[Congressional Record Volume 153, Number 190 (Wednesday, December 12, 2007)]
[House]
[Pages H15400-H15407]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                              HEALTH CARE

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 18, 2007, the gentleman from Texas (Mr. Burgess) is recognized 
for 60 minutes.
  Mr. BURGESS. Madam Speaker, I come to the floor tonight to talk, as I 
often do, a little bit about health care, the state of health care in 
this country, where we are, where we've been, where we're going.
  Tonight, I do want to focus on one particular issue that is before 
this Congress. It's a critical issue facing our doctors in this country 
who provide care for Medicare patients, because if this Congress does 
not act before midnight on December 31, those physicians are facing a 
rather significant reimbursement reduction, and that would have an 
adverse affect on their ability

[[Page H15401]]

to see patients, to care for patients and, indeed, would have an 
adverse effect upon access.
  So I do want to spend some time talking about that, why that is the 
case and what we in this Congress can do about it and what we need to 
do about it. And again, that action has to take place prior to December 
31 of this year. It's not something we can punt into next year and then 
come back and try to collect our thoughts and make another run at it. 
We have to fix it with the time we have remaining in this first half of 
this Congress.
  Another issue that I want to address is the issue of the physicians 
workforce. Of course, the Medicare reimbursement rates directly affect 
the physician workforce, but we can't forget physicians who are at the 
very beginning of their training, physicians in residency, and we 
certainly can't forget those individuals who might even be 
contemplating a career in health care and how can we help them make the 
correct decisions.
  I do want to talk a little bit and focus a little bit on medical 
liability reform because that does play an integral role in the overall 
quality and makeup of the physician workforce.
  I'd like to talk a little bit about the history of medicine, some of 
the things that have happened in the last 100 years and some of the 
things I see just happening and just over the horizon as we begin the 
dawn of the 21st century.
  And finally, I do think we need to talk a little bit about the status 
of the uninsured and, again, some of the other current events that 
surround health care in this Congress.
  Madam Speaker, we pay doctors in our Medicare system under a formula 
known as the sustainable growth rate formula, and this has been the 
case for the past several years, and it has led to problems, certainly 
every year that I have been in this Congress, and I took office in 
January of 2003, and the problems actually predate that for some time.
  The difficulty with that formula is it ties physician reimbursement 
rates to a number based upon the gross domestic product which, in fact, 
has no bearing on the cost of delivery and the volume and intensity of 
medical services delivered.
  And Medicare, of course, many people know Medicare is supposed to be 
an integrated program but, in fact, in many ways it is high load. You 
have part A that's paid for with a payroll deduction just much the same 
as Social Security. Part A, of course, covers hospitalization expenses.
  Part B covers physician expenses. That is paid for out of member 
premiums that citizens purchase every year, and it is paid for out of, 
25 percent by law by the premium dollar and 75 percent comes out of 
general revenue.
  Part C, the recently enacted Medicare prescription drug benefit, had 
money budgeted for that purpose. Remember that was all the fight of 
November of 2003 when we enacted that law, but money was actually on 
the budget and dedicated for that purpose. And those moneys exist and, 
indeed, are appropriated automatically year over year. I beg your 
pardon, part C is the Medicare HMO. Part D is Medicare prescription 
drug. Part C is funded again, likewise, out of the general Treasury.
  Part A, part C and part D each have essentially a cost-of-living 
adjustment that's made every year. So that the cost of delivering the 
care doesn't exactly keep up, but it more or less keeps up with the 
costs and with medical inflation, but not so part B, which pays the 
physician. And the part B part of Medicare is governed under this 
sustainable growth rate formula.
  And really, Madam Speaker, I know I'm not supposed to talk to Members 
directly, only supposed to address the Chair, and I will confine my 
remarks to the Chair, but just talking to the Chair, if I were able to 
talk to people directly, I know I run some risk of people turning off 
their televisions, but I do want to take you through what is known as 
the sustainable growth rate formula because I think it's instructive. 
Even though not every person can understand every nuance of the 
formula, I think it's instructive to actually look how the formula is 
constructed and how we come up with the dollar figure every year.
  Madam Speaker, I know people who are particularly astute will notice 
there is a typographical error on this graphic. I would point out that 
the typographical error was actually made by the Congressional Research 
Service and not by my crack staff. Again, the very gifted will be able 
to pick that up right away, but we'll get to that in just a moment.
  Here's the calculation of the payment formula under the physician's 
fee schedule. Here we see payment equals and here's a whole bunch of 
letters that follow along, and the explanations are given underneath 
the formula. The relative value unit for work versus, rather multiplied 
by a geographic index; a relative value unit for practice expenses, 
again multiplied by another fudge factor for geographical location and 
geographical practice expenses; a relative value unit for the cost of 
medical liability insurance, again also adjusted for geographic 
location; all multiplied then by what's called the conversion factor, 
CF, at the end. And this CV down here actually should say CF, and that 
would stand for ``conversion factor.''
  Well, that's all very interesting, and obviously the conversion 
factor plays a big role in this, so let's just dig a little bit deeper 
into how that conversion factor or that adjustment factor is 
calculated. And here we see a sample calculation for the formula for 
the year 2007, and again, we won't get into all of the nuances of this 
formula, but you see the update adjustment factor, UAF, the prior year 
adjustment component plus a cumulative adjustment component, and the 
formula for 2007 is calculated as follows, where the target 2006 minus 
the actual spending in 2006 divided by actual spending in 2006 
multiplied again by conversion factor.
  I want to draw your attention, Madam Speaker, though, to the fact 
that every year the prior adjustment component, and then added into 
that is the cumulative adjustment component, that's significant, 
because every year for the past 5 years that I have been here the 
United States Congress has come in at the last minute, at the last 
minute with some way to prevent these physician cuts from going into 
effect.
  But as the Congressional Budget Office calculates this number year 
over year, this cumulative adjustment component grows over time such 
that we are told in order to repeal the cost of repeal of the 
sustainable growth rate formula, when I first came to Congress in 2003 
was around $118 billion over 10 years.

