[Congressional Record Volume 152, Number 132 (Tuesday, December 5, 2006)]
[House]
[Pages H8707-H8713]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                        HEALTH CARE EXPENDITURES

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 4, 2005, the gentleman from Georgia (Mr. Price) is recognized 
for 60 minutes as the designee of the majority leader.
  Mr. PRICE of Georgia. Mr. Speaker, I want to thank you so very much 
for allowing me to come to the floor. I want to thank the leadership 
for allowing me to come and talk about an issue that is extremely, 
extremely important and timely right now as we complete congressional 
business this week.
  I would like to talk a bit about health care and health care 
expenditures and how the current system is set up that will, I believe, 
and many people believe, adversely affect how patients are treated 
across our Nation. And it has to do with the Medicare program, and it 
has to do with something called a sustainable growth rate, or SGR, 
which is currently the way in which it is determined on the part of the 
government how physicians are compensated for caring for Medicare 
patients.
  Now, before I came to Congress, Mr. Speaker, as you know, and others, 
I was a physician, orthopedic surgeon; practiced over 20 years in 
private practice of orthopedic surgery on the north side of Atlanta. 
And there are probably another 10 or 12 physician Members of the United 
States House of Representatives, and each of us knows and appreciates 
and understands that the manner in which the government has decided 
reimbursement for physicians over the past number of years has resulted 
in, in many cases, in many cases across this Nation, a disincentive for 
physicians to be able to see patients.
  And that is an important point that we need to think about, Mr. 
Speaker, because as that disincentive has increased over a period of 
time, and I, and many others would argue that it continues to increase. 
In fact, it is getting much, much worse. There is a decrease in the 
access that patients have to quality care all across this Nation, and 
we are seeing it in numbers that we will talk about today, time and 
time again, especially in many of the specialties, subspecialties.
  So what has happened with the manner in which the government makes 
decisions regarding reimbursement, regarding how much physicians are 
paid for services, oftentimes what has happened is that patients can no 
longer find doctors, having difficulty finding doctors. So what we 
would like to do for the next few moments is to chat about, to discuss 
this issue of physician reimbursement as it relates to patient access 
to care and to talk about this SGR, sustainable growth rate.
  I joke back home about how the SGR really is not a sustainable growth 
rate; it is an unsustainable reduction rate, URR, and we will have some 
numbers that will back that up.
  Oftentimes when we think about the expenditure of health care dollars 
in this Nation, we think, well, every single dollar is obviously going 
to doctors to take care of patients. In fact, that is not what happens. 
And this chart is a great example of that.
  This is national health care expenditures in the year 2004, the most 
recent for which this kind of data is available. The total in 2004 was 
$1.88 trillion, Mr. Speaker, $1.88 trillion of money being spent on 
health care. And I always, whenever I present this kind of information 
in a forum where individuals can ask questions, they are always 
surprised to find that a relatively small portion of that health care 
dollar goes to their doctors. In fact, on this pie chart, only 21 
percent goes for what are called clinical services; that has physician/
clinical services, which means what it takes to take care of patients, 
ordering tests and prescription drugs and the like.
  In fact, the amount of money going to physicians out of a given 
health care dollar is in the low teens, 12, 13, 14 percent on the 
dollar, which means that it really is pennies out of the health care 
dollar that we are spending in this Nation that goes to the individuals 
who are providing the vast majority of the care.
  Now, that is not to say that these other things aren't important; but 
it is important to appreciate, Mr. Speaker, that the amount of 
compensation, the reimbursement, the providing of the cost for the 
services that are being provided by physicians is a relatively small 
portion of the health care dollar. And that is important, because what 
we have seen over the past number of years is that the way in which the 
Federal Government is reaching their targets as to how much they spend 
on health care is to decrease the reimbursement for physicians, and 
therein lies the significant problem.
  So how did we end up in this boat?
  Well, in 1965, middle '60s, Medicare was passed. And at that time, 
the manner in which it was determined how much physicians should be 
paid and therefore what kind of access patients had to physician care 
was that each individual physician would bill Medicare for certain 
services, and then the amount of difference between the amount that 
Medicare paid and what they had billed, the physicians were then 
allowed to then what's called balance bill or bill the patient. And 
initially this program compensated the physicians, as I mentioned, on 
the basis of their charges, and allowed them to balance bill.
  What happened over a period of time, for a variety of reasons, and I 
would suggest, not necessarily physician related, but in 1975 the 
Medicare payments were continued to be linked to physicians. But the 
annual increase in cost, the annual increase in fees began to be 
limited by what was called and is called the Medicare economic index or 
MEI. And because the changes were not enough to prevent the total 
payments from rising more than were desired at that time, from 1984 
through 1991, the yearly change in fees was determined specifically by 
legislation.
  So between 1984 and 1991, instead of allowing physicians to bill for 
certain procedures and certain activities that they would perform in 
taking care of patients, what happened is that Congress decided, 
between 1984 and 1991, what physicians in the Medicare program would be 
compensated for those procedures or that activity. And then starting in 
1992, this charge-based system was replaced by what was called a 
physician fee schedule. And this fee schedule bases payment for 
individual services on measures of the relative resources provided to 
them.
  Now, this is extremely important because in 1992 was the time when 
the Federal Government, and we as a Nation, decided, in essence, we 
will determine at the beginning of the year, January 1, how much money 
we will spend for health care for the entire year to come. Without 
regard to how many patients there were to be seen, what kind of health 
challenges and problems they had, we were going to set this finite pot 
of money as a Nation and say, this is what we will spend on health 
care. It doesn't make a whole lot of sense when you think about it, 
because those kinds of things are not necessarily predictable.
  Now, at that time it was stated that that schedule, this physician 
fee schedule, was not intended to control spending; but it was designed 
to redistribute the spending among various physician specialties, so if 
it was determined by the Federal Government that thoracic surgeons were 
gaining too much of this small portion of the pie, then they would 
shift that money to another specialty, remembering that when those 
monies are shifted, what happens is that many patients oftentimes lose 
access to the care of a quality physician.
  Now, the schedule was updated at that time, in 1992, using a 
combination of the Medicare economic index that I mentioned before and 
an adjustment factor that was designed to counteract changes in volume 
of services being delivered per beneficiary. That adjustment factor was 
known as the volume performance standard. And over a period of time, 
relatively short period of time, that led to significant variability in 
the amount of payment rates. And Congress then replaced, in 1998, all 
of this system with what is currently in place, which is called the 
sustainable growth rate.

