[Congressional Record Volume 144, Number 11 (Thursday, February 12, 1998)]
[Senate]
[Pages S679-S682]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                          HEALTH CARE QUALITY

  Mr. NICKLES. Mr. President, I want to make some statements dealing 
with health care. There has been a lot of discussion on health care and 
improving the quality of health care. Some of our colleagues have 
introduced legislation dealing with the quality of health care. I think 
that is important. But I think it is also very important that we 
actually improve quality, not improve the number of regulations.
  Today, Mr. President, Americans enjoy the highest quality of health 
care in the world.
  In 1993, President Clinton proposed a plan that would have devastated 
health care quality. It would have limited the amount of health care 
that Americans could receive by limiting the amount of money, whether 
private or public, that could be spent on health care services. It 
would require that everyone have the same one-size-fits-all package of 
health insurance benefits. And it would have enrolled everyone in 
managed care plans.
  Had President Clinton had his way, Americans would now be trapped in 
a health care system with the efficiency of the post office and the 
compassion of the IRS at Pentagon prices. The Republicans led the fight 
against President Clinton's health care plan because we believe 
Americans deserve the best. We believed it then and we believe it 
today.
  Now President Clinton wants to lead an assault on private managed 
care plans. The man who wanted to put everyone in an HMO now wants the 
Government to wage war on HMOs. That is a pretty dramatic change. But 
one thing has not changed: President Clinton still wants Government-run 
health care. As he said to the Service Employees International Union 
less than 5 months ago regarding his rejected universal health care 
program:

       If what I tried before won't work, maybe we can do it 
     another way. That's what we've tried to do, a step at a time, 
     until we eventually finish this.

  President Clinton is now attempting to impose on you his newest 
attempt at Government-run health care and masking his efforts with the 
name ``quality.''

[[Page S680]]

  Mr. President, Republicans want only the highest quality health care. 
But I have not seen anything to convince me that bigger Government, 
more regulations, and expanded bureaucratic control is the means to 
higher quality.
  Look at just one example of Government-controlled health care: The 
Medicare system. I am a member of the Finance Committee, the tax-
writing committee of the Senate. We have been looking at the IRS and 
its treatment of taxpayers. There are 12,000 pages that deal with tax 
policy. I might mention, that is about 10 times the size of the Bible 
and, unlike the Bible, has no good news.
  Well, there are 12,000 pages dealing with tax policies. That is a 
lot. But, Mr. President, do you know how many pages govern Medicare? 
Forty-five thousand, about four times as much as we have on tax policy. 
That comes from Dr. Robert Waller, the Mayo Clinic, Health Care 
Leadership Council. Forty-five thousand pages, yet the system is 
archaic, inefficient, and on the path of bankruptcy despite 
astronomical tax increases.
  We know many people have believed they were denied coverage that 
their plans were supposed to cover. We recognize that some individuals 
fear that their health care plans will not give them access to 
specialists when they need them. We know that some Americans think 
their health care plans care more about cost than they do about 
quality. These are real fears of unacceptable conditions. We must do 
better. I think we can do better.
  But the way to do better is not by politicizing health care quality 
or entrusting Government bureaucrats with policing health insurers. The 
way to do better is to emphasize what makes our system the best in the 
world--employers who insist their employees have access to the best 
plans, doctors and hospitals who aspire to excellence, and informed 
consumers who will not settle for anything less than the best. Quality 
health care cannot be managed and directed from Washington, DC.

  Unfortunately, Mr. President, in the rush to respond to both real and 
perceived problems in managed care, members of both parties have 
introduced comprehensive proposals which potentially threaten--not 
enhance--the quality of health in our health care system.
  Some of my colleagues may ask how I can make such a statement. You 
only have to look back to the end of the 104th Congress to illustrate 
my point. A majority of Congress supported an effort last year to 
mandate that all insurance plans cover 48-hour maternity stays in 
hospitals. Many of my colleagues on both sides of the aisle felt that 
it was socially unacceptable to discharge newborns and mothers from the 
hospital after only 24 hours and crafted legislation largely around 
social opinion.
  Many Members felt great about voting for something positive for women 
and children. However, several months following the passage of that 
legislation an article appeared in the Journal of the American Medical 
Association. And here is what the clinical researchers and physicians 
had to say about what Congress accomplished.

