[Congressional Record Volume 153, Number 160 (Monday, October 22, 2007)]
[House]
[Pages H11837-H11843]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                         HEALTH CARE IN AMERICA

  The SPEAKER pro tempore (Mr. Space). Under the Speaker's announced 
policy of January 18, 2007, the gentleman from Texas (Mr. Burgess) is 
recognized for 60 minutes.
  Mr. BURGESS. Mr. Speaker, I come to the floor of the House tonight, 
as I often do, to talk a little bit about health care, the status of 
health care here in America.
  Tonight, if we could, I would like to talk a little bit about the 
past, talk some about the present, and maybe just look a little bit 
into the future.
  Mr. Speaker, as I see it, over the last 70 years there have been 
three transformational times in American medicine: one in the 1940s, 
one in the 1960s, and I believe we are on the threshold or the 
beginning of another transformational time here early in the 21st 
century.
  Mr. Speaker, medicine itself, the science of medicine, is pretty 
highly ordered, highly structured. It's very scientific. The scientific 
method is always employed in medicine. And when you get to government 
politics, government policy in regards to health care, in regards to 
medicine you would expect it to also rest on a firm foundation of 
science. But I have to tell you, Mr. Speaker, after being here for less 
than 5 years, you oftentimes see where that intersection of health care 
policy and health care reality sometimes creates more confusion than 
shedding light on the subject. And the thing is, Mr. Speaker, when we 
create these policies in Congress, we affect things not just today, not 
just for the time the bill-signing occurs, but we affect things for 
decades into the future. And that is the responsibility that we hold in 
our hands here in this House of Representatives when we talk about 
changes in the health care system.

                              {time}  2145

  Now, Mr. Speaker, I referred to the 1940s as a transformational time 
in medicine. Obviously there were a lot of things going on in the world 
in the 1940s. But just prior to the 1940s, Mr. Alexander Flemming, an 
Englishman, made a startling discovery. He made a discovery that a 
mold, the penicillin mold, created a substance that was diffusible 
across an auger plate that would inhibit the growth of bacteria. He 
further found that this substance apparently was not harmful to humans. 
So we have the concept of selective toxicity, something that will 
attack a microbe and not hurt the host; the first time that science had 
delivered that type of hope, that type of promise to the world.
  Now, Sir Alexander Flemming, receiving all the accolades he did for 
discovering penicillin, really created, at that point, something that 
was in such short supply, was so difficult to produce and so expensive 
that it really had no practical utility. It was almost like a medical 
trick or parlor game, but it was not something that could be generally 
used by the public, who was ill and needed access to the medicine. But 
American scientists, working in this country, created a system whereby 
they could grow large quantities of this mold, remove the substance 
from the vats that surrounded it, and purify it in large quantities. 
This occurred in 1942. We were in the middle of World War II. What a 
phenomenal discovery. Now this wonder drug that had only recently been 
discovered but was so rare, so scarce and so expensive that it had no 
practical utility, now it was cheap, readily available and, in fact, 
probably made a significant difference in the recovery of some of our 
soldiers who were wounded in the landing in Normandy. Battlefield 
infections were notoriously bad for causing loss of life and limb, and 
now we had an agent that was capable of treating those.
  Now, another discovery that occurred in the 1940s, cortisone had been 
discovered before the 1940s, but again, a laborious process for 
actually extracting this anti-inflammatory medicine. In fact, Mr. 
Speaker, they extracted it from the adrenal glands of oxen. So you can 
imagine how labor intensive that process was. And so only small amounts 
of this compound were available to treat injured individuals.
  But in the 1940s, an individual, Dr. Percy Julian, a Ph.D. 
biochemist, in fact we honored Percy Julian on the floor of this House 
as one of the outstanding African American scientists of the last 
century. I think we did that during the last Congress. And I was very 
happy to vote for that because Dr. Julian's contribution to American 
medicine was nothing short of astounding. He was able to use a 
precursor of a soybean and create cortisone in a laboratory and mass 
produce it. Once again we had a wonder drug that previously was 
available only in such small supply as to only be of benefit to a 
handful of people; now, suddenly, it was readily available, and 
available to large numbers of people at a reasonable price.
  So the 1940s ushered in the era of anti-infective antibiotic agents 
and anti-inflammatory agents, two true wonder drugs that, again, 
American medicine had not had available prior to that time.
  Now, Mr. Speaker, today we get sick, we go see the doc, he or she 
writes out a script, tears it off, sends you on the way to the 
pharmacy, you get it filled and you never give it a second thought. But 
prior to 1940, that wasn't an option; it didn't happen. Again, our 
soldiers landing in Normandy who were injured had available for the 
first time an anti-infective agent that was of such caliber that it 
provided many of those wounded men to gain back the use of limbs that 
otherwise would have been placed in peril by battlefield injuries.
  The discovery of cortisone really revolutionized at that time the 
treatment of illnesses such as Lupus and rheumatoid arthritis. There 
are other medications that are available now. Cortisone, of course, has 
some side effects and some problems, but still, cortisone is in 
widespread use in a number of areas in medicine today. So still, these 
are concepts that we benefit from.
  When you also think of the 1940s, what else was going on? Well, of 
course, the Second World War. We were in the middle of a two-front war. 
The American workforce was severely contracted because of the number of 
men and women who were fighting for our country, so employers back in 
this country who wanted to produce the material for the war, who wanted 
to continue to operate their businesses, were pretty hard pressed to 
find employees to work there.
  One of the things that was happening during the war, because of this 
shortage of workforce, was that compensation for workers started going 
up pretty fast. President Roosevelt saw that and felt that he needed to 
put some brakes on the rapid growth of wages; otherwise, the economy 
would get out of control and inflation would spiral out of control. So 
he put in place wage and price controls, and he did so because, again, 
the country was at war and the severe contraction of the workforce 
caused disruption of the labor market, and the President sought to 
correct that.
  Now, employers said we want to do things for our employees that make 
them want to work for us and make them not look for other employment in 
other locations, so if we can't offer