                              {time}  2200

  A pretty significant amount of money, no question about it. But that 
number has increased with every year that we have postponed the cut, 
that we have come in at the last minute, the last of December and 
prevented the cuts from happening. Those moneys actually don't just go 
away. The moneys that were to be saved in that cut don't just 
disappear. The Congressional Budget Office adds them onto the total 
expense of the repeal of the sustainable growth rate formula such that 
the price tag for repeal of the sustainable growth rate formula last 
year, the last session of Congress, when I introduced a bill to repeal 
the sustainable growth rate formula, was $218 billion. It increased 
almost $100 billion over 3 or 4 years' time, and this year is 
calculated to be $268 billion. If we do manage to get something done 
before the end of the year, those moneys again the Congressional Budget 
Office will add on with that cumulative adjustment component.
  One last graphic on this issue is the calculation of the update of 
the conversion factor, where, again, we see the current year is equal 
to the prior year plus the conversion factor update. And the conversion 
factor update is calculated as being 1 plus the Medicare economic index 
increase divided by 100, multiplied by 1 plus the updated adjustment 
factor.
  You can see this is pretty complicated stuff, and for that reason 
many Members, when you try to talk to them about changes in the 
sustainable growth rate formula, will just simply tune you out because 
we all have a little place where we put in our minds things that are 
too hard to deal with. And the SGR formula is one of those things that 
most Members will put into the too hard box. It's something that I have 
got to come back to later because I really don't understand it. And it 
is

[[Page H15402]]

an understandable human reaction to a situation that's terribly 
complex.
  But, Mr. Speaker, let me just illustrate for you what will happen if 
Congress does not do its duty and does not do something to prevent the 
physician cuts, the Medicare payment cuts, that are already on line to 
occur January 1 unless Congress acts legislatively prior to that time. 
The Center for Medicare and Medicaid Services on November 1 of this 
year, after running through the formula, they said, okay, this year 
based on what we budgeted for and what the actual spending was, we are 
going to have to downwardly adjust physician payment rates by 10.1 
percent. That's 10.1 percent, a pretty significant amount of money. If 
we don't do something, that's what is going to hit January 1.
  You say, well, okay, Medicare payments aren't that great anyway and a 
lot of physicians' offices don't rely just strictly on the Medicare 
reimbursement they get to keep their doors open; so it won't really 
affect my doctor's practice. But one of the things that we forget in 
this House of Representatives, one of the things that we just 
conveniently again stash away in that part of our brains where we put 
things that are too hard, almost every commercial insurance company in 
the United States pegs their reimbursement rates to Medicare. So what 
happens when Congress or the Center for Medicare and Medicaid Services 
mandates a 10 percent physician fee cut in Medicare and we don't do 
anything to correct it before the end of the year? That has an 
extremely deleterious effect on almost every practicing physician's 
office in this country. There are very few who will be absolutely 
isolated from that. I realize some in academic medicine may not 
actually feel it. Some doctors who practice in federally qualified 
health centers may not see that or may not feel it. But the bulk of the 
practicing physicians, the men and women who are out there every day 
seeing us when we get sick, seeing our kids when they get sick, those 
are the ones who are going to feel the brunt of this inactivity by this 
Congress.
  I bring this up tonight not because we were inherently any better at 
doing it when the Republicans were in charge, but it's so important to 
get this work done and to get it done in the limited time that we have 
left this year.
  I introduced just this week a resolution in the House of 
Representatives, House Resolution 863 for those who are keeping score 
at home, and House Resolution 863 is a pretty simple bit of legislative 
language. I will be honest. It doesn't do a whole lot. It doesn't 
really save any money. It doesn't spend any money. It's more or less 
like sending a get well card to the doctors who participate in our 
Medicare system and take care of our seniors. But the sentiment, just 
like when you send a get well card, the sentiment is important. And for 
Members who feel they could sign onto this bill, I think it would send 
a powerful message to House leadership over the next several days if we 
could, in fact, put a number of names with this House Resolution 
because I think that would get the attention of leadership. Even though 
leadership is of the other party than myself, I think they would have 
to pay attention if the bulk of the Members of House of Representatives 
sign onto this resolution.
  And the resolution, as most go, is multiple whereases followed by a 
``resolved.'' And the resolved says that it is the sense of the United 
States House of Representatives to immediately address this issue, the 
physician pay cuts under SGR, and halt any scheduled cuts to Medicare 
physician payments and immediately begin working on a long-term 
solution, and implement it by 2010, that pays physicians a fair and 
stable way and ensures Medicare patients have access to the doctor of 
their choice.
  Fairly simple language. What does it mean? It means stop the cuts, 
repeal the SGR. We know we can't repeal the SGR straight up right now, 
that it will take a time line in order to do that, and that is why I 
suggest 2010. I would be open to other suggestions. But that seems like 
a good time line for us to follow. It gives us a little over 2 years to 
get that done.
  When we face a problem as complicated as the formula that I put up in 
front of you tonight, some of those things are just too difficult to 
tackle head-on all at once. So you need a near-term, a mid-term, and a 
long-term strategy to deal with these very complicated problems, and I 
have outlined it here tonight. The near-term, the short-term strategy, 
stop the cut. Find some money. There's plenty of money. In a $3 
trillion budget, you tell me we can't find someplace to save some money 
in a $3 trillion budget to pay the doctors what they are fairly owed 
for taking care of the patients we have asked them to take care of.
  So the near-term solution is stop the cuts. The mid-term solution is 
we sit down and work together with the common goal of the long-term 
solution, which is the repeal of the sustainable growth rate formula, 
and begin to pay physicians on the same sort of schedule that we pay 
our hospitals, that we pay our HMOs, that we pay our drug companies. 
Put them on a cost-of-living-type adjustment. It's called the Medicare 
economic index. It's not something that is unique to me. I didn't make 
it up. I didn't make up the term of how it is calculated. But this is a 
known number put out by the Medicare Payment Advisory Committee, and 
year over year it suggests a modest update in physician reimbursement 
to keep up with the cost of delivering care.
  Let's be honest. From a Federal Government standpoint, Medicare 
reimbursement rates were never meant to match private insurance rates. 
Someone explained to me one time if you practice medicine and do a lot 
of Medicare, you're going to go broke. You'll just go broke a little 
more slowly because we bleed you to death more slowly. Not a pleasant 
analogy, but Medicare never has been designed to completely cover the 
cost of delivering the care. The problem is we have now ratcheted that 
number down so far that physicians across the country are honestly 
looking at the situation and saying I don't think that this is 
something that I can legitimately continue to do. I've got to find 
other ways to make a living.

