[Congressional Record Volume 153, Number 191 (Thursday, December 13, 2007)]
[House]
[Pages H15453-H15460]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                              HEALTH CARE

  The SPEAKER pro tempore (Mr. Johnson of Georgia). Under the Speaker's 
announced policy of January 18, 2007, the gentleman from Texas (Mr. 
Burgess) is recognized for 60 minutes as the designee of the majority 
leader.
  Mr. BURGESS. Mr. Speaker, why don't we just continue on talking about 
health care over the next hour. It's a relevant subject, and many of us 
are concerned about health care in this country. Many of our 
constituents are concerned about health care.
  Mr. Speaker, I was a physician in my former life before coming to 
Congress almost 5 years ago. Perhaps it's time that we approach this as 
maybe a checkup on American health care. And like any good physician, 
as when I approached someone with a medical condition, maybe make a 
little problem list and try to run through that and see if we can't 
break things down and come to some problems that are more manageable or 
come to some solutions that may, in fact, be possible.
  The first problem that I want to talk about are problems that affect 
really the law of supply and demand, the problems that affect the 
physician workforce in this country. The second problem that I would 
like to focus on is the one we hear a lot about on the floor of this 
House, the problem with people who lack coverage for their medical 
expenses, the people who lack health insurance. The number varies 
depending upon the source that you check, but by anyone's estimation, 
the number is too large, and Congress does have an obligation to try to 
ameliorate that if it can. And then the final problem is how much more 
government involvement do we want in our health care. And that 
government involvement, by its involvement, will that lead to the type

[[Page H15454]]

of solutions that we'd like to see in America?
  So starting with problem number one, it, again, addresses some of the 
physician workforce issues that we face in this country. And, again, 
it's one of those fundamental supply and demand questions, and if we 
don't have the correct supply of physicians, it is going to affect the 
overall cost, price and quality of the health care that we receive.
  Probably now almost 2 years ago, right before he left as the Chairman 
of the Federal Reserve Board, Alan Greenspan came and talked to a group 
of us one morning, and the inevitable question comes up about Medicare: 
Mr. Chairman, how do you see us as ever being able to fund the 
obligations that Congress has taken on in the Medicare system with the 
baby boomers now retiring, and starting January 1, 78 million of us 
will be coming through over the next 40 years?
  And the Chairman thought about it for a moment, and he said, It's 
going to be difficult, but I think when the time comes, Congress will 
make the correct decisions and the Medicare system will be preserved 
and it will endure.
  Then he stopped for a moment, a thoughtful pause, as the Chairman 
always has wont to do, and he said, What concerns me more is will there 
be anyone there to deliver the services when you require them?
  And that was a very insightful comment and one that has stayed with 
me over the past 2 years.
  Now, my State medical association, the Texas Medical Association, 
every month they put out a periodical or journal that talks about some 
of the issues affecting medicine in the State. And this is the cover 
from the March issue of 2007, and the title of the article is ``Running 
Out of Doctors.'' The Texas Medical Association is concerned about the 
number of physicians that are in the State that are being educated in 
the State and that are staying in the State to enter their practice 
lives. And it is, indeed, a problem for the State of Texas, but it's a 
greater problem. It's a ubiquitous problem across the country.
  Now, some of the things that we do here actually have a direct and 
consequential bearing on the number of physicians. And here we are 
bearing down very quickly on the very last of this year. We passed a 
bill today called a continuing resolution, and that continuing 
resolution was passed because tomorrow all of the funding for all of 
the Federal agencies and all the Federal programs, with the exception 
of the Department of Defense, all of that funding was going to expire 
because we have not passed 10 of our 11 appropriations bills. So today 
we passed, really, a deceptively short bill that actually funds the 
government for those 10 appropriations bills for another week. So 
perhaps not a great lift, but when you consider that this Congress 
spends about $3 trillion a year, you can imagine what 1 week's pay 
amounts to.
  As we did that, there, of course, is an acknowledgement that we may 
indeed have to pass another continuing resolution on into next week if 
we can't indeed pass our spending bills. And that continuing 
resolution, because of the fact that Congress is going to wind down one 
way or the other toward the end of next week and then not be in for the 
remainder of the year, we are indeed going to have to ensure that the 
funding for those Federal programs continues.
  But, Mr. Speaker, there's one aspect of that continuation that you 
really can't punt, you really can't just push it down the road and put 
it in the ``too hard'' box and we'll deal with that in January or 
February, and that one aspect is how Medicare compensates the 
physicians that see our Medicare patients. They are physicians that 
we've asked to see our Medicare patients. We require them in some 
instances to see our Medicare patients. And the fact is that Congress 
for the last several years has had a program in place that actually 
reduces year over year what we return to physicians in terms of payment 
for delivering those services.
  Stop and think about it. A physician's office is a small business. 
Most people don't think of it that way, but it is a service industry 
business. It is a small business. And any other business that faced 
year-over-year cuts in projected revenue or cuts in what the 
reimbursement rates were going to be would have a difficult time 
surviving, because guess what? The energy costs for a physician's 
office are no different than the energy costs for the hospitals or for 
the bank across the street. They've gone up every year just as they 
have for our homes and our businesses across our communities.
  What about the cost of paying the people who work there in the 
physician's office? That has gone up year over year. What about the 
cost of insuring those employees that work in the physician's office? 
Well, that has gone up year over year. But it's kind of ironic that the 
same time the cost of providing health insurance for the employees in 
that physician's office goes up every year, the actual return on 
investment goes down. The reimbursement rate from those insurance 
companies goes down. And one of the reasons for that is, again, how we 
compensate physicians in the Medicare system.
  There is a very technically complicated formula that calculates 
physician reimbursement rates, and last night I went through that in 
some detail. I have heard from some of my colleagues that perhaps 
that's a little too complex and maybe something that doesn't project 
well on television and doesn't project well here on the floor of the 
House, but let me give you just a flavor of what's involved with our 
calculating the reimbursement rates for America's physicians who choose 
to participate in the Medicare system because we have asked them to who 
take care of, arguably, some of our most complex and some of our most 
fragile patients.

