[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.''
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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.
____________________