  It's House Resolution 863, and I do urge Members to look that up on-
line. It's up on Thomas. Have a look at it and see if it is not 
something that you can't support because, again, I think it would send 
a powerful message to House leadership. If over the next several days 
prior to the time that we are slated to adjourn for this year, I think 
it would send a powerful message that Members of the House want this 
fixed. And I know they do because every time I talk to a Member of the 
House, whether it be on my side of the aisle or the Democratic side of 
the aisle, if you just ask a simple, straightforward question: Do you 
ever hear from your doctors? Do your doctors ever talk to you about 
what is happening to them in Medicare reimbursement? And the answer is 
almost immediately, Oh, yes, I hear it all the time. Do you have 
something that will fix that? And the answer is, Yes, sort of. I've got 
something that will focus our attention, I hope, on getting this 
problem resolved.
  It's a shame we didn't take this up earlier in the year. I introduced 
several pieces of legislation to try to do that both in the last 
Congress and in this Congress. It's a shame we didn't take it up this 
year. It seems like many times this year we'd rather fight about almost 
anything we can think of to fight about and not solve the problems that 
the American people sent us here to solve. Well, here's one we can work 
on, and cosponsoring House Resolution 863 would go a long way toward 
moving us in that direction.
  Let me just put up another slide, and this one is a little bit dated. 
This slide is a year old, and I should update it for the current year 
except that I don't know what is going to happen in the current year. 
But this is illustrative. This is demonstrative of what happens to 
physician reimbursement rates under the sustainable growth rate formula 
for physicians. And this is a comparative payment analysis of the 
various updates that have gone on since 2002, the year before I came to 
Congress. And this particular graph goes up through an estimated fiscal 
year 2007. And, again, actually it needs to be updated for this year.
  But as you can see, Medicare Advantage plans, they're doing pretty 
good. Hospitals, it's up and down a little bit, but generally their 
market basket update that they receive every year is hitting about 3.6 
to 3.8 percent, and all

[[Page H15403]]

in all the hospitals are doing generally well under that scenario. 
Nursing homes, a little less generous. And, again, it does bounce up 
and down a little bit. But as you can see, year over year a positive 
update, certainly a positive update that's in excess of 2 percent. And 
many times for nursing homes it approaches 3 percent.
  But look over here at the doctors in 2002, and this was the last year 
I was practicing medicine. And sure enough, we got a 5.4 percent pay 
cut just right across the board for any Medicare procedure that we 
performed.
  Now, for the next several years, 2003, 2004, and 2005, we did manage 
to find the money to provide a little bit of a positive update. Notice 
even in these years when physician practices were flush with cash from 
Medicare payments, they really never even approached what nursing homes 
were receiving in updates and certainly were nowhere near what 
hospitals and Medicare Advantage plans received. Medicare Advantage 
plans, I would point out, did not exist prior to 2004. That's why they 
start with that darker line there.
  Then in 2006 there is nothing recorded on the physicians. We 
euphemistically termed that a zero percent update. Anything else that 
we do in the Federal Government, if we say we are going to hold you at 
level funding for this fiscal year, people would be coming out of the 
woodwork crying that's a cut, that's a cut because you're not keeping 
up with the cost of living. It didn't seem to bother us a bit to do 
that to America's physicians. But at least a zero percent update is a 
whole lot better than that what was originally proposed in 2007, which 
was, again, about a 5 percent negative update. We actually were able to 
stave this one off and keep that again at a zero percent update for 
2007. And now for this next year, 2008, whatever color we decide to put 
on the bar for that will dip down to almost the bottom of the chart 
because a 10.1 percent negative update is going to have a significant 
deleterious effect, a significant pernicious effect on our practicing 
physicians. Again, our physicians that we have asked to take on the 
burden of seeing our Medicare patients.
  Now, I do spend a lot of time on the floor of this House talking 
about physicians workforce issues. This is the cover of the March 2007 
periodical that is put out by my State medical society, the Texas 
Medical Association, appropriately titled ``Texas Medicine.'' And the 
cover story last March was ``Running Out of Doctors.'' And this was a 
fairly significant graphic for me when I saw that at the time.