                              {time}  1530

  Now, the sustainable growth rate is something that has come under 
significant scrutiny, because in fact it hasn't been a growth rate; it 
has been, as I mentioned before, a reduction rate. It hasn't answered 
the true question of

[[Page H8708]]

how we are going to provide services as a Nation, how the physicians of 
this Nation are going to provide appropriate health care services to 
patients all across the Nation and what kind of compensation they 
should receive.
  Many people, when I talk about this at home to folks and talk in 
health care conferences, many people really don't appreciate and 
understand that, in fact, the Federal Government is setting 
reimbursement rates for physicians all across this Nation, the kind of 
price-fixing that we have as a Nation said, no, it doesn't work in any 
other industry. But, in fact, that is the way we do it in health care.
  The reason that it is important and not just related to Medicare is 
that the vast majority, Mr. Speaker, the vast majority of insurance 
companies tie their reimbursement rates of physicians to what the 
reimbursement rate is for Medicare. So what happens is that an 
individual insurance company will impose reimbursement for physicians 
of a certain percentage, 100 percent of Medicare, 90 percent of 
Medicare, 110 percent of Medicare. The result is that, de facto, the 
Federal Government is setting the reimbursement rates for physicians 
all across this country, and it hasn't worked well. It hasn't worked 
well.
  The SGR mechanism aims to control spending on physician services 
provided under Part B of Medicare, which is where the physician block 
is, but it is also where other services are. It does so by setting, 
once again, an overall target amount of spending on certain types of 
goods and services, as well as payments that Medicare makes for certain 
items. As I mentioned, there are other things besides physician payment 
in this portion of this pie; for instance, laboratory tests and X-rays, 
imaging services and many of the physician-administered drugs.
  Now, the Congress had two main goals in mind when it adopted the SGR 
mechanism: the sustainable growth rate mechanism, ensuring adequate 
access to physician services and controlling Federal spending on those 
services in a much more predictable way than that volume performance 
standard did. The problem is that the SGR accomplishes neither well.
  We find ourselves now over the past few years in a very, very 
difficult situation. Since 2002, the spending measured by the SGR 
method has consistently been above targets established by the formula. 
As a result, the SGR mechanism under current law will substantially 
reduce payment rates for physician services over the next several 
years. Payment rates would decline by a total of somewhere between 25 
and 40 percent, 40 percent, over that period of time.
  I have got some charts that will demonstrate a few other matters as 
they relate to physician reimbursement and access to care and quality 
care.
  This is a chart that compares the payments for varying aspects of our 
health care delivery system, and each of these bars, there are four 
bars, for Medicare Advantage which is part of the Medicare program, 
hospitals, nursing homes and then physicians on the far right portion 
of the chart.
  It is important to keep in mind that the physician portion of this 
was slated for a decrease in all of these years, but these are the 
actual payments that have gone out, increases in payments or decreases 
in payments over the past 4 years. The portion of the Medicare program 
Medicare Advantage has seen decreases in the 5 to 7 percent range over 
the past 4 years.
  Hospitals, appropriately, they do it, they perform a wonderful 
service in our health care systems. What they have seen is increases in 
the range of 3, 3\1/2\ percent over the last 4 years. Nursing homes, a 
comparable level.
  It is important that when we have this discussion that we get across 
the point that nobody, nobody is saying that these numbers necessarily 
ought to decrease, because hospitals and Medicare Advantage, nursing 
homes, all of them are providing an absolutely vital and imperative 
service. The problem comes, I and many others would suggest, in the 
final group of numbers, which is where the physicians have been over 
the last 4 years, remembering that the physicians were slated for a 
decrease every year.
  What that means is when physician reimbursement goes down, physicians 
who have been contemplating retirement say, well, it is just not going 
to cover my costs anymore; I am not going to be able to practice, too 
many headaches from the Federal Government. And many of them retire 
prematurely.
  I am a third-generation physician. My grandfather saw patients until 
he was 94 years old. I guess there are some that would argue that he 
ought not to have been seeing patients at that time, but physicians 
routinely, over the last 30 to 100 years of the history of our Nation, 
routinely retired at a much later date than the general population. 
They oftentimes practiced into their seventies and eighties.
  That whole trend, that whole trend has changed completely, so that 
now we see physicians retiring, if not at the rate of their peers in 
other businesses and other endeavors, in fact, many physicians are 
retiring at a much younger age because of a combination of factors: 
litigation problems, reimbursement problems, aspects of governmental 
intervention, regulation kinds of things. But what that means is that 
when physicians retire is that patients have a decreasing likelihood of 
having access to care, and that is where the concern lies.
  When you see this chart here and the past 4 years as it relates to 
physician reimbursement, what has happened is that physician increase 
in 2004 and 2005 was in about the 1.5 percent range last year. It was 
absolutely flat.
  So the proposal for this next year, a 5.1 percent decrease that will 
take effect, Mr. Speaker, in less than 30 days, in less than 30 days 
unless this Congress acts, unless this Congress acts, and there are 
incredible surveys and statistics and information we have on what the 
consequences, what will be the consequences to American health care if 
that 5.1 percent decrease takes effect.
  As I mentioned a little bit ago, that decrease is slated to be year 
after year after year for the next 6 to 8 years. So it is not that a 
5.1 percent decrease in fiscal year 2007 would result in a significant 
increase in 2008 or 2009 or 2010 so that folks could plan their future 
in terms of their practice and caring for their patients; that would be 
followed by a 5 percent decrease in 2008, a 5 percent decrease in 2009, 
a 5 percent decrease in 2010 and so on and so on.
  The challenges are huge, because what will happen if we allow this to 
occur is that patients, many patients across this Nation will have 
continuing and increasing difficulty in finding a physician to care for 
them. The information on the amount of the number of physicians who 
would see these decreases, because it isn't absolutely even 5 percent 
across the board for every single physician, is that the vast majority 
of physicians would see more than a 5 percent, a 1 to 5 percent cut.
  In fact, some physicians would seek decreases in their reimbursement 
of 16 to 20 percent, 13 percent of those would see decreases up to 15 
percent. So you see where the nationwide effect would be. Sometimes you 
will hear folks from the Center from Medicare and Medicaid Services 
saying, yes, but some folks would be getting increases. I think that is 
arguable.