                              {time}  1615

  And the reason this is so important, if we don't do something before 
midnight, December 31 of this year, there is a 10.1 percent payment 
reduction to America's physicians who participate in the Medicare 
system. Not a really great way to go about rewarding them for doing the 
work that we've asked them to do.
  And the truth is, every year there has been a projected reduction in 
reimbursement rates for America's physicians who participate in the 
Medicare system. Every year for the 5 years that I have been here, 
Congress has come riding in at the last minute and stopped those 
reductions in reimbursement rates. But the fact is, Congress has to act 
before December 31 or those rates that were posted by the Center for 
Medicare and Medicaid Services November 1, which this year is a 10.1 
percent across-the-board reduction in physician reimbursement rates, if 
Congress does not do something affirmatively before midnight December 
31, those cuts go into effect, and physicians wake up on January 31 
earning 10 percent less for doing the same amount of work that they did 
the week before. Again, no other business would be asked to absorb this 
type of activity.
  You can just imagine how tough it is to plan for the future. Here you 
think about a physician's office and they've got the rent, they've got 
the employee cost, they've got, or course, liability insurance, and 
various and other sundry things, one of the toughest things for a small 
physicians' office, and I would talk to you in terms of a group of 
between two and five individuals, which compromises a vast number of 
the physicians' offices in the country, one of the biggest expenses 
they have is the cost of capital when they want to do what? Expand.
  And what does expansion mean? Hire another doctor to come in and help 
them do the workload because, again, 78 million people are entering the 
retirement age where they will be eligible for Medicare, and that 
starts January 1 of this year. What a coincidence. How ironic. January 
1 of this year we start into the baby boom surge, and at the same time, 
oh, by the way, Doctor, we're going to be reducing your reimbursement 
rates by 10 percent.
  That cost of capital to bring in a new physician is one of the 
biggest hurdles that a small physicians' office has to overcome. 
Granted, there may be large pieces of equipment that are purchased from 
time to time, and those also incur a cost of capital, but planning for 
the future, planning your own future workforce within your office is 
one of those things that keeps managing partners up at night in those 
types of practices. And it becomes even more complex and certainly more 
difficult to predict the future on what future earnings and what future 
requirements are going to

