country,
and I am looking forward to hearing today from Dr. Bennett, who
is with the University of Washington, about one of those
efforts called Project ECHO for geriatrics, which takes a novel
approach to better tailoring care and lowering health care
costs for our seniors.
The program sets up a regular teleconference for family
medicine residents and others on their team in rural areas to
learn from geriatrics experts and consult on issues like which
prescriptions are best for elderly patients, how they can help
patients manage chronic illness, and what preventative steps
can they suggest to patients at risk of dementia or seniors who
are concerned about falling. By giving primary care providers
access to experts on these issues, this application of Project
ECHO helps bring specialized care to seniors who might
otherwise have to wait for weeks or months for an appointment.
It might even put off getting cured in the first place, if
required to travel far from their home. Dr. Bennett, I am very
excited to hear more about this work this program is doing and
how it leads to better outcomes and lowers costs for seniors
across the Northwest.
Of course, while primary care providers can play a critical
role in coordinating care and reducing costs, they can only
play that role when people have access to care. In fact, when
people do not have access to primary care, they do not just
miss out on care that could improve their health and drive
costs down, this lack of access can actually drive costs
higher. Patients go to ER for non-urgent medical care, or
worse, without medical care, entirely until non-urgent issues
become urgent ones that are more expensive to treat, more
debilitating, and more challenging to overcome. So, while
innovation and primary care is important, we must absolutely
remember to focus on access to it as well, and work to help
people overcome barriers like cost, and language, and location.
As we heard last week, community health centers play a
critical role in doing that. They provide 27 million people
across the country with affordable care close to home. So, I am
very glad that Chairman Alexander has joined with me. We are
introducing a bipartisan bill to ensure they have stable
funding for the next five years. That is a very important step
in supporting centers across the country that provide primary
care to underserved communities. And so, we continue to focus
on the issue of health care costs.
I am hopeful we can find more common ground on issues like
how to bring down skyrocketing drug costs so families are not
worried about whether they can afford life-saving drugs like
insulin, how to address surprise balance billing so patients
are not caught off-guard by unexpected and unaffordable price
tags for out-of-network care, and how to address President
Trump's health care sabotage and lower premiums for families in
the country. Democrats have a lot of ideas on how to do all
this. We are very eager to make it happen, and I am very--I am
actually looking forward to sitting down with Republicans to
work with common sense solutions to these health care costs
issue we face.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Murray. So the witnesses
will know, we have a finance committee meeting today and many
of our Members are also on the finance committee so there will
be some coming and going. But this is our second hearing on
primary care and it is a considerable interest to both the
Democratic and Republican Members here, in terms of specific
recommendations about what we can do, so we look forward to
your testimony.
I thank Senator Murray for the way that she has shown
leadership on the community health issue and introducing
legislation for five years of stable funding, and this hearing
as well. Each witness will have up to five minutes for his or
her testimony. I am pleased to welcome our four witnesses.
Senator Roberts, would you like to introduce the first
witness?
Senator Roberts. Yes, sir. I certainly would. And I would
like to say, prior to that introduction, I want to thank the
Chairman, I want to thank Senator Murray for your opening
comments, more especially with regards to what we can do to
help the rural health care delivery system, which is now in
pretty rough shape. I do have the privilege of being the
chairman of the rural health care caucus. We need to split our
membership a bunch to work alongside this Committee, but thank
you both.
It is my honor and privilege to introduce Dr. Josh Umbehr
before the Senate HELP Committee this morning. Dr. Umbehr is a
native Kansan. He was born and raised in Alma, Kansas. Alma,
Kansas is the home of the Amish Cheese Factory located on
Interstate 70, and you see a lot of cars driving off to Alma
and proceeding onward. He attended the Manhattan High School in
Manhattan, Kansas. He and his wife Lisa both attended Kansas
State University, home of the ever-optimistic and fighting
Wildcats, my alma mater, who play the University of Kansas
tonight, roughly around the same time we are having the State
of the Union--tough choice, but not really.
[Laughter.]
Senator Roberts. Dr. Umbehr is reported to be both a fan of
the University of Kansas and Kansas State. I do not know how he
does that. It is like holding water, sheep, and cattle and
everything else you would like to use as an allegory. He
majored in human nutritional sciences with a minor in biology.
After graduating from K-State, Dr. Umbehr went on to the
University of Kansas School of Medicine, before completing his
family medicine residency at Wesley Medical Center in Wichita.
Dr. Umbehr is a board-certified family physician. In 2010, he
founded Atlas MD Family Practice, a membership-based, direct
primary care practice with two locations in Wichita that has
been expanded, as he will talk about later. And to that
innovative model, Atlas MD offers its members free home, work,
and office visits, unlimited, free telemedicine, free office-
based procedures, and a guarantee of no copays.
Atlas MD focuses on building relationships between patients
and their doctors through transparent partnerships that
prioritize face-to-face care, avoiding unnecessary and
burdensome paperwork. Kansas is very fortunate to have Dr.
Umbehr and his colleagues at Atlas MD to service a model for
how direct primary care can help drive down health care costs,
while still delivering high-quality care to patients. Welcome,
Dr. Umbehr. We are very interested in your testimony. Thank
you, Mr. Chairman.
The Chairman. Thank you, Senator Roberts. And I would note
that number one, Tennessee plays Missouri at 9 p.m. also
tonight. Maybe we can arrange for some sort of split-screen
television while----
[Laughter.]
The Chairman ----watching the State of the Union.
Senator Roberts. Would that be on the floor of the Senate,
Mr. Chairman?
The Chairman. Well, I do not know. We will have to discuss
that.
[Laughter.]
Senator Roberts. Right.
The Chairman. Next, we will hear from Dr. Sapna Kripalani.
She is the primary care physician and assistant professor of
clinical medicine at Vanderbilt University Medical Center.
Managing more than 2 million patient visits each year,
Vanderbilt University Medical Center is one of the largest
academic medical centers in the Southeast, and it is the
primary resource for specialty and primary care, and hundreds
of adult and pediatric specialties for patients throughout
Tennessee and the Mid-south.
Senator Murray will introduce our third witness.
Senator Murray. Mr. Chairman, joining us today from the
University of Washington's School of Medicine is Dr. Katherine
Bennett. She has worked tirelessly throughout her career to
help make sure seniors across the state have health care
providers who understand what they need to stay healthy. She
has worked toward that goal as a physician at a senior care
clinic in Seattle, as a researcher focused on addressing issues
that affect older adults like fall prevention, as an assistant
professor at UW where she teaches gerontology and geriatric
medicine, as president-elect of the National Association for
Geriatric Education, and as the founding medical director of
UW's Project ECHO for geriatrics, which she will be talking
about today. So, thank you very much, Dr. Bennett, for being
here. I am looking forward to your testimony, and everyone's.
The Chairman. Thank you, Senator Murray. Finally, Ms. Tracy
Watts, welcome. She is a partner in Mercer Human Resources
Consulting's Washington, DC office. Mercer is a global
consulting firm that works with clients in 130 markets around
the world, helping them continue to advance the health, wealth,
and performance of their people.
Welcome again to all of our witnesses. Doctor--if you would
each summarize your remarks in about five minutes, we will have
time for conversations with the Senators after that. Dr.
Umbehr.
STATEMENT OF JOSH UMBEHR, M.D., ATLAS MD, WICHITA, KS
Dr. Umbehr. Good morning, Chairman Alexander, Ranking
Member Murray, and distinguished Representatives of the HELP
Committee.
As mentioned, my name is Dr. Josh Umbehr, a family
physician from Wichita, Kansas, and we are striving to fix
health care. We all fundamentally understand that health care
is broken for reasons that we agree to, increased bureaucracy,
paperwork requirements, reporting, things that raise the burden
on physicians while also raising the cost of care and
decreasing access for patients. Nobody is necessarily happy
with this. Physicians, patients, employers, and even insurance
companies are struggling to stand under this increasing weight.
But I love the quote, the future is here, it is just not evenly
distributed.
Direct primary care is a growing solution across the
country, where patients are having that next level version of
primary care that is 10X savings. The ability to pay a low
monthly membership, based on age only--so no pre-existing
conditions matter anymore, all patients are welcome--as low as
$10 for kids, $50 for most adults, for again like Senator
Roberts mentioned, unlimited home visits, work visits, office
visits, telemedicine visits. We have no copays for anything in
our office, and any procedure we can do is free of charge. An
EKG costs me $0.36. The coffee in the waiting room costs $0.60
a cup. If I do not charge your insurance for the coffee, I
probably do not need to charge for the EKG. This is the value
we can present to the patient that justifies our membership,
because now we are not going through a third party where costs
are hidden behind a mountain of paperwork.
We can continue to add to that value proposition with
unlimited, free stitching, free lung testing, bone testing,
biopsies, joint injections, and basically any procedure a
family physician can do in the office, for free in our office.
Some physicians will choose to charge a small fee of $5 to
cover their, cost of equipment and supplies. But we try to
reach out, like Senator and Chairman mentioned, that even
though primary care physicians salaries only make up a small
portion of the health care spend, we touch almost everything.
So, for us to be able to--for the time saved in doing insurance
paperwork, we are able to reach out and provide value for our
patients. We do this through wholesale medications and labs.
Forty-four states allow physicians to dispense medications
wholesale to their patients, and actually always have.
A lot of what we have done is not brand new. It is just a
new way of using the pieces that have always been on the table.
When we go direct to the wholesaler, we can get medications for
up to 95 percent less. I can buy a thousand blood pressure
pills for $4.90. I cannot buy a thousand rice for $4.90.
Insurance is an excellent tool. I support the concept of
insurance when used appropriately. Insurance is best managed as
a tool for expensive and frequent expenses. Car insurance, home
insurance, life insurance all make sense. The way we are
utilizing health insurances does not make sense. I think we put
the cart before the horse here when we try to do health
insurance reform, and unless we bend or break the cost curve of
primary care, we will never be able to achieve our goal of more
affordable health insurance.
By removing primary care office visits, procedures, copays,
and the extension of what else we can do, we decrease the need
for as much health insurance. I think often, to the detriment
of the movement, we can get type-casted as anti-insurance or
anti-government, and that could not be the case. We are pro-
efficiency. We want these pieces to move better together so
that the patients have the best of both worlds--affordable,
accessible primary care, but affordable, meaningful health
insurance that does not cost more than their mortgage. We can
also go into, we have been able to get breast cancer
chemotherapy for $6 a month when the patient was quoted $600 a
month with her health insurance, not because we are special but
because that is the wholesale price. So essentially, any
physician in the system could be doing the same model on their
own very easily.
We can extend that reach out into laboratory testing, which
is again up to 95 percent cheaper. I can check your blood count
for $1.50, your thyroid for $1.60, again see if you are
diabetic for $2.25. If you are diabetic, I can treat it with a
thousand metformin pills for $11. So, we have a way of getting
great access to patients while also decreasing the cost, which
often seems counterintuitive. Again, cash is king so this
extends into further ancillary services. Thank you.
[The prepared statement of Dr. Umbehr follows:]
prepared statement of josh umbehr
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The Chairman. Thank you, Dr. Umbehr.
Dr. Kripalani, welcome.
STATEMENT OF SAPNA KRIPALANI, M.D., ASSISTANT PROFESSOR OF
CLINICAL MEDICINE, DIVISION OF GENERAL INTERNAL MEDICINE AND
PUBLIC HEALTH, VANDERBILT UNIVERSITY MEDICAL CENTER, NASHVILLE,
TN
Dr. Kripalani. Thank you, Chairman.
Thank you, Chairman Alexander, Ranking Member Murray, the
esteemed Members of this Committee for allowing me to be here
today to speak with you.
As a primary care physician for the last 17 years, I have
had the privilege of sharing in the lives of thousands of
patients and helping them navigate a health care system that
fails too often, to meet the needs of too many Americans. Let
me start by sharing a story with you about a patient that I
have come to care deeply about. Jane is a 27-year old woman who
I have taken care of for 5 years. She has diabetes, high blood
pressure, seizures, and bipolar disorder. She cannot afford
healthy food and she often stops taking her insulin because she
cannot afford supplies and the medication. She is socially
isolated. Although I see her in clinic every one to two weeks,
she makes frequent visits to the emergency room and to urgent
care clinics several times a month. How can our health care
system better support patients like Jane?
As primary care physicians, we are the front line in
promoting the health and wellness of our patients. We provide
preventive services, diagnose and treat medical conditions, and
educate patients about their health risks. We bridge the gap in
services that may have limited availability, such as mental
health, and we coordinate care with multiple specialists. In
this way, the primary care doctor is the quarterback, who makes
sure all the players in the health care team are following the
outlined plan, including the patient. This vital role is
essential in improving the quality of health care and lowering
cost. In short, primary care matters.
Unfortunately, primary care is undervalued in the United
States. Reimbursements are more robust for treatment of disease
rather than prevention. For example, insurers will cover weight
loss surgery, but not the lifestyle and behavioral
interventions needed to treat obesity. There are numerous ways
in which investments in primary care can improve health
outcomes in a cost-effective way. I will focus on one,
encouraging innovation, two, redirecting spending, and three,
investing in the primary care workforce.
First, we should invest in innovative models of health care
delivery, and enhance access and convenience, such as home
telehealth and shared medical appointments. Home telehealth is
an efficient and convenient way to address health needs, and
manage chronic illnesses, and gain insight into the home
environment. In Tennessee, most payers only cover when they
occur in rural health care clinics, but not from home.
A shared medical appointment is a medical consultation that
combines peer support in a structured group setting. Since
2017, I have been conducting these visits for diabetics and for
exercise counseling. Patients' value sharing their firsthand
experiences and health challenges with other patients. These
visits can last 90-120 minutes, as opposed to 10-15 minutes for
a traditional appointment, and can improve both the patient and
physician experience.
Secondly, we must reduce and redirect spending in our
health care system. In the U.S., only 6 to 8 percent of health
care spending is in primary care. And between 2012 and 2016,
spending declined 6 percent in primary care, but increased 31
percent for specialists. I find this statistic alarming.
Internationality nearly every developed country has a
higher rate of spending between primary care and sub-
specialists, compared to the U.S., and the result is lower cost
and higher life expectancy. Studies have shown that greater use
of primary care is associated with fewer hospitalizations,
fewer ED visits, and lower mortality. Investment in primary
care pays for itself by reducing overall health spending and
freeing up critical resources for those who truly need them.
Third, we must invest in the primary care workforce. As the
baby boomer generation ages and more Medicare beneficiary's
access health care, the primary care doctor shortage will
worsen. The problem is even more pronounced in rural areas that
struggle to attract new physicians. This affects patients with
diabetes, seeking a new doctor for refills, the young woman
with abdominal pain who cannot get in to see her doctor for
several weeks, and the heart failure patient, who is short-
breath and needs to see a doctor. We must lessen the gap in
salary between sub-specialists and primary care physicians that
leads doctors to choose more lucrative careers to offset their
educational debts. And we must keep doctors in primary care by
eliminating onerous documentation burdens and administrative
burdens that disproportionally affect PCPs.
For every hour of face-to-face time we spend on patient
care, we spend an additional one to two hours completing
administrative tasks. Let us allow physicians to spend more
time caring for patients and less time performing tasks that do
not improve care.
In returning to our patient Jane, several interventions
have proven helpful. She attends our shared medical
appointments. She enjoys those interactions. She gets daily
phone calls from physicians and nurses from our clinics, and
that has reduced the frequency of her ED visits.
Telehealth visits and lifestyle counseling could be helpful
if these services were covered, and they could significantly
change the health trajectory for Jane. I strongly believe that
investments in primary care will help us take better care of
patients like Jane and so many other Americans.
Thank you, Senators, for the opportunity to talk about
primary health care today, and I welcome your questions.
[The prepared statement of Dr. Kripalani follows:]
prepared statement of sapna kripalani
Thank you, Chairman Alexander, Ranking Member Murray, the Members
of this Committee, and their staff for giving me the opportunity to be
here today to discuss the role of primary care in shaping our health
care and controlling costs as we head into the future. As a primary
care physician for the last 17 years, I have had the privilege of
sharing in the lives of thousands of patients and helping them navigate
a complicated health care system that fails to meet the needs of too
many Americans.
I have had the opportunity to work in a variety of health care
settings over the years. I attended medical school at Emory University
School of Medicine and completed much of my training at Grady Memorial
hospital, which is the largest safety-net hospital in the State of
Georgia. I had the privilege of serving our veterans at the Atlanta VA
hospital, and worked in the hospital and clinics of Emory University.