                              {time}  2215

  About a year before this publication came out, Alan Greenspan, in one 
of his last trips around the Capitol right as he was retiring as 
Chairman of the Federal Reserve Board, Chairman Greenspan came and 
talked with a group of us one morning. And the inevitable question came 
up, how are we ever going to find the funding for the unfunded 
obligations that Congress has taken on? How are we going to pay for 
Medicare when the baby boomers retire? And the Chairman thought about 
it for a moment and he said, you know, ``when the time comes, I trust 
that Congress will make the correct decisions, and that the Medicare 
program will continue.'' He stopped for a moment, thought some more, 
and then added to that, ``What concerns me more is, will there be 
anyone there to deliver the services when you want them?'' And that is 
one of the critical issues facing us today.
  And of course it's this inequity in supply and demand, supply and 
distribution of the physician workforce that's driving a lot of the 
problems that we find in health care today. And no question it has some 
effect of elevating prices, and just the fact that it takes so long to 
get in to see some types of physicians. There was a very compelling 
article here in the Washington area a few months ago about the travails 
and toils a reporter had with trying to get their child in to see a 
pediatric neurologist. You hear these sorts of stories. I travel, not a 
lot, but some around the country to visit with medical groups in the 
country, and you will hear all those stories from all over the country. 
It's not unique to one geographic location.
  Three bills that were introduced earlier this year to deal with 
physician workforce issues, H.R. 2583, H.R. 2584 and H.R. 2585. Now, 
H.R. 2585 deals with what I like to term ``the mature physician.'' So, 
it deals a lot with the sustainable growth rate formula and the 
inequities of the sustainable growth rate formula as it pertains to how 
the Federal Government compensates its medical workforce.
  The thrust behind 2585 was to, again, take that short-term, mid-term 
and long-term approach to the problem such that we would fix the 
problem, we would stop the cuts in 2008 and 2009 and 2010. We would 
gear towards absolute repeal of the SGR formula. Again, remember I said 
that it's going to cost money when that time comes. And that has always 
been the difficulty when trying to talk to Members about, I want you to 
help me repeal the SGR. The next question always is, Well, how much 
does it cost? You tell them, and, oh, my gosh, it's a bridge too far. 
We've got other priorities and we just can't get there. Well, let me 
tell you a little secret. That money that we have to come up with to 
repeal the sustainable growth rate formula, guess what? We've already 
spent that money. We've already sent that money to physicians' offices 
across this country and they've already spent it.
  So, it is merely a bookkeeping adjustment that the Congressional 
Budget Office has to make to reconcile its books to compensate for, 
remember, that cumulative index that I showed you, one of those earlier 
poster boards. That is the difficulty. It's essentially a bookkeeping 
entry that has not yet been made. The money has been spent, it's gone. 
It's not sitting somewhere in the Federal Treasury drawing interest. It 
is a bookkeeping entry that has yet to be made.
  We have to take this on. We have to do this. It's the moral thing to 
do; it's the right thing to do. We want our Medicare patients taken 
care of. They are arguably some of the most complex clinical situations 
that a doctor encounters on a daily basis, and we ought to do the right 
thing.
  Now, how do you do that and be able to encourage Members to look at 
this seriously when the published price tag is so large? When I 
initially tried to do this in the last Congress, a bill I introduced 
called 5866, when, remember the cost of repeal was $216 billion, I 
thought at that time perhaps the correct way to go about this was just 
to work on the repeal straight up, maybe look for the pay-fors later as 
we got toward the conclusion of the process. And I was hopeful that 
hospitals, nursing homes, other medical entities that draw on Medicare 
funding would perhaps come forward with their own suggestions of where 
savings could be made because I don't think there is a single person in 
this Congress who doesn't feel that there are some inefficient ways 
that the Federal Government spends money in the Medicare system, and 
perhaps if we collected those together, we could find the monies to 
help cushion the offset expense of repealing the sustainable growth 
rate formula. But I was wrong, no one was willing to come forward. And 
as a consequence, I never really got the traction or the momentum that 
I needed on 5866. And again, the 109th Congress ran out before we could 
get anything done.
  So, early in this Congress I thought, I need to get something out 
there quickly. I need to get people to understand this problem. We 
certainly don't need to leave it until the last minute this year, but 
unfortunately that's what has transpired. So, the idea behind 2585, 
introduced earlier this year, was to get that concept out there 
earlier, get Members talking about it.
  How was I going to approach it? Well, 2008 and 2009, remember, we 
don't repeal the SGR. So, many doctors looked at that and said, Well, 
if you don't repeal the SGR formula in 2008 and 2009, I'm going to take 
significant hits those years, and I can't afford to do that. But 
actually, there is another bookkeeping entry you can do; it's called 
readjusting or resetting the baseline on the SGR formula. And by doing 
that, you actually then can score a modest positive update for 2008 and 
2009 for physicians who participate in this program. In fact, 
interestingly enough, in 2008, it's almost equal to the Medicare 
Economic Index update. In 2009, it's a little bit less than that, but 
still a positive update, a fairly generous positive update of just 
under 1 percent for 2009.

[[Page H15404]]

  During those 2 years' time, the run-up to the repeal of the 
sustainable growth rate formula, we recognize that we are saving money, 
we are doing things better in medicine today than we did yesterday. And 
how do I know this? What is a metric that I can use? Well, the Medicare 
Trustees Report that came out in June of this year pointed out that the 
bad news is Medicare is still going broke, but the good news is it's 
going to go broke a year later than what we told you the year before. 
So in other words, somewhere along the line there had been some savings 
in the Medicare system. And where did that savings occur? Well, one of 
the places it occurred, as identified in the Trustees Report, was 
600,000 hospital beds weren't filled in the year 2005 that were 
expected to be filled. Why weren't they filled? They weren't filled 
because, again, the doctors were doing things on a more timely basis, 
more accurate diagnoses, the whole ability to timely treat disease with 
the prescription drug benefit now available for seniors in the Medicare 
program. All of these things had a bearing, and as a consequence, more 
patients were treated as outpatients, treated in the doctor's office, 
perhaps treated in an ambulatory surgery center, perhaps treated in a 
day surgery center, but these patients were kept out of the hospitals, 
and so those hospitalizations were avoided.
  Remember when I talked about the funding silos for Medicare. Although 
we will talk about Medicare as an integrated program, part A, which 
pays for the hospital expense, is funded out of a payroll deduction 
just like the FICA tax, just like Social Security. Part B is funded out 
of member premiums and general revenue. By law, only 75 percent of it 
can be funded out of general revenue; 25 percent of that number has to 
come from member premiums.