[[Page H11838]]

wages, can we offer benefits? Could we, perhaps, offer retirement 
benefits? Could we, perhaps, offer health benefits? And the United 
States Supreme Court ruled in 1944 that, indeed, those benefits could 
be offered and they would not violate the spirit of the wage and price 
controls. And furthermore, they should be available to the individuals 
as a pretax expense. And hence, the era of employer-derived health 
insurance as a pretax expense was born and survives to this day. And 
many people are very satisfied with that as a method of having 
insurance for their health care. And it has its roots back in 1940. 
Again, a truly transformational time in American medicine. We've got 
new medicines to treat infections and inflammatory conditions, and 
we've got a new way of paying for health care for Americans in 
employer-derived health insurance.
  The 1960s; what do we see then? We see the introduction of new 
generations of antibiotics, antibiotics that were more potent. Some 
bugs had developed resistances to the old antibiotics; we had new 
antibiotics that were less prone for bacteria developing resistance. We 
had new antipsychotic medications. We had new antidepressant 
medications, medications to treat conditions that heretofore had not 
been treatable. There had not been a rational or a viable treatment 
available to those patients.
  What else did we see in the 1960s? We saw in this House, in 1965, the 
enactment of a law that we now know as Medicare for protection of 
United States seniors. For the first time the United States Government 
was in a position to finance a large portion of health care in this 
country. In fact, since 1965, over the last 42 years, the portion of 
health care that is paid for by the Federal Government, about 50 cents 
out of every health care dollar, begins right here in Washington, D.C. 
You've got Medicare/Medicaid, the VA System, the Indian Health Service, 
TRICARE, Department of Defense, as well as the Federal prison system. A 
lot of health care is paid for and it originates here in the United 
States Congress.
  The other 50 percent, commercial insurance to be sure, some self-pay. 
And I would actually include the newer health savings accounts in that 
part that I would designate as self-pay. And then of course there is 
some care that is just simply not paid for, and some that is given as 
charity by the hospital or the doctor who provides the care and does 
not expect compensation.
  And now, early in the 21st century, I believe, again, is a 
transformational time in American medicine. And I think it extends 
before us really as far as the eye can see. Mr. Speaker, I think this 
transformation will occur whether we want it to or not. Whether we lead 
it or not, the transformation will happen. Changes in information 
technology, concepts like rapid learning, changes in the practice of 
medicine regarding genomics, protein science. A new era of personalized 
medicine extends before us. And as we usher in this new era in 
medicine, how can we facilitate or at least not obstruct the scientific 
discoveries and allow this important process to go forward? And nowhere 
will this be more starkly apparent than in our ability to provide this 
new care at an affordable price to the majority of Americans and ensure 
that there are the doctors involved who will deliver that care.
  Now, as I see it, the problem right now is that most health care is 
administered through some type of third-party arrangement so the 
patient and, quite honestly, the physician is generally aware of the 
cost of care that they receive. This arrangement has created an 
environment that permits the rapid growth, the rapid escalation of 
prices in all sectors of health care. So how do we improve the model of 
this current hybrid system, this public/private partnership that we 
have right now? How do we improve the current hybrid system that 
involves both public and private payment for health care but at the 
same time anesthetizes most of us to the true cost of that care?

  Now, Mr. Speaker, we hear it all the time here on the floor of this 
House that we're just entering into the first retirees of the baby 
boom, and this is all we can see demographically for years and years to 
come. There will be more demand for medical services. Medical 
procedures and techniques and pharmaceuticals will tend to cost more 
because there is the advancing complexity of what we're able to do. 
Medicine is going to continue to evolve as it always has.
  Now, Mr. Speaker, Alan Greenspan, former Chairman of the Federal 
Reserve, right around the time that he was retiring spoke to a group of 
us one morning, and the inevitable question came up to Mr. Greenspan, 
``How in the world are we ever going to pay for the liability that we 
have in Medicare in the future?'' And Mr. Greenspan was quite 
circumspect about it, but eventually he offered the opinion that, when 
the time came, the Congress would find the courage and the resources to 
do what was necessary, and he thought that Medicare would be solvent 
into the future. He then stopped and went on to add, ``What concerns me 
more is will there be anyone there to deliver the service at the time 
you need it?''
  Now, Mr. Speaker, I will tell you that those words have stuck with me 
these last 2 years and caused me to devote a great deal of time and 
study to the concept of the physician workforce in the United States. 
Let me just share with you, Mr. Speaker, the Texas Medical Association, 
back in my home State of Texas, puts out a magazine every month called 
``Texas Medicine,'' and this was their March issue of this year, and 
the title story was, ``Running Out of Doctors.'' My State is far below 
the national average when it comes to physicians. The national average 
is 230 per 100,000 residents; Texas' ratio is 186 to 100,000 residents. 
The American Academy of Family Physicians predicts serious shortages of 
primary care doctors in five States, including Texas. And further, they 
go on to say that ``all States will have some level of family physician 
shortage by the year 2020.'' That's 13 years from now, three 
Presidential elections from now.
  The Council on Graduate Medical Education, a congressionally 
authorized entity, estimates that after 2010, growth in the physician 
workforce will slow substantially, and that after 2015, the rate of 
population growth will exceed the rate of growth in the number of 
physicians.
  Now, what do we do? My opinion, I think there is a three-part 
approach, a three-part solution to mitigate this shortage in the 
future.
  First and foremost, and it seems so simple that I cannot believe that 
it doesn't occur to more people, we need to construct a payment system, 
particularly on the governmental side, that pays doctors fairly to keep 
them in practice longer. Additionally, improved assistance to medical 
students, to encourage college students and medical students to go into 
medicine and practice in high-need specialties in medically underserved 
areas. And then finally, to increase the number of residency programs, 
especially in rural or suburban areas, to keep the physician pipeline 
open.
  And the real crux of this article, Mr. Speaker, in ``Running Out of 
Doctors,'' was the observation that doctors tend to have a lot of 
inertia. We don't tend to go very far from where we're hatched. And 
doctors who go through a residency program tend to practice within 50 
to 100 miles of the location of that residency. That's why, if we can 
encourage the development of more residency programs in underserved 
areas, we will encourage the growth of the physician workforce in that 
area.
  So, before we go completely into the three-point solution aimed at 
mitigating the possibility of an even greater solution in the future, 
let's talk about some of the basic principles that I had in mind as I 
developed this concept of physician workforce reform.
  Now, Mr. Speaker, I believe that Congress must develop physician 
workforce initiatives that ensure future patient access and sustain a 
robust physician workforce, and this must be both separate, but 
complimentary, to Medicaid physician payment reform. Why do I say that? 
Well, Mr. Speaker, as you know and many in Congress know and many 
across America know, in Medicare we have different payment systems for 
part B as opposed to part A, part C and part D. In A, part C and part 
D, there is sort of a cost of living adjustment every year for 
hospitals, for HMOs, for drug companies. There is a cost of living 
adjustment that occurs every year so that these institutions, these 
entities are reimbursed based upon the cost of inputs.