Through my work in a private primary care clinic in a rural town
outside of Atlanta, I witnessed the challenges in accessing specialty
care services for patients in a timely manner. These delays placed
patients at risk of serious medical consequences. These experiences
allowed me to learn about the challenges of health care delivery that
transcend socioeconomic classes and affect the cost of health care for
all of us. Since 2007, I have been on faculty at Vanderbilt University
Medical Center and have been involved in teaching undergraduates,
medical students, and residents as they embark on their careers in
medicine. I have seen them choose their fellowships in subspecialties
rather than a career in primary care in order to avoid the onerous
burdens that force primary care doctors to spend more time with
documentation and administrative tasks than direct patient care and
often lead to physician burnout.
I would like to share a patient story that is all too familiar in
our clinics. Jane is a 27-year old woman who has diabetes,
hypertension, seizure disorder and bipolar disorder and due to the
severity of her mental condition, has not been able to work in years.
She is morbidly obese and has a BMI of 45. She cannot afford healthy
food and she often stops taking her insulin and other medications when
she runs out of money. Due to her seizure disorder and mental health
issues, she is socially isolated. Despite all this, she is interested
in making healthier choices and taking better care of herself. She
calls the office daily with concerns about her blood sugar level or
blood pressure. She is seen by me in clinic every 1-2 weeks. Despite
these frequent contacts, she visits the walk-in clinic 1-2 times a week
and goes to the emergency department 2-3 times a month for various
ailments.
How does our current system provide support and assistance for
patients like Jane?
How do we control the overwhelming cost of caring for someone like
her?
As primary care physicians, we are the front line in promoting the
health and wellness of our patients. We help them understand the
nuances of their individual health plan and the meaning of terms such
as co-pay, co-insurance, deductible and out of/in-network charges. We
often personally pick up the phone to speak with administrators of
health companies who deny necessary services, so our patients can get
the care they need, and we serve to bridge the gap in services that may
have limited availability, such as mental health. We educate patients
and families about their diseases and counsel them about prevention,
vaccines and wellness. We provide them with advice when they see a new
medication on TV, hear about a fad diet, or want to try alternative
therapies. We help to coordinate visits with subspecialists and make
sure they are keeping up with follow-up appointments. In this way, the
primary care doctor is the ``quarterback'' who makes sure all the
players in the health care team (including the patient) are following
the outlined plan. This vital, albeit time-consuming, role in medicine
is essential in improving the quality of health care and lowering cost.
In short, primary care matters!
Unfortunately, primary care is undervalued in the U.S.
Reimbursements are more robust for the treatment of disease with
expensive regimens rather than for prevention. Time spent in educating
and counseling about lifestyle modifications is not well reimbursed,
and there is little investment in ancillary services by CMS or most
insurers. Primary care is the front line for addressing mental health
issues and obesity, yet reimbursement is poor for these services.
Dietician services are still not covered for people with obesity until
they develop diabetes, and insurers will often cover bariatric surgery
to treat obesity but will not pay for treatments that target lifestyle
and behavioral change.
Health care spending in the U.S. continues to grow. In 2017, we
spent an estimated 3.5 billion dollars on health care, which amounts to
$10,739 for every man, woman and child in the U.S. This represents 17.9
percent of our GDP which far exceeds the amount spent in other
developed countries. This excess spending has not resulted in improved
health outcomes compared to other countries. This problem is
multifactorial and there will not be a singular solution. There are
numerous ways in which investments in primary care can improve health
outcomes in a cost-effective way. My testimony will focus on
innovation, reducing spending, and investing in the primary care
workforce.
(1) Investment in innovative models of health care delivery.
This includes coverage for alternative models of care such as home
telehealth, which allows patients to receive care in their own home.
Advantages include the ability for medical personnel to thoroughly
review medications (including over the counter medicines) that patients
take at home, but frequently forget to bring to their doctor's visits,
which can help prevent drug interactions, duplication, and other
medication errors. Telehealth can enhance the patient history by
allowing family members in the home to participate in the visit, when
they may not have been able to attend a face-to-face visit. It allows
the physician to gain insight into home conditions which may affect the
safety or health of the patient. In our clinic, we are preparing to
pilot a telehealth program for urgent care needs, but the potential for
telehealth in managing chronic diseases such as diabetes, hypertension
or behavioral health needs is promising. Imagine the time and cost
saved for the patients and the system if the patient and physician
could coordinate a time to ``log-in'' and conduct a visit without the
administrative burden, time, cost and inconvenience of an office visit.
Telehealth may also increase access to primary care and certain
limited-supply resources such as mental health, dermatology, and other
subspecialties. Currently, in the State of Tennessee, telehealth visits
are only covered by Medicare and Medicaid when patients present to
specific rural health care sites. Some commercial insurers will pay for
telehealth if the patient presents to a remote health care site, but
not from home. This eliminates the numerous advantages and convenience
of an at-home visit. I encourage the Committee to support coverage of
at-home tele-visits so that Tennesseans and all Medicare beneficiaries
can more easily access the health care they need. Although telehealth
will not be appropriate for all situations, I believe primary care
doctors would embrace it as an option to enhance patient care.
Another opportunity to improve access is the Shared Medical
Appointment (SMA) which is a clinical encounter that allows patients to
receive counseling, education, and individualized interventions in
group setting. This is a visit in which physicians and facilitators can
simultaneously address disease-specific concerns and issues with 8-12
patients in a group setting. In 2017, with the help of our social
worker and office staff, I implemented a Shared Medical Appointment
program with my diabetic patient population. We conducted monthly
visits with this group to set goals, share experiences and provide
diabetes-specific education. We later expanded the program in 2018 with
a new group of patients who were interested in improving physical
activity, called ``Healthy Steps.'' Through collaborative efforts with
the Dayani Wellness center at Vanderbilt and a small institutional
grant with which we purchased pedometers and supplies, the ``Healthy
Steps'' program has been very successful. A quote from a patient sums
it up well . . .
``Thank you for the opportunity to join the excellent Healthy Steps
meetings. The information was very valuable. Without the boost of this
program I would not have disciplined myself to get more serious about
exercising.''
With appropriate patient selection, consent forms that address
HIPAA policies, and advanced planning, this is a highly successful and
innovative way to deliver care and has an additional advantage of
creating a support structure for patients who are isolated or feel
alone in their disease. Studies have shown potential for enhancement of
quality and consistency of care provided as well as improvement in
self-management with reduction in cost through use of SMAs. Advantages
for patients include reduction in sense of isolation which can improve
self-efficacy in managing their chronic illness. Patients learn
vicariously about disease management by hearing the perspective of
others facing similar challenges in managing their illness. SMAs bring
patients together so that those who are managing well can help
encourage those who may be struggling.
One memorable moment in a recent shared medical appointment was
when a patient-participant provided information to others in the group
about the pharmacies that provided the lowest prices on metformin,
statins, and blood pressure medications, and which online coupons saved
her the most money on her medications. Many of the people in the group
were taking the same medications and were delighted to learn how to
reduce their monthly medication costs.
The SMA also has advantages for physicians due in part to the
ability allocate a longer amount of time with the group than they
typically have with patients in a traditional one-on-one model. Typical
SMAs last 90-120 minutes (as opposed to 10-15 min for a traditional
visit) which allows for a more in-depth exchange of information, allows
patients to feel more supported, and can help combat the fatigue that
physicians experience as they dash from one room to the next.
By encouraging the implementation of newer methods of delivering
primary care, we can improve access and reduce physician burn out while
providing cost-saving, high-value care.
(2) Reduction of excess spending in our health care system.
This Committee has heard the statistic on many occasions that as
much as 1 out of every 3 healthcare dollars is ``wasted.'' It is
thought that much of this waste is attributable to excessive or
unnecessary testing but defining inappropriate care can be challenging.
However, we do know that patients who have primary care doctors
have fewer preventable ED visits which reduces cost. Data have shown
that primary care doctors overall use fewer tests, spend less money and
provide more high-value care, such as cancer screening, blood pressure
testing, diabetes care and counseling on weight loss, smoking cessation
and exercise. In lower income populations, primary care use is
associated with improved immunization rates, better dental health,
lower mortality and higher self-reported quality of life.
Primary care encourages the ``right care, right time, right
setting'' model in which patients can be directed to the most
appropriate facility that meets their health care needs. Too often, our
emergency departments are filled with patients who present with
symptoms that could have been managed in an outpatient clinic. We
should seek to divert common non-emergent health care needs to a
setting that is better matched economically than the ED. Efforts to
identify high health care utilizers and intervene before they seek care
can help to reduce the overall cost of health care.
No conversation about healthcare cost is complete without
mentioning prescription drugs and the soaring prices of essential
medications that lead to significant burden on patients and insurers.
This leads to frustrating changes in drug coverage as insurers seek the
best deals on medications within a class of drugs. Higher costs lead to
higher copays for patients, some of whom must choose between food and
rent or their life-saving medications. Medication non-adherence leads
to more healthcare costs when that patient ends up in the hospital from
poorly controlled hypertension that results in a stroke or other
adverse outcomes. We must find a way to control prescription costs so
that patients can consistently afford them and avoid higher downstream
medical spending.
(3) Invest in the primary care workforce.
As the baby-boomer generation continues to age and more Medicare
beneficiaries are accessing healthcare, there continues to be growing
shortage of primary care doctors nationwide. As a lead physician in my
clinic, I have seen new PCPs join our practice and quickly fill their
schedules with patients who have been waiting to find a doctor. Within
a few weeks, the wait time to see a new provider can quickly climb to
several months. This issue is even more prevalent in rural areas which
struggle to regularly attract new physicians. While high demand may be
good for business, it is not optimal for the patient whose doctor has
retired, and refills expire before they can see a doctor. It doesn't
help the older patient who cannot get in to see a new doctor after
declining health has required her to move in with her daughter. It
certainly does not benefit the countless Americans who are unable to
find a doctor who accepts new Medicare patients. It is estimated that
the United States will face a shortage of between 42,600 and 121,300
physicians by 2030. The declining number of medical students and
residents who enter primary care will further aggravate this shortage.
Many physicians are discouraged from pursuing primary care due to the
relatively low compensation compared to specialists. They recognize the
``half the pay, twice the work'' penalty of primary care, and with
burgeoning educational debts, decide to pursue more lucrative careers.
The solution lies in recognizing that primary care is unique from other
medical specialties. The emphasis is on disease prevention rather than
disease treatment. Primary care physicians, like myself, enter this
career in order to develop relationships with patients and families
over many years. We share in their joys, sorrow, losses and successes
and learn to modify our treatment strategy to meet the unique needs of
each individual patient. We thrive in cultivating and nurturing these
relationships and in helping patients realize a healthy future.
Unfortunately, Federal regulations such as meaningful use and
onerous documentation requirements have been burdensome on primary care
doctors, without enhancing the quality of the care provided. Electronic
health records have the capability to aid in the identification of
deficiencies in care but are not aligned with the work flow of
physicians and slow the pace of care in clinic. For every hour of face-
to-face patient encounters, we must spend an additional 1-2 hours
completing documentation and administrative tasks. This is
unsustainable and leads many primary care doctors to leave the
workforce. I hope this Committee looks to alleviate this burden so that
physicians can spend more time engaging with patients and providing
high value care, and less time facing a computer.
In returning to our patient, Jane, several interventions have
proven helpful. She has attended our Shared Medical Appointment for
diabetes and has enjoyed the personal interactions and advice from
other patients who have been in her situation. She is contacted weekly
by the primary care nurse to review her medications. These
interventions have reduced the number of ED and urgent care visits she
makes. She has successfully lost 50 lbs. and is checking her glucose
and blood pressure several times a week. She would be a great candidate
for regular telehealth visits, exercise and diet coaching, and
medication adherence counseling, if these services were covered by
Medicare. Although she has a long road ahead, I believe assistance for
patients like Jane could significantly change her health trajectory. I
hope future investments in primary care will help us take better care
of patients like Jane and many others.
References
(1) Phillips Jr, R.L. and Bazemore, A.W., 2010. Primary care and
why it matters for US health system reform. Health Affairs, 29(5),
pp.806-810. doi: 10.1377/hlthaff.2010.0020.
(2) Fishman, J., McLafferty, S. and Galanter, W., 2018. Does
Spatial Access to Primary Care Affect Emergency Department Utilization
for Nonemergent Conditions? Health Services Research, 53(1), pp.489-
508. doi:/10.1111/1475-6773.12617.
(3) Levine DM, Landon BE, Linder JA. Quality and Experience of
Outpatient Care in the United States for Adults With or Without Primary
Care. JAMA Internal Medicine. Published online January 28, 2019.
doi:10.1001/jamainternmed.2018.6716.
(4) Menon, K., Mousa, A., de Courten, M.P., Soldatos, G., Egger, G.
and de Courten, B., 2017. Shared medical appointments may be effective
for improving clinical and behavioral outcomes in type 2 diabetes: A
narrative review. Frontiers in Endocrinology, 8, p.263. doi:10.3389/
fendo.2017.00263.
(5) Kirsh, S.R., Aron, D.C., Johnson, K.D., Santurri, L.E.,
Stevenson, L.D., Jones, K.R. and Jagosh, J., 2017. A realist review of
shared medical appointments: How, for whom, and under what
circumstances do they work? BMC Health Services Research, 17(1),
p.113.doi:10.1186/s12913-017-2064-z.
______
[summary statement of sapna kripalani]
Case: Jane is a 27-year-old woman with diabetes, high blood
pressure, seizures and bipolar disorder. She cannot afford healthy food
choices, and often stops taking her insulin due to medication and
supply costs. She is socially isolated. Although I see her in clinic
every 1-2 weeks, she also goes to the walk-in clinics and has expensive
emergency department visits several times a month.
How can our healthcare system better support patients like Jane?
How do we control the overwhelming cost of caring for someone like
her?
As primary care physicians, we are the front line in promoting
health and wellness of our patients. Roles include:
(1) Preventive services such as vaccines, cancer screenings,
and healthy lifestyle recommendations
(2) Diagnosing and managing chronic illnesses such as diabetes
(3) Educating patients about medical disease and public health
risks
(4) Coordinating care with subspecialists
(5) Bridging the gap in services, such as mental health.
Primary care doctor is the ``quarterback'' who makes sure all the
players in the health care team (including the patient) are following
the outlined plan. Unfortunately, primary care is undervalued in the
U.S. Reimbursements are more robust for the treatment of disease than
prevention.
Investments in primary care in the following ways will improve
outcomes and reduce cost:
(1) Providing opportunities for innovative models of health
care delivery such as home telehealth and shared medical
appointments.
a. Increases access
b. Improved convenience
c. Other benefits such as social support
(2) Shifting spending toward improving high-value care such as
cancer screening, prevention and chronic disease management
which reduces cost.
a. Primary care prevents ED visits and hospitalizations
and lowers mortality
b. High prescription cost leads to medication non-
adherence
(3) Increasing the primary care workforce to better manage the
needs of our population.
a. There is a growing shortage of primary doctors
despite an aging population with increasing health care
needs.
b. Salary gaps keep doctors from choosing a career in
primary care
c. Documentation and administrative burdens lead to
physician burn out. For every 1 hour of patient care,
we spend 1-2 hours in administrative activity.
______
The Chairman. Thank you, Dr. Kripalani.
Dr. Bennett, welcome.
STATEMENT OF KATHERINE A. BENNETT, M.D., ASSISTANT PROFESSOR OF
MEDICINE, DIVISION OF GERONTOLOGY AND GERIATRIC MEDICINE,
UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE, SEATTLE, WA
Dr. Bennett. Thank you. Good morning, Chairman Alexander
and Ranking Member Murray, who I am proud to say is my Senator,
and distinguished Members of the Committee. Thank you for the
opportunity to speak with you today about Project ECHO, its
impact on primary care, and my experience using it to improve
the care of older adults.
My name is Dr. Katherine Bennett, and I am an Assistant
Professor of medicine and geriatrics at the University of
Washington where I am the founding Medical Director of Project
ECHO-Geriatrics. This hearing topic is of critical national
interest and something that I am pleased Congress is working
hard to address.
Project ECHO, or the Extension for Community Health
Outcomes, was designed by Dr. Sanjeev Arora, at the University
of New Mexico. He was a liver disease specialist there, and
found that he needed to address the issue of inadequate access
to his specialty care, particularly in rural and underserved
areas. His Model involved a specialist team, or hub, at an
academic medical center and spokes, who were primary care
providers at community clinics. Weekly, video-based mentoring
sessions included teaching and case consultations. With this
model, he was able to reduce the wait times for appointments at
his hepatitis C clinic from eight months to two weeks. And the
care provided by the ECHO trained primary care providers was
equivalent in outcomes to that provided by specialists.
Since then, Project ECHO has been launched throughout the
country for many complex conditions. ECHOs have shown impactful
outcomes such as reduced hospital readmissions and reductions
of physical restraints in nursing homes.