  So, if we're saving money on the hospital side, we're saving money 
for part A. But why are we saving the money? We're saving the money 
because we're working better, smarter, faster in part B. So it would 
only make sense to have CMS identify those savings that right now are 
going on the books as savings for part A, identify those savings, 
aggregate those savings, collect those savings, and use them to offset 
the cost of repealing the sustainable growth rate formula in part B.
  You know, remember, Madam Speaker, the lock box from the year 2000, 
in the Presidential race everyone was talking about a lock box and they 
were going to put Social Security in a lock box, and with all the 
discussion of whose lock box was bigger than whose? But we've still got 
the lock box. We can put these savings that we're creating in part A, 
put them in a lock box, 2 years later open it up, and we offset some of 
the cost of paying down the so-called debt in repealing the SGR 
formula.
  There were some other things that I identified in the bill as other 
ways to perhaps enhance savings. Certainly we asked CMS to try to 
identify the 10 diagnoses where most of the money was spent, and let's 
really focus our efforts on those 10 diagnoses and see if we can't 
create greater and greater efficiencies in treating those 10 conditions 
that lead to the greatest expenditures in the Medicare system. And 
let's look honestly at what we can do on the preventive side. Remember 
what our mothers always taught us, an ounce of prevention is worth a 
pound of cure. If we want that pound of cure, let's go ahead and spend 
a little bit for that ounce of prevention on the front end so we don't 
have to spend so much for that pound of cure on the out end. And then 
let's take that pound of cure that we've saved and use it to offset the 
cost of repealing the sustainable growth rate formula.
  Well, another way we could save some money is, any of the monies that 
are recovered by the Department of Justice, the Inspector General for 
Health and Human Services, and the so-called Medicare audits, money 
that is fraudulently taken from Medicare and then recovered, again, 
that's money that's stolen from part B. Let's not just put that money 
into the coffers of somewhere else. Let's let that accrue as part of 
the savings that we put in that lock box that we use to offset the cost 
of repealing the sustainable growth rate formula.
  Two other things that I did in the bill, which I think are important 
as far as gaining some overall efficiency in the system, was added some 
voluntary positive updates for physicians who were willing to 
voluntarily participate in quality reporting exercises, and physicians' 
offices who were willing to voluntarily participate in improvements of 
health information technology.
  We don't have, and certainly in Congress, certainly the Federal 
Government does not have all the answers as to what creates the perfect 
health information technology platform. In many ways, private industry 
is light years ahead of where the Federal Government is. And maybe, you 
know, Madam Speaker, some days, honestly, I just wonder if we should 
get out of the way with some of our regulatory burdens, some or our 
stark laws and let private industry develop these platforms, because 
clearly, in the last 5 years that I've been here, we've had a lot of 
talk, we've had a lot of bills introduced, we've had a lot of debate, 
we've even passed some bills in the House during the last Congress, but 
we are no closer to having any sort of a national standard for health 
information today than we were when I first got here 5 years ago. I 
believe the individual's name was William Brailer who was in charge of 
that project. He is now, unfortunately, no longer with Health and Human 
Services.
  The project has, for all intents and purposes in my mind, been a 
disappointment, but it doesn't mean that health information technology 
has just been stagnant. Other stakeholders, other participants in the 
health care system in the United States have created and drafted and 
are working on their individual platforms. And at some point they will 
reach critical mass in the private sector where there will be general 
acknowledgement that, yes, this is the health information technology 
platform of the future and the one to which we all should subscribe. It 
would have been a useful function of the Federal Government had we been 
able to do that, but honestly, I don't see us there yet, and I don't 
see us there in the foreseeable future. You would think the Federal 
Government would have had a significant role to play in that because if 
you look at health care expenditures in this country, almost 50 cents 
out of every health care dollar that's spent in this country has its 
origin right here on the floor of the House of Representatives.
  When you consider what we spend in Medicare, what we spend in 
Medicaid, what we spend in the VA system, what we spend in Indian 
health service, the Federal prison system, a lot of health care dollars 
are generated through the authorization, the appropriation process in 
this Congress. And as a consequence, Congress has a big stake in trying 
to get some efficiencies and some improvements. But in this instance, 
in developing the health information technology platform of the future, 
I almost think that we need to get out of the way and let the 
entrepreneurs, let the bright folks who can do these tasks, let them 
proceed with that.
  Let me just talk about a couple of things that will illustrate that.

                              {time}  2230

  I will just tell you, Mr. Speaker, I did practice medicine for 25 
years. In fact, I started medical school 30 years ago this year in 
1974. I can't tell you that I was a big acolyte of electronic medical 
records when I was a practicing physician. I dabbled in it some. I 
would listen to people talk who came to sell us various packages.
  We had to buy a new computer right before the Y2K scare where all of 
our computers were going to lock up at midnight and we wouldn't be able 
to get anything done the next day. So like everyone else, I went out 
and bought a new computer system. I asked what it would cost to add an 
electronic medical records package on to the basic computer system that 
I purchased for my five-physician office. The basic computer system 
itself cost about $60,000 or $70,000. Some other contracts we had to 
sign for maintenance and upkeep were not cheap. Adding a medical 
records package to that was 30 to $40,000 for a five-physician 
practice. Quite honestly, at the time, it seemed way too expensive for 
a small group such as mine to participate in. So I really wasn't sold 
on the concept of electronic medical records. Then in the end of August 
2005, we saw probably the