[[Page H11839]]

                              {time}  2200

  But part B, the physician part, is under an entirely different 
formula that is coupled to the gross domestic product. Furthermore, it 
is a finite, a finite, number of dollars that are available to pay 
physicians who participate in the Medicare program. What happens over 
time, since that doesn't grow, what happens over time, the individual 
payments to physicians are scheduled to shrink 5 to 10 percent a year 
over the next 9- to 10-year budgetary cycle.
  This program is so unfair that it causes physicians to retire early, 
stop seeing Medicare patients and leave the physician workforce. The 
solution is very, very simple, and it is one that is so simple that, 
quite frankly, it oftentimes gets lost in all of the other talk and 
debate. The solution to this problem is stop the cuts, repeal the 
formula, and then replace it with the Medicare economic index, the 
cost-of-living formula that hospitals, HMOs and drug companies are paid 
with.
  Now, the current Medicare payment system exacerbates negative 
physician workforce trends. That is why I feel that the sustainable 
growth rate formula must be eliminated. Let me just show you a little 
graph of that. Mr. Speaker, I think this graph accurately represents 
what I am talking about. Again, we talk about the physician payment as 
compared to HMOs, hospitals and, in this bar graph, nursing homes. You 
can see over the years 2002 to 2007 increases in HMOs, hospitals, and 
nursing homes and very flat increases for a few years for physician 
payment after an initial decline, and actually this was projected for 
2007. We actually held physician payment at a zero percent update, 
which anywhere else other than in Washington, D.C. let's be honest, 
that would be a cut but we call it a zero percent update because we 
like to be euphemistic when we talk to our physician friends. Again, I 
submit, stop the cuts, repeal the formula.
  Now, any new system that we create has to be able to adjust for 
growth in services, but it has to be agile enough to determine what 
constitutes appropriate care in service and service volume when growth 
results in better patient outcomes. Any new coverage decisions by law 
or regulation must be accompanied by additional financial sources 
relative to their value for the services.
  Now, Mr. Speaker, we spent a lot of time in my committee, Committee 
on Energy and Commerce, last year having hearings about physician 
payments. And one of the things that is obvious when you look at recent 
trends in Medicare outlays is that in fact the trustees report that 
came out last June talking about the year 2005; 600,000 fewer hospitals 
beds were filled that year. Why? Because the physician component is 
doing things better, more timely treatment of disease. I will submit 
that perhaps some of the new Medicare prescription drug program is 
playing a role in that as well; doctors are doing more procedures in 
their offices in ambulatory surgery centers.
  The net effect of that, Mr. Speaker, is to keep down the costs for 
part A, but then that expense occurs in part B. So how could we get the 
savings that we are managing for part A, how could we get that back for 
part B? That is really the challenge that is before us.
  Now, the Congressional Budget Office and all of the budgetary people 
who work up here on Capitol Hill will tell you that you can't 
prospectively go out and say, since you are going to save so much 
money, you saved so much money last year, and you are going to save so 
much money next year and the year thereafter, but you can't get credit 
for that until it actually happens. My belief is that savings will 
occur. It will accrue.
  So what if we pay it forward, so to speak, we don't repeal the SGR in 
2008 or 2009, we will repeal it in 2010. But in the meantime, 2008 and 
2009 whatever savings occur because the physicians in part B are doing 
things better, cheaper and safer and saving money for part A, part C 
and part D, that those savings be sequestered and they be walled off. 
Remember the famous lockbox for 2000 everybody talked about for Social 
Security? Let's drag up that lockbox and put the savings in the 
lockbox, and we will open it up in 2010 and reduce the cost of 
repealing the SGR formula.
  That has been the obstacle, Mr. Speaker. The Congressional Budget 
Office estimates the cost of repealing the SGR today right now at $268 
billion. Last year when I tried a different approach to this same 
problem, the cost for repeal was the $218 billion. It goes up every 
year. One of the reasons it goes up every year is that every year we 
come swooping in at the last minute with some sort of last-minute fix. 
But all that money that we used to come in for that last-minute fix 
gets added on to the budgetary out-years. So we compound the problem. 
Every year that we don't fix it, we compound it. That is why it is so 
critical to fix that date that we repeal the formula.
  Now, in the bill 2585 that I have introduced, we actually do that. We 
actually capture and sequester those savings and use that paying it 
forward to bring the cost of repealing the SGR down.
  Now, just a couple of other points in general about physician 
workforce, preserving the physician workforce. You know, I said the SGR 
formula, the sustainable growth rate formula, is linked to the growth 
in the gross domestic product. There is a reason for that. That needs 
to be delinked. Quality reporting. What about quality reporting? We 
hear a lot about that. We hear a lot about pay for performance here on 
the floor of this House. Well, Mr. Speaker, I would submit to you, pay 
for performance is keeping the mature physician involved in the 
practice of medicine. If we drive all of our talented and experienced 
doctors out of the practice of medicine because of what we are doing 
with the Medicare formulas, it is going to be pretty tough to pay for 
performance.
  Now, I do think some type of performance indicators need to be 
included in whatever process is going forward. We don't need to 
reinvent the wheel every time we sit down to talk about this. Many of 
the specialty organizations have already developed their own criteria. 
We have the QIOs. The quality improvement organizations have been in 
existence really I think for 20 years since the latter part of the 
second Reagan term. So these measures are all available to us.
  What I would submit is that if a doctor or a physician group would 
voluntarily report to one of these quality measures, that there be some 
positive adjustment, in whatever formula we give them, that there be 
some positive adjustment for participating in that quality activity.
  Similarly, I talked a little bit about this in the beginning. We are 
in a transformational time. What is one of the things that is going to 
drive that transformation? It is going to be changes in health 
information technology, whether we want it to or not. We struggled with 
the health information technology bill last year. We talked a little 
bit about one this year. The fact remains, it is happening whether 
Congress is involved or not. As a consequence, I think we ought to do 
what we can to encourage physicians' offices and individual physicians 
to begin to embrace this, to begin to investigate this and an 
additional positive update would be available to physicians who 
voluntarily participated in improvements in health information 
technology and their individual practices.
  You know, Mr. Speaker, one of the things that I think would make a 
lot of sense and I don't know why we haven't done it, we ought to share 
with our Medicare beneficiaries what did your care cost last year. I 
get a statement from the Social Security Administration about what my 
Social Security contributions have been year over year since I first 
started paying that FICA tax. We could do the same thing with our 
Medicare patients: What did you contribute over your working lifetime? 
And now what are expenses attributable to you that are incurred to the 
system? That information should be confidential. You obviously don't 
publish that, but give back to the patient that information on what the 
cost of their care was over the past year because otherwise they have 
no benchmark. They have no way to know are they, in fact, getting value 
for their dollar or not.

