[Congressional Record Volume 149, Number 176 (Tuesday, December 9, 2003)]
[Senate]
[Pages S16137-S16140]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mrs. CLINTON:
  S. 2003. A bill to amend the Public Health Service Act to promote 
higher quality health care and better health by strengthening health 
information, information infrastructure, and the use of health 
information by providers and patients; to the Committee on Finance.
  Mrs. CLINTON. Mr. President, today, I am introducing a bill that 
seeks to begin a dialogue on one of the most important yet neglected 
aspects of our health care system--health care quality. this is an 
enormous issue that affects every single one of us who has ever needed 
medical care, and it affects all taxpayers because quality care has 
such potential to avoid waste and save millions of dollars in health 
care costs. I have raised many of these ideas as amendments in other 
contexts, such as the Medicare debate on S. 1, and the debate over S. 
720, the Patient Safety and Quality Improvement Act of 2003. I intend 
to continue working with my colleagues on improving these ideas and 
proposing additional concepts. But with this bill today, I seek to put 
forward a package of ideas, provoke conversation, and present this as a 
first step in making quality a focus of my health care efforts next 
year. My goal with these efforts is to both improve quality and 
outcomes, and reduce costs by encouraging care that is more effective.
  There is no reason why we cannot achieve this. We have the most 
advanced medical system in human history--the finest medical 
institutions, the newest treatments, the best trained health care 
professionals. But in spite of the best intentions of clinicians and 
patients, our health care system is plagued with underuse, overuse, and 
misuse. currently, only about 50 percent of care that is known to be 
effective is provided, and the care given is supported by solid 
scientific evidence, and the pace of dissemination of new evidence is 
painfully slow. It may take up to 17 years for treatments found to be 
effective to become common practice.
  Much of the overuse or misuse of health services stems from the 
fragmentation of our system. In a recent study in Santa Barbara, CA, 20 
percent of lab tests and x-rays were conducted solely because previous 
results were unavailable. One in seven hospitalizations occurs because 
information is unavailable, and a shocking percentage of the time, 
physicians do not find patient information that had previously been 
recorded in a paper-based medical record.
  Despite all of our Nation's medical advances, health quality is 
becoming even more endangered in some respects. Nursing care which is 
often shown to be a decisive factor for hospital patient outcomes, its 
in grave shortage, and a majority of U.S. physicians surveyed by the 
Commonwealth Fund perceive their ability to provide quality care as 
having worsened over the last 5 years.
  Additionally, even as the quality of health care we purchase lags, 
our spending on inadequate and wasteful care is spiraling out of 
control. Premiums increased 13 percent last year, and health care costs 
are increasing at nearly 10 times the rate of inflation. To make 
matters worse, the public health system is straining to meet the 
challenges of bioterrorism or emerging infections, the number of 
uninsured Americans is rising, clinicians are leaving practice, and the 
older adult population is set to double by 2040.
  The reason is not because doctors aren't trying hard enough, or 
hospitals are at fault. That we're able to get good health care at all 
is testament to the genius and heroism of doctors and nurses who 
deliver care, despite all the obstacles, despite every effort of the 
system to hinder them.

  But what our medical system requires of providers is a little like 
asking pilots to routinely land planes without any information from the 
control tower. The best of them can do it--they could land a plane with 
one arm around their backs missing key information and confirmations, 
but why force them to do it? Why deny them critical information when it 
could be easily available? There is no plausible reason for denying 
needed information, especially when life and death are at stake.
  That's unfortunately exactly what our health care system says to 
doctors, nurses, and hospitals. Physicians for example spend four years 
in medical school, and then several years more in their residency 
training, cramming medical information into their heads. Then we expect 
them to look at a patient taking four different drugs, with a heart 
condition, and immediately remember any drug-drug interactions that 
could occur. We ask them to do it without looking up any reference 
materials. We ask them to do it in the few minutes that they have with 
each patient given the ever-shorter visits, and ever-increasing patient 
and paperwork load. Moreover, in their free time, they are expected to 
keep up with all the new journal articles and learn about every new 
drug.
  Yet hand-held computers can now allow the doctor to pull up up-to-
date information immediately, right at the bedside, if he or she has 
any question. And NIH spends billions of dollars in research to 
generate that information. Shouldn't that investment reap results for 
the patient as quickly as possible? This bill seeks to provide the 
direction that would support such technology and make it widely 
available to physicians.
  Right now, doctors, nurses, and hospitals are holding the health care 
system up, preventing utter collapse by sheer, heroic, force of will. 
Instead of the clinicians supporting the system, we should build a 
system that supports clinicians instead.
  The premise of this legislation is that information, in the hands of 
the right people at the right time, drives quality and value. We need 
to empower patients and health care providers to make the right 
choices. And to do that, health care decisionsmakers--providers, 
payers, and patients--need to have access to the right information, 
where and when it is needed, securely and privately.
  This legislation seeks to: 1. Generate information about health 
quality through increased research, increased public reporting along 
key quality measures, and standardization of those measures to assure 
comparability and usability of reported information; 2. Ensure that 
payers, providers and patients get information in a usable form so they 
can make effective decisions; and 3. Reduce barriers to the development 
of an IT infrastructure that is so critical to achieving those first 2 
goals.
  Eighty percent of the care delivered today is not backed by sound 
clinical