[[Page H15405]]

worst hurricane to hit the United States that certainly has happened in 
recorded history, Hurricane Katrina that hit New Orleans, and then the 
subsequent flooding after the levees broke. Touring New Orleans 5 
months later with the Energy and Commerce Subcommittee on Oversight and 
Investigations, we were permitted to go into the basement of Charity 
Hospital into their records room. This was the basement of Charity 
Hospital. You can see the temporary lighting that they have got strung 
along the ceiling. There is actually still, it doesn't show in this 
photograph, there is still water on the floor 5 months into this 
process. And you can see the paper medical records. There was shelf 
after shelf after shelf.
  Remember that Charity Hospital was one of the venerable old 
institutions in this country. It was one of the hospitals that has 
trained many of the premier physicians in this country. Charity 
Hospital had been there for a long time. They had multiple racks and 
stacks of medical records. But look at these things. This isn't smoke 
damage. This isn't fire damage. This is black mold that is growing on 
the paper, on the manila folders and on the paper in the medical 
records. Clearly, these are medical records that in all likelihood now 
are lost to the ages. I don't know. The water was up to the top shelf 
when the building was underwater. A lot of the ink and writing may well 
have washed off. But you honestly could not ask someone to go in here 
and pull a record and provide you some of the medical information that 
might been contained therein, because clearly it would simply be too 
hazardous to ask anyone to go in there and retrieve it.
  Well, when I visited the basement of Charity Hospital that day, I 
became a convert for recognizing that medicine does need to come into 
the 21st century. It is going to be expensive. There is going to be a 
learning curve for, again, mature physicians like myself to have to 
learn this new technology and to have to learn how to use a keyboard. 
But it would be an investment that we would have to make.
  I think we have to pay for it. I don't think we can simply say to a 
doctor's practice, you are going to have to just do this. It is part of 
the cost of doing business. And although you can't attribute any direct 
revenue increase to the fact you are making this $100,000 expenditure 
for a five-physician practice, you are just going to have to spend the 
money. Well, we are probably going to have to help that. Number one, we 
are not paying doctors enough, anyway, and number two, if we ask them 
to go out and do this, there will be a lot of resistance, and a lot of 
practices just simply won't do it. They will drop out of Medicare and 
whatever insurance company requires electronic medical records.
  If we pay for it, if we allow an increase in reimbursement for 
physicians who voluntarily undertake this kind of training and upgrade, 
I think that's a very reasonable return on investment. So included in 
the bill that I introduced to initially repeal the sustainable growth 
rate formula was a 3 percent positive update for physicians who 
voluntarily undertake to modernize their recordkeeping and to embark 
upon the 21st century sojourn of creating electronic medical records.
  But I think that is the way we have to do it. It has to be voluntary. 
You can't force people to do these things. You can't force them to 
learn these techniques. You can't force them to devote the time 
necessary to learn these techniques. It does have to be done on a 
voluntary basis. That is the correct way to learn things, not through 
mandates, but through creating programs that people actually want and 
getting their participation voluntarily, not because the Federal 
Government has said thou shalt.
  Now, it stands to reason that after a certain period of time, part of 
that funding for that infrastructure will be completed. And this 
positive update does go away after a period of time, but it does 
provide a bridge for physicians who are using paper records today. It 
provides them a bridge, an opportunity to go into a electronic medical 
record system.
  The reason I spend so much time on this is we had introduced in the 
Senate last week a bill that would require electronic prescriptions. 
Well, it's a good idea. The theory is a sound one, electronic 
prescriptions. The Institute of Medicine says that doctors' handwriting 
is terrible. I am here to tell you mine is. The ability, though, to 
whip off a written prescription takes about 10 seconds. The time 
involved for filling out an electronic prescription, even on a little 
handheld is going to be somewhat longer than that, particularly at the 
beginning of the learning curve.
  Well, the average physician practice as I had back in 2002, you would 
have to see between 30 and 40 patients a day in order to pay the 
overhead and have something to take home at the end of the day. You add 
a minute or 2 on to every patient's encounter, and that is going to be 
adding about an hour a day on to that physician's practice time, an 
hour that they are simply going to be filling out an electronic form 
for E-prescribing. Clearly, again, they have to be compensated for that 
time.
  The bill that was introduced I think recognized that and said there 
would be a 1 percent update for doctors, a 1 percent bonus for doctors 
who indeed undertook that. Well, just doing a little bit of the math, a 
moderately complicated Medicare patient return visit probably didn't 
pay as much as $50 a visit, but let's say for the sake of argument that 
is what it paid. Well, a 1 percent bonus for that patient's encounter 
if you use an electronic prescription will be, what, 50 cents. So you 
can see about four of those patients in an hour's time, so that is an 
additional $2 an hour that we are paying for that. It doesn't seem like 
a lot. I say that, too, because you look at all of the various 
stakeholders and interest groups, the insurance companies, the pharmacy 
benefit managers, the community pharmacists who want this done see 
value in it, and they see the potential for deriving great value, 
particularly the vendors who are selling the electronic prescribing 
modules. There is going to be significant financial return for them.
  So why are we low-balling it at the doctor's end with simply a 1 
percent bonus? And then the other part of that concept that I found 
disturbing was, it was kind of billed as a carrot and stick approach, 
the carrot was the 1 percent bonus, the stick was when 5 years, 4 years 
or 5 years, I forget which, Doctor, if you're not doing this, we're 
going to penalize you 10 percent. So wait a minute. I go from if I do 
this, I am going to make an extra 50 cents on that patient encounter or 
$2 an hour additional if I do this. If I don't do it in a few years, I 
am going to be down $20 an hour for not participating. The inequity of 
that just strikes me as being, again, ``disturbing'' is probably the 
kindest word that I can use in this context. I honestly think while, 
again, I will agree with the theory, the application is flawed, and we 
have to think of a better way to do that. That is why when I was 
crafting 2585 it was a voluntary participation. It stayed voluntary.