  So there are three bills that I've introduced to help tackle these 
problems and get at the essentials of what is creating the near havoc 
situation in the physician workforce. I think these bills are essential 
to ensuring that America will always have a good supply of

[[Page H11840]]

qualified, satisfied doctors to address the growing health care needs 
of an ever-growing population.
  Now, we have already talked a little bit about the sustainable growth 
rate formula. Getting Medicare payment policy right is the first point 
to make in any type of reform that is going to affect the physician 
workforce. Paying physicians fairly will extend the careers of many 
doctors who otherwise would just simply opt out of Medicare or opt out 
of the practice of medicine entirely. Paying physicians fairly also has 
the effect of ensuring an adequate network of doctors. That adequate 
network of doctors is available to treat some of those complex patients 
we have in this country, and that is the elderly patient on Medicare 
and as this country makes a transition to the workforce of the future.
  Now, the bill I introduced, 2585, Ensuring the Physician Workforce 
Act of 2007, modifies the Medicare physician reimbursement policies. It 
is important because you do have to pay doctors fairly for their 
services so that they will want to go into medicine, they will want to 
continue to practice medicine, and maybe even practice medicine to a 
later point in their life. So we extend the effective practice life of 
physicians who are already out there practicing.
  Now, the fundamentals of 2585 we have covered already a little bit. 
But I like to think of it as a workforce solution for the mature 
physician. It provides sustainable Medicare reimbursement now and in 
the future by getting out of the chasm created by the sustainable 
growth rate formula and completely eliminating the sustainable growth 
rate formula by the year 2010. It includes truly transformational 
incentives to further the development and implementation of quality 
measures and health information technology in a way that makes sense to 
the business aspect of the practice of medicine.
  Furthermore, in 2008 and 2009, physicians could opt to take advantage 
of those bonuses, return value back to their practices, and, in fact, 
return value back to the taxpayer by participating in those measures. 
Quality measures would be built around high-cost conditions and strive 
to improve the quality of care for those conditions and ultimately 
drive down the cost of delivering the care in the Medicare program. The 
bill would also include a Federal incentive to implement health 
information technology along with provisions providing safe harbors for 
the sharing of software, technical assistance and hardware as well as 
the creation of a health information technology consortium.
  That last point is important because there are laws and regulations 
that Congress has passed in the past that prevent hospitals and doctors 
working together to develop the type of health information technology 
network that is really going to be necessary to manage this sea change 
that we are going to see in medicine in the coming years.
  I will confess, Mr. Speaker, let me put another chart up here. Mr. 
Speaker, I will readily acknowledge that I have not always been a firm 
believer in things like health information technology and electronic 
medical records. In fact, right before I left practice, my practice in 
medicine, we were given a charge to beta test an electronic e-
prescribing sort of format and there was certainly no financial outlay 
on our part. We were simply to use these little hand-held devices and 
report back as to their utility. There were obviously some plus sides. 
You knew right away if there was a drug interaction or a patient had an 
allergy that wasn't apparent on their chart. The computer knew and it 
would flag that for you. But it slowed you down. It slowed you down in 
that it took about a minute or 1\1/2\ minutes to add this information 
in for the patient.
  Mr. Speaker, when I first went into private practice after I 
completed my residency at Parkland Hospital, went into private practice 
in 1981, reimbursement rates were such that if you saw 15 to 17 
patients a day, you pay your overhead and have a nice amount to take 
home at the end of the month. With everything that has happened with 
HMO declining reimbursement rates, from private insurance declining 
reimbursement rates from the government-funded sector of health care to 
be sure and a growing government sector of health care that 
historically underfunds their component and undercompensates their 
component, what has happened over time in order to maintain that 
similar amount of money that is needed to pay for overhead and have 
something to take home at the end of the month, physicians are now 
finding that instead of seeing three patients an hour, they have to see 
five. Instead of working 7 hours in the office, they now need to work 8 
or 9.
  So if you are not seeing 35 or 40 patients a day, you may not be 
measuring up as far as covering that overhead and having something to 
take back to your family. After all, they put up with the sacrifice and 
aggravation of having you, their husband or father as a physician, 
meaning you are frequently gone from home, you go and leave in the 
middle of the night to attend to problems. And we always do that 
willingly and lovingly; but at the same time, it does create wear and 
tear on families, and certainly any doctor's family can tell you that. 
Doctors, over time, have tended to be fairly well compensated. As a 
consequence, families have been ready and willing to accept that. But 
in order to maintain that same level, we have gone from a time where we 
were seeing 15 to 17 patients in a day to 35 to 40 patients in a day.
  Let me go back to the e-prescribing. If it is taking you 1\1/2\ 
minutes to enter in the patient data and hit the send key to send the 
e-mail to the pharmacy to provide that prescription for that patient, 
that is another hour you have added on to that physician's day.

                              {time}  2215

  How are you going to pay the doctor for that? None of this has ever 
been worked out. If you go even further and say we're going to go with 
a full-on electronic record, there's a learning curve there. It's going 
to take some time, and it's going to slow that doctor down. Not only 
will it slow him down so he is able to see fewer patients, it slows him 
down so that there's less face time, if you will, with the patient, 
less time to listen to what the patient is saying, to look the patient 
in the eye and make sure you're getting the straight story so that you 
come to the correct diagnosis.
  Mr. Speaker, I was late to come to the table as far as electronic 
medical records. I will tell you the sentinel moment that changed my 
mind, that shifted me on this issue, and said, you know, it is going to 
take more time; there has to be a way to compensate doctors for the 
time involved in doing that e-prescribing and creating those electronic 
medical records.
  Well, 2 years ago, of course, we were suffering in the aftermath of 
Hurricane Katrina. Two years ago next January our Committee on Energy 
and Commerce had a field hearing down in New Orleans, and one of the 
places we went on that field hearing was to Charity Hospital, one of 
the venerable old teaching institutions in this country. Many of my 
professors at Parkland Hospital had been trained by professors at 
Charity Hospital. It was truly an icon in American medicine. It was 
absolutely devastated in the flooding that followed Hurricane Katrina 
in New Orleans.
  Mr. Speaker, we went into Charity Hospital. We went down to the 
basement where the records room typically is in a hospital. And here, 
Mr. Speaker, is the medical records department of Charity Hospital. 
Now, this isn't fire or smoke damage on these charts. It's black mold. 
You really can't send someone down there to retrieve medical data 
without putting the medical records transcriptionist at risk.
  These records are essentially lost forever, if the ink hasn't washed 
off all the pages. Remember, this was all completely underwater, 
because this was in the basement. You remember how much water was 
standing in the streets of New Orleans. So completely underwater. We 
don't even know if these are readable. But who is going to get in there 
and risk disturbing all the black mold and getting the health 
consequences that would result from it?
  So all of this medical data is lost. Who's to know? Maybe there is a 
kidney transplant there, some important data. Maybe someone being 
treated for non-Hodgkin's lymphoma here, and important clinical data 
lost. Maybe there was a child with a rare illness that,

[[Page H11841]]