[[Page S16139]]

research. That is why we need to do more research, and see if the care 
we provide today has sound justification in science. But even where we 
know what to do, we don't always do it because the information is 
insufficiently disseminated and utilized. Studies have shown some 
procedures being performed even when they have not met accepted 
criteria for appropriateness: In one study, of all the non-emergent, 
noncancerous hysterectomies performed, only 30 percent had been 
properly worked up and met the full medical criteria for necessity. In 
another study, about one-fourth of coronary angiographies and upper 
gastrointestinal endoscopies did not meet standards of medical 
appropriateness.

  On the flip side, in situations where the benefits of an intervention 
are clear, many patients do not receive the indicated care: Very few 
hospitalized patients at-risk for pneumococcal pneumonia who had not 
been previously vaccinated end up being vaccinated during their 
hospital stay. Routine peak flow measurements are conducted in only 28 
percent of pediatric patients with asthma. And only one-half of 
diabetics receive an annual eye exam.
  We know what good health care means in these areas, but we don't 
practice it, in part because that information may not be readily 
available, and regardless, there is no incentive for quality. We are 
suggesting--track the outcomes, share that information with patients, 
providers, and insurers, and ultimately, pay for performance.
  This bill will help us become better purchasers of care, and help us 
take the first steps toward aligning the incentives so that higher 
quality is rewarded. I ask unanimous consent that the attached article 
from last week's New York Times be printed in the Record showing how 
our current reimbursement system is gravely misaligned. Under the 
current system, higher quality can be penalized, while worse care can 
ironically be more profitable.
  Today, by introducing these ideas for the purpose of seeking feedback 
from my colleagues and experts in the field, I am taking the first step 
toward improving our health care system for everyone and saving money. 
I invite interested colleagues to join me in partnership on this 
important venture and look forward to taking strong, positive action 
next year to improve health quality for all Americans.
  There being no objection, the article was ordered to be printed in 
the Record, as follows:

                [From the New York Times, Dec. 5, 2003]

     Hospitals Say They're Penalized by Medicare for Improving Care

                           (By Reed Abelson)