  However, even if that were true, it is only in the 6 percent range, 
and it is not among the primary care folks, the internists, family 
medicine specialists, family practitioners, those individuals all would 
be seeing a decrease.
  Remember, Mr. Speaker, the consequence of a decrease in physician 
reimbursement rate in Medicare means that there is a ripple effect 
throughout the entire system, so that insurance companies reimburse 
physicians at a decreased rate, and consequently what happens is that 
patients, patients lose their ability to see physicians all across this 
Nation.
  Now, any of that might be okay if, if there were decreases in the 
costs of providing the services. But you and I both know, Mr. Speaker, 
that when you go to your doctor, there are more tests that are 
oftentimes taken now, because the technology is available. I know when 
I go it oftentimes seems to me that there are more people in the office 
itself, and most often they are individuals who are not necessarily 
involved in the actual care, they are individuals who are involved in 
the administrative side of a medical practice; so they are filling out 
the paperwork for the insurance company or filling out the paperwork 
for the government. So the costs continue to increase.

[[Page H8709]]

  This chart here is titled ``The Gap Between Cost Increases and 
Payment Updates,'' and this goes from 2001 through 2007, so the past 6 
or 7 years. If you take zero percent at 2001 as the baseline, what has 
happened to physician practice costs over that period of time is that 
the annual increase has bumped up each and every year. Each and every 
year the costs of providing the service to patients in any practice has 
increased, and that is just like anything else in our economy, by and 
large.
  Now what has happened to physician payments or physician 
reimbursement over that period of time, and you see, Mr. Speaker, where 
the challenge is, because this line is not even flat, it is a 
continual, continual decrease over a period of time.
  Again, the problem, the consequence of this, is that patients are not 
able to see the physicians that they desire oftentimes or they are not 
able to find a physician to take care of them. It has been estimated 
that fully a quarter of patients out there who are trying to find a 
primary care physician who will accept Medicare cannot do it. They 
cannot do it right now.
  When you talk with physician groups about what are the consequences, 
again this kind of decrease in 2007, what is going to happen? Nearly 
half of the physicians who say if that decrease goes into effect, then 
what will happen is that they, their practice, will no longer be able 
to take new Medicare patients.
  Mr. Speaker, you and I both know that as members of the baby-boom 
generation that we are demographically an aging population in this 
Nation, and there are more and more individuals who are reaching 
Medicare age. Now, if there are more and more individuals reaching 
Medicare age, and fewer and fewer physicians or physician practices who 
are able to take new Medicare patients into their practice, then, as 
you see, Mr. Speaker, it means that access to care is limited and 
consequently quality health care in this Nation will suffer. That is 
the magnitude of the challenge that we are talking about.
  As I mentioned before, there are a dozen or so physicians in the 
United States Congress, and I am pleased to have, hopefully, many of 
them join us today, this evening, to talk about this issue. I am so 
pleased to have my good colleague and friend from Georgia, Congressman 
Phil Gingrey, who is a fellow physician and obstetrician/gynecologist. 
Both he and I served in the Georgia State senate together, and we are 
both privileged to serve here in the United States House of 
Representatives.
  I thank you so much for coming today and sharing some words about 
what is truly, truly a matter that we must address as a Congress this 
week.
  Mr. GINGREY. Mr. Speaker, and Dr. Price, thank you for giving me the 
opportunity to weigh in on this. I appreciate Representative, Doctor 
Price, leading this hour. It is such an important issue and time, of 
course, is of the essence. The physicians, the chart that Dr. Price is 
showing, is a clear indication that, as he points out, Mr. Speaker, the 
cost of doing business, in this instance, the business of providing 
medical care to our seniors especially, continues to go up, as does the 
cost of doing business in any other profession.
  Yet the reimbursement is not even staying level. Our physicians, our 
providers, are not just running in place, they are losing ground each 
and every year, and that therefore the need is to try to fix this 
ultimately on a permanent basis by eliminating this flawed formula, 
this so-called SGR way of reimbursing our providers.
  But at this point we have to do something about the scheduled 5.1 
percent decrease update, a loss of reimbursement for the fiscal year, 
or calendar year 2007. And we have a very short period of time to do 
this. Dr. Price and Dr. Boustany and Dr. Burgess and the other 
physicians, medical and dental, doctors in this House of 
Representatives, hopefully on both sides of the aisle, understand the 
urgency of this.