again, no one would be able to retrieve those medical records. This is 
the reason why I have now become a believer in the electronic medical 
records system.
  Furthermore, when a large number of persons who were evacuated from 
New Orleans and brought to the Metroplex in the north Texas area, north 
Texas physicians turned out in great numbers to receive people who had 
been in the domed stadium in New Orleans, the Superdome I guess it's 
called, as well as other individuals who were evacuated from the 
Convention Center, and they were brought in buses to downtown Dallas 
and doctors met them as they were coming off the bus.
  One of the large pharmaceutical chains set up there with their 
computer system, and if that patient had gotten their prescription at 
that chain drug store, they were able to recreate not their entire 
medical record, but at least their prescription history, which a lot of 
times will give you a great deal of insight into what a patient's 
conditions are and what they are being treated for.
  So the availability of that, albeit very limited pharmaceutical data, 
provided a great deal of service to the doctors who were on the ground 
receiving these individuals who had to be evacuated out of the city of 
New Orleans. Again, it really made a believer out of me that that data 
needs to be retrievable wherever you are, wherever you go.
  Mr. Speaker, all too often we run into in medicine the fact that, 
yes, the patient went down somewhere and had a CT scan, and now they're 
seeing a different doctor and that CT is not available because it's 
only a written, typed report and it's locked up in some other office 
and they are now closed. So we either go on a hunch without the 
information, or you repeat the test and spend another $1,000. It is so 
critical to have that information where it is readily retrievable by 
any doctor involved in taking care of the patients.
  Mr. Speaker, I have digressed just a little bit from the physician 
workforce issues, but I do think this is such an important issue, and 
that is why I included in H.R. 2585 bonus payments for doctors who are 
willing to begin to make that change into improved health information 
technology and perhaps consider electronic medical records, perhaps 
consider e-prescribing.
  There is no question that our handwriting as physicians is generally 
abominable. I will tell you, Mr. Speaker, it doesn't improve with age. 
Medication errors that are because of poor handwriting or illegible 
handwriting on the prescription pad, we have all encountered it during 
our practices.
  It is so critical to be able to have that information in a legible, 
reproducible form and have it available when a patient goes from city 
to city, as these individuals were because of a crisis in their 
hometown, where they had to leave and go to another town. But even just 
for someone on vacation who develops a problem, if you have the 
availability of accessing their medical records online or through some 
service, that is going to make a tremendous difference.
  Now, Mr. Speaker, one of the things we talked about, too, when I 
first began this discussion on the workforce issue is how do we help 
the physician who's through with medical school and pondering a 
residency, or in fact in a residency. Could we develop a program that 
would permit hospitals that do not now currently have a residency 
program to begin a training program where none has existed previously.
  So the second bill, H.R. 2583, would create a loan fund available to 
hospitals to create a residency training program where none has 
operated in the past. These programs, of course, would require full 
accreditation by the appropriate agencies and would be focused in 
typically medically-underserved areas, rural, suburban, frontier 
community hospitals.
  Mr. Speaker, on average it costs about $100,000 a year to train a 
resident. For a lot of small hospitals, that is a barrier to entry that 
they just cannot meet.
  Two, the Balanced Budget Act passed by this Congress long before my 
service here, back in 1997, 10 years ago, placed the cap on residency 
slots Medicare would fund, making it very difficult for some programs 
to expand and hospitals to create residency programs. So, especially 
for smaller hospitals that are interested in creating a residency 
training program, federal regulations, federal regulations stop them 
cold, dead in their tracks, from creating that residency program.
  Again, these are some of the things that were done in the Balanced 
Budget Act, but these regulations need to be streamlined. We need to 
have a second pathway for these hospitals to follow to establish a 
residency training program. It is a major financial investment for 
small hospitals to undertake, and frequently they just simply have to 
forego, because they can't afford it, even though their community might 
very well benefit from having such a training program.
  Now, in the bill before the Congress, H.R. 2583, loan amounts would 
not exceed $1 million and the loan would constitute startup funding for 
new residency programs. The start-up money is critical here. Since 
Medicare graduate medical education funding can be obtained only once a 
residency program is firmly established, the cost to start a training 
program for a smaller, more rural or suburban hospital is cost 
prohibitive. The barrier to entry is just too high, because these 
hospitals operate on much narrower cost margins.
  H.R. 2583 is a bill that has been introduced as part of the physician 
workforce package of bills. It will allow smaller hospitals to 
establish residency training programs.
  As I said earlier, Mr. Speaker, doctors tend to have a lot of 
inertia. We don't fall far from the tree when it comes time to start up 
practice. We tend to go into practice within 100 miles of where we did 
our residency. That would be the reason to move the residency programs 
into the areas of States, into the areas of the communities where 
doctors are most needed.
  Two, this program could be a recruiting tool for small communities to 
recruit essential professionals to consider a residency program in 
their town and then hopefully stay around once the training program is 
finished, because, after all, you know all the referring doctors, you 
know the personnel in the hospital, and that arduous task of setting up 
a practice becomes perhaps just a little less daunting because you are 
working with known entities.
  The third point of assuring availability of an adequate future 
workforce is providing medical students or college students who are 
considering a career in health professions, to provide them with 
assistance and incentives to practice in shortage areas in shortage 
specialties.
  The third bill, H.R. 2584, would establish a mix of scholarships, 
loan repayments and tax incentives to encourage more students into 
medical school and beyond. It also creates incentives for those 
students and newly-minted doctors to become family docs, general 
surgeons, geriatric doctors, OB-GYNs, and practice in shortage areas 
such as rural and frontier areas.
  H.R. 2584, the High Need Physician Workforce Initiative Act of 2007, 
amends the Public Health Service Act to alleviate critical shortages of 
physicians in the fields of family practice, internal medicine, 
pediatrics, emergency medicine, general surgery and OB-GYN. H.R. 2584 
would establish additional loan and scholarship programs and would 
assist underserved communities to build a pipeline for the medical 
professionals of tomorrow.
  Mr. Speaker, I spoke already about the medical records situation in 
New Orleans. Also as an outgrowth of actually several trips I made to 
the New Orleans area in the fall of 2005 and the early part of 2006, 
you really began to see the attenuation of the physician workforce in 
that area and you really saw the arduous task of rebuilding the 
physician workforce in that area.
  Mr. Speaker, it is almost as if a physician or his spouse, if they 
weren't from the area, they likely weren't staying. They had to have 
significant family ties to make them consider staying in the area. That 
is so unfortunate, Mr. Speaker. But not only do we have the unspeakable 
horror of the hurricane itself, but then we had the slow response in 
getting aid through State and Federal and local agencies to physicians 
in private practice and they were left to fend for themselves. They 
ended up spending their own savings to keep their practice open and 
they reached a point where they simply could not sustain that any 
longer. It will be hard to entice people back.