       Salt Lake City.--By better educating doctors about the most 
     effective pneumonia treatments, Intermountain Health Care, a 
     network of 21 hospitals in Utah and Idaho, say it saves at 
     least 70 lives a year. By giving the right drugs at discharge 
     time to more people with congestive heart failure, 
     Intermountain saves another 300 lives annually and prevents 
     almost 600 additional hospital stays.
       But under Medicare, none of these good deeds go unpunished.
       Intermountain says its initiatives have cost it millions of 
     dollars in lost hospital admissions and lower Medicare 
     reimbursements. In the mid-90's, for example, it made an 
     average profit of 9 percent treating pneumonia patients; now, 
     delivering better care, it loses an average of several 
     hundred dollars on each case.
       ``The health care system is perverse,'' said a frustrated 
     Dr. Brent C. James, who leads Intermountain's efforts to 
     improve quality. ``The payments are perverse. It pays us to 
     harm patients, and it punishes us when we don't.''
       Intermountain's doctors and executives are in a swelling 
     vanguard of critics who say that Medicare's payment system is 
     fundamentally flawed.
       Medicare, the nation's largest purchaser of health care, 
     pays hospitals and doctors a fixed sum to treat a specific 
     diagnosis or perform a given procedure, regardless of the 
     quality of care they provide. Those who work to improve care 
     are not paid extra, and poor care is frequently rewarded, 
     because it creates the need for more procedures and services.
       The Medicare legislation that President Bush is expected to 
     sign on Monday calls for studies and a few pilot programs on 
     quality improvement, but experts say that it does little to 
     reverse financial disincentives to improving care.
       ``Right now, Medicare's payment system is at best neutral 
     and, in some cases, negative, in terms of quality--we think 
     that is an untenable situation,'' said Glenn M. Hackbarth, 
     the chairman of the Medicare Payment Advisory Commission, an 
     independent panel of economists, health care executives and 
     doctors that advises Congress on such issues as access to 
     care, quality and what to pay health care providers.
       In a letter published in the current edition of Health 
     Affairs, a scholarly journal, more than a dozen health care 
     experts, including several former top Medicare officials, 
     urged the program to take the lead in overhauling payment 
     systems so that they reward good care.
       ``Despite a few initial successes, the inertia of the 
     health system could easily overwhelm nascent efforts to raise 
     average performance levels out of mediocrity,'' they wrote. 
     ``Decisive change will occur only when Medicare, with the 
     full support of the administration and Congress, creates 
     financial incentives that promote pursuit of improved 
     quality.''
       Medicare's top official is quick to agree that the payment 
     system needs to be fixed. ``It's one of the fundamental 
     problems Medicare faces,'' said Thomas A. Scully, who as the 
     administrator of the Centers for Medicare and Medicaid 
     Services has encouraged better care by such steps as 
     publicizing data about the quality of nursing home and home-
     health care and by experimenting with programs to reward 
     hospitals for their efforts.
       But the steps taken so far have been small, and many 
     experts say that rather than paying for more studies, 
     Congress should start making significant changes to the way 
     doctors and hospitals are paid.
       ``They're splashing at the shallow end of the pool,'' said 
     Dr. Arnold Milstein, a consultant for Mercer Human Resource 
     Consulting and the medical director for the Pacific Business 
     Group on Health, an association of large California 
     employers. He would like to see as much as 20 percent of what 
     Medicare pays doctors and hospitals linked to the quality of 
     the care they provide and their efficiency in delivering 
     treatment.
       Two decades ago, Medicare led a revolution in health care. 
     By setting fixed payments for various kinds of treatment--a 
     coronary bypass surgery or curing a pneumonia or replacing a 
     hip--rather than simply reimbursing doctors and hospitals for 
     whatever it cost to deliver the care, it encouraged shorter 
     hospital stays and less-expensive treatments.
       But today, many health care executives say, Medicare's 
     payment system hinders attempts to improve care. Dr. James, 
     the Intermountain executive, said that he wrestled with the 
     situation every day.
       By making sure its doctors prescribe the most effective 
     antibiotic for pneumonia patients, for example, and thereby 
     avoiding complications, Intermountain forgoes roughly $1 
     million a year in Medicare payments, he estimated. When a 
     pneumonia patient deteriorates so badly that the patient 
     needs a ventilator, Intermountain collects about $19,000, 
     compared with $5,000 for a typical pneumonia case. And while 
     it makes money treating the sicker patient, Dr. James said, 
     it loses money caring for the healthier one.
       Nor is Intermountain rewarded for sparing someone a stay in 
     the hospital--and for sparing Medicare the bill. Shirley 
     Monson, 74, of Ephraim, Utah, said that she expected to be 
     hospitalized when she developed pneumonia last year. 
     Instead, Sanpete Valley Hospital, part of Intermountain, 
     sent Mrs. Monson home with antibiotics, and she recovered 
     over the next two weeks. Such visits produce just token 
     payments for hospitals.
       In addition to losing revenue each time it avoids an 
     unnecessary hospital stay, Intermountain is penalized for 
     treating only the sickest patients, Dr. James said. 
     Medicare's payments for pneumonia are based on a rough 
     estimate of the cost of an average case and assume a hospital 
     will see a range of patients, some less sick--and therefore 
     less expensive to treat--than others. But because 
     Intermountain now admits only the sickest patients, its 
     reimbursements fall short of its costs, Dr. James said, 
     resulting in an average loss this year of a few hundred 
     dollars a case.
       Similarly, averting hospital stays for congestive heart 
     patients by prescribing the right medicines costs 
     Intermountain nearly $4 million a year in potential revenues, 
     according to Dr. James. And every adverse drug reaction 
     Intermountain avoids deprives it of the revenue from treating 
     the case.
       ``We are really rewarded for episodic care and maximizing 
     the care delivered in each episode,'' said Dr. Charles W. 
     Sorenson Jr., Intermountain's chief operating officer.
       Like the visit majority of the nation's hospitals, 
     Intermountain is a nonprofit organization, and executives 
     here say financial penalties do not damp their desire to 
     provide the highest quality care, which they see as their 
     central mission. But Intermountain, which operates health 
     plans and outpatient clinics in addition to its hospitals, 
     says it beds to keep hospital beds filled and make money 
     where it can to subsidize unprofitable services and pay for 
     charity care.
       Outside of Medicare, Intermountain often benefits from its 
     quality initiatives, executives said, because it gets to 
     pocket much of the savings they produce. For example, 
     Intermountain has generated about $2 million annually in 
     savings by reducing the number of deliveries that women 
     choose to induce before 39 weeks of pregnancy--and thereby 
     reducing the risk of complications to the mother or baby. 
     According to Dr. James, almost all that money has been spent 
     on other kinds of care.
       Hospital executives elsewhere say that they, too, have come 
     up against the cold reality of the Medicare payment system. 
     Partners HealthCare, the Boston system that includes 
     Massachusetts General and Brigham