[[Page H15455]]

be when every year Congress comes in and says, oh, by the way, at the 
end of the year we are going to be enacting a physician reimbursement 
reduction which will significantly affect your ability to pay your 
bills and perhaps have something at the end of the month to take home 
to your family.
  Well, what is the formula? And let me just back up for a moment. 
Let's talk about the Medicare system in the broad perspective for just 
a moment. Because the Medicare system, every time you hear somebody 
talk about Medicare, they say it's an integrated system that works 
seamlessly and flawlessly. But the reality is that Medicare, in many 
ways, is stove-piped or siloed. You have part A, part B, part C and 
part D, which was just enacted a few years ago. Part A pays the 
hospitalization expense. Part B pays the physician expense. Part C is 
the Medicare HMO. And part D is the prescription drug benefit that was 
enacted back in 2003.
  If you look at the other funding silos, A, C and D, each year those 
undergo sort of a cost-of-living adjustment for hospitals that's called 
a ``market basket update.'' So the cost of inputs is calculated by the 
Center for Medicaid and Medicare Services. They probably have a 
complicated formula for that, or at least I would imagine that they do. 
They calculate what the cost of inputs is and they come back to the 
hospital and say, well, next year we're going to pay you this much more 
than we paid you last year. The same is true for the Medicare HMOs; the 
same is true for the Medicare prescription drug account.
  Physicians, part B, is constructed entirely differently. And I have 
to confess, I don't quite understand why it's constructed differently; 
but when Medicare was first enacted over 40 years ago, this seemed to 
be a sound way to approach the problem. Part A, hospitalization, funded 
out of a payroll deduction, just the same as Social Security tax every 
month. There is that 1.5 percent Medicare charge, your employer kicks 
in a similar amount, so about 3 percent of your gross pay is deducted 
to cover Medicare expenses for the future.
  Part B is funded from two sources, one is general revenue, and the 
other source is premiums that are paid by people who are Medicare 
recipients. By law, the Medicare recipient's premiums must account for 
25 percent of the total expenditures in part B; the remaining 75 
percent is made up in the general revenue.
  Part C and part D, again, have different funding streams. Part D, 
when we created the prescription drug a few years ago, has dedicated 
funding to that. You may recall there was some argument about what the 
total cost of that would be. Thankfully, it has come in under cost, and 
that's been a great boom and a great savings; but nevertheless, there 
is a dedicated stream of money for the Medicare prescription drugs. 
Part C, the Medicare HMOs, also has some dedicated funding, plus some 
cost-of-living adjustments that occur there as well.
  So physicians are clearly in sort of a class by themselves when it 
comes to Medicare reimbursement. So, how does the Center for Medicare 
and Medicaid Services, how does it calculate what the payment rate for 
physicians is going to be? It's calculated under a formula called the 
sustainable growth rate formula, referred to as the SGR. And you will 
probably hear people talk about the SGR a lot next week because, again, 
if we don't do something about the SGR, it is going to automatically 
proceed with a 10.1 percent reimbursement reduction for the Nation's 
physicians who choose to see Medicare patients.
  Now, for the people who are very astute, there is a typographical 
error on this page, and I cannot take ownership of the typographical 
error; this was actually a pdf file simply taken from a CRS report to 
Congress about physicians' payment. But here's how we calculate 
physicians' payments: the relative value unit of work times essentially 
what is a geographic factor, or fudge factor for the geographic 
location of the practice, a relative value unit for the practice 
expenses, and then, again, the geographic adjustment for practice 
expenses in that area factors in things like the cost of labor force 
and what have you in different areas of the country.
  And then a relative value cost for providing liability insurance. And 