[[Page H11842]]

  So the reality is the physician workforce of tomorrow, especially in 
an underserved area like the City of New Orleans, is going to require 
growing your own. And part of growing your own is this mix of 
scholarships, loan forgiveness and tax incentives to encourage 
physicians to go into the health professions, and as part of the loan 
payback, they agree to serve in a medically underserved area in a high-
need specialty. This bill provides targeted incentives to develop 
medical students and encourages the growth of specialties that will be 
in high demand in underserved or emerging communities.
  So, Mr. Speaker, those are the three bills, H.R. 2583, H.R. 2584 and 
H.R. 2585, that deal with the problems that I see as emerging with the 
physician workforce. Remember, we are in a transformational time. We 
are in a time that is just as transformational as 1940, 1965, or even 
some of the earlier transitional times that we didn't have time to talk 
about tonight. We are in a transitional time that is going to require 
us, require us as legislators, to be at the top of our game so we don't 
obstruct this process and, dare I say, we enhance this process, we 
further this transformation, we make the transformation proceed in an 
orderly fashion, in a fashion that is beneficial.
  But, Mr. Speaker, I can hardly, hardly, talk about physician 
workforce issues and not address the number one issue that is so 
pernicious to physician practice and drives more doctors into early 
retirement, and that is the state of the medical justice system in this 
country.

                              {time}  2230

  Texas in 2003, September of 2003, a little over 4 years ago, passed 
what I considered a very reasonable bill to put some caps on 
noneconomic damages in medical liability cases.
  Texas was in crisis. When I was running for Congress in 2002, we had 
really hit rock bottom as far as medical liability issues were 
concerned. We had gone from 17 medical liability insurance companies 
down to two. They were leaving the State in droves. If you only have 
two companies, it is difficult to have competition. Premiums were going 
through the roof. Every year I was seeing premium increases of 20, 25 
or 30 percent. And the reality was that reimbursement rates were not 
keeping up and doctors couldn't keep up.
  I remember when I was campaigning in 2002 at an event I ran into a 
young woman who was a radiologist. I say young woman, she had been 
through medical school and residency. She said, I hope you can get 
something done about the liability situation because as a radiologist, 
I lost my insurance because my company left the State and I can't get 
insurance with the two remaining companies. As a consequence, I cannot 
practice interventional radiology without liability insurance. I can't 
accept that kind of risk, taking care of high-risk patients without 
some type of liability coverage.
  So the State of Texas paid to educate this woman. The woman went to a 
State-supported school, so taxpayers partially paid for her education 
because she went to a residency program at one of the State 
universities, and she was lost as a provider to the State of Texas 
because of the liability situation.
  Texas, fortunately, stepped up to the plate and recognized they had a 
serious problem. Across the board in Texas, everyone was talking about 
the crisis in medical liability. So they passed a bill in 2003 that put 
a limit on noneconomic damages in medical liability suits. It was 
patterned after the Medical Injury Compensation Reform Act of 1975 
which affects the State of California and has done a good job in 
California as far as keeping doctors involved in practice and keeping 
medical liability rates low.
  Well, in California, the Medical Injury Compensation Reform Act of 
1975 put a cap on noneconomic damages at $250,000. That was a tall 
order in Texas. They were not able to achieve the same level of cap on 
noneconomic damages, but they went about in a way so that a $250,000 
cap on noneconomic damages exists for the doctor, for the hospital or 
nursing home or a second hospital. So each provider named is going to 
be capped at $250,000, and a maximum of $750,000 that could be awarded 
to a plaintiff in noneconomic damages. Actual damages, punitive 