       While the spirit of the current legislation may be 
     laudable, its content does not solve the most important 
     problems regarding the need for early postpartum/postnatal 
     services.
       The legislation may give the public a false sense of 
     security. It may call into question the reasonableness of 
     relying on legislative mechanisms to micromanage clinical 
     practice.
       Good clinical judgment, based on careful consideration of 
     available evidence, suggests that the difference between a 
     postpartum stay of 24 hours and a stay of 48 hours is 
     unlikely to be a critical determinant of newborn or maternal 
     health outcomes.

  In other words, Congress made a nice, laudable attempt. We said we 
are going to mandate 48 hours, but it has had no appreciable 
improvement on the quality of health care.
  It appears that our so-called victory in passing 48 hours may have in 
fact done more harm than good in helping women and newborns. This 
experience, and others like it, should have taught us what not to do. 
So what should our guiding principles be? I believe that there are 
three.
  Whatever the proper role for Government in the health care debate, we 
must assure that it does not increase health insurance premiums, reduce 
the number of people who have health insurance coverage, or create 
massive new bureaucracies that will harm health care quality.
  Why are these things important? Well, let us take a look at cost. We 
have a bill pending in Congress--the Patients Access to Responsible 
Care Act--and that is a pretty nice title. It is one of many that 
attempts to address health care by expanding Government control. But a 
recent study concluded that provisions in that bill alone would raise 
premiums by an average of 23 percent. That was done last year, 1997, by 
Milliman and Roberts.
  Let us take a look at what that means. To the average family, that is 
an increase of about $1,220 per year. That is over $100 per month. That 
is real money. And I think a lot of families cannot afford that.
  Cost is a very real issue. We do not want health care costs and 
prices to rise. We already know from the Congressional Budget Office 
that without any additional regulations at all, the growth in private 
health care premiums will be about 5.5 percent in 1998. That is up from 
3.8 percent in 1997. So why in the world would we want to do anything 
that would accelerate the increase? I do not think we should.
  No. 2, we do not want to do anything that will drive people from 
health insurance.
  For a long time we have heard people beat up employers for not 
offering health care to their employees. But what are the facts? Well, 
someone looked into it and now we know that more employers than ever 
are offering health insurance. The problem is that employees are 
choosing not to take advantage of it because of cost. That came out 
from a study in 1997 by Cooper and Schone.

  A separate study concludes that every 1 percent increase in private 
health insurance premiums results in 400,000 additional uninsured 
Americans. That was from a 1997 Lewin study. So, 400,000 additional 
uninsured Americans every time health insurance premiums increase 1 
percent in real terms.
  Now, wait a minute. If the PARCA bill--the Patient Access to 
Responsible Care Act--is estimated to increase costs by 23 percent, and 
every one of those percentage points equals 400,000 additional 
uninsured Americans, my calculations work that out to over 9 million 
Americans would lose their health insurance.
  Mr. President, we do not want to do that. That may not be sound 
science, but the potential for such an outcome would be a disaster. It 
is too big of a gamble, in my opinion. Higher prices and more uninsured 
Americans does not sound like better health care quality to me. So let 
us not do that.
  Thirdly, and finally, we want to make sure that the very best entity 
is monitoring the health care industry. And what are the options?
  Many in Congress seem to think the answer is Government, so let us 
talk about Government overseeing health care. I can think of a few 
examples of the government's bad track record. We have the Indian 
health care in New Mexico and Oklahoma. There is an Indian hospital in 
Oklahoma right now that provides, I am going to say, pathetic service. 
And it happens to be bankrupt. We have had this problem, in addition to 
Medicaid and veterans hospitals and on and on and on. I mention that 
Government facilities, 100 percent Government-run facilities, are not 
the solution. It is probably some of the poorest quality of health 
care, not the best quality of health care. We want to improve quality, 
not reduce quality.
  Some of the Nation's leading health care facilities today are 
expressing their concerns about Government oversight. I am thinking of 
the Mayo Clinic, Baylor Health Care System, and the Cleveland Clinic. 
They are all raising their voices in opposition to more Federal 
regulation of health care quality. I would like to share with my 
colleagues a few of their comments. I will ask unanimous consent that 
their letters be printed in the Record following my statement.
  Baylor Health Care System--I will just read a couple of the 
paragraphs. It says:

       There has been an enormous commitment on the part of Baylor 
     Health Care System and providers throughout the country to 
     evaluate and put in place the processes for continuous 
     quality improvement. We believe it must be done at this 
     level. Providers of care are in the unique position, based on 
     their personal commitment to the well-being

[[Page S681]]

     of the individual patient, to drive quality improvement 
     initiatives. Nothing could stifle innovation quicker than 
     external mandatory standards.