as you might imagine, there is also some geographic discrepancies there 
across the country, so that is factored in, times CF, which actually 
down here is written as CV, but that's the conversion factor. And we'll 
get to the conversion factor in just a moment.
  But I think you can see a pretty complex formula. And perhaps that's 
why I was criticized for going through that last night. And I will 
abbreviate the discussion of the formula, but I just want to give you a 
sense of how complex this is and why, certainly, the average person 
doesn't understand it, the average physician doesn't understand it, and 
I will submit to you that most average Members of Congress don't 
understand how this formula is calculated either.
  Here is a calculation again of the update adjustment factor, perhaps 
a little bit different way of looking at some of the same sort of data. 
But the thing that I want to point out on this, because it is extremely 
important to understand this, the update adjustment factor here is 
equal to the prior year adjustment component, what we did last year, 
plus a cumulative adjustment component. Why is that important? Well, 
every year that we sweep in at the last minute and we say we're going 
to fix this reduction in reimbursement for physicians and we're going 
to make that go away, or maybe even provide a little bit of a positive 
update, every year that we do that, because of the cumulative nature of 
this formula, we make the overall expense of eventually repealing the 
formula, we make that expense increase. And every year the amount of 
increase actually grows, it snowballs, if you will.
  To give you an example, when I first came to Congress in 2003, the 
year before, in my practice, we had sustained a 5.4 percent reduction 
in Medicare reimbursement rates. A great hue and cry from across the 
country and Congress recognized that and said, we're going to do 
something this year to prevent that from happening. And that something 
did, indeed, occur in an omnibus bill right as I got to Congress in 
January of that year.
  The cost of repealing the sustainable growth rate formula at that 
time was calculated by the Congressional Budget Office to be $118 
billion, give or take a billion here or there; $118 billion, a 
significant amount of money, but that actually is a 10-year figure. So 
it's about 11 to $12 billion a year that we would have to come up with 
in Congress to offset the cost of repealing that formula. Big sum of 
money to be sure.
  But every year now, over the last 5 years, we've done something at 
the last minute, and that something has increased the cost of the 
ultimate repeal of the sustainable growth rate formula, such that now 
it is calculated by the Congressional Budget Office this year as being 
$268 billion over 10 years' time. If, indeed, we get our work done and 
prevent that cut from going into place at the end of this month, the 
cost, again, that cumulative adjustment factor will come into play, and 
that cost will be bigger in 2008 than it was in 2007. And it will be 
bigger by a larger amount than it was in 2007, depending upon the 
amount of rescue that Congress chooses to bring to the table.
  And then again, I just can't help myself, one last slide, talking 
about the complicated nature of this. And again, I show you this not to 
invoke sympathy from someone who has spent some time studying this, but 
I show you this because I want to give you a sense of how complicated 
the problem is. Again, I will submit to you that many Members of 
Congress just simply do not, cannot, will not understand this. And as a 
consequence, it kind of gets put in that ``too hard box'' over here and 
we'll think about that later. That's why there is always the temptation 
to try to kick it down the road.
  The fact is, we have to do something by December 31. If we don't, 
that 10.1 percent reduction comes into play. You might say, well, okay, 
that's for Medicare patients, but doctors see more than just Medicare 
patients in their office, so they will be able to deal with that in 
some way, won't they? Just raise the rates on someone else. Here's the 
deal: almost all of the major insurance companies in this country peg 
their reimbursement to what Medicare reimburses. So the contracts may 
be a