The University of Washington was the first replicator of
ECHO outside of the University of New Mexico, and has 10 ECHOs
with topics such as hepatitis C, HIV, chronic pain, and my
program, geriatrics. In my work as a geriatrician, a specialty
in short supply, I see patients who come from areas all
throughout the region. Many are on very long lists of
medications. Others have dementia that has gone undiagnosed for
years. Others have osteoporosis that has not been treated
despite falling and breaking bones again and again. These
scenarios are not happening because primary care providers do
not care. It is because many have not received geriatrics
training. We launched Project ECHO-Geriatrics to address this
problem.
Our ECHO is part of our HRSA-funded Geriatrics Workforce
Enhancements Program. Our ECHO is unique because our primary
audience is physicians in training throughout a regional family
medicine residency program--residency network, excuse me. Our
specialist panel includes a geriatrician, social worker,
psychiatrist, pharmacist, nurse, and Area Agency on Aging
staff. Sessions focus on key primary care topics such as
dementia, depression, and fall prevention. We have trained over
300 people across several states since our initiation in 2016.
I see a clear improvement in care over time. For example, a
young doctor wanted guidance to help a new patient, a woman in
her 90's, who was fatigued and having trouble getting around.
She was on 36 medications. Months later the same resident
presented a different patient. He told us how he had already
worked to eliminate medications that could cause confusion or
sedation, and was now looking for suggestions to help her
remain independent at home. This type of care improves quality
of life for older adults and reduces costs by preventable
hospital admissions and preventable nursing home placement.
There are currently 10 geriatrics-focused ECHOs throughout
the country. Many geriatrics ECHOs do not have patient outcomes
data yet, and we need continued funding to obtain this critical
information. Knowing that we are moving best practices to the
frontline of primary care, and based on what I have seen, I am
confident the outcomes are there.
I am grateful to Senators Collins and Casey for introducing
the bill to reauthorize the Geriatrics Workforce Enhancement
Programs and the Geriatrics Academic Career Awards, which
together help us prepare the workforce to meet the unique needs
of older adults.
Project ECHO programs need sustained funding to do their
work well and to reach more underserved patients. ECHOs are
supported through a patchwork of funding mechanisms that are
often short-term and unpredictable. Just this month, the Center
for Health Care Strategies released a report that reviews a
variety of potential sustainability strategies for ECHO. I have
included this reference in my written testimony. I am very
hopeful that through this Committee, you will enact a strategy
to sustain and grow ECHO so that all patients, regardless of
where they live, can receive the highest quality health care.
Thank you for this opportunity to speak with you today and
I look forward to answering your questions.
[The prepared statement of Dr. Bennett follows:]
prepared statement of katherine bennett
Good morning, Chairman Alexander and Ranking Member Murray--who I
am proud to say is my Senator--and distinguished Members of the
Committee. Thank you for the opportunity to speak with you today about
Project ECHO, its impact on primary care, and my experience using it to
improve the care of older adults. My name is Katherine Bennett, and I
am an Assistant Professor of Medicine in the Division of Gerontology
and Geriatric Medicine at the University of Washington (UW) and Program
Director of the Geriatric Medicine Fellowship. I am the Education Lead
for the Northwest Geriatrics Workforce Enhancement Center, which is the
University of Washington's HRSA-funded Geriatrics Workforce Enhancement
Program (GWEP). In that role I am the founding Medical Director of
Project ECHO-Geriatrics. I am also President-Elect of the National
Association for Geriatric Education, and a member of the American
Geriatrics Society, the Association for Directors of Geriatric Academic
Programs, and the Gerontological Society of America. This hearing topic
is of critical national interest and something that I am pleased
Congress is working hard to address.
Project ECHO was Developed to Improve Access to High Quality Care and
Reduce Disparities
Project ECHO, or the Extension for Community Health Outcomes, was
designed by Dr. Sanjeev Arora, a liver disease specialist at the
University of New Mexico. Dr. Arora had a problem where patients with
hepatitis C in New Mexico had to wait up to 8 months to see a
specialist for treatment, and many were too sick and/or too far away to
feasibly get this specialty care. He sought to address the issue of
inadequate access to specialty care, particularly in rural and
underserved areas. He launched Project ECHO in 2003 in order to solve
this problem. His Model involved a specialist team, or ``hub'', at an
academic medical center and ``spokes'' who were primary care providers
at community clinics. Sessions involved weekly mentoring sessions with
teaching and consultations held via secure video conferencing
technology. Although everyone is geographically far apart, over time it
feels like you are in the same room. With this model, wait times for
appointments in the hepatitis C clinic were reduced from 8 months to 2
weeks. Dr. Arora also found that the care provided for hepatitis C by
the ECHO-trained primary care providers was just as good, with the same
cure rates, as the care from specialists. \1\
---------------------------------------------------------------------------
\1\ S. Arora, et al. ``Outcomes of treatment for hepatitis C virus
infection by primary care providers.'' The New England journal of
medicine 364.23 (2011): 2199-207. Web.
Due to this success, Project ECHOs have been launched throughout
the country and world to address many complex conditions such as HIV,
tuberculosis, and mental illness. There are now over 400 ECHO Programs
throughout the country at over 160 locations. \2\
---------------------------------------------------------------------------
\2\ https://echo.unm.edu/locations-2/.
---------------------------------------------------------------------------
Health Outcomes are Improved With ECHO
Over 100 papers have been published on ECHO. Although many have
focused on increased provider confidence for treating common
conditions, we have ever increasing evidence that Project ECHO improves
important health-systems and patient outcomes. Below are some examples.
A pain management ECHO for Community Health Centers
reduced the use of opioids for chronic pain, reduced
inappropriate referrals to surgeons, and increase referrals to
physical therapy. This aligns with recommended best practices
in pain management. \3\ A recent CDC report showed that
patients in rural areas are 80 percent more likely to receive
opioid prescriptions (vs those in urban areas). ECHO is
perfectly suited to reduce this disparity. \4\
---------------------------------------------------------------------------
\3\ D. Anderson, et al. ``Improving Pain Care with Project ECHO in
Community Health Centers.'' Pain medicine (2017).
\4\ Garcia MC et al. Opioid Prescribing Rates in Nonmetropolitan
and Metropolitan Counties Among Primary Care Providers Using an
Electronic Health Record System--United States, 2014-2017. MMWR Morb
Mortal Wkly Rep 2019.
A care transitions ECHO significantly reduced
readmission to the hospital from nursing homes, reduced nursing
home length of stay (avg. 5-day reduction), and reduce cost
(about $2,600 lower per patient). \5\
---------------------------------------------------------------------------
\5\ Moore AB, et al. Improving Transitions to Postacute Care for
Elderly Patients Using a Novel Video-Conferencing Program: ECHO-Care
Transitions. Am J Med. 2017.
An ECHO targeting providers caring for nursing home
patients with dementia significantly reduced the use of
---------------------------------------------------------------------------
physical restraints.
A 2016 paper in Academic Medicine, ``The Impact of Project ECHO on
Participant and Patient Outcomes: A Systematic Review'' gives a high-
quality overview of ECHO outcomes from all ECHOs who have published
results. \6\
---------------------------------------------------------------------------
\6\ Zhou Cet al. The impact of Project ECHO on participant and
patient outcomes: A systematic review. Acad Med. 2016.
---------------------------------------------------------------------------
The University of Washington is a Leader in ECHO Replication
My home institution, under the leadership of Dr. John Scott was the
first replicator of ECHO outside of the University of New Mexico. The
University of Washington now has 10 active ECHOs addressing a range of
complex conditions including Hepatitis C, HIV, Chronic Pain, Heart
Failure, and Mental Illness. Given this track record, it was the ideal
environment for me to implement an ECHO for Geriatrics.
Many Older Adults Receive Suboptimal Care
As a geriatrician at Harborview Medical Center (a UW-affiliated
county safety net hospital, and the only level one trauma center for 5
states), I see patients who come from areas all throughout the five-
state region. Many are on very long lists of medications. Others have
dementia that has gone undiagnosed for years. Some have never been
treated for osteoporosis despite falling and breaking bones again and
again. These scenarios are not happening because primary care providers
do not care, but because most have received minimal, if any, geriatrics
training. \7\ Given the critical shortage of geriatricians, and the
rapidly growing older adult population, it is the primary care
providers of this country who will be caring for the vast majority of
older adults.
---------------------------------------------------------------------------
\7\ Institute of Medicine Committee on the Future Health Care
Workforce for Older Americans. (2008). Retooling for an aging America:
Building the health care workforce.
The field of geriatrics has experienced a rapid advance in the
evidence base thanks to the hard work of dedicated researchers.
However, the high-quality, cost saving healthcare that is supported by
evidence is often not making it to the forefront of care. As a result,
older adults suffer from preventable falls; preventable delirium (i.e.
confusion) in the hospital; undertreatment of important conditions
(such as osteoporosis); and overtreatment with medications and other
interventions that do not improve their health, quality of life, or
ability to maintain independence. We launched Project ECHO-Geriatrics
to address this problem.
Project ECHO-Geriatrics at the University of Washington
Project ECHO-Geriatrics is part of our HRSA-funded Northwest
Geriatrics Workforce Enhancements Center, which is the University of
Washington's Geriatrics Workforce Enhancement Program (GWEP). The broad
goal of the GWEP is to prepare primary care practitioners to provide
high quality care for older adults. We do this by training the health
care workforce and family caregivers to care for the complex health
needs of older Americans. We train them to use the most effective and
efficient methods to provide higher quality care and save valuable
resources by reducing unnecessary costs, such as unneeded
hospitalizations. In the 2016-2017 academic year, GWEPs provided 1,578
unique continuing education courses, including 467 on Alzheimer's
disease and related dementia, to 173,078 faculty and practicing
professionals from disciplines such as medicine, nursing, health
services administration, social work, and psychology.
The University of Washington was pleased to receive funding under
HRSAs GWEP Program in July 2015. We launched Project ECHO--Geriatrics
in January 2016 under the mentorship of the experienced telehealth team
at the UW.
Our ECHO is unique because our primary audience is physicians in
training throughout a regional family medicine residency network. We
felt that there may be an advantage to training primary care providers
before they set out into practice. We partnered with many of the
residencies in the region, who all agreed that their residents need
more geriatrics training. Family medicine residents are required to
complete 100 hours (approximately 1 month) of geriatrics training
during their three years of residency. However, the great majority of
these residencies do not have a geriatrician available to help with
this education. Project ECHO--Geriatrics helps fill this need.
Sessions followed the ECHO model of teaching and case
presentations. Our specialist panel includes a geriatrician, social
worker, psychiatrist, pharmacist, nurse, and Area Agency on Aging
staff. Sessions focus on key primary care topics such as dementia, fall
prevention, and depression. All didactics (but not case discussions)
are archived on our website (nwgwec.org).
University of Washington's Project ECHO--Geriatrics has Been Successful
in Training Future Primary Care Providers
We have thus far trained 300 unique individuals across several
states. The majority of participants were physicians training, but also
included faculty, nurses, students, and others. We found a significant
increase in self-reported knowledge for essential topics in the primary
care of older adults, and 70 percent of participants reported that they
plan to change their practice as a result of our sessions. These
results were published in the Journal of Graduate Medical Education in
2018. \8\
---------------------------------------------------------------------------
\8\ K. A. Bennett, et al. ``Project ECHO-Geriatrics: Training
Future Primary Care Providers to Meet the Needs of Older Adults.''
Journal of Graduate Medical Education (2018).
More importantly, I see the clear improvement in participants' care
over time. For example, a young doctor wanted guidance to help a new
patient, a woman in her 90's who was fatigued and having trouble
getting around. She was on 36 medications! Months later the same
resident presented a different patient. He told us how he had already
worked to eliminate medications that are sedating or cause confusion
and was now looking for suggestions to help her remain independent at
home. This type of care improves quality of life for older adults and
reduces costs from preventable hospital admissions and nursing home
---------------------------------------------------------------------------
placement.
Here is a quote from Dr. Braun, a faculty member at the Providence
St. Peter Family Medicine Residency Program which has sites in Olympia
and Chehalis, WA.
``We have actively participated regularly for years and have found
it invaluable. The program not only helps achieve our hours of required
geriatrics training but has transformed the care I see provided by our
residents in clinic and across healthcare settings.''
Involvement of the Area Agency on Aging in Project ECHO--Geriatrics is
Invaluable
As mentioned, one distinguishing feature of our Project--ECHO is
the partnership with the Area Agency on Aging (AAA). The AAAs in King
County (where we are based) and in Southwest Washington (who serve a
large area including many rural and underserved older adults) were our
community partners for our initial application to the Geriatric
Workforce Enhancement Program. AAAs coordinate and deliver Federal
Older Americans Act (OAA) and other programs to help older Americans
and their caregivers get the support needed to help them stay in their
homes and communities. We created the position of Primary Care Liaison
at these two AAAs as part of our Center. This position aims to decrease
the silos between primary care and the community resources that can
help keep older adults independent. I invited the AAA Primary Care
Liaisons to participate in our ECHO session as panelists, and that
ended up being a vital part of our program.
We track the content of our sessions, which are summarized in the
Table below:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
As you can see, in every session, we discuss community resources.
This is something of vital importance to the health and quality of life
for older adults and can help avoid or delay a move to a higher level
of care such as in a nursing home. The ECHO learners greatly value the
input of the AAA staff, and the AAA staff have said that participating
in ECHO helps them have a better understanding of how physicians think
through complex cases. It helps us both speak the same language, which
is the first essential step in ensuring the highest quality, evidence-
based care for older adults.
AAA services save taxpayers money by helping older adults remain
independent and healthy in their own homes, helping them stay where
they prefer to live, and avoid unnecessary Medicaid and Medicare
spending. AAAs have resources that can prevent falls, smooth
transitions out of the hospital, help patients learn to manage their
chronic diseases, and support family caregivers (just a few examples).
The reauthorization of both the GWEP and the Older American's Act will
help health care and AAAs work together to help older adults age
successfully in place. I believe this collaboration is critical to
improving the health and well-being for older adults and reducing
healthcare costs.
The HRSA Geriatrics Workforce Enhancement Program supports
geriatrics ECHOs and is essential to improving the care of older
adults.
There are currently 10 geriatrics-focused ECHOs throughout the
country. The current application cycle for the Geriatrics Workforce
Enhancement Program recommended ECHO to all applicants, so we expect
more very soon. Many geriatrics ECHOs do not have patient outcomes data
quite yet, and we need continued funding to obtain this crucial
information. Knowing that we are moving best practices to the front-
line of primary care, and based on what I have seen, I am confident the
positive outcomes are there.
I would like to take this opportunity to mention the need for
reauthorization of the GWEP and the Geriatrics Academic Career Award
program (GACA) programs and to thank Senators Collins and Casey who
last week introduced the Geriatrics Workforce Improvement Act (S. 299).
I have included with my written testimony a copy of the National
Association for Geriatric Education's letter of support for this
important bill. This bipartisan reauthorization and related funding are
needed for the continued development of our Nation's primary care
workforce. Currently there are only 44 GWEP sites in 29 states. The
modest increase in the authorization in the bill (from $40.7 million to
$51 million) will have an important impact on training in geriatric
care, including the funds authorized for the GACA program which
complements the GWEP, and support faculty that will teach and lead
geriatrics programs. The GWEP is the only Federal program designed to
increase the number of health professionals with the skills and
training to care for older people. Nancy Lundebjerg the Chief Executive
Officer of the American Geriatrics Society stated it clearly.
``The GWEP provides support for the current transformation of
primary care, while the GACA develops the next generation of innovators
to improve care outcomes and care delivery. Together, these platforms
play a critical role in developing the workforce we all need as we
age.''
The bill will also assist in ensuring that rural and underserved
areas will have geriatrics education programs.
ECHOs Need a Steady Funding Source to Have a Greater Impact
Project ECHO programs, in all topics, need sustained funding to do
their work well and reach more underserved patients. ECHOs are
supported through a patchwork of funding mechanisms that are often
short-term and unpredictable. Just this month, the Center for Health
Care Strategies released a report that reviews a wide variety of
potential sustainability strategies for ECHO. \9\ I am very hopeful
that through this Committee, you will enact a strategy to sustain and
grow ECHO to allow all patients, regardless of where they live, to
receive the highest quality health care. Thank you for this opportunity
to speak with you today and I look forward to answering your questions.