damages, are not affected by this law. So average compensation for 
patients is still going to be very, very high, but it removes a lot of 
the uncertainty that was present in the medical liability market. And 
as a consequence, it provides fair compensation for injured patients 
and their families. It has been a success in Texas. Liability premiums 
have dropped. Competition has invigorated the insurance market, and 
patients once again have access to the doctors they need. Remember, we 
dropped from 17 down to two insurers. The next year we were back up to 
15, and I believe the number is substantially higher today.
  The best news is they came back to the State without asking for an 
increase of premiums. Texas Medical Liability Trust, my old insurer, 
has provided a 22 percent reduction in premium expenses for physicians 
since 2003. Remember, we were going up by 20, 25, 30 percent a year 
every year prior to 2003, so this has been a dramatic turnaround in 
Texas.
  Remember, I talked about Texas as being one of the States that is 
medically underserved. Remember that figure of 186 doctors per 100,000 
population. But since this law took effect, things are on the upswing 
as far as physician workforce in Texas. Over 10,000 new physicians have 
been licensed, including a record 3,300 doctors licensed in fiscal year 
2007. The Texas State Board of Medical Examiners can scarcely keep up 
with the demand. Several have asked what is taking the Texas State 
Board of Medical Examiners so long, and there is a lot of demand. When 
you have to ask how big are you winning, that is a good thing, and 
Texas is winning big with this legislation.
  Doctors are moving back to areas that were underserved and critical 
specialties are moving back into the State. Doctors who practice a 
specialty called perinatal medicine where you take care of the most 
complicated pregnancies and the sickest babies, these doctors could not 
get insurance at any price in 2002. And I remember talking to a young 
doctor at a hospital who said, I am going to have to stop practicing. I 
have all of these loans to pay back, and I can't practice because I 
can't afford the liability premiums.
  Our whole trauma network in north Texas was put at risk because 50 
percent of the neurosurgeons, that is one out of two who were 
available, said he got his six-figure premium notice, and he said, 
That's it, I can't do this any more. With him leaving, leaving only one 
neurosurgeon in the trauma network, it put north Texas in a serious 
position for how they were going to be able to handle trauma cases in 
north Texas.
  Since the passage of this law in Texas, that perinatologist has gone 
back into practice. He went to work for a computer firm, believe it or 
not, and now he is back in practice and probably saving babies today 
that wouldn't have been saved without his care and expertise. I am sure 
he did a good job taking care of computers, but babies are more 
important than computers.
  New neurosurgeons are attracted to the north Texas area, preserving 
the trauma network we have in the north Texas area. It was very much 
put at risk by the crisis in medical liability.
  One of the unexpected beneficiaries of this law in Texas has been the 
smaller, not-for-profit hospital that is self-insured. They were having 
to put so much money away to protect against future losses because the 
upper limit was unknown. Now they are able to take some of that capital 
and reinvest it in capital equipment, nurses' salaries and outreach and 
education, the very things you want your hospital to be doing. They are 
able to do those things because of sensible reform that happened in the 
State of Texas.
  Claims and lawsuits have declined, and the current situation that 
exists in some States only drives up the cost of health care and forces 
doctors to treat every patient as a potential lawsuit.
  Mr. Speaker, the Founding Fathers suggested that the States could 
function as laboratories for the rest of the country, and I think this 
is one of those instances where we have seen the function of the 
laboratory, that is Texas in medical liability, function in every way 
as we would want it to. In fact, when we were going through the budget 
process last March, I provided the ranking member, our ranking member 
of the Budget Committee, the legislative language that would be the