[[Page S16140]]

     and Women's Hospitals, has taken steps to reduce the number 
     of unnecessary diagnostic tests it conducts at outpatient 
     radiology centers, though executives know that smarter care 
     will cut into their revenues.
       ``That's where you're smack up against the perverseness of 
     the system,'' said Dr. James J. Mongan, chief executive of 
     Partners.
       Medicare's payment policies have stymied efforts in the 
     private sector to improve care, as well.
       For example, the Leapfrog Group, a national organization of 
     large employers concerned about health issues, has tried to 
     encourage more hospitals to employ intensivists--specialists 
     who oversee the care provided in intensive-care units. Though 
     studies show that such doctors significantly improve care, 
     Medicare does not pay for them, and employers and insurers 
     are having difficulty persuading some hospitals to take on 
     the added expense.
       ``It's going to be very hard to compete with the incentives 
     and disincentives in Medicare,'' said Suzanne Delbanco, the 
     group's executive director.
       Others argue that hospitals and doctors should not be paid 
     extra for doing what they should be doing in the first place.
       Helen Darling, the executive director of the National 
     Business Group on Health, a national employer group, said 
     Medicare instead should take a firmer stance in demanding 
     quality. The program had a significant effect, she noted, 
     when it said that only hospitals meeting a minimum set of 
     standards could be reimbursed by Medicare for heart 
     transplants.
       ``The payment system drove quality,'' Ms. Darling said.
       Medicare itself is taking some other tentative steps, 
     including an experiment that pays certain hospitals an extra 
     2 percent for delivering the highest-quality care, as 
     measured, for example, by administering antibiotics to 
     pneumonia patients quickly and giving heart attack patients 
     aspirin. But some hospital industry executives question 
     whether that is enough money to offset the costs of improving 
     care.
       ``It can only be a motivator if you really have an 
     incentive,'' said Carmela Coyle, an executive with the 
     American Hospital Association, who noted that hospitals on 
     average are paid only 98 cents for each dollar of Medicare 
     services they provide.
       Mr. Scully, the Medicare administrator, defends the 
     experiment, saying that the agency's goal is to determine if 
     it is using the right measures to reward quality. ``If this 
     works, we'll do a bigger demonstration,'' he said.
       But many policy analysts and employer groups want Medicare 
     to do more. ``Today, Medicare needs to step out front,'' said 
     Peter V. Lee, chief executive of the Pacific Business Group 
     on Health, who argues that how hospitals and doctors are paid 
     is a critical component of motivating them to improve care. 
     ``There needs to be money at play.''

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