---------------------------------------------------------------------------
\9\ Project ECHO: Policy Pathways for Sustainability. Center for
Health Care Strategies.
https://www.chcs.org/media/Project-ECHO-Policy-Paper_012019.pdf
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
[summary statement of katherine bennett]
Good morning, Chairman Alexander, Ranking Member Murray, and
distinguished Members of the Committee. Thank you for the opportunity
to speak about Project ECHO, its impact on primary care, and my
experience using it to improve the care of older adults. I am an
Assistant Professor of Medicine and Geriatrics at the University of
Washington, where I am the founding Medical Director of Project ECHO-
Geriatrics.
Project ECHO, or the Extension for Community Health Outcomes, was
designed by Dr. Sanjeev Arora, a liver disease specialist at the
University of New Mexico. He sought to address the issue of inadequate
access to his specialty care, particularly in rural and underserved
areas. His Model involved a specialist team, or ``hub'', at an academic
medical center and ``spokes'' who were primary care providers at
community practices. Weekly video-based mentoring sessions included
teaching and case consultations. With this model, wait times for
appointments in his hepatitis C clinic were reduced from 8 months to 2
weeks, and the care provided directly by ECHO-trained primary care
providers had equivalent outcomes to that provided by specialists.
Since then, Project ECHOs have been launched throughout the country
for many complex conditions. ECHOs have shown impactful outcomes such
as reduced hospital readmissions and reduction of physical restraints
in nursing homes. The University of Washington was the first replicator
of ECHO outside of New Mexico and has 10 ECHOs with topics such as
hepatitis C, HIV, chronic pain, and my program, geriatrics.
In my work as a geriatrician, a specialty in critically short
supply, I see patients who come from throughout the region. Many are on
very long lists of medications. Others have dementia that has gone
undiagnosed for years. Some have never been treated for osteoporosis
despite falling and breaking bones again and again. These scenarios are
not happening because primary care providers do not care, but because
most have received minimal geriatrics training.
We launched Project ECHO-Geriatrics to address this problem. Our
ECHO is part of our HRSA-funded Geriatrics Workforce Enhancement
Program (GWEP). Our ECHO is unique because our primary audience is
physicians-in-training throughout a regional family medicine residency
network. Our specialist panel includes a geriatrician, social worker,
psychiatrist, pharmacist, nurse, and Area Agency on Aging staff.
Sessions focus on key primary care topics such as dementia, fall
prevention, and depression. We have trained over 300 people across
several states. I see the clear improvement in their care over time.
For example, a young doctor wanted guidance to help a new patient, a
woman in her 90's who was fatigued and having trouble getting around.
She was on 36 medications! Months later the same resident presented a
different patient. He told us how he had already worked to eliminate
medications that are sedating or cause confusion and was now looking
for suggestions to help her remain independent at home. This type of
care improves quality of life for older adults and reduces costs from
preventable hospital admissions and nursing home placement.
There are currently 10 geriatrics-focused ECHOs throughout the
country. Many geriatrics ECHOs do not have patient outcomes data--yet--
and we need continued funding to obtain this crucial information.
Knowing that we are moving best practices to the front-line of primary
care, and based on what I have seen, I am confident the positive
outcomes are there. I am grateful to Senators Collins and Casey for
introducing a bill to reauthorize Geriatrics Workforce Enhancement
Programs and the Geriatric Academic Career Awards, which together will
help us prepare the workforce to meet the unique needs of older adults.
Project ECHO programs need sustained funding to do their work well
and reach more underserved patients. ECHOs are supported through a
patchwork of funding mechanisms that are often short-term and
unpredictable. Just this month, the Center for Health Care Strategies
released a report that reviews a variety of potential sustainability
strategies for ECHO. I have included this reference in my written
testimony. I am very hopeful that through this Committee, you will
enact a strategy to sustain and grow ECHO to allow all patients,
regardless of where they live, to receive the highest quality health
care.
Thank you for this opportunity to speak with you today, and I look
forward to answering your questions.
______
The Chairman. Thank you, Dr. Bennett.
Ms. Watts, welcome.
STATEMENT OF TRACY WATTS, SENIOR PARTNER, NATIONAL LEADER FOR
U.S. HEALTHCARE REFORM, MERCER, WASHINGTON, DC
Ms. Watts. Chairman Alexander, Ranking Member Murray, and
Members of the Committee, thank you for the opportunity to
discuss how primary care affects healthcare costs and outcomes.
My name is Tracy Watts. I am a Senior Partner and the U.S.
Leader for Healthcare Reform at Mercer, and I serve on the
Board of the American Benefits Council. Mercer is a business
unit of Marsh & McLennan Companies. It is a U.S.-based leading
professional services firm with a global network of 65,000
experts in risk, strategy, and people. I have more than 30
years of experience helping Fortune 500 companies design,
finance, and administer health care programs to lower costs and
improve health.
As you know, 181 million Americans, well over half the
population, receive healthcare coverage from their employer.
Given the significant role that employers play in the
healthcare market, I really appreciate the opportunity to
participate in today's hearing. One of the ways that employers
are working to improve primary care is through onsite or near-
site clinics, as you mentioned Senator Alexander. I would like
to share data from Mercer's National Survey of Employer-
Sponsored Healthcare Plans to illustrate this point. If you are
not familiar with our survey, it includes the responses from
more than 2,500 employers and is the oldest, largest, and most
comprehensive survey. The results are statistically valid, and
they can be projected over U.S. employers with ten or more
employees.
Over the past decade, the prevalence of onsite or near-site
clinics providing non-occupational health services has
increased, particularly among employers with 5,000 or more
employees. Only 17 percent had a general medical clinic in
2007. By 2012, the number grew to 24 percent, and in 2018, we
are at 31 percent, with another 10 percent of employers of this
size considering adding a clinic by 2020.
In a follow-up survey of 121 employers that offer a
worksite clinic, 61 percent say that the clinic has been
successful in managing costs increases, and 71 percent say it
has been successful in improving employee health and wellness.
For the 41 percent that completed a financial evaluation, the
return on investment ranges 1:1, to a high of $4.00 of return
to every $1.00 invested. In my written testimony I included a
case study with results of an evaluation we did of PepsiCo's
onsite clinics, documenting a financial ROI of 3.1:1, plus
increases in employee engagement and productivity.
For years, employers have been pioneering strategies that
directly address the biggest cost drivers in the U.S. health
care system. Our report, Leading the Way: Employer Innovations
in Health Coverage co-authored with the Council, illustrates
how employers recognize primary care as the foundation for
better health care outcomes and value for their employee. For
example, a professional services company contracted with a
shared onsite clinic that is open 24/7 and saw a 10 to 30
percent reduction in health care spend over a 4-year period.
Princeton University's Health-Coaching Program helped
participants reduce their hemoglobin A1C levels, translating to
a 65 percent reduction in cardiovascular risk. 43 percent
reduced their value A1C to a target level, and 10 percent to a
pre-diabetes level.
In Mesa, Arizona, Boeing launched a direct primary care
arrangement. The clinics receive a capitated per-member, per-
med fee, providing all primary care required by the enrollee--
much of what you have heard about. Boeing pays the fee for
that. There is no cost to the employee to participate.
Enrollment is optional. In the first nine months of the
program, members with chronic conditions have gravitated to the
TPC program at a greater rate than expected and with very
positive results.
There is also a new front door that promises to change the
way primary care is delivered by using more convenient means
such as telehealth or even artificial intelligence supported
technology that directs consumers to self-care, or triages them
to the most efficient and convenient point of care. Eighty
percent of employers offer telehealth today, although
utilization is slow. Through research done by Oliver Wyman, we
know that consumers are growing more comfortable with these
technologies and 52 percent are showing a willingness to share
personal health data in exchange for services tailored to their
needs.
In closing, I would like to share two ways Government
policies can support primary care. First, currently onsite
medical clinics are included in the Affordable Care Act's
Cadillac tax, and as the effective date nears, employers will
have to start making tough financial decisions, and we may see
some employers decide to walk away from onsite clinics. Full
repeal of this tax would encourage expanded use of onsite and
near-site clinics. Second, measures to allow more pre-
deductible coverage and HSA-qualifying high-deductible health
plans for people with chronic conditions, and to permit pre-
deductible use of DPC telemedicine services or employer onsite
medical clinics without risking HSA eligibility, would also
increase the use of primary care services and would improve
care adherence.
Thank you for the opportunity to share our employer data
and these case studies with the Committee. I will be pleased to
answer your questions.
[The prepared statement of Ms. Watts follows:]
prepared statement of tracy watts
Chairman Alexander, Ranking Member Murray, and Members of the
Committee, thank you for the opportunity to discuss how primary care
affects healthcare costs and outcomes.
My name is Tracy Watts. I am a Senior Partner and US Healthcare
Reform Leader at Mercer, and I serve on the Policy Board of Directors
for the American Benefits Council. I have more than 30 years of
experience in helping Fortune 500 companies design, finance and
administer their healthcare programs to control costs and improve
quality of care.
Mercer is a business unit of Marsh & McLennan Companies (MMC), a
US-based leading professional services firm with a global network of
more than 65,000 experts in risk, strategy, and people. In addition to
Mercer, the businesses of MMC, include Marsh, Guy Carpenter and Oliver
Wyman, and we employ 25,000 colleagues in the US. Together, we
collaborate with our clients to navigate the increasingly complex
healthcare marketplace in order to: (i) help individuals, families and
employees stay healthy and productive, (ii) enable innovation and (iii)
lower their costs.
As you know, more than 181 million Americans--well over half the
population--receive healthcare coverage through an employer. (US Census
Bureau, Health Insurance Coverage in the United States: 2017). Given
the significant role employers play in the healthcare market, I
appreciate the opportunity to participate in today's hearing.
Employers, like other healthcare purchasers, have been plagued by
ever-increasing healthcare costs. Because employers are frustrated with
paying for the volume of healthcare services delivered rather than the
value received, they are taking meaningful action to transform the
healthcare system. This is the message of Leading the Way: Employer
Innovations in Health Coverage, a report co-authored by Mercer and the
American Benefits Council (the Council). The report notes that
employers have pioneered strategies that directly address the biggest
cost drivers in the US healthcare system. Employers recognize that
primary care lays the foundation for better outcomes and better value
in healthcare, and employer-led innovations have created greater value
in healthcare spending by both the private sector and government.
Mercer employs 18 clinicians in our health and benefits consulting
practice, including physicians, registered nurses and behavioral health
specialists. I have often asked them, ``What's the one thing that makes
the biggest difference in an employee's health?'' They've consistently
said, ``primary care.'' Primary care is ideally where care should
start, including guided navigation across the confusing healthcare
continuum.
Today I will focus my remarks on ways employers are working to
improve employee health and manage healthcare costs through onsite
clinics and other innovative strategies. I will begin by sharing some
important and relevant findings from Mercer's National Survey of
Employer-Sponsored Healthcare Plans. Then I will share case studies
that profile new employer strategies. I will highlight some new
technologies that are giving employees a smarter, more convenient
``front door'' to healthcare and close by suggesting some updates to
the rules governing health savings accounts (HSAs) that would better
align with these employer innovations.
Continued Growth of Onsite Clinics
Mercer's National Survey of Employer-Sponsored Healthcare Plans
includes responses from more than 2,500 employers and is the oldest,
largest and most comprehensive survey of its kind. Its results are
statistically valid and projectable to all employers in the US that
offer health benefits and have ten or more employees.
Over the past decade, our survey has shown an increase in the
prevalence of onsite or near-site clinics providing non-occupational
health services, particularly among very large employers. General
medical clinics are offered by 31 percent of organizations with 5,000
or more employees (up from 24 percent in 2012 and just 17 percent in
2007), and another 10 percent of employers of this size are considering
adding a clinic by 2020.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Among employers with 500-4,999 employees, growth has been slower.
Though only 17 percent currently provide a general medical clinic,
another 10 percent are considering adding one in 2020.
In a follow-up survey of 121 employers that offer a worksite
clinic, employers listed their top objectives in establishing worksite
clinics as: (i) better managing overall health spend, (ii) reducing
member health risk, (iii) reducing absenteeism/presenteeism and (iv)
increasing employee productivity and (v) chronic condition management.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
When asked about their organization's perception of the financial
success of the clinic in terms of reducing health benefit cost trend,
61 percent of respondents believe it has been successful. Respondents
were also asked about the clinic's performance in improving employee
health and wellness, and 71 percent say it has been successful in this
regard. For 41 percent, the return on investment ranges from 1:1 to a
high of 4:1.
TABLE 1. Return On Investment (ROI) for the Worksite Clinic in the Most Recent Reporting Period
Majority of respondents (54 percent) don't know or haven't attempted to measure ROI
----------------------------------------------------------------------------------------------------------------
Return Percent of respondents
----------------------------------------------------------------------------------------------------------------
Less than 1.00 7 percent
----------------------------------------------------------------------------------------------------------------
1.00-1.49 11 percent
----------------------------------------------------------------------------------------------------------------
1.50-1.99 13 percent
----------------------------------------------------------------------------------------------------------------
2.00-2.49 8 percent
----------------------------------------------------------------------------------------------------------------
2.50-2.99 3 percent
----------------------------------------------------------------------------------------------------------------
3.00-3.99 3 percent
----------------------------------------------------------------------------------------------------------------
4.00 or more 3 percent
----------------------------------------------------------------------------------------------------------------
Source: Mercer's Survey of Worksite Clinics 2018
Case Study 1: PepsiCo Offers Onsite Clinics to Improve Employee
Engagement and Manage Occupational Injuries
PepsiCo has over 45 onsite clinics throughout the United States
that were established to treat and manage occupational injuries and act
as an engagement point for employees' health intervention and wellness
programs. They asked Mercer to help them measure the impact of the
centers using rigorous, defendable methodology. We used a best practice
match cohort approach--which means we matched clinic users to non-users
with similar episodes of care and other characteristics and examined
multiple outcomes: healthcare, productivity and disability. The onsite
clinics have resulted in:
Healthcare ROI of 3.1 to 1. Clinic users had:
healthcare savings of $117 per member per month, which was
primarily driven by medical spend; lower utilization across all
areas (outpatient, specialist, ER, inpatient, diagnostics, Rx);
higher engagement in coaching and care management, but lower
compliance. The majority of healthcare savings were seen in the
first year after the first visit to the clinic.
Productivity 3.9 to 1. Visits completed at the clinic
compared to those with community providers generated $9.3
million or 47 Full Time Equivalents in productivity savings
over the 3-year period, driven by non-occupational acute care
visit savings.
No significant impact on disability or Workers'
Compensation metrics for overall clinic users. Among those who
sought medical services there were reductions in short-term
disability and long-term disability frequency and duration.
The following case studies are from Leading the Way: Employer
Innovations in Health Coverage, the report from Mercer and the Council
that profiles 15 companies that are implementing cutting edge
strategies to manage healthcare costs, drive better quality and
personalize the experience for their plan members.
Case Study 2: Professional Services Company Contracted with Shared
Onsite/Nearby Primary Care Services Facility to Address Healthcare Cost
Trend
A professional services firm provides employees and family members
with free 24/7 access to onsite or near-site clinics offering primary
care services and generic drug dispensing. The clinic accepts a fixed
per-member per-month payment for the service. The reduction in
emergency room and urgent care utilization has produced significant
savings--from 10-30 percent in actual healthcare spend. Savings have
been maintained year-over-year for 4 years.
Despite the positive results, the Affordable Care Act's ``Cadillac
tax'' on high-cost health plans may prompt employers to reduce the
types of services provided in onsite and near-site clinics, or close
them all together. Currently, onsite medical clinics offering more than
``de minimis'' medical care are included in the excise tax calculation.
As the Cadillac tax looms, we've been surprised by employers' continued
commitment to onsite clinics. But as the effective date nears,
employers will have to start making tough financial decisions--that
unwavering support may not hold. This is one of the many reasons we
continue to work for repeal of the tax.
Innovative Contracting Strategies
Onsite clinics aren't the only strategy employers are using to
enhance the use and effectiveness of primary care. Taking a page from
the patient centered medical home care delivery model, where you have a
multi-disciplinary team of providers who proactively manage a patient's
care, the following case studies illustrate some of the ways employers
are incorporating aspects of that model into their own health plans.
Case Study 3: Intel Connected Providers to Focus on Outcomes, Eliminate
Waste
Intel found members with chronic conditions needed assistance
coordinating their care to avoid wasted spending and achieve improved
health outcomes. They contracted with health systems in key markets to
create accountable care organizations in which payment reflects
performance on cost, quality and patient experience measures. With an
emphasis on care coordination, the Connected Care program is achieving
higher member satisfaction, lower cost trend and overall lower spending
per member.
Case Study 4: Boeing Opens New Doors to Behavioral Health
Boeing is removing barriers to behavioral healthcare. Through an
innovative program in one of Boeing's accountable care organizations,
primary care doctors can consult directly with a psychiatrist's office
during a patient's office visit--a collaborative care model that
produces better outcomes. A new program will provide members with same-
day telephone or video access to a psychiatrist or doctoral
psychologist for free.