                           *   *   *   *   *

       We strongly believe that the private sector is heavily 
     committed and working very diligently on continuous quality 
     improvement and that this will bring about the best outcome 
     for the patients and communities we serve.

  The Cleveland Clinic--one paragraph says:

       Second, we are already subject to extensive federal, state 
     and private regulations through oversight by private payors 
     and accrediting bodies. Adding yet another layer of 
     regulation will only further complicate matters, add 
     administrative costs to our organization, and in all 
     likelihood have little or no effect on the actual quality of 
     care provided.

  Dr. Bob Waller of the Mayo Clinic has stated:

       Quality is a continuous process that must be woven into the 
     fabric of how we think, act and feel. Government regulation 
     places a stake in the ground that freezes in place a quality 
     standard that may become obsolete very quickly. The 
     Government simply cannot react quickly to the changing 
     quality environment. The goal of quality is to 
     continuously improve patient care--not to achieve some 
     defined regulatory standard.

  On January 28, several organizations--including the Joint Commission 
on Accreditation of Health Care Organizations, the National Committee 
for Quality Insurance and the American Medical Association--sent a 
letter to the President and Republican leadership stating their concern 
and opposition to the Federal Government preempting the private sector 
and creating new Federal agencies and entities. Specifically, they said 
quality would:

       * * * become hamstrung by political considerations, with 
     the practical effect of retarding innovation and advance in 
     the field of accreditation and performance measurement. In 
     our experience, the private sector is more capable of keeping 
     pace with the rapid changes in health care delivery and 
     medical practice that affect quality of care considerations. 
     Therefore, we cannot support proposals that might have the 
     unintended effect of undermining marketplace incentives for 
     rigorous accreditation programs and robust performance 
     measures.

  Mr. President, I don't think the Government is the best caretaker of 
health care quality. I'm much more inclined to trust the independent 
organizations like the Joint Commission on Accreditation of Health Care 
Organizations and the National Committee for Quality Insurance. Because 
the Government alternatively leaves oversight to the folks at the 
Department of Labor and the Health Care Finance Administration--who, I 
might mention, took 10 years to implement a 1987 law establishing new 
nursing home standards; who have not bothered to change the fire safety 
standards for hospitals since 1985; and--in a most egregious instance--
who are running end-stage renal disease facilities under Medicare using 
1976 health and safety standards.
  I think the answer is plain. We will not and we must not create 
massive new bureaucracies that will harm health care quality.
  We have a real challenge ahead. We have to figure out how we can best 
address the very real complaints and concerns of the American people 
while not rushing to pass legislation that will exacerbate the problems 
or create new problems altogether.
  To that end, our majority leader has instructed me to take a hard, 
honest look at issues that affect health care quality. At his 
instruction, I have put together a health care quality task force to 
examine the problems in our current system. Senators Roth, Chafee, 
Coats, Collins, Frist, Santorum, Hagel and myself will be working 
together to find real answers to hard questions.
  I know some of my colleagues have introduced legislation and they 
have very good intentions. We want to work with those colleagues, but 
again we want to make sure that we don't pass legislation that 
increases health care costs, we want to make sure we don't pass 
legislation that will put millions of people into the uninsured 
category for the first time. That would be a real mistake, and we don't 
want to pass legislation that will increase bureaucracy and reduce 
quality health care.
  Mr. President, we have a big challenge: We will ask what the real-
life impact of proposals like PARCA and President Clinton's Consumer 
Bill of Rights has on cost and on coverage. What will it mean to 
quality? We will ask whether Americans, given the choice, would rather 
have cutting edge institutions like Johns Hopkins setting trends in 
health care quality or the folks at the Department of Labor, or the 
Health Care Finance Administration. We will ask whom Americans should 
trust to monitor health care quality. Should the Federal Government do 
it or independent organizations who have been studying the issue and 
setting the pace for many years?
  It is incumbent upon us as elected leaders to address these questions 
fairly, honestly, openly, and with an eye toward what is best for the 
health of a nation and not what is politically expedient.
  Our objective at the very minimum is to do this: Ensure that Congress 
in its haste to do good does not cause an increase in the cost of 
health insurance, that we do not pass legislation that will 
unintentionally force individuals to give up their coverage, and we 
want to protect consumer quality by ensuring that the best possible 
caretakers are monitoring the quality of your health care, and not 
bureaucrats at the Department of Labor or at HCFA.
  Mr. President, I want to make something very clear. This Republican 
Congress will not hijack the quality of our Nation's health care for 
political gain. We will, however, thoroughly and thoughtfully debate 
this issue and ensure that Americans continue to enjoy the highest 
quality health care in the world.
  I ask unanimous consent the letters previously mentioned be printed 
in the Record, in addition to a letter that is signed by the American 
Medical Accreditation Program, the Joint Commission on Accreditation of 
Health Care Organizations, and the National Committee for Quality 
Insurance.
  There being no objection, the letters were ordered to be printed in 
the Record, as follows:

         American Medical Accreditation Program,
                                                 January 28, 1998.
     Hon. Don Nickles,
     Senate Majority Whip and Assistant Majority Leader,
     Washington, DC.
       Dear Majority Whip Nickles: As the nation's leading 
     independent health care accrediting organizations, we are 
     writing to recommend an alternative approach to certain 
     quality oversight provisions contained both in proposals now 
     before Congress and in the preliminary recommendations of the 
     Presidential Advisory Commission on Consumer Protection and 
     Quality in the Health Care Industry.
       First, we would like to commend both this Congress and the 
     Commission for taking up the issue of health care quality and 
     consumer protections. Our health care system continues to 
     undergo dramatic change, and there is a pressing need to 
     answer the public's concerns with better information, 
     improved oversight, and increased choice. Critical to these 
     efforts will be enhanced consumer protections, and all three 
     of our organizations stand ready to work with this Congress 
     and the Administration to see that this happens.
       Separate from the issue of consumer rights and protections, 
     however, is the attempt by some to preempt private sector 
     accreditation and performance measurement activities with 
     proposals that favor the creation of new federal agencies and 
     entities. Because these proposed federal agencies and 
     entities would be charged with establishing minimum criteria 
     for accreditation and core sets of performance measures, we 
     have a keen interest in their potential outputs. Our basic 
     concern is that this output will become hamstrung by 
     political considerations, with the practical effect of 
     retarding innovation and advances in the field of 
     accreditation and performance measurement. In our experience, 
     the private sector is more capable of keeping pace with the 
     rapid changes in health care delivery and medical practice 
     that affect quality of care considerations. Therefore, we 
     cannot support proposals that might have the unintended 
     effect of undermining marketplace incentives for rigorous 
     accreditation programs and robust performance measures. We 
     believe that the work of accreditors should be highlighted 
     and encouraged.
       As an alternative to these new federal bureaucracies, we 
     are intent on together developing a comprehensive quality 
     measurement and reporting strategy that engages consumers and 
     private and public sector purchases; minimizes duplication; 
     and maximizes the incentives for organizations and 
     individuals to undergo accreditation and report standardized 
     performance information. Our organizations have recently 
     engaged in some noteworthy collaborative efforts such as the 
     National Patient Safety Foundation; the Joint NCQA-JCAHO Work 
     Session on Protecting Patient Confidentiality in a Managed 
     Care Environment; cross-representation on the AMAP governing 
     body; and coordination among our respective performance 
     measurement councils. We intend to build on these ventures 
     and ones already ongoing with others to keep excellence in 
     patient care our number one priority.

[[Page S682]]

       We believe the federal government should reward high 
     quality health plans and providers. As the largest purchaser 
     of health care services, the federal government must take a 
     leadership role in value-based purchasing. The federal 
     government is already benefiting from closer coordination 
     with private sector accreditation bodies, and the Balanced 
     Budget Act of 1997 contains provisions for even greater 
     collaboration. However, in addition to using those private 
     sector accreditation and performance measurement tools 
     developed by organizations such as ours, the federal 
     government must progressively adopt the posture of leading 
     private-sector purchasers and insist on high quality care for 
     the 67 million Medicare and Medicaid beneficiaries and the 9 
     million federal employees, retirees, and their dependents.
       We appreciate your consideration, and stand ready to work 
     with this Congress and the Commission to build upon the 
     successes of private sector accreditation without interfering 
     in the operation of a marketplace that has produced programs 
     as rigorous as ours. Please do not hesitate to contact any of 
     our offices.
           Sincerely,
     Dennis S. O'Leary, MD,
       President, Joint Commission on the Accreditation of 
     Healthcare Organizations.
     Margaret E. O'Kane,
       President, National Committee for Quality Assurance.
     Randolph D. Smoak, Jr., MD,
       Chair, American Medical Accreditation Program.
                                  ____