                              {time}  1545

  It is not about necessarily boosting the income of any of our 
providers, although those who practice the specialty of primary care, 
our pediatricians, our family practitioners, our general internists, 
their income is certainly not extravagant by any stretch of the 
imagination.
  But it is really about, and I am sure that Dr. Price has already 
mentioned this, the availability of providers for our seniors. That 
pressure is getting greater each and every day. Thank God, they are 
living longer and healthier lives, and I think the Medicare part D 
provision that we passed in November of 2003 is really adding to that 
well-being, that our seniors are going to get the benefit of a 
prescription drug coverage that they never had.
  But if we don't have any of these primary care physicians willing to 
accept these patients because we are not paying them enough to even 
reimburse their practice overhead, much less a small profit margin, as 
has been pointed out by my colleagues, then the situation gets worse 
and worse.
  So thank you to my colleague and friend, Dr. Price. As a physician, 
Members are here today to try to emphasize the importance to each and 
every Member, to our leadership. Let's get this done. Let's make sure 
that we not only mitigate a 5.1 percent loss that is calculated on the 
basis of this flawed formula, but let's have a positive, a slight 
increase of maybe 1 percent for all of our providers. Then if voluntary 
reporting is a part of this bill, then, fine, increase it a little bit 
more. That is an issue that Dr. Price may want to discuss in more 
detail as we go forward in the hour.
  But I want to thank him again for taking the leadership on this issue 
and giving me an opportunity to weigh in.
  Mr. PRICE of Georgia. Mr. Speaker, I thank my colleague for coming 
and joining us today and pointing out the importance of this, but also 
pointing out very clearly the urgency of this matter.
  As I mentioned before, if this Congress doesn't act, then what 
happens on January 1, less than 30 days away, is that patients will 
have less access to high quality health care than they do today; 
patients all across this Nation, not just Medicare patients, patients 
all across this Nation, from birth to their last days.
  It is extremely important that we as a Congress address this. Again, 
it is not just Medicare. It ripples into all sorts of other insurance 
company reimbursement to physicians all across this Nation. I think 
that is important to appreciate, because with the election results on 
November 7 of this year, what has happened is that the party in power 
will shift after the first of the year, and there are some on the other 
side of the aisle, some of my friends on the other side of the aisle 
believe we ought to move toward a Medicare system for all, for all 
people across this Nation. I personally believe that would be an 
absolute disaster in terms of the level of quality care available to 
patients all across this Nation. I believe that for a variety of 
reasons, not the least of which is this kind of issue.
  What we see is a Congress that has been for years, not just 2, 3, 4, 
5 years, for years, decades, has struggled with how to fashion 
reimbursement for health care across this Nation. I believe that as we 
continue to move in the direction of greater control at the level of 
the Federal Government, that what happens is that we actually decrease 
the access of patients to care and decrease the quality of care that is 
provided.
  So I thank my colleague from Georgia so very, very much for doing 
this and for pointing out the urgency of this, the importance of acting 
while we are here this week.
  There are a number of proposals that are available in order to allow 
us to solve this problem, and I urge my colleagues on both sides of the 
aisle to embrace one of these and try to make certain that we do so 
before we head home.
  I am so pleased to be joined by a new Member of the United States 
Congress, another physician Member, Dr. Shelley Sekula Gibbs from 
Texas, a practicing dermatologist before she came to Congress, who has 
great experience in the community back in Texas and served on the local 
city council and has struggled as well, I know, with the kind of 
ability to deliver high quality health care to her patients.
  We appreciate you coming today and look forward to your insights and 
perspective as it relates to patient access to care and the sustainable 
growth rates.
  Ms. SEKULA GIBBS. Thank you very much, Dr. Price. I appreciate you