Case Study 5: Princeton University Health-Coaching Program Targeted
Diabetes
At Princeton University, diabetes was the biggest health plan cost
driver with claims averaging $13,000 annually per member. By offering
monetary incentives, they doubled participation in their health-
coaching program. Sixty-six percent of those program participants
reduced their hemoglobin A1c levels--translating to a 65 percent
reduction in cardiovascular risk. Of those with high A1c levels prior
to entering the program, 43 percent reduced their values to a target
level and 10 percent to a pre-diabetes level.
These are just some of the ways employers are working to improve
care under a fee-for-service system that does not encourage proactive
health management activities by primary care providers, and where
individuals only interact with providers when they are ill.
The case studies demonstrate how employer plan sponsors are
succeeding at lowering costs and improving the quality of service
through innovation. If recognized, scaled and promoted, the innovations
highlighted in these studies can serve as a roadmap to fundamentally
improve the healthcare system as a whole.
The New ``Front Door'' to Healthcare
I would be remiss if I didn't address how primary care is being
affected by the new ``front door'' to healthcare. In general, this
refers to moving certain types of care out of the emergency room and
doctor's office and delivering it through more convenient means such as
telehealth and Artificial Intelligence (AI) which helps consumers
either direct self-care, or triage them to the most efficient and
convenient point of care.
Telehealth has become the norm in employers' plans--it is now
offered by 80 percent of employers. But consumer research recently
conducted by our sister company Oliver Wyman found that only 10 percent
of consumers have used telemedicine services over the past year. The
utilization rate for AI was similar. Despite low utilization, openness
to telehealth and AI has grown dramatically in the past 3 years.
Consumers are growing more comfortable with these technologies and
showing a greater willingness to share personal health data (52
percent) to receive services tailored to their situation. (Oliver
Wyman, 2018 Consumer Survey of US Healthcare: Waiting for Consumers).
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
While we expect utilization of these services to increase, state
licensure laws vary widely, adding complexity and uncertainty to
telehealth consultation. There is also a danger that the new front door
could further fragment care delivery without effective communication
and information sharing back to a patient's primary care physician.
Enacting policies that promote interoperability and greater
transparency will help guard against fragmentation and support
coordinated primary care.
Modernize Health Savings Accounts
In addition to the policy priorities outlined here, modernizing
laws and regulations governing Health Savings Accounts (HSAs) would
better align this increasingly popular plan design with innovative
delivery system reforms that drive more efficient care and better
outcomes. HSAs have been used to help make health coverage more
affordable, encourage wiser consumption of health services and allow
pre-tax spending on a wide range of qualified services. The current
regulatory regime, however, has not kept pace with employer
innovations.
We encourage Congress to pass legislation that would provide
flexibility to allow more pre-deductible coverage in HSA-qualifying
high-deductible health plans for people with chronic conditions, and to
permit pre-deductible use of telemedicine services or employer onsite
medical clinics without risking HSA eligibility. Such legislation
should also allow individuals to use HSA funds to pay for ``direct
primary care service arrangements,'' a promising strategy being adopted
by some major employers. These changes would help decrease overall
healthcare spending and improve employees' quality of life.
Thank you for the opportunity to share our employer data and these
case studies with the Committee. I'll be pleased to answer your
questions.
______
[summary statement of tracy watts]
Chairman Alexander, Ranking Member Murray, and Members of the
Committee, thank you for the opportunity to discuss how primary care
affects healthcare costs and outcomes. My name is Tracy Watts. I am a
Senior Partner and US Healthcare Reform Leader at Mercer, and I serve
on the Policy Board of Directors for the American Benefits Council.
Employers have been plagued by ever-increasing healthcare costs,
and they have responded by pioneering strategies that directly address
the biggest cost drivers in the US Healthcare System. Employers
recognize that primary care lays the foundation for better outcomes and
better value in healthcare for their employees.
Some of the ways employers are working to improve primary care is
through onsite clinics (offered by 31 percent of organizations with
5,000+ employees), telehealth (offered by 80 percent of employers),
improved care coordination and proactive health management. The
following case studies demonstrate how employers are lowering costs and
improving the quality through innovation.
PepsiCo's onsite clinics have: an ROI of 3.1:1,
increased employee engagement, and generated a productivity
savings of 3.9:1.
A professional services company contracted with a 24/
7 shared onsite clinic and saw a 10-30 percent reduction in
healthcare spend.
Intel connected providers to improve care
coordination and is achieving higher member satisfaction, lower
cost trend and overall lower spending per member.
Boeing is improving access to behavioral healthcare
and seeing better outcomes with their collaborative care model.
Princeton University's health-coaching program helped
66 percent of participants reduce their hemoglobin A1C levels
(translating to a 65 percent reduction in cardiovascular risk).
Forty-three percent reduced their A1C to a target level and 10
percent to a pre-diabetes level.
If recognized, scaled and promoted, the innovations highlighted in
these studies can serve as a roadmap to fundamentally improve the
healthcare system as a whole. The transformation will require the full
participation and collaboration of all stakeholders, including the
government. Examples of ways in which the government can implement
appropriate health policies include:
Currently, onsite medical clinics offering more than
``de minimis'' medical care are included in the Affordable Care
Act's ``Cadillac tax.'' As the effective date nears, employers
will have to start making tough financial decisions and we may
see some employers decide to walk away from onsite clinics.
Measures to allow more pre-deductible coverage in
HSA-qualifying HDHPs for people with chronic conditions and to
permit pre-deductible use of telemedicine services or employer
onsite medical clinics without risking HSA eligibility should
increase the use of primary care services and improve care
adherence.
______
The Chairman. Thank you, Ms. Watts, and thanks to all four
of you. We will now begin a five-minute round of questions. Dr.
Umbehr, you mentioned something that I have been thinking
about, which is we have conclusively proven on this Committee
and on the Congress that we know how to argue about health
insurance and take different positions, so my hope is that over
the last year we have moved our focus from just health
insurance, or even a portion of it at the individual market, to
looking at reducing health care costs because, as you said, we
are not going to have less expensive health insurance until we
have less expensive health care costs.
Then our testimony last year was that as much as a half of
our health care spending is unnecessary, which is a startling
figure. And while there are no silver bullets in life, I have
learned there are sometimes levers that make a difference, and
primary care seems to be a logical, sensible focus for anyone
seeking to improve outcomes, improve experiences, and lower
costs, as all four of you have said, which is the purpose of
this hearing. Now, the direct primary care services that you
offer, and you went through an impressive list of lower costs,
better experiences, and good outcomes--can you suggest to us
two or three barriers to the expansion of what you do that we
could do something about?
Dr. Umbehr. Yes. The key focus that we have is on educating
patients and employers, if this is an option, but also
broadening the IRS's definition of what an HSA expanse is.
Right now, it is a grey area.
The Chairman. Right.
Dr. Umbehr. 213(d) says physician----
The Chairman. I believe that is a bill Senator Cassidy
has--Senator Murray and others have. Would that bill make a
difference in your opinion in the expansion of direct primary
care?
Dr. Umbehr. I think when that is left broad enough to
encompass all types of care, often because we are primary care
focused, we mentioned that, but as direct primary care grows, I
think we will see an extension of that in direct specialty
care.
We have also already launched direct neurology,
endocrinology, pediatric endocrinology, cardiology. So, we want
to make sure that we are not over-focused on just the value
that primary care can give, but cardiologists and
endocrinologist are burdened by the same problems in the
system. If they had the opportunity for direct care as well,
then that will further extend specialty care in the same way
that we are extending primary care. So we want a very broad
definition of what physician care is allowed for health care--
health savings expenses.
The Chairman. Ms. Watts--let me go to worksite primary
care. As I mentioned before he came, Senator Braun has some
experience with that in his company in Indiana. In 1987,
Senator Romney and I, when we were in the private sector, he in
Boston and me in Nashville, each started a company on worksite
daycare, which really had no Federal involvement, which grew
into a big company when the two companies merged 10 years
later. Worksite primary care seems to be an obvious solution to
better outcomes, better experience, and lower costs. You have
mentioned a couple of barriers to the expansion of worksite
primary care. Can you say a little more about the second one,
which was the IRS treatment of health savings accounts and
their connection to onsite worksite primary care?
Dr. Watts. Right. So currently employers that offer an
onsite health clinic, if they also have a medical plan that is
HSA eligible, for anybody that is enrolled in the HSA eligible
plan, they need to charge them the value of that visit so as to
not disqualify those HSA contributions. And if that were not
the case, those services would probably be provided for free or
for a very low dollar copay. And so, it is just an extra layer
of paperwork and administrative expense for employers that are
offering those.
The Chairman. I have about 30 seconds left. Dr. Kripalani,
telemedicine--what can we do about barriers to more effective
use of telemedicine for primary care doctors?
Dr. Kripalani. One of the challenges that we experience is
that currently in Tennessee those telemedicine services are
only offered if the patient presents to a rural health care
clinic that is deemed----
The Chairman. Whose decision is that? Is that state,
Federal, or insurance?
Dr. Kripalani. I think it is insurance and probably state
as well. So, I know right now we are in the process of starting
a pilot within Vanderbilt for Vanderbilt insured employees to
see about telehealth that is provided from the home to the
clinic.
The Chairman. Thank you.
Senator Murray.
Senator Murray. Thank you, Mr. Chairman. Again, thank you
to all the panel for excellent testimony. I really appreciate
you all being here, and Dr. Bennett especially for flying all
the way across the country. I appreciate you coming out here. I
want to start with you, and thank you for telling all of us
about the important work that you do. As we all know, there is
a growing shortage of providers, you mentioned it in your
testimony, who can provide appropriate care for seniors. In
fact, the Commission of the Department of Health and Human
Services estimates that by 2025 there will be a national
shortage of nearly 27,000 geriatricians. So, one thing I want
to focus on is one of the reasons why I am so interested in the
way the University of Washington is using technology and
Project ECHO to stretch resources for their--and improve health
care quality in particular for patients. And I wanted to ask
you how Project ECHO has helped improve patient outcomes, and
can you tell us more about what those outcomes are that you
hope to improve with this project?
Dr. Bennett. Thank you, Senator Murray. So as I mentioned,
a lot of Project ECHO-Geriatrics programs do not yet have
outcomes. A lot of them are quite new. We have outcomes from
programs that preceded ours that showed a reduction of physical
restraints used in nursing homes by appropriate behavioral
care, and also care transitions ECHOs that have reduced
readmissions. In our particular program, we are looking at a
few outcomes that we hope to move the needle on, some that we
base on what we see with the residents, and that includes more
appropriate prescribing of medication, reducing medications
that can increase the risk of falls or cause cognitive
impairment that is reversible because the medication is causing
it. Also looking at whether primary care providers change their
behavior, such as doing fall screening or advanced care
planning with their patients.
Senator Murray. I assume that those improved outcomes would
lead to lower health care costs?
Dr. Bennett. Absolutely. Those are things that we know--
preventing falls saves a lot of money. Falls are one of our
most costly items in our health care system, more expensive
than diabetes. So, if we could prevent some falls, we can save
a lot of money.
Senator Murray. You said that a critical part of keeping
employees is helping in controlling the growth of their
insurance premiums. But I wanted to ask you and see if you
would comment on another driver of health care costs for
employers, and that is the cost of prescription drugs. Data
shows that retail drugs alone account for about a fifth of
employee health care costs similar to the amount that spend on
hospital stays. I want to ask you as a consultant for a number
of large employers, which types of drugs are contributing the
most to cost increases?
Ms. Watts. Currently, specialty drugs spend accounts for,
on average, about 35 percent of prescription drug cost. But I
think the thing to keep in mind is that it is probably going to
go to 50 percent within the next couple of years. It is growing
at the rate of about 20 percent a year on the----
Senator Murray. The specialty drugs?
Ms. Watts. The specialty drugs spend. Right. And there are
more than 300 drugs, specialty drugs, currently in the pipeline
that will become available within the next 12 to 18 months. And
a lot of these are drugs that are designed to treat orphan
situations, so they are not, broad spread therapies. And this
is the number one concern of employers as they are
contemplating what they need to do to manage their health care
spend.
Senator Murray. Are there any measures that employers are
taking right now to drive down the cost of prescription drugs?
Ms. Watts. Absolutely, especially with some of these higher
cost drugs. They are looking at strategies that address side of
care for where the drug is administered, and so in some cases,
it is a lot less expensive to have someone administer that drug
in the patient's home, which is actually a much nicer place for
them to do that. And so, side of care is definitely a strategy.
Where the drugs are purchased, some of the larger employers are
starting to carve out their specialty drugs purchasing program
to leverage lower spend. There is a case study in our white
paper on that. So----
Senator Murray. What do you mean carve out?
Ms. Watts. Go to a specialty pharmacy vendor where they can
get directly lower pricing for those specialty drugs that
enhanced over what we get through their pharmacy benefit
manager.
Senator Murray. Thank you. And I will yield my time at this
point.
The Chairman. Thank you, Senator Murray.
Senator Roberts.
Senator Roberts. Yes, thank you Mr. Chairman. I want to
talk about rural health care, and to Dr. Umbehr, to Josh, in
your testimony, you mentioned the value that a direct primary
care model could bring to rural areas, and as has been said by
Senator Murray and the Chairman, one of the greatest threats to
rural providers is the low and steadily diminishing volume of
patients. You say that DPC is a valuable solution for rural
areas because the model does not rely on a high volume of
insured patients. Can you explain more about how your model can
help increase access? Senator Murray said, access, access,
access, and we all could say that as well, but access to care
for rural patients?
Dr. Umbehr. Absolutely. Thank you for the question. The
typical fee-for-service insurance-based primary care office is
going to need between 2,000 and 3,000 patients to be viable, 5
to 7 support staff per physician and a healthy mix of high-end,
low-end insurers so that the providers can cover the cost of
doing business. And in the Direct Care Model, we are able to
minimize that. We have one nurse, one full-time equivalent
employee for every two physicians. So, that drastically
decreases the overhead. We pass those savings along to the
patients. This model is very viable at 600 patients, with the
physician actually having a slight increase in their income
because of those savings on the overhead. We have been able to
help over 600 physicians move to clinics like these or start
their own clinics in the last few years.
The smallest town is Buena Vista, Colorado with a
population of 2,500. I grew up in a town of 900 if you count
everybody twice. And these models still work there because now
you are going to catch most of that town because you are the
only provider in the area anyway, but you can bring jobs to
that area. Direct primary care can decrease small business
health insurance premiums by up to 60 percent. Health insurance
being the largest--second largest item on every employer's
budget, and it is driving employees away from rural care. So,
if we can bring employers back and decrease the cost of
employing them while improving the access to care, this becomes
an incredibly viable model.
Then of course telemedicine as well extends that reach so
that patients in rural Kansas do not have to drive their farm--
gas-guzzling farm vehicle 90 miles to pick up a medicine for
$4.00 that should be $0.13. I think everywhere we look at this,
it improves significantly.
Senator Roberts. Now, you mentioned you are expanding up
and down I-70--that is the big interstate that goes through
Kansas, and also on 54 over to Dodge City, which I am always
interested in, but elaborate on how you are expanding this or
how fast this model is really growing?
Dr. Umbehr. About four years ago when we started doing all
the consulting for Free for Physicians--we are movement
obsessed. We want to see this movement grow and every time a
physician attempts this model and fails it slows the movement.
Every time they attempt it and succeed, the movement grows.
Doctors are, for better or for worse, very evidence-based, and
if the evidence in the model fails, they listen to that and
vice versa. So, if we can get good information out to
physicians--70 percent of primary care physicians meet criteria
for burnout. It is not working well for them or their patients.
Then when they believe there is a viable alternative, they
start to explore that significantly. When we started, we would
convert one or two practices a month. Now, we routinely convert
20 to 30 practices a month. So we are seeing a significant
increase as the pain of staying in the system, the status quo
continues to grow, the incentive to change to a more cost-
effective model rises as well.
Senator Roberts. Well, thank you for being part of the
answer as opposed to the problem. Mr. Chairman, I remember the
thrilling days of yesteryear when we passed the Affordable
Health Care Act and I got all wound up with the four rationers,
iPad, CMII, PCORI, and something called USPSTF, which is a
preventive services task force, so I am not going--I cannot do
anything with that acronym. So----
[Laughter.]
Senator Roberts. Two of those, one is expiring--iPad, there
is no longer. I would hope that we could make some more
progress on that, but your model does not have to contend with
that.
Dr. Umbehr. Correct. We are free from the paperwork process
of scrubbing the chart, doing the paperwork, checking the boxes
to make sure we get paid. We are doubling our efforts to show
the patients that they are getting a high value for their care.