                                    Baylor Health Care System,

                                    Dallas, TX, February 11, 1998.
     Hon. Don Nickles,
     Assistant Majority Leader, U.S. Senate,
     Washington, DC.
       Dear Senator Nickles: First, let me thank you very much for 
     your leadership and for your commitment to health related 
     issues, specifically the matter of quality health care.
       There has been an enormous commitment on the part of Baylor 
     Health Care System and providers throughout the country to 
     evaluate and put in place processes for continuous quality 
     improvement. We believe it must be done at this level. 
     Providers of care are in the unique position, based on their 
     personal commitment to the well being of the individual 
     patient, to drive quality improvement initiatives. Nothing 
     could stifle innovation quicker than external mandatory 
     standards.
       Quality improvement is the key strategic objective for 
     Baylor Health Care System. An example is the creation of our 
     Institute for Quality which is driven by the board of 
     trustees, physicians and senior management and extends 
     throughout our organization. On a community level, we are 
     involved with the Dallas-Ft. Worth Business Group on Health 
     in building quality initiatives.
       We strongly believe that the private sector is heavily 
     committed and working very diligently on continuous quality 
     improvement and that this will bring about the best outcome 
     for the patients and communities we serve.
       Again, we appreciate your support and look forward to 
     working with you on this important issue.
           Sincerely yours,
                                                Boone Powell, Jr.,
     President.
                                  ____



                                  Cleveland Clinic Foundation,

                                 Cleveland, OH, February 11, 1998.
     Hon. Don Nickles,
     U.S. Senate, Washington, DC.
       Dear Senator Nickles: The Cleveland Clinic Foundation, a 
     not-for-profit health care organization devoted to patient 
     care, education and research in care for the ill, has serious 
     reservations about many of the bills now pending in Congress 
     to regulate quality in health care delivery. Our reservations 
     are twofold.
       First, quality is an elusive matter to quantify. 
     Individual's versions of quality may vary considerably from 
     their perspective of the health care system. A physician's 
     emphasis, for example, is on the content of the care 
     provided; a patient may judge quality more by the process of 
     care delivered. In both instances, the standards are in flux 
     as both the quality and process are constantly changing in 
     response to new learning and new ways of better relating to 
     patients and their families.
       Second, we are already subject to extensive federal, state 
     and private regulations through oversight by private payors 
     and accrediting bodies. Adding yet another layer of 
     regulation will only further complicate matters, add 
     administrative costs to our organization, and in all 
     likelihood have little or no effect on the actual quality of 
     care provided.
       We would urge that Congress proceed cautiously as it begins 
     its debate about whether federal authority should be expanded 
     in this important but necessary complex area of patient care.
           Sincerely,
                                               Floyd D. Loop, M.D.

  The PRESIDING OFFICER. Under the previous order, the Senator from New 
Mexico is recognized to speak up to 45 minutes.
  Mr. DOMENICI. Mr. President, I may not use that 45 minutes. I expect 
five or six Senators to join me and they have given me their 
statements. If they do not come I will place their statements in the 
Record.
  (The remarks of Mr. Domenici, Mr. Cleland, Mr. Dodd, Mr. Cochran, Ms. 
Mikulski, and Mr. Kempthorne pertaining to the introduction of S. Res. 
176 are located in today's Record under ``Submission on Concurrent and 
Senate Resolutions.'')
  Mr. BYRD addressed the Chair.
  The PRESIDING OFFICER (Mr. Hagel). The Senator from West Virginia is 
recognized.
  Mr. BYRD. Mr. President, how much time do I have?
  The PRESIDING OFFICER. The Senator has one hour.
  Mr. BYRD. Mr. President, I ask unanimous consent that any time that I 
do not use of my hour be reserved for later in the day.
  The PRESIDING OFFICER. Without objection, it is so ordered.

                          ____________________