  I think if you show physicians that you are able to deliver something 
of value, eventually, we are a very competitive lot. That is why we 
become doctors. And we will want to have the practice that has the 
newest and latest and greatest, and if other physicians' offices, hey, 
they are doing this e-prescribing and it is great, by the time I get to 
the pharmacy after my doctor's visit, the order has already been e-
mailed to the pharmacist, it's been filled, it is sitting there waiting 
for me, and the insurance stuff is already filled out, patients are 
going to see value in that, and they will begin to ask that of their 
doctors. But to do this in a terribly punitive way, I think we are 
going to drive more doctors out of taking care of our Medicare 
patients, and that really should not be our goal.
  The two other bills I introduced dealing with the physicians 
workforce dealt with physicians who might be contemplating a career in 
health professions and dealt with physicians who were in their 
residencies. We recognize that we are facing a shortage of primary care 
doctors, a shortage of general surgeons, OB-GYNs, gerontologists. And 
these bills were geared toward getting more of those doctors to 
consider medical school, getting more of those newly minted doctors 
into residency programs near their homes. Because doctors do possess a 
lot of inertia, and if you train those doctors in the places where they 
are needed, they are likely to stay within a 50-mile, 100-mile radius 
of where they

[[Page H15406]]

have undergone that training. That is one of the thrusts of the article 
from the Texas Medicine piece, that doctors do tend to locate close to 
where they are trained, so if we can expand the number of primary care 
residencies in medically underserved areas with high-need residencies, 
we will find that we actually attract more physicians to those areas. 
That is a vastly preferable way of dealing with some of the manpower 
shortages than just simply telling people where they have to go.
  Under the issue of medical liability reform, let me just share 
briefly some of the experiences we have had in the State of Texas 
because it has been a good story. The State of Texas in 2003 passed 
some reforms that were based off of the 1975 law that was passed in the 
State of California called the Medical Injury Compensation Reform Act 
of 1975, you see the acronym for Medical Injury Compensation Reform 
Act, and this has been an astounding success in the State of Texas. 
Medical liability insurers were leaving the State in droves. We were 
down to two liability insurers my last active year of practice 2002, 
and let me tell you, you don't get much price competition when you have 
only got two liability insurers in your State. By invoking this bill 
and passing a constitutional amendment that allowed the bill to stand 
placing a cap on noneconomic damages, $250,000 for the doctor, $250,000 
for the hospital, $250,000 for a second hospital or nursing home, if 
one is involved, by trifurcating that cap for noneconomic damages, we 
really feel that we have a system in place that does adequately 
compensate patients who are injured, and at the same time provide some 
stability in the medical liability insurance market that they needed to 
be able to look to Texas as a place where they wanted to do business. 
And they have. They have come back to the State. We have got many more 
insurers now than we, in fact, had before the exodus started in the 
early 2000s.
  Most importantly, they have come back into the State without an 
increase in premiums. Texas Medical Liability Trust, my old insurer of 
record, the premium reductions and the dividends paid back to their 
shareholders aggregate to about a 22 percent reduction in medical 
liability insurance. And mind you, my last year of practice, I recall 
medical liability premiums going up by significant amounts year over 
year over year, and now we have seen an aggregate 22 percent reduction 
since passage of this bill in 2003.
  A lot of times when I talk about medicine, I talk about the fact that 
I am optimistic. I think medicine is on the cusp of a significant 
transformation. When you look at the last century, and there was kind 
of some instructive periods, the period of 1910 when, boy, we are 
really coming out of the dark ages of medicine. Prior to that time, the 
accepted methods of practice, blistering, burning and bleeding were 
what were practiced by physicians, and everyone thought you were a good 
doctor if you did those things. We were leaving those days behind. We 
were coming into the time of anesthesia, we were coming into the time 
of modern blood banking, vaccinations had become available, new ways of 
looking at public health and public sanitation. And at the same time, 
all those advances happening in the science of medicine, we had some 
social change that was occurring as well, and part of it occurred up 
here at the United States Congress with the commissioning of a group 
called the Flexner Commission. Ultimately they produced what was called 
the Flexner Report that directly addressed the discrepancies in medical 
training and in medical schools across the country. It was the 
standardization of medical school curricula as a result of the Flexner 
Report, and albeit that function was then taken over by States, but it 
was that standardization of medical curricula that allowed for medicine 
to capitalize on all those good things that were happening around that 
time.
  Well, jump ahead to the middle of the 1940s, we are in the middle of 
the Second World War, penicillin had been discovered a few decades 
before, but it wasn't really commercially available because no one had 
really perfected the process.
  During the war, an American company working in this country was able 
to produce penicillin on a scale never before imagined. It was cheaply 
commercially produced for the first time in 1943 or 1944 and, in fact, 
was available to treat our soldiers who were injured at the landing of 
Normandy, and many lives and limbs that otherwise would have been lost 
as a consequence of infection following those wartime injuries were, in 
fact, saved because of the introduction of penicillin. It went from 
being a laboratory curiosity to something that was readily available, 
inexpensive and available to almost any doctor practicing.
  At the same time, cortisone, again introduced many years ago before 
but a commercial process developed by Percy Julian, a Ph.D. biochemist, 
an African-American that we honored in this House during the last 
Congress because of his contributions to medicine. He developed a way 
to mass-produce cortisone using a soybean as a precursor.
  So suddenly you had an antibiotic and you had a potent anti-
inflammatory. These two powerful medical tools placed into the hands of 
our practitioners in this country, and, again, at the same time you had 
a significant social change because of the Second World War and wage 
and price controls that President Roosevelt put into place to prevent 
inflation, those wage and price controls were putting a damper on 
employers being able to keep their employees satisfied and happy. So 
they said, look, can we offer benefits like retirement plans and health 
insurance. The Supreme Court weighed in and said yes, you can, and not 
only that, you can provide those as a pretax expense.