They want preventative care. They want to know that they are
meeting guidelines. We have to be overly transparent to say,
well, the USTSPF does not find evidence to support testing of
prostate cancer in men, but the American Academy of Family
Physicians says, have a conversation with your patients, and
the American Urology Association says absolutely check all men.
So then we have to have a conversation with those patients, see
where do you feel you most fit. When it is $1.69 to check, a
PSA becomes a much easier conversation, but we still want to be
cautious about incidentalomas, where we did something and now
we have to do something with it. But we have the time, as my
colleague mentioned----
The Chairman. We have to stay within the 5-minutes----
Dr. Umbehr. Thank you, sir.
The Chairman ----if we can, so all the Senators----
Dr. Umbehr. Yes, sir.
Senator Roberts. I led him into that----
The Chairman. I know you did.
Senator Roberts ----into that pasture. I apologize.
Mr. Chairman. Thank you both for your leadership. Thank
you, Senator Roberts. Senator, Kaine.
Senator Kaine. Thank you, Mr. Chairman, and Dr. Umbehr, my
dad is from Wamego. I spend a lot of time in Alma. Senator
Roberts hates it when I say this. My dad was his fraternity
brother at Kansas State.
[Laughter.]
Senator Roberts. I was his pledge son.
[Laughter.]
Senator Roberts. He comes to me on the floor, Mr. Chairman
and says, Al Kaine, says hello, and I say, how do you know Al
Kaine? He said, well he is my dad. Boy, to talk about making
you feel like going to a critical access hospital.
[Laughter.]
Senator Kaine. He actually called me an epithet, which I am
not going to repeat, when I said that.
[Laughter.]
Senator Kaine. But anyway, very good to have you all. I
want to ask a quick question about workforce and I want to
focus, Dr. Bennett, on ECHO, which I think is fascinating. So
on workforce issues, Dr. Kripalani raised them, for the primary
care workforce, I assume you all agree that the variety of
public service loan forgiveness programs, whether it is
National Health Service or others whereby we provide some kind
of incentive, for example, loan forgiveness, to have folks go
into important specialties like primary care or serve
underserved populations, I assume you all agree that is an
important component in having the primary care network that we
need. Do you do you agree with that?
Just--the reason I want to point out is, if you think there
is a way we can do it better. There might be opportunities. We
are working on the Higher Education Act Reauthorization, and
there are--it is part of the work plan for the Committee over
the next couple of years. And so if there are ways to do it
better that could more produce the workforce, primary care
workforce we need, especially in rural areas, we would love the
advice of folks on this panel.
Another--so that is number one. Number two, in Virginia a
lot of the primary care workforce, especially in rural
Virginia, are immigrant, often born abroad or sometimes born
and trained abroad. Is that consistent with your own
experience?
Dr. Umbehr. To answer your first question, yes, I think
loan forgiveness is helpful. But the way it is being done now
is, I think it perpetuates the status quo. A lot of the times
there is that string attached of if you go rural, you are going
to accept state Medicaid, Medicare insurance because that is
the current model. I mean that is not malicious, but if they
were to broaden that as to just provide cost-effective care by
whatever yardstick we measure----
Senator Kaine. In those areas.
Dr. Umbehr. In those areas, I think that would incentivize
adoption and innovation, as well as increasing the workforce in
rural communities.
Senator Kaine. Any thoughts about the second half of the
question dealing with immigration?
Dr. Kripilani. Thank you, Senator Kaine. You know, as far
as foreign born and foreign trained physicians, I think there
is definitely a large number of physicians who are joining the
workforce and interested in working in the United States,
particularly in rural areas. I know many of them find
challenges in finding residency positions.
Senator Kaine. Right.
Dr. Kripalani. That is certainly a limitation in increasing
that workforce for people who might be interested later on in
primary care.
Senator Kaine. Sometimes between getting a residency match
in March, and getting your immigration arranged to start in
late June, early July that can also be very difficult.
Dr. Kripalani. Absolutely.
Senator Kaine. The point that I make in that, and then I
want to move to ECHO, is immigration debates seem to be
predominately about security, security, security. In my state,
immigration is fundamentally about workforce. There are
security issues that are very, very real, but immigration is
about workforce, and if we did not have foreign-born or
foreign-trained health providers in Virginia, it would hurt our
rural parts of the state in a very, very dramatic way. And so,
we need to always think about immigration as a workforce issue.
Dr. Bennett, I want to ask you, your ECHO program is based
on a national model of ECHO programs, some that focus on
geriatrics in Virginia. We have an ECHO program structured in
the same model, sort of a hub with telemedicine and other
spokes out into the communities. And our focus in Virginia is a
multi-university consortium to deal with Opioids and addiction
issues using that ECHO model. And I am fascinated with the
model. I am fascinated with its application. For example, the
school nurses. I mean, I think there are a lot of opportunities
to use that model. In particular, talk about your own model in
dealing with the issues of dementia. This is an issue that
Senator Collins and I, well everyone on this Committee, has
focused a lot of attention on. So, Alzheimer's and Dementia
care.
Dr. Bennett. You know, dementia is a condition we are all
dealing with. They are a growing number. One in ten older
adults has dementia. It is really common and needs an
interdisciplinary team to care for these folks. And so, our
interdisciplinary panel provides suggestions, models, the
interdisciplinary care that is needed for older adults with
dementia. And it is not just making the diagnosis or providing
medications, it is knowing how to support the caregiver and
refer people to community resources. So, we include all of that
in our ECHO and model so that the residents leave with those
best practices.
Senator Kaine. Right. Thank you. Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Kaine.
Senator Cassidy is not here so, Senator Collins.
Senator Collins. Thank you. Mr. Chairman. Miss Watts and
Dr. Kripalani, each of you mentioned the importance of patient
engagement in the area of diabetes. In the aging committee,
which I chair, we had a recent hearing in which Martin's Point,
which is a Medicare Advantage Program in Maine, testified about
their innovative diabetes program that included care managers
who work directly with their members, with their patients, and
it includes a weekly telephone call to check compliance with
blood sugar readings, with diet, with the exercise. And it has
had truly extraordinary results. Emergency room visits have
declined by 10 percent for this population. Inpatient
admissions have declined by 30 percent. But what they are
struggling with is a lot of the work that they do is not
reimbursed by Medicare. And Senator Jeanne Shaheen and I, who
chaired the diabetes caucus, are trying to change that and to
have Medicare, for example, cover diabetes self-management
training sessions.
Could you talk about how reimbursement policies of insurers
Medicare, Medicaid either impede or facilitate these kinds of
interactions directly with the patient, that can try to avoid
serious complications that can occur for people who are unable
or do not comply? Doctor, we will start with you.
Dr. Kripalani. Thank you, Senator Collins. Yes, I agree
with you 100 percent that the importance in having frequent
check-ins for patients with diabetes that is poorly controlled,
or for patients who are struggling to remain consistent and
compliant with their medications, is of utmost importance in
adequately managing their diabetes and their chronic conditions
that can be results of uncontrolled diabetes. I know in our
clinic, we have a designated care coordinator for diabetes who
we can call upon if we find that someone is struggling and
needs additional resources and contact, and she can
independently make phone calls and contact that patient in
between visits to make sure that their needs are met, to make
sure that they are able to afford their medications, and that
there is no other issues that arise in between visits. And that
has been extremely valuable in preventing elevated blood
glucose causing someone to go to the emergency room to seek
treatment.
Senator Collins. Thank you.
Miss Watts.
Ms. Watts. You know, on the employer side, it is not
uncommon these days for employers to have specialized programs
that target diabetes, that they pay for outside of their
traditional insurance program. We call them carve-out programs.
And within these specialty programs, there is great technology
that exists today, wireless glucometers that keep track of
someone's A1C levels, and there is even a newer one that I have
seen that can project out your A1C level for the next 12 hours.
And think about how powerful that is, especially for childhood
diabetics. And so those are the types of things that employers
are doing to really push the market for better outcomes, better
engagement, and compliance that results in an overall,
healthier person. That helps prevent those emergency room
visits and other higher costs of care.
Senator Collins. Thank you. Dr. Bennett, I appreciated your
mentioning the Geriatrics Workforce Improvement Act that I
introduced last week with Senator Casey. The statistics are
really startling. We only have 7,300 geriatricians who are
board certified. We need about 20,000 today and we are going to
need 30,000 by the year 2030. In addition to improving health
outcomes, could you explain why a geriatric capable workforce
would also reduce costs? Unnecessary costs?
Dr. Bennett. We can prevent falls. We can keep people
living independently in their homes by good care of people with
dementia, helping support their chronic diseases. Geriatrics is
just made to save money.
Senator Collins. Thank you.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Collins.
Senator Hassan.
Senator Hassan. Thank you, Mr. Chairman and Ranking Member
Murray, and thank you guys for this hearing. And count me in as
a fan of medical homes and coordinated care. I also just wanted
to thank all of you for being here today and for your work
helping promote health care in our country and lowering costs.
So, Dr. Bennett, I just wanted to follow Senator Collins'
question just a little bit more because we know how much our
population is aging. I am from New Hampshire where 18 percent
of our total population is 65 years or older, and it is among
one of the highest senior populations per capita in the
country. So, we are in need of more primary care providers,
especially those who specialize in geriatrics. And you have
discussed in your testimony that there is a lack of geriatric
training that primary care physicians receive. We just talked a
little bit about how more expertise in geriatrics can help
lower costs, but can you just put it in terms of patients for a
second? How will this--how would an increase in geriatricians,
and more training for primary care physicians in geriatrics,
really help patient outcomes?
Dr. Bennett. Thank you for that question. In geriatrics, we
have a large body of research and a lot of experience knowing
how to prevent things like falls, delirium in the hospital,
which is very costly. We have learned how to reduce the length
of stay and reduce the incidence of delirium, which helps
patients live better. And geriatricians really focuses on four
primary things. One is, what matters most to the patient. The
second one being, making sure that we are screening for
cognitive impairment and addressing it when we find it. Helping
with mobility, making sure people stay moving around and
independent, and preventing falls. And then the final thing is
making sure medications and multiple medical conditions are
well managed. So all of that complexity is in the geriatrics
expertise realm and we have proven cost savings by addressing
all of those four issues.
Senator Hassan. A win, win. Better outcomes for patients--
--
Dr. Bennett. Yes, the patients----
Senator Hassan ----and lower costs.
Dr. Bennett. The patients get what is most important to
them, which is often quality of life and maintaining
independence----
Senator Hassan. Right
Dr. Bennett ----while we are also saving health care costs.
Senator Hassan. Terrific. Well, thank you. Dr. Kripalani, I
wanted to touch on the issues of integrating behavioral health
into primary care. We know that kind of integration can be
really critical in addressing a patient's health care needs.
But we also know that people across the United States are still
struggling to access the behavioral health services they need,
including substance use disorder services, which are obviously
in great need throughout the country, in places like my state
in particular. Congress is taking critical steps to encourage
the integration of primary care services and behavioral health
services, most recently with the passage of the Support Act.
But it is clear we need to do more. So, I am interested in your
thoughts about what Congress can do to further improve the
integration of primary care and behavioral health services?
Dr. Kripalani. Thank you, Senator, for that question. You
are absolutely right in that primary care needs more resources
to help our patients who are struggling with mental health
issues. In primary care, we actually provide a great deal of
mental health services as it is, because we are usually the
first place patients come to when they need help. However, we
are not equipped to handle very complicated and complex cases,
and we need ways in which we can easily refer patients to get
into behavioral health in a timely fashion for those cases that
we feel exceed our abilities. And right now, there is a
significant delay in getting new patients in to see a
behavioral health specialist. It can take months, in Tennessee,
and that is a big problem.
Senator Hassan. Okay. Dr. Umbehr, Dr. Bennett, do you have
anything to add to that? How can we do better at integrating
these services?
Dr. Umbehr. I think direct primary care encompasses so
much. The broader the brush of value we can paint, the more
patients we can attract. The ability to be outside of the
insurance model allows maximum flexibility for the patient and
the provider. Depending on the study, 22 to 75 percent of a
physician's day, like you mentioned, is up to 2 hours on
paperwork relative to patient care. When we were able to carve
out that inefficiency, we get those 2 hours back for patient
care. Now, we can extend our behavioral training to the
patient.
The use of telemedicine--the depressed or anxious patient
does not do the self-care necessary to schedule the appointment
to make it during office hours. They are afraid to leave work
because they are already anxious and they may be concerned that
the employer is watching how many doctor visits they have. If
they are up at 2 a.m., and they want to type out a long email
to their provider, they should be able to. And be able to
extend that conversation with their provider on an ongoing
basis, I think, leads to much better outcomes. But also, when
we can show that name brand Lexapro is $11.97 a pill, and
generic Lexapro is $0.07 a pill, we just maximize the patient's
ability to even get the care they might need. So, on all fronts
that is very patient obsessed.
Senator Hassan. Thank you. And I know I asked Dr. Bennett
too, but I see I am over time, so can we ask Dr. Bennett to
just come in on that quickly?
The Chairman. Well, let us go to the other Senators. Then
you will come back for second round of questions, and we would
like to, Senator Hassan.
Senator Romney.
Senator Romney. Thank you, Mr. Chairman. And thank you to
each of you for taking time to be with us this morning. Your
thoughts and insights are actually quite encouraging and very
much appreciated. I am going to begin by talking to Ms. Watts,
and just to get your perspective on something. My limited
experiences suggested that those places in our economy, in our
lives, that are driven by consumers making choices with strong
incentives or companies making choices based upon incentives,
tend to have the quality go up and the price go down. Almost
everything we buy or we use in our country today, the quality
keeps getting better and better, the price gets lower and lower
in real terms.
The exception to that is in areas where the Government
plays a very heavy role, health care, education, the military.
With the military, we are not going to have competition. We are
not going to find a way to help consumers make those choices,
but with regards to education and health care, it seems that
incentives are one of the reasons why we are driving the cost
up instead of bringing those costs down. You have been
associated with Mercer for some time and obviously, do
extensive work in the health care arena. Do we have an
incentive problem, and is there a way to create incentives like
companies that are doing what you are suggesting right now,
which is putting together these clinics at the work site. This
seems like a no-brainer for a company to do. To make sure their
employees are healthier and lower costs. Do we have an
incentive problem in health care, and are there some broad ways
that we ought to address those incentives?
Ms. Watts. Thank you, Senator Romney. There is a theme.
There is an underlying theme here where we are trying to make
the transition from purchasing based on volume, than the
services that are provided. You know, charging for each of
those services to paying for delivering a value. So, the direct
primary care model is an example of paying for delivering
value. And that is definitely a focus of employers. There are a
lot of large employers across the U.S. that are direct
contracting with accountable care organizations purely for that
reason, to get the value of the services. To focus more on, how
are you driving the best outcomes, are people healthier once
they have completed their treatment, how are we improving the
health risk of our population, and so that very much is the
focus and it is a big part of what is highlighted in our white
paper that we wrote with the Council. But we have only made a
little bit of progress. There are still many, many health care
services that are fee-for-service that are not based on value,
and then on top of that, we have the issue that Senator Murray
asked about with regard to specialty pharmacy costs. And so,
those are two things that we still have quite a bit of work to
do.
Senator Romney. Yes. Thank you. Dr. Umbehr, I am curious as
to how it is that a direct primary care model is so much less
expensive and requires one assistant for two physicians as
opposed to five assistants for one physician. What is the major
difference in cost? What is driving such a dramatically lower
cost in direct primary care? I presume it is applicable to
other sources of direct care for various specialties, and I
imagine that some of this has to do with just keeping up with
the insurance requirements of all the different insurance
companies and so forth. But I presume these direct primary care
physicians also have to deal with Medicare and Medicaid,
particularly in rural areas where that would be a big share of
their reimbursement. How do you get the cost down? How is it
you are successful? And how do you deal with Medicaid and
Medicare?
Dr. Umbehr. Excellent. Thank you very much for those
questions. I would like to say it is because we are so darn
good----
[Laughter.]
Dr. Umbehr ----but really this is not a proprietary model.
This is the free market, like you alluded to. When doctors free
themselves up from using 66 percent of their time doing
insurance paperwork, they need less staff, they have lower
prices, they can provide more value, but they can focus on
solutions too. So, to speak to the specialty medicines,
Remicade is a medicine we were working with a hospital, or an
employer group in Maine. It was being charged $28,000 per month
per treatment. The wholesale price is $1,100. I have a patient
with brain cancer, 21, at college, and her insurance was
charged $26,000 a month for chemotherapy we could get wholesale
for $1,900. Same medicine, same supplier, the difference is
between the wholesaler and the markup. And that is not to say
that those companies are bad. They suffer the same burden that
you alluded to, which is if the primary care doctor has 66
percent of their day spent on paperwork, so does everyone else.
