[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
                                
                                
                                
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                               _____                      


             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
                   
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    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.]

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