[[Page H8710]]

bringing the subject up for the people at home so that they can 
understand where their Medicare premiums are going and how the Medicare 
dollars are being spent.
  I want to also thank Congressman Dr. Gingrey, Dr. Boustany, Dr. 
Burgess and a number of the other physician Congress Members who have 
worked very diligently to bring this issue to the floor and ask the 
American people for their support and understanding of how to make 
health care more accessible to our seniors.
  I think that having family members, like many of us, who are under 
the Medicare program, it is easy to see how Medicare has become more 
and more complex over the years and how each time there is one of these 
actions that you detailed chronologically, 1965 when it was implemented 
it was much simpler and easier. There were also fewer seniors at that 
time to cover. Then as time passed, the government looked for ways to 
reduce expenditures, reduce spending, but at the same time we saw other 
pressures coming to bear on the senior population.
  We saw the fact that more and more people are living longer. They are 
having vigorous, active lives; and they want to have access to 
activities that will allow them to enhance those lives. They are 
working longer. They are active in sports.
  In order to achieve that and to make sure that they can participate 
fully, and that is what I want when I hit those years as well, it 
requires a lot of work on the part of the physicians and the health 
care industry. That means that they have to have access to 
physicians; they have to have access to primary care doctors. And I was 
one of those before I was a specialist. I went through that residency. 
I know how hard that is, to take care of the whole person and to work 
and interrelate with a specialist. It is very difficult, and it 
requires the right kind of individual to do that.

  We need to support it. And the primary care doctors are the ones who 
get hit sometimes the hardest. In your graph that you showed on which 
doctors are going to receive a little tiny bit more with that 5 percent 
cut, and the vast majority, 95 percent are going to get cut, quite 
frequently it is the primary care doctors who get stuck in that. And we 
want to encourage people to go into primary care and take that loving 
hand who will help our seniors.
  But those patients are more complicated. They require more medical 
care when they do get sick, and they require more specialists to bring 
them out of those medical crises and restore them back to their health 
so they can get back to the business of living full quality lives.
  I have been a physician for over 20 years, and I have watched as the 
Medicare situation has gone really from a situation of more and more 
complicated and the reimbursements now are going down, down, down. I 
have watched it, how it affects my father and my mother.
  My father, who recently passed away, was lucky enough to receive 
veterans benefits. That really moved him out of the Medicare arena and 
allowed him to have access to the benefits he deserved through the VA.
  My mother, on the other hand, has witnessed something that I hope 
others never have to see, but she actually has had a physician, a 
primary care doctor in a small town in south Texas, go bankrupt, go out 
of business.
  That is shocking, to think that someone who has spent all the years 
that this doctor did in training and becoming a quality physician could 
then lose their practice. It is predominantly because in a small town 
in south Texas many of the younger people who have private insurance, 
some of them move away. And who are left? A lot of the seniors.
  Now, it is not to say that is all that is left, but whenever that 
balance of having a larger and larger Medicare practice goes out of 
kilt, sometimes the physician can't even keep their doors open because 
there are so many patients who are there, complicated, elderly patients 
who need that care, and they can't get the reimbursement to keep those 
doors open, to pay their staff, to keep the lights on and to pay the 
rising medical malpractice insurance that goes along with it these 
days.
  So the notion, knowing that that already happened to my mother and 
she lost that doctor who she really trusted and he went out of 
business, knowing that that happened before this cut goes into place, I 
shudder to think what will happen across small towns all over the 
Nation if they are visited with a 5 percent cut, not only in 2007, but 
then a large cut in 2008 and another cut in 2009. What will that do to 
the primary care doctors who are trying to give that care across the 
small towns of our country? We can't let that happen.
  So I really support you today, Dr. Price, in asking the colleagues 
here on the floor, give the physicians an opportunity to continue to 
deliver care to the seniors. Don't make it so hard that they have to 
limit the flow of the seniors who are coming in their doors.
  That will happen first. They won't out and out quit, but they will 
start to limit the numbers that they take. And that is also very 
disabling to a senior, when they call and say, do you take Medicare, 
don't make it so that they hear on the other end, I am sorry, we can't 
see you. That is not right, and we need to open the doors so that more 
seniors can have access to health care.
  I join you in asking for that, and I hope that our colleagues will 
find a way to fix this situation and allow the seniors across the 
country to continue to receive the very best health care that is 
available in the world.
  Mr. PRICE of Georgia. Thank you so very much for your comments and 
your participation and for your commitment to service, to standing up 
and rising and being a Member of the House of Representatives. We 
commend you and thank you for what you have done and appreciate your 
perspective and your expertise.
  You said it better than anybody could about this isn't about 
necessarily reimbursement or money for physicians, this is about access 
to care. Because when that physician closed his or her doors in small-
town Texas, which is not unlike small-town America anywhere, then those 
patients, those citizens, those American citizens, lose their access to 
care.
  So this is an urgent issue. It is absolutely imperative that we in 
this Congress address it. Once again I call on colleagues on both sides 
of the aisle to make certain that we do so this week.
  I am pleased as well to be joined by some other physician colleagues. 
Dr. Boustany, Congressman Boustany, is a fellow freshman Member from 
Louisiana, a cardio-thoracic surgeon, has great expertise in this area 
and an understanding and appreciation for the finances of what it takes 
to deliver health care, but more importantly for the finances and what 
it takes to provide that kind of access to quality health care that 
patients all across our Nation deserve and expect. So I welcome you, 
Congressman Boustany, and look forward to your comments.
  Mr. BOUSTANY. Mr. Speaker, I am pleased to be here today. I want to 
thank my colleague and friend from Georgia for organizing this hour and 
for yielding me time.
  A December 1 Congressional Quarterly article mentioned that a 
colleague from California across the aisle shed crocodile tears, 
``crocodile tears for providers who faced a cumulative cut of almost 30 
percent under the Medicare physician payment formula.'' This colleague 
quipped that he had difficulty sympathizing with providers who might be 
giving up their golf games.
  Instead of revoking negative stereotypes to justify cuts under an 
artificial price control formula, Congress ought to consider the real 
injustice the formula imposes on patients, such as an 85-year-old 
caregiver who has to wait longer and drive further so her ailing 
husband can visit a physician.
  While Medicare does not force providers to treat Medicare patients, 
especially when the cost of providing care exceeds declining payments, 
for seniors who turn 65, it is Medicare or no care. It is virtually 
impossible for someone at age 65 to find insurance coverage for 
physician services outside of Medicare part B.
  Medicare needs to honor its commitment, and seniors need more than 
access to a waiting list. MedPAC, the independent Federal body created 
to advise Congress on Medicare reimbursement issues, calls the Medicare 
physician payment formula ``a flawed inequitable mechanism for volume 
control.'' It says it could ``threaten beneficiaries' access to care.''