And so the more middlemen there are, the higher that price goes
up. When a physician is freed from that unnecessary work, they
can thrive on what matters and that is finding those
prescriptions. And really it is one website. It is a
wholesaler. It is easy.
Senator Romney. Thank you.
Dr. Umbehr. Apologies for not getting to Medicare----
Senator Romney. I could keep going if you let me, Mr.
Chairman, but my time is up.
Dr. Umbehr. I would like to come back to Medicare and
Medicaid.
The Chairman. We can go back to a second round if you would
like, but let us--thank you, Senator Romney.
Senator Casey.
Senator Casey. Thank you, Mr. Chairman. We thank the panel
for your testimony, your work in this area. And I know I have
missed some of the testimony because of our finance committee
hearing, but I will be brief and focus on Dr. Bennett's
testimony. Doctor, I was looking at pages 4 and 5 of your,
excuse me, your testimony and the interaction or interplay
between community agencies and the geriatric workforce. In this
case, I was thinking of the area agency, agencies I should say,
on aging. We have in Pennsylvania a really robust network of
those Area Agencies. And I guess the primary question I want to
ask you is, can you share with us how partnerships between the
primary care providers and the Aging networks, like Area
Agencies, can both bring down spending as well as improve
quality?
Dr. Bennett. Thank you so much for your question, Senator
Casey. I am a huge fan of Area Agencies on Aging. And we have
partnered with Area Agencies on Aging as part of our Geriatrics
Workforce Enhancement Program. Area Agencies on Aging are
experts in addressing the social determinants of health, but
most primary care providers and clinics do not know about the
services of Area Agencies on Aging, so we created a program
called the Primary Care Liaisons, where we with our workforce
enhancement program funding, funded a position at two different
triple A's. And their job was to go to primary care clinics and
make sure they were aware of the Area Agencies on Aging
resources. And by doing that, they were able to dramatically
increase referrals.
The southwest Washington's Area Agencies on Aging just sent
me their numbers. They increased referrals by 170 percent with
this program. And Area Agencies on Aging have programs that are
evidence-based and reduce costs. Examples include their Chronic
Care Program, which helps older adults manage their chronic
diseases. And that has been proven to save hundreds of Medicare
dollars per month. Area Agencies on Aging, with Health Homes
Innovation Program in Washington, were able to save 67 million
health care dollars over 2 years by providing care coordination
in the home. Very simple stuff. Just going to the home, making
sure the patient was keeping track of their chronic conditions,
and helping coordinate their appointments. And that saved lots
of money. So, Area Agencies on Aging are perfect partners, and
we need to do more of it.
Senator Casey. Thanks very much and I will cut my question
short. I might submit one for the record. I just note for the
record what Senator Collins said. She and I have introduced the
Geriatrics Workforce Improvement Act. We hope we can--and you
spoke to that in both your testimony and answered her question.
Mr. Chairman, thank you very much.
The Chairman. Thank you, Senator Casey.
Senator Cassidy.
Senator Cassidy. Thank you. First, I want to know for the
record, I think I heard Senator Murray say ``y'all'', and so I
felt like I was back home for just a second. She must be from
south Washington State.
[Laughter.]
Senator Cassidy. Dr. Bennett, I am a big fan of Project
ECHO. I have been out to New Mexico where they have used it. I
am very aware of the incredible potential there. Ms. Watts, you
mentioned that Princeton University is using monetary
incentives to get diabetics to go through programs that have
given so much benefit. I believe the ACA restricted the ability
to lower obesity, clearly the major driver of diabetes. The ACA
restricted the ability, I believe, to lower premiums for those
who enter a weight loss program. What is the nature of these
monetary incentives and how does it interplay with the ACA? And
I may have my--I may not remember correctly regarding that, but
still what is the nature of these monetary incentives?
Ms. Watts. It is probably in the form of lower costs for
diabetic supplies. Better discounts, lower costs, if you
participate in the program, and perhaps that includes the
glucometer and other materials, but also personalized coaching
to help you deal with questions that you have about managing
your condition. Many people, when they are first diagnosed with
diabetes----
Senator Cassidy. But that would not be a monetary
incentive, that would just be kind of the general sort of wrap
around----
Ms. Watts. Right.
Senator Cassidy ----to support somebody.
Ms. Watts. Right.
Senator Cassidy. By the way, I am a big fan of onsite
clinics. When I was in my previous life, we took immunization
programs to children in schools because it turns out working
moms have a non-healthcare-related cost of taking their child
to the pediatrician. They have to leave work. They have to pick
up the child. They have to take the child to the pediatrician,
and it is lower income mothers for whom the burden is greatest,
because they have to take public transportation, for example.
Often times that is the reason the child would not be
vaccinated. So, I am totally with you on the onsite. I do
think, I do not know, if we have to completely repeal the
Cadillac tax, which I would not mind doing, to allow onsite
clinics to be exempt from that consideration.
I will go back to the lower income worker disproportionally
benefiting as a percent of their income from being a given a
flu shot for free, and I do think that is something, although
beyond the scope of this clinic--we should do that. It holds
down cost and it should not cannibalize someone's HSA. Let me
ask as well, you also mentioned using HSA for people with
chronic conditions. Now, theoretically that is what the HSA is
for unless you are describing allowing HSAs to be marketed
specifically for diabetics, or specifically for hypertensives.
What did you mean by that?
Ms. Watts. Yes. So I think the idea is that in order for a
benefit plan to be HSA eligible, all of your expenses have to
be applied to the deductible before they can be covered, with
the exception of preventive care. And preventive care does not
include helping to manage a chronic condition.
Senator Cassidy. Meaning that you have to use your HSA if
you want to go buy a glucometer or you want to see the doctor
for that coaching which you described.
Ms. Watts. Right. You would have to use your HSA dollars or
you would need to meet your deductible before the insurance
would cover it.
Senator Cassidy. We could, if you will, come up with HSAs
that would allow management of a chronic condition to not be
subject to a deductible. I think that is what I am hearing from
you.
Ms. Watts. Yes. Yes, you could change the requirements of a
high deductible health plan for HSA eligibility.
Senator Cassidy. You are saying that you think that would
be a positive development because--by the way, we have been
talking about that and there are models in South Africa that do
that. I think it would be wonderful for us to consider, but I
am glad to hear you are endorsing that.
Ms. Watts. Yes. Well, and I think as well, when you think
about the direct primary care model, if we were able to use
that, that also definitely benefits those with chronic
conditions because all of their primary care is included in
that direct primary care model.
Senator Cassidy. Yes. Be still my heart, you are kind of
Nirvana, where I think we should go to empower patients. Dr.
Kripalani, you mentioned that you are not allowed to use
telehealth, or at least not be reimbursed, unless Medicare or
Medicaid--but are you in any capitated arrangements? I would be
surprised if there was not an insurance plan by which you are
taking the risk that they would not just say, manage the
patient however you wish. If you waste money, you lose, but if
you have a better outcome and lower cost, you win. Is that
not--are these arrangements not allowing telehealth to occur?
Dr. Kripalani. Thank you for that question. As far as I
know, those arrangements have not been negotiated with my
institution. I know that they are through our employer plan.
Through Vanderbilt's own plan, they are trying to create an
arrangement where we can utilize telehealth, recognizing that
will reduce the cost of insuring these patients and provide
care in between visits.
Senator Cassidy. I can see somebody thinking it could be a
ruse. You just have some doc, who has lost his license in some
faraway state just racking up telehealth, but if you are on a
capitated two-sided risk, I can see it working. But you do not
know of a legal barrier, rather it is just a question of the
contractual relationship. Is that----
Dr. Kripalani. That is correct.
Senator Cassidy. I am out of time. I appreciate it. I yield
back.
The Chairman. Thank you, Senator Cassidy.
Senator Rosen.
Senator Rosen. Thank you. Thank you, Chairman Alexander,
Ranking Member Murray, thank you for being here, for what you
do, and how you are improving patient outcomes every day and
elevating the conversation of how we need to help, and treat,
and expand our education in this area. And so, I think that the
community health centers, the teaching health centers, we had a
hearing about this just last week, are really important models
for integrated health care.
But as we continue to expand those, we are going to have
increasing doctor shortages and of course, shortages across the
medical workforce support spectrum. So in my home state of
Nevada, we actually ranked 48th in terms of a primary care
physicians per capita. And if our state's population just
remains stagnant, it would take over 2,500 doctors just to
bring us up to the national average. And of course geriatrics.
Nobody is like--no one is getting any younger, right. We have a
rapidly aging population. More Americans are retiring to Nevada
each year. And so, this gap, of course, is going to continue to
widen over time. And so, to all of our witnesses, however, you
want to answer, what are the barriers that we have to
redistributing and increasing medical residency slots? Of
course, we talk about scholarships, payment, debt, all those
kinds of things. That is one part. But how do we do this to
empower more physicians? And then also, how do we increase the
medical support team for everyone, because doctor or provider--
it does not work in a vacuum. You need an X-ray tech, a
phlebotomist, etc., etc., etc. So, what ideas do you have to
expand that or what challenges do you see to expand the
residencies in our medical staffs?
Dr. Umbehr. I would like to take that first question. Thank
you very much, Senator Rosen. I would actually, just for kind
of exploration, challenge the assumption that is often held
that we are going to experience a physician shortage. If we
stay in the current model, we absolutely will have a physician
shortage. But the American Academy of Family Physicians has the
most conservative estimate of this at 22 percent of a
physician's time being spent in non-clinical paperwork during
the day. They estimate that if that 22 percent of each
physician's time was given back to them--that would be the
equivalent of 165,000 full-time equivalent positions added back
into the workforce. The most aggressive estimate is that we
will have a shortage of 130,000 primary care physicians by
2025. So, it is less of a quantity and more of an efficiency
issue.
Senator Rosen. I want to ask you about the paperwork. Some
things only the doctor can dictate. Some things insurance
paperwork, we know that you have to labor intensive--you have
to hire staff. But what you see it then, is a barrier to just
you dictating your reports after that. That is not going to be
eliminated, unless you have someone, I suppose in the room,
right?
Dr. Umbehr. Well, we have eliminated it, like, by not
accepting any insurance Medicare, Medicaid----
Senator Rosen. You do not dictate reports? What goes in the
H&P, your physicals, all those things?
Dr. Umbehr. Charting the experience of the visit is fine.
Charting it for reimbursement is the issue.
Senator Rosen. Okay.
Dr. Umbehr. Making sure you hit MACRA and MIPS, medical
decision making, all those things. And if--you could spend 30
minutes with the patient, but if you document it wrong, you
will not be reimbursed for that time.
Senator Rosen. No, I understand.
Dr. Umbehr. Those are the restrictions. We can pay for
patient care or paperwork. We cannot pay for both. If the
barriers were removed for reporting, physicians would have more
time to see more patients and that would take the burden off
the shortage.
Dr. Kripalani. Thank you, Senator Rosen. I would like to
comment on your mentioning the lack of access and the teamwork
approach, which I think we definitely need to invest in, in
primary care, in a more robust way. You know, I think that we
need to find ways to combine mental health services, behavioral
services, all within the structure of the visit when the
patient is there. And I think if we can provide those services
in real-time that would be much more impactful for the patient
in allowing them to make sure when they walk out that door,
that they have a full understanding of what their expectations
are between then and their next visit.
Senator Rosen. What barriers do you see to increasing just
your workforce, not just physicians', but those that you need
on the support team?
Dr. Kripalani. Well, currently under the current
reimbursement model, those funds to actually employ those
additional resources from, sort of more diverse fields, those
funds are not there. Our clinics cannot afford to support those
additional team members.
Senator Rosen. Anyone else have anything to add?
Ms. Watts. The reimbursement impacts what specialty people
go into when they are residents. There is a huge debt burden
and primary care has lower reimbursement in the current model.
So that is a big barrier to more physicians going into primary
care.
The Chairman. Five minutes is up.
Senator Rosen. Five minutes is up. Thank you very much.
The Chairman. Thank you, Senator--thank you, Senator Rosen.
Senator Braun.
Senator Braun. Thank you, Mr. Chairman, Ranking Member
Murray. I was not here for the beginning, but it is true about
nine, ten years ago, we took on everything we are talking about
here and would want to make the statement that the hardest part
to get right was to get the industry to listen to what you are
talking about. It was like pulling teeth the day we did it, and
all I can tell you is that there is so much room for potential
to lower costs if we just get it right. You see, I see here
unprecedented transparency and I can see what you are offering
is use the tools you have at your disposal, to give that to the
folks that become members of your direct primary care. I can
tell you that we work real hard to create transparency and I do
not know how long it has taking you to get--to be able to peek
in and see and get the industry to provide it.
I tried a simple bill in our state legislature that if you
are in the business of providing health care services at any
level, publish your prices in print or on the web, it was like
it was going to blow up the place and I never even got a
hearing, and that was in 2015. A lot of strides to make. We
finally figured out how--what the formula was. And if we all
here wanted to start with something very simple, shed light on
the process, let the consumer, like Senator Romney referred to,
do all the work and there are ways for the folks that do not,
maybe, have the resources to do it. In my company where--and I
come from an area where we have not had to address that--you
can even incorporate that in. Unprecedented transparency, we
ought to focus on that. Skin in the game was the other thing
and it was hard to do because people were relying on co-pays. I
see here you have no co-pays, which means, I think, that they
do not have to spend any money on that because you do not have
co-pays.
In our case, we needed to get rid of co-pays to get some
involvement in the process of buying health care. And then I
had to make sure that I could lower costs enough to make sure
they were not getting premium increases, and the tools that we
could provide can make this whole thing work. Nine years, we
have done it and it is due to the fact that we have done
everything you are talking about, and the industry has got to
get with it or else, I think, there is going to be a strong
case to try other methods. And most of us in the business
world, will throw our hands up in the air. That it has just
been an industry too tough to break. $10 to $100 per patient,
why such a wide range and what is the differentiation between
one membership versus the other at that amount?
Dr. Umbehr. Thank you very much for those questions. That
is based on age only. So, kids 0 to 19 are $10 a month.
Senator Braun. Okay.
Dr. Umbehr. $50 for ages 20 to 40. $75 a month, 45 to 65--
--
Senator Braun. Tied into the utilization rate as you age.
Okay, that makes sense.
Dr. Umbehr. Right. The employer rate though is a flat $50
for all adult ages.
Senator Braun. Okay. And then when we looked at clinics or
direct primary care, first of all, the economy of scale, you
mentioned 2,000 to 3,000 patients. It was a 1,000 to 1,500
then, and we would have had to have pooled or associated with
other companies to do it. And you do have it to where 600 is a
new lower economy of scale where many of your centers survive
on that number of members?
Dr. Umbehr. Thrive at that----
Senator Braun. Thrive. That is great. You made big strides
there then.
Dr. Umbehr. Just to hit on that point quickly because it
pulls in the shortage issue, if doctors see fewer patients,
there will inevitably be a shortage. But back to the
efficiency, there are roughly 500,000 primary care providers,
300 million Americans. If each of them saw 1,000, that is 500
million Americans. So, we know somewhere that number is off.
But 300 million divided by 500,000 is 600.
Senator Braun. Okay.
Dr. Umbehr. There is the ability there to reach all
citizens, especially with the advent of telemedicine.
Senator Braun. When we finally found the formula, and I
think it is scalable, for what we do through Government, our
improving private insurance, there does--there is a need just
like in LASIK surgery. I mean that is simply providers and
patients coming together, and that is fallen by 80 to 90
percent just by getting the market to work. Transparency from,
what I see, is going to take a law to do it. Could not get it
done in Indiana. And if we want to do one simple thing, the
people in the business have to show us what they are charging.
We do telemedicine, coaching, HSAs because we were at the
critical level of being able to self-insure, which was about
300 employees. That enables everything to become consumer-
driven. If you get entrepreneurs like yourself, I think there
is a chance of taking costs out of the system because we are
starting to do a few things that all other industries do.
Dr. Umbehr. I think the benefit here is that based on the
research from large corporate groups, 70 percent of jobs come
from small businesses and they do not have enough employees to
hire their own, but this essentially lets them do just that.
So, they will have the same benefits of hiring a physician, but
they can do it for 10 employees.
Senator Braun. You are at the leading edge of, I think,
maybe the industry getting with it. So, thank you.
Dr. Umbehr. Thank you.
The Chairman. Thank you, Senator Braun.
Senator Warren.