                              {time}  2245

  Well, suddenly you go just almost overnight to the era of employer-
derived health insurance. And it was extremely popular, extremely 
popular. It persisted after the war was over and wage and price 
controls were removed. But, again, it was a time when the science of 
medicine was changing rapidly and the social structure around medicine 
was changing rapidly.
  The same can be said for the middle 1960s. For the first time we had 
anti-psychotic medications available. Prior to that, we had only 
restraints to treat people who were badly mentally ill. We also had the 
introduction of antidepressants.
  We had the introduction of newer hypertensive drugs. Remember, just a 
generation before we lost our President, Franklin Roosevelt, to the 
ravages of unchecked hypertension. In the 1960s we could treat that.
  At the same time, we had the introduction of Medicare and then 
subsequently Medicaid. Suddenly the Federal Government had a large and 
profound footprint and a profound influence over the practice of 
medicine.
  Mr. Speaker, I think we are on the cusp of just such a 
transformational time right now. I think the changes occurring in 
information technology, the speed with which we learn things, is now 
unlike any time in this country's past.
  Think of this: People are going to be able to go and with a 
relatively inexpensive test have their human genomes sequenced. They 
will be able to know, as more and more is found out about the human 
genome, what diseases may pose a risk for them in the future, what 
things they are not at risk for, powerful information that is going to 
be in the hands of our patients.
  They are going to come to the office with this information in hand. 
It won't be a test that we order them to take or that we request them 
to take, but think of the difference in the practice of medicine. In 
the 1980s, I would tell someone a diagnosis. They would ask me what I 
was going to do about it. In the 1990s, I would give a diagnosis. They 
would go home, look it up on the Internet and come back and tell me 
what I was supposed to be doing about it. Now patients are going to 
come in with genetic information in hand say, this is what I am at risk 
for. What are you going to do to prevent it, doctor?
  It will be an entirely different way, an entirely new paradigm, an 
entirely different way of approaching the practice of medicine, a 
transformational time. Yet, at the same time, if Congress does not, 
does not invoke the right policies, Congress is inherently a 
transactional body. We heard the House Policy Chairman talking about 
that in the last hour. Congress is inherently transactional. We 
redistribute income. We take things from one group

[[Page H15407]]

and give it to another. The transactional can become the enemy of the 
transformational.
  Our former Speaker, Newt Gingrich, is famous for saying ``real change 
requires real change.'' I believe that to be true. I think that is his 
second principle of transformation. And, more to the point, this is a 
time of real change, and medicine is really changing under our feet. 
Whether we like it or not, whether we think we can control it or not, 
it doesn't matter. Medicine is changing. That real change requires us 
to change how we think about and how we approach these problems. The 
old ways, the SGR formulas of the 20th century, aren't going to work in 
the 21st century. They cannot be allowed to impede the incredible 
transformation that stretches before us.
  Mr. Speaker, before I wrap up, I do want to mention one additional 
bill that I introduced recently, and Members may want to consider 
adding themselves as cosponsors. It is H.R. 4190.
  This is an interesting bill, because we talk in this House about what 
are we going to do about the uninsured. And we all sit back and think 
big thoughts about what we are going to do about the uninsured. Well, 
H.R. 4190 actually moves that process along in kind of a different way.
  H.R. 4190 would take health insurance benefits away from Members of 
Congress. Yes, it would provide a voucher to Members of Congress to buy 
health insurance, but we would no longer be participants in the Federal 
Employee Health Benefits Plan. We would become uninsured, and it would 
force us to look at the market, what is available for someone who 
doesn't have insurance.
  It might cause us to be a little more clever about some of the things 
we do in our Tax Code, and perhaps we wouldn't be so punitive toward 
people who want to individually own their insurance policy as opposed 
to someone who wants to get it from their employer. So it would be an 
entirely different way for Members of Congress to approach this 
problem. Quite honestly, I don't expect a long line of cosponsors when 
I get back to my office later tonight, but I would like for Members to 
think about this.
  It is terribly difficult for us to come up with solutions when we are 
sitting back in a situation where we are insulated, we are 
anesthetized, where we are never going to have to face those types of 
decisions and those types of problems that our constituents face on a 
daily basis.
  We also need to be more careful about how we talk about people who 
are uninsured. We toss around numbers and basically use them as 
political bludgeons or political wedges. We need to be more specific 
when we talk about the specific demographic groups that are contained 
within that large number of people who are labeled ``the uninsured.''
  A significant number, 10 percent in some estimates, are people who 
are university students or just graduated from the university. These 
are people who are generally healthy and relatively inexpensive to 
insure. We ought to find a way to make that happen. We ought to find a 
way to at least allow the possibility and ability for that demographic 
group to purchase insurance. Twenty percent of the number actually earn 
enough money to buy health insurance. They just don't see the reason or 
necessity in doing so.
  A lot of that is cost driven. It is price driven. We have done things 
to insurance policies to make them so expensive. We are unequal in our 
tax treatment for individuals who want to individually own their 
policies.
  We need to look at those things, because, again, if we made the 
product affordable, if we made it desirable, again, if we put products 
out there that people would actually want, then they are more likely to 
participate. I think that is vastly, vastly superior to simply saying 
there is going to be an individual mandate or a State mandate or an 
employer mandate where people will be required to line up and file into 
these programs.
  Let's approach it differently. Let's create the programs so that 
people want them, rather than creating the condition that forces people 
into programs that maybe they want and maybe they don't want, but we 
will never know because we never ask.
  But we can be more insightful. In fact, we can be more valuable to 
the American people if we will think about things in terms of who is 
involved in the demographics of that large group of the number of 
uninsured, and how can we best approach that in a way that we are 
producing or providing the environment for them to be able to have that 
insurance coverage that they desire.
  Well, there is a lot left unsaid at this point. I do appreciate the 
indulgence of the Chair.

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