[[Page H15456]]

little more generous than Medicare, they may reimburse at 110 percent 
of Medicare, 115 percent of Medicare, 120 percent of Medicare; but they 
peg to what the Medicare reimbursement rate is. So if we come in with a 
10.1 percent reduction in physician services reimburses, guess what 
happens to private insurance at the same time? That same reduction goes 
into play.
  So I called my old medical practice yesterday and I just asked them, 
what do you think about this? And of course they were more or less 
unaware that this was happening, and that's really not unusual. Most 
physicians' offices don't pay a lot of attention to what we're doing up 
here in Congress because they're busy, they're taking care of sick 
people. And that's what we want them to do. We don't want them 
necessarily watching every move we make here in Congress.
  But when I related that, no, we actually need to do something or 
there will be a 10 percent reduction at the end of this year, then I 
got their attention and then they were very interested. And I said, 
well, give me an idea of what this will do to your commercial 
insurance. And very quickly the response came that almost all of our 
contracts that we have with commercial insurance actually pegged to 
Medicare. So it will have more than just a ripple effect. It will be 
almost like a tidal wave effect through the rest of the reimbursement 
rates for the other plans and insurance companies that this office, for 
which they receive reimbursement for taking care of those patients.
  Now, what happens if we don't do it by January 1? The cuts go into 
effect. But maybe we go ahead and do it and take care of it in January 
or February, we kick the can down the road a little bit and then we 
come back later and do it. Actually, this happened in 2005. We had the 
fix in a big bill that was being passed that year. It was called the 
Deficit Reduction Act. And we kind of ran out the clock at the end of 
the year and on a technicality the bill had to come back to Congress, 
but we weren't in session anymore, so it had to wait until January. And 
the effect was that those cuts did go into effect January 1 of that 
year. And I know that because my fax went crazy. There was no one in 
the office that day to answer the phone, but the fax machine went crazy 
from physicians across the country sending me notices, Congressman, I 
want you to see the letter I sent out to my patients this week. I will 
no longer be able to provide Medicare services because of the 
cumulative effect of these reductions on my practice. It had a very 
immediate and detrimental effect on practicing physicians across the 
country.
  The same would be true this year. In fact, it would be worse because 
that year the reduction was 5 percent; this year it is 10 percent. And 
I would just imagine that it would at least double, if not more, the 
anxiety that's felt within our physician community across the country.
  Moreover, the Center for Medicare and Medicaid Services said, we will 
come back and make whole those practices that continue to see Medicare 
patients without interruption, and we will go back and reimburse them 
the difference when Congress finally passes a law. And that's all well 
and good, but there's very little way to control if those private 
companies come back and make the adjustments retroactively the same as 
Medicare did.
  Again, very, very difficult to know that because we're talking about 
very small amounts of money. It's very difficult for a practice to 
actually track that through the overall cycle of a patient's care, but 
the result is, cumulatively across the country, the numbers could have 
been quite, quite large.
  And it was never the intent of Congress to provide a benefit for 
commercial insurance by reducing the Medicare rate. It's just an 
unfortunate consequence of having what are essentially Federal price 
controls on Federal reimbursement rates.

                              {time}  1630

  Well, again, I promised not to spend too much time on the formula, 
but I think it is important. I think it is important for Members to 
understand. I have had several bills over the years trying to deal with 
this. One thing that I have introduced just this week is a resolution 
in the House of Representatives. And I will admit this resolution does 
not have the force of law. It actually doesn't spend any money. It 
almost is like sending a get well card to the doctors who take care of 
our Medicare patients. But the resolution is multiple whereases 
detailing the problems that I have just been through followed by a 
single, Resolved: That it is the sense of the United States House of 
Representatives to immediately address this issue and halt any 
scheduled cuts to Medicare physician payments and immediately begin 
working on a long-term solution and implement it within 2 years that 
pays physicians in a fair and stable way, that ensures Medicare 
patients have access to the doctor of their choice.
  Mr. Speaker, I know I have to confine my remarks and I only speak to 
the Chair, and I will do that, but if I could speak to my colleagues, 
the Members on both sides of the aisle, I would ask them to take a very 
serious look at House Resolution 863. Again, it spends no money. It 
does not have the force of law. But I think if a significant number of 
Members were to participate in signing on to this particular 
resolution, it would be a powerful message to send to House leadership 
on both sides of the aisle that we want this problem fixed before we go 
home at the end of the year. This is one of those things on our to-do 
list that we must address, that we must take care of.
  Now, one of the other things that I do want to spend just a minute 
talking about, and in some of the physician workforce bills that I have 
introduced in Congress, I