Senator Warren. Thank you, Mr. Chairman. So, I would like
to ask today about how to address behavioral health needs
through primary care. I know that Senator Hassan asked about
this, but I just want to dig in a little bit more on it because
I think it is so important. At our Teaching Health Center in
Lawrence, Massachusetts, medical residents get unique training
in an underserved community, training to help with all of the
challenges their patients face including mental health and
addiction. All of the medical residents at Greater Lawrence
Family Health Center are trained to prescribe medication for
addiction treatment, training that not every primary care
resident gets. Even so, we have a significant unmet need for
services across the state.
A recent survey found that more than half of Massachusetts'
adults under 65, who sought behavioral health care, either for
mental health or addiction services, struggle to find
treatment. Two out of five of them went without the care they
needed. One in eight went to an emergency room when they needed
treatment. This is not fair to those patients and it is not a
cost-effective way to be addressing behavioral health. So, let
me ask you, Doctor Kripalani, in Tennessee, how hard is it for
your patients to access behavioral health services?
Dr. Kripalani. It is a very big problem in Tennessee. Thank
you, Senator Warren, for asking that question. It is something
we do struggle with every day. Up to 20 percent or more of
residents of Tennessee, suffer from some sort of behavioral
health disorder for which they need care. And primary care
provides a good portion of this, but we are not equipped to
deal with complex cases, and it is challenging for us to get
patients in to see a provider in an efficient way. And so it is
something we struggle with every day.
Senator Warren. Very helpful to know. Are primary care
providers able to provide some of this care or provide
appropriate referrals, or do they need more support to be able
to do this?
Dr. Kripalani. We absolutely need more support. Although we
are able to manage a good bit of some of the simpler, more
simple depression and anxiety cases, there are some more
complicated medical and mental health issues that require
specialist care. It can take months to get in. Many of the
behavioral health specialists in Tennessee do not accept
insurances and they require private pay or cash pay up front.
And so, that further limits the patient's ability to get in
with them. So, it is a further barrier.
Senate Warren. Yes, thank you. Thank you. That is very
useful information. You know, it is clear that providers in
primary care settings could also use more guidance on this.
Luckily, there are some unique models that we can look to. Dr.
Bennett, you have done a lot of work to train primary care
physicians in geriatric care through Project ECHO. Can you
explain what this program is and how it might be used to meet
other needs like general behavioral health needs?
Dr. Bennett. Thank you for your question, Senator Warren.
Project ECHO is really meant to reduce disparities. It helps
information that is otherwise monopolized by specialists get to
primary care so that patients can get the care directly from
their primary care provider. So, through video mentoring and
case consultations, these primary care providers, over time,
buildup that knowledge base. It is perfectly well suited for
shortage areas such as behavioral health, and it has been
already successfully used for that. There are behavioral health
ECHOs that have trained providers in prescribing those
medications for addiction that have been very successful.
Senator Warren. Good. That is very helpful. You know, in
Massachusetts, the Boston Medical Center has an ECHO program
that does exactly what you are describing, helping providers in
primary care settings across the state provide addiction
treatment. There are other unique programs as well at Boston
Children's Hospital. The Adolescent Substance Abuse Program
partners with primary care practices around the state to get
addiction expertise right where it is needed in the local
doctor's office. Our health care providers are getting really
creative, and they are working hard to provide their patients
with the behavioral health care they need, but they need more
support and training. I am committed to helping our frontline
doctors, nurses, social workers, and other mental health
providers get the support that they need. So thank you all for
being here today.
The Chairman. Thank you, Senator Warren.
Senator Baldwin.
Senator Baldwin. Thank you. So, patients face a number of
obstacles when it comes to accessing the care that they need,
and it is especially true when it comes to expectant mothers. I
worked with my Senator Ryan and colleague Senator Murkowski, to
enact recently the Improving Access to Maternity Care Act to
help reduce maternity care shortages in rural and underserved
communities. It impacts all of our constituents, but I remember
hearing from a Wisconsinite, Rachel, who is a mother who lives
in Sister Bay in Door County. She had to drive 90 minutes while
in labor to the city of Green Bay just to find a doctor who
could deliver her baby.
Our recently enacted legislation enables the health
resources and services administration, HRSA, to begin
collecting data on shortages of maternity care providers,
similar to the data that they already collect on primary care
provider shortage areas. It is going to allow us to better
target our human resources through the National Health Services
Corps and enhance patient care. Dr. Bennett, you shared how
data has allowed you to advance and monitor improvements in the
delivery of care and patient outcomes for our older adults. And
so, I wonder if you could describe how existing data from our
Federal agencies, including HRSA, has informed the development
of the Project ECHO model around the country, and specifically
interested in knowing where you have identified gaps in the
data that is collected that this Committee should be aware of--
that would be helpful for our Nation to collect?
Dr. Bennett. When we all created our geriatric workforce
enhancement programs the first time around, we all did local
needs assessments in our areas to see what was needed for the
older adults in that region. Most of that aligned across the
country. A lot of the data collected has to do with how many
people were training and does not really get at outcomes. But
this time around, the application for the Geriatrics Workforce
Enhancement Program is having us look at outcomes and helping
us collect information about, are we moving? Are we increasing
referrals to caregiver resources for people with dementia? Are
we screening for falls? Are we reducing Opioid--are we
addressing Opioid misuse in older adults? And all of these
things will help us change the services that we create and
change the education we create, in order to improve the care of
older adults.
Senator Baldwin. Excellent. Our family caregivers play an
enormous role in a largely unrecognized and largely unkempt,
uncompensated fashion, but they so help our Nation's elderly
and disabled. The last data collected on family caregivers
suggested that 40 million family caregivers provided an
estimated $470 billion in uncompensated long-term care in 2013.
It is an issue that is personal to me because I was raised by
my maternal grandparents, and a much younger woman served as my
grandmother's primary caregiver as she grew older and more
frail. And it is why I worked with Senator Collins on the
Committee to enact our Raise Family Caregivers Act, which more
formally recognizes family caregivers.
That bill is just beginning to be implemented, and so Dr.
Bennett, I wanted to ask you, given the growing population of
older adults and the workforce shortages that you have given
voice to, what should we be doing to ensure that our older
adults and our loved ones with disabilities receive the highest
quality of care in their own homes? And how do you see the need
to empower family caregivers?
Dr. Bennett. Supporting family caregivers is central to the
Geriatric Workforce Enhancement Program, and one of the main
foci, in addition to improving geriatrics and primary care. And
a partnership with the Area Agencies on Aging is essential to
solve this problem because they already have fantastic family
caregiver support programs that have been proven to delay
nursing home placement by up to 2 years. But primary care does
not connect as well as it could with triple A's, and that is a
huge part of the solution.
Senator Baldwin. Okay. I am out of time.
The Chairman. Thank you, Senator Baldwin.
Senator Scott.
Senator Scott. Thank you, Mr. Chairman. And thank you to
the panel for being here with us this morning. As the greatest
provider of health insurance in the country, it makes sense
that employers are looking for innovative ways to contain costs
while ensuring a high level of care for their employees. A few
years ago, Boeing established the Preferred Partnership
Program, which allows the company to contract directly with
health systems like Roper, St. Francis in Charleston to provide
coordinated care specifically tailored to their employees.
The company discovered that they can improve health
outcomes and lower costs by integrating primary care with
behavioral health, and focusing on the 5 percent of the
employees mostly with chronic conditions that produce nearly 50
percent of the costs. Boeing is also one of many employers in
my state, including Volvo, BMW, Detyens Shipyard in North
Charleston that provide care to their employees. And in some
instances, even their families benefit from the care through
these onsite clinics. Ms. Watts, what can we do to ensure that
employers have the ability to continue to innovate in this
space?
Ms. Watts. Thank you, Senator Scott, for the question and
the story that you told about the work that Boeing is doing is
also documented in our white paper. We have seen growth in the
use of onsite clinics, and I specifically cited survey data for
larger employers, but we are actually seeing take up with that
with smaller employers as well. We are at a point now where, on
your own, you could have an onsite clinic with as few as 500
employees in a location. And there are also instances where
several employers will get together and have an onsite or near-
site clinic that several of them sponsor.
For all the reasons stated, it does help reinforce the
value of primary care, as well as providing very necessary
support for chronic conditions. So the things that could help
support that would be, first of all addressing the fact that we
cannot provide first-dollar coverage for certain services in
HSA eligible plans, which has been mentioned. Also onsite
clinics, the cost of them are included in the calculation for
the Cadillac tax threshold, and even though that continues to
be delayed, as that approaches, as the date for that
approaches, employers are going to have to look really hard at
where they are making their investments and whether or not that
will continue to make sense.
Senator Scott. Thank you very much. Mr. Chairman, thank
you.
The Chairman. Thank you, Senator Scott.
Senator Jones.
Senator Jones. Thank You, Mr. Chairman. Thanks to all our
witnesses for coming here today. And I especially appreciate
the testimony regarding telehealth, and ECHO program, and
things because I think telehealth is a way that we can really,
in today's world, get good quality health care into our rural
areas. But when it comes to barriers, we also have a barrier in
rural Alabama, in rural America, for lack of broadband. So, I
hope that as you continue to advocate for telehealth, you will
advocate for Members of Congress and state legislatures around
the country to increase access to broadband, because I think it
is very important.
Following on that, Dr. Kripalani, there are a couple of
other barriers, and you kind of touched on the fact that it
would be great to get more people being seen in their homes,
but it seems to me that one of the barriers that we have got is
the originating site rules with reimbursements and that sort of
thing. And I would like for you to just comment on that and how
that might--removing those, might help in this entire area? And
you might want to just explain for the record a little bit of
what that originating site rule is.
Dr. Kripalani. Thank you, Senator Jones. Yes, so the
originating site rule states that in order to provide
telehealth services, a patient must present to a rural health
clinic site that has been deemed an area of a low position
coverage, and a--basically a site that is considered rural. And
then that clinic site can then communicate via telehealth to a
providing site that can then basically connect as a physician-
physician or a clinic-to-clinic type of service.
I think this poses a great barrier to patients, because I
think a great percentage of patients who would most benefit
from telehealth services are those who have limited
availability for transportation. And providing a service that
will cover clinic-to-clinic coverage does not eliminate the
transportation that patient has to provide to get from their
home to this clinic site--to this originating site. So, that
still continues to provide a major barrier for patients.
Senator Jones. All right, and if we--that just kind of fits
into your model about trying to get more people into their
homes. And transportation is always a problem, not just the
cost, but sometimes just physical transportation is a big deal.
Dr. Umbehr, I wanted to--I really appreciate your taking the
time to talk to us about the Direct Care Model. One of the
concerns that folks have expressed a lot in the last year
especially concerns pre-existing conditions, and what
protections in your model, the Direct Care Model, do people
with direct care memberships have that their membership may not
be terminated after they develop some type of time-intensive
health care condition?
Dr. Umbehr. It is a good question. What I would say is,
what is the ability of a physician in an insurance accepting
model to do the same thing? They have more incentives to see
more patients who are less complicated in less time. So the
insurance accepting provider is penalized extensively more by
spending 30 or 60 minutes with a patient when they should be
seeing four, five, six patients per hour. The Direct Care Model
is trying to maximize that value.
One, you will have a reputation of not being able to care
for sick people, and then essentially that is going to hurt the
brand, but also if you can show that you can take care of sick
people, then you will develop a reputation and brand for being
a good provider and everybody wants to know that their doctor
is capable. But also, as we accept patients, we do not know who
is going to be sick and who is not, so we accept them all. And
yes, some will develop complicated cases, but we develop
relationships with these patients, with their employers. I
think it would be inconsistent of the physician oath to just
drop a patient because they have become complex. We continue to
work with them. We may be able to do all their care. We may be
required to work with a specialist. But again, actually, I
think it is the current model that incentivizes doctors to
accept easier patients over complex patients.
Senator Jones. Right. Well, thank you. Thank you all again
for coming here. Mr. Chairman, thank you very much.
The Chairman. Thank you, Senator Jones.
Senator Murray, you have any other comment?
Senator Murray. I would just like to thank all of our
panelists. It has been a very interesting focus today and you
have all really contributed a lot, and we thank you for that.
The Chairman. Thank you, Senator Murray. I just have one
question, Dr. Umbehr or anyone. I want to make sure I
understand this. You are saying that a doctor may buy
prescription drugs directly from the wholesaler----
Dr. Umbehr. Correct.
The Chairman ----at these remarkably lower prices?
Dr. Umbehr. Any physician in 44 states can do it.
The Chairman. State law allows it in 44 states?
Dr. Umbehr. Yes. Any pharmacist could do it in all 50
states. As an example, of speaking to the cost of diabetic
care, a glucometer, brand new, is $0.02.
The Chairman. Well, what about insulin? We hear a lot about
insulin.
Dr. Umbehr. Insulin does not have a generic and they fight
hard against that.
The Chairman. It is the generic----
Dr. Umbehr. Well, when there is a generic, there is
competition. And so now, you might have four or five generic
manufacturers creating a blood pressure medicine. And so now,
they do not have a corner on the market, much like we saw with
the EpiPen issue. Once they have a corner on the market, the
price goes up.
The Chairman. But most drugs purchased are generic drugs
now, right? 85, 90 percent. But, you can go--but the prices you
gave are tremendously different prices. Is the price at the
wholesaler the list price that the wholesaler paid the
manufacturer, or less than that, or more than that?
Dr. Umbehr. Well, the manufacturer would sell it to the
wholesaler. I would assume that a keystone markup of 50
percent, but then the manufacturer does not want to do the
legwork of working with individual physicians, pharmacists,
hospital----
The Chairman. Yes, but let me go back, so there is a list
price, that is the manufacturer's published list price. What
does the wholesaler pay the manufacturer typically?
Dr. Umbehr. Less than our price.
The Chairman. Less than your price?
Dr. Umbehr. The prices are in my testimony----
The Chairman. The wholesaler must pay a lot less than the
list price.
Dr. Umbehr. Exactly.
The Chairman. Then charge you some markup.
Dr. Umbehr. Our exact price from the wholesaler is in our
written testimony. We mark everything up 10 percent. That
covers the $0.03 in the label, the $0.10 in the bottle, and the
2 percent in credit card fees, typically. So for us, it is a
pass-through--very Costco-esque. It is our way of creating
value that helps to justify the----
The Chairman. Well if any doctor can do that in 44 states,
why do not more do that?
Dr. Umbehr. Most do not know they can. Most pharmacists do
not know they can. Most physicians are in a system where they
are seeing 30 people a day and doing all the paperwork.
The Chairman. Wait a minute, they do not know they can go
to the wholesaler and buy prescription drugs at that--much less
expensively?
Dr. Umbehr. As the Senator alluded to earlier, just
shedding light on this topic would be revolutionary. Most
physicians still are surprised to find out what the true
wholesale price of medicines are, which is why we try to be so
upfront with our data. We are making bold claims and we want to
back that up with transparent data to show the true cost of
care.
The Chairman. Well one of the problems with transparency
is, as we found out with the Medicaid or Medicare published
price, are incomprehensible to most people, but I think, on the
other hand, at least it gives some nonprofit, or Bluebook, or
somebody a chance to arrange that data in a way that an
ordinary primary care physician could figure out what the
prices are. Is that true?
Dr. Umbehr. At our level of transparency, I do not think
those things are necessary. The last time I went to Best Buy to
buy a TV, the gentleman said we price quote, let me go see if
anyone sells it cheaper, and we will match that price. He did
not want me to leave the store.
The Chairman. Well, can you do that? Can you do that with
prescription drugs?
Dr. Umbehr. You cannot do that at the pharmacy because of
gag orders.
The Chairman. But the gag orders we just repelled.
Dr. Umbehr. Sure, but now it is hard still to shop because
the pharmacist is not as interested in getting the lowest
price, they are interested in the sales price.
The Chairman. But you could go to the wholesaler.
Dr. Umbehr. The physician can, not the patient. So by the
physician in this model doing less insurance paperwork, we have
more time to fold that service in. So, we can go to the
wholesaler for the patient and pass that to them.
The Chairman. Okay. Let me thank the witnesses. Senator
Murray and I were just talking about how useful your testimony
has been today and you could see from the large number of
Senators who came and asked good questions. We appreciate it.
We are looking for specific suggestions, and many of you have
given us specific suggestions. In other words, we see the
problem and we are beginning to understand it better. So, we
need to know exactly, what can we do to help? So the more
specific you are, as some of you have already been, the more
help it will be to us as we see if we can agree on some steps
to take. The hearing record will remain open for 10 days.
Members may submit additional information for the record within
that time if they would like.
Our Committee will meet again on Tuesday, February 12th at
10 a.m. for a hearing on managing pain during the Opioid
Crisis. Thank you for being here today. The Committee will
stand adjourned.
[Whereupon, at 12:02 p.m., the hearing was adjourned.]