[[Page H8711]]

  In fact, the agency already warns that subsets of beneficiaries 
report access problems. In 2005, more than one in five Medicare 
beneficiaries reported that they sometimes, usually or always 
experienced delays in getting an appointment. The same proportion 
indicated that they had difficulty finding a new primary care physician 
to treat them. MedPAC also writes that among the subset of people who 
reported any problems, Medicare beneficiaries were somewhat more likely 
in our 2005 sample to characterize the problem as big versus small than 
their privately insured counterparts.

                              {time}  1600

  Also, the share of Medicare beneficiaries indicating that they 
experienced big problems accessing a primary care physician grew in 
both 2004 and 2005 samples. One in four seniors who faced access 
problems said that their problem finding a doctor was because they were 
covered by Medicare, and this is simply unacceptable.
  Equally troubling is a recent survey reporting that 38 percent of 
responding physicians indicate that they would decrease the number of 
new Medicare patients they accept when the next physician payment cut 
occurs and Medicare payments continue falling below the cost of 
providing care.
  Congress might avoid a cut this year, and it is imperative that we do 
that, while leaving the artificial price control intact, as it did for 
2003, 2004 and 2005. Yet officials with the Congressional Budget Office 
have repeatedly explained that the formula requires these automatic 
cuts to be made up in future years. This kick-the-can approach might 
seem like the least expensive on paper, but it is clearly 
unsustainable. The formula must be changed. Otherwise, the annual cuts 
will become more difficult to avoid, and the problem of access will 
only grow worse.
  Congress needs to look past government accounting gimmicks and 
realize that adequate payments will help to ensure timely care and be 
more cost-effective for the overall program than addressing serious 
health problems with more intrusive and costly medical procedures 
later.
  Also, all Americans have a personal stake in this issue, and once 
informed of the cuts, people understand that cuts mean more than just a 
canceled golf game. Almost 9 out of 10 respondents agree that cuts 
would severely limit seniors' access to physicians.
  Seniors want the freedom to access their physicians, but cuts will 
exacerbate projected provider shortages as the baby-boom generation, 
one-third of our workforce, becomes Medicare eligible. MEDPAC aptly 
warns that the formula's cuts could ``discourage medical students and 
residents from becoming primary care physicians.''
  Today, fewer radiologists specialize in mammography and fewer 
surgeons complete breast cancer fellowships. In addition, fewer 
students are entering the specialty of heart and lung surgery, while 
half of the heart and lung surgeons in the United States intend to 
retire within the next decade, and more than 70 percent plan to retire 
within 13 years.
  Mr. Speaker, it is disappointing that some lawmakers want to expand 
price-fixing in Medicare under the false label of negotiation. 
Economists widely agree that artificial price controls lead to 
scarcity, which is why Americans do not rely on them in other sectors 
of our economy and why we must develop market-based alternatives in 
Medicare.
  Congress, Mr. Speaker, has a duty to avoid the cuts and to replace 
the artificial price control formula with a realistic physician payment 
system that protects patient access.
  Mr. PRICE of Georgia. Mr. Speaker, I thank Congressman Boustany so 
much and appreciate your perspective and the stories that you told and 
the statistics you brought to us because it really puts a face on it. 
When we have the kind of divisive conversations that oftentimes occur 
on the floor of the House, it is not helpful, does not help patients 
all across this Nation. So I appreciate you bringing that perspective.
  You mentioned again many of the ripples that occur when these kinds 
of decisions are made here. What happens in terms of access to care is 
maybe the most important thing, but what also happens is it ripples 
down the line of what bright young men and women across this country 
choose as a profession. Are they choosing to go into medicine; are they 
choosing to go into some of the more difficult subspecialties that many 
of us will require the care from over our lifetime? And what is indeed 
happening is that they are not choosing those things. They are not 
choosing to go into medicine in the numbers that they have in the past. 
So the ripple effect is huge.
  All of it boils down to a decreasing access to care that patients 
have across this Nation and a decreasing access to quality care across 
this Nation.
  I am so humbled by the participation of many of our physician 
colleagues in this hour on the floor of the House today. And 
Congressman Burgess from Texas has joined us, an individual who has 
great expertise in the health care arena, a preeminent member of the 
Energy and Commerce Committee, and has a wonderful perspective and has 
talked about this issue since his arrival in Congress and has put on 
the table specific solutions.
  So I welcome him today and thank you for your comments.
  Mr. BURGESS. Mr. Speaker, I thank the gentleman for his kind 
comments. Of course, the gentleman from Georgia has already done a 
great task with the posters this afternoon, but let me just reuse one 
that was seen a little bit earlier today.
  This one tells such a great story, but unfortunately, it only tells a 
portion of the story. The year I took office was 2003. That means my 
last active year in practice was the year 2002, and missing from this 
graph, the year 2002, is a similar downward bar when doctors received 
the 5.1 percent what we euphemistically called a negative update. So 
the actual physicians' compensation for the 5- or 6-year moving 
budgetary window that we are all so fond of talking about has in fact 
been much less than is actually shown on this graph. And that is an 
important point to be made because, as we can see, all of the other 
aspects that deal with health care reimbursement once a year receive a 
cost of living, a market-basket update, but physicians' offices are 
expected to bear the brunt of cost reductions on a year-by-year basis.
  As you so eloquently pointed out a few moments ago, that is 
unsustainable for any small business. If you are losing something on 
every transaction, you do not make it up in volume and stay in practice 
for very long.
  One of the things that I think is so important that we discuss, we 
spend some time discussing this afternoon, as hopefully we get to a 
resolution of this problem in the conference committee that is now 
going on, is to talk a little bit about the pay-for-performance aspect 
of it. So much of the physicians' reimbursement is tied up in the talk 
of the pay-for-performance concept.
  I would just like to submit that if we drive the best doctors out of 
providing Medicare services, if we really let the train run off the 
tracks on this, we will not be able to pay enough for performance in 
the future if we do not recruit our best and brightest to be the 
physicians of tomorrow, as Dr. Price has so eloquently stated, or if we 
drive out doctors who are in their mid-forties to their mid-sixties, 
doctors who are at the peak of their diagnostic abilities, the peak of 
their skills in the operating room. If these individuals stop seeing 
Medicare patients, we then make the whole system more expensive to 
administer if we have only the second and third tier of providers 
involved in that care.
  Well, one of the things that we hear talked about is a pay-for-
performance indicator, one that has the initials PVRP that stands for 
Physician Voluntary Reporting Program. Now, this is a program that is 
going to be articulated by CMS some point later in this year, and the 
reason I am concerned about it is we are being asked to accept the PVRP 
performance indicators as the standard against which we are going to 
judge physician practices for years to come, and we have not yet seen 
them in their totality. These are rules that will be put out by CMS 
some time later this year, perhaps April, perhaps May or perhaps June.
  My understanding of the PVRP program is that it is largely a 
structural program and not necessarily outcomes-based. That is, does 
every diabetic receive a hemoglobin A1C test every so many months, 
rather than do we look