[[Page H11843]]

Texas law if it were written by legislative counsel here in the House 
of Representatives.
  And they took the bill and did a back-of-the-envelope score and came 
up with a $3.8 billion savings over 5 years that would be available to 
the budgeteers had they chosen to accept that. In other words, do 
medical liability reform like we did in Texas across the country, and 
you are going to save some money.
  It is not a huge amount of money. I know in Washington-speak $3.8 
billion doesn't resonate like some other figures, but it is real money 
and it is available to us. All we have to do is enact some type of 
sensible medical liability reform across the country like we did in my 
home State of Texas.
  So I took that language that ran through legislative counsel on the 
Texas liability law and actually introduced the Texas medical liability 
law. It is H.R. 3509, the Medical Justice Act of 2007. It is now 
available. Members may cosponsor it. I recognize in the current climate 
in the United States House of Representatives it is going to be very 
difficult to get any type of medical liability reform passed, but at 
the same time, this is important work and we shouldn't shy away from 
it. We should at least have the discussion and the debate. Let's clash 
in the marketplace of ideas here. Here is a system in Texas that is 
delivering real value to the patients of Texas and to the doctors of 
Texas.
  Mr. Speaker, we can't rise to the transformational challenge that 
stretches before us without keeping the best doctors involved and 
recruiting and training the best and brightest doctors who are coming 
behind them, recruiting and training those doctors for tomorrow. This 
is going to require a near-term, a mid-term and a long-term strategy. 
Mr. Speaker, we have to work together, both sides of the aisle. This is 
not a partisan issue. This is going to face every single one of us in 
our district as we go through this next several years. And we are not 
going to be able to master the transformational challenge that extends 
ahead of us without America's best and brightest staying involved and 
providing care for patients in this country. The best and brightest men 
and women of medicine, we need to keep them on the front lines. I 
stress, this is a true bipartisan issue. There is not a single party 
label attached to this concept.
  So let's sit down, both sides of the aisle, and work together to 
insure a healthy future for all Americans. The bottom line is we have 
to make certain that doctors are continuing to practice, they are 
satisfied with their compensation and satisfied with their ability to 
deliver services to the patients.
  You hear the phrase in Washington, ``well, we will cross that bridge 
when we come to it''; in other words, we won't act until we absolutely 
have to act.
  Mr. Speaker, this is a transformational time. I think this calls for 
a different type of thinking. We are going to have to build a bridge 
while we are crossing it, not wait until we get there. We are going to 
have to build that bridge ahead of time, and I think we can.
  I visited a group of scientists at the National Institutes of Health 
and they talked about the challenge of working through the genetic 
sequence of the human genome and sequencing the base pairs in the human 
genome. And they started this project in the 1990s, a very labor-
intensive project, and they didn't have the Internet. They didn't know 
that they needed the Internet. Fortunately, the Internet came along 
while they were in the process of cracking the genetic code. But if it 
hadn't been the Internet, they wouldn't have been able to share 
information with other scientists around the world on a real-time 
basis. And I don't know if by today we would have cracked the genetic 
code, so an example of building the bridge while you are crossing, and 
certainly those scientists at the National Institutes of Health really 
did take that to health.
  Why wait any longer? Why should we keep doctors and patients waiting? 
Sensible legislation is before us now. Again, I repeat, I urge my 
colleagues to look at this, talk to me if you have questions about it. 
It is extremely important for those students who are looking to go into 
health care as a profession, those in medical school now, those doctors 
in residency, and again, what I would refer to as the mature physician. 
It is important to the whole continuum of the timeline of the physician 
workforce.
  We don't want to end up in that day that Alan Greenspan looked into 
the future and saw a couple of years ago. We don't want to arrive at 
that day where there is no one there to take care of America's seniors 
because we didn't pay attention, we took our eye off the ball back here 
in the year 2007.

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