[[Page H8712]]

at the world of diabetic patients within this physician's care and make 
certain that the emergency room visits and the out-of-control 
hospitalizations are, in fact, in line with what would be expected.
  Earlier this year, I introduced bill, H.R. 5866, to repeal the SGR 
formula in its totality, in order to acknowledge that there is a 
growing sentiment out there that some type of performance measure has 
to be built in. I did ask that the individual quality organizations 
that are already in place be allowed to provide voluntary guidelines 
for physicians to follow. These quality measures taken as a whole 
provide a balanced overview of the performance of an individual doctor 
or clinic or billing unit, if you will.
  The whole idea was that they would be consistent; they would be 
relevant. They would be not overly burdensome time to collect and they 
would account for patient satisfaction. The goal of the system was fair 
assessment to reduce health care costs, improve health care outcomes, 
but very importantly, not contribute to the problem that we already 
have in this country of health care disparities in some communities.
  Therefore, in order to account for the differences in patient 
population, health status and compliance, these formulas would need to 
be very tightly drawn.
  In addition, there would be a measure reported back to the physician 
himself or herself as to how they did in comparison with their peer 
groups. These report cards, if you will, would not necessarily be made 
generally available to the public, but whether or not a physician or a 
clinic complied with the data that was required, would be made public.
  I think it is important to give providers, to give clinics, to give 
doctors some measure of flexibility in this regard, and whether it be 
the participation in a medical home, whether it be the participation in 
the PVRP program, whether it be the participation in the national 
quality forum programs, that any of these should be seen as complying 
with the intent of the legislation to provide quality measures. They 
should be voluntary, and any increase in reimbursement should not 
necessarily be tied to the baseline of quality reporting, but an 
additional increase in reimbursement would be provided to those 
physicians and clinics and offices that did indeed provide some type of 
reporting data.
  Again, I want to thank the gentleman from Georgia for bringing this 
very timely issue to the floor of the Congress. I do know there is a 
lot of work going on on this very issue right now, and my goal in this 
is to be helpful in the overall process and make certain that in the 
future we do not saddle physicians' offices and physicians' practices 
with additional reporting requirements that are not voluntary, that are 
mandatory, that are punitive in their nature and end up decreasing the 
overall quality and character of medicine that we have grown to enjoy 
in this country.
  I thank the gentleman from Georgia.
  Mr. PRICE of Georgia. Thank you so much for your perspective and for 
your wisdom in this area. It is extremely helpful and positive and 
productive for the debate that we are having or the discussion that we 
are having.
  I think you point out a very important aspect, and that is, this 
voluntary reporting requirement that might come soon for physicians is 
an increase in the regulation. And as you so appropriately point out, 
it ought not be punitive in nature, because if it is, what we will see 
in addition to the challenges that we have with levels of 
reimbursement, decreasing access that patients have to care, we will 
see further decrease in physicians in the community, and that will 
significantly harm the ability of patients to see physicians and get 
the care that they so appropriately deserve and require.
  Sometimes you will hear folks say in this debate or this discussion, 
well, there really is not an access problem. And in having some 
discussions with the folks at the Center for Medicare Medicaid 
Services, the high-level individuals in the department who are charged 
with making certain that physicians are there to take care of patients 
from a Federal Government perspective, I had a specific conversation 
with one of them.
  I said it is imperative that you not continue to decrease the 
reimbursement to physicians because they will no longer be able to 
cover the costs of providing that care and they will decrease the 
number of Medicare patients, if not end seeing Medicare patients all 
together.
  The response from that individual was chilling, Mr. Speaker. What 
that person said was, well, we have not seen it yet, and until we do, 
we have not cut them enough.
  Mr. Speaker, that is not the kind of collegial activity that we know 
to be productive in health care. It also takes incredible advantage of 
the Hippocratic oath that all physicians take in this Nation.
  I have come to a conclusion that has been very difficult over the 
past decade, and it is more so true now, I believe, than ever before, 
and that is, that our health care system is held together today by many 
things but not the least of which is the altruism of the physicians 
involved in caring for patients who understand and appreciate the 
importance of that care and also respect and recognize that the oath 
that they took to care for patients, oftentimes regardless of the 
reimbursement, is the most important thing, but that takes advantage of 
the goodwill of so many men and women who are highly trained and 
educated across this Nation and who each of us rely on for high-quality 
health care.
  Because all of us are patients at some point, every single one of us. 
So it is imperative that we do the right thing here as a Congress and 
make certain that we address this issue.
  Sometimes you will hear folks say there is not an access problem, 
like the fellow at CMS who made that statement. Let me point out, Mr. 
Speaker, a couple items.
  A recent survey, a recent study by the Medicare Payment Advisory 
Commission charged with looking into these things found that even 
before these cuts that we are talking about today might go into effect, 
25 percent, fully one-quarter of Medicare patients looking for a new 
primary care physician are having difficulty finding one.

                              {time}  1615

  One out of every four new Medicare patients is having difficulty 
finding a primary care physician, and that is all the more important as 
we mentioned before, Mr. Speaker, that our population is aging. The 
demographics are making it such that we are seeing a graying of our 
population. So more and more Medicare patients will be coming online.
  The congressionally created Council on Graduate Medical Education, 
which is the body charged with making certain that we have high quality 
physicians trained in this Nation, have reported existing or looming 
physician shortages. In fact, they are predicting that as again the 
baby boomers enter Medicare and more seniors are requiring health care, 
that the country will experience a shortage of 100,000 physicians over 
the next 15 years. 100,000 physicians over the next 15 years. And that 
is an important time frame to talk about because that is about the time 
that it takes to train a physician. From undergraduate school to 
medical school and through residency, it is somewhere between 10, 12, 
15 years, sometimes even longer.
  Mr. Speaker, it is appropriate that we are discussing this. It is 
urgent, it is urgent that we correct this remarkable, remarkable 
challenge that we have to make certain that all patients across this 
Nation have the opportunity to see and be seen and cared for by a 
caring, high quality physician.
  In closing, Mr. Speaker, let me just say that you have heard much 
discussion about the problem, you have heard some discussion about the 
solution. I would point out that I think there is a short-term solution 
and a long-term solution. A short-term solution is to make certain that 
the cuts that have been envisioned and are on the books right now and 
will take place on January 1 if the Congress does not act, to make 
certain that those decreasing reimbursements don't occur. It is 
imperative that we make certain that those don't occur so that we 
maintain the opportunity for patients all across this Nation to see 
their physicians.
  In the long term, it requires either a fix of the formula or truly 
changing the system that we have in place that

[[Page H8713]]

provides for reimbursement of physicians so that we can ensure into 
generations to come that we have a system in place that respects 
individuals who are caring for patients and, more importantly, respects 
patients' opportunity to receive access to the highest quality health 
care that is available.
  And the system that we currently have will not provide for that. It 
will not deliver that kind of health care system not only today but 
into the future. And so I challenge and ask my colleagues on both sides 
of the aisle, we have so much opportunity to do good in this 
institution, this is one of those instances that ought not be a 
Republican challenge or a Democrat challenge. It is an American 
challenge, and we need to come together to make certain that we address 
this in a way that allows patients all across this Nation to continue 
to have access or to regain access to the highest quality health care 
that is available.
  I thank once again the leadership for allowing me to organize this 
hour. I thank my colleagues who participated and brought so much wisdom 
and light to this issue. I appreciate the leadership for allowing me 
this time, and I thank you, Mr. Speaker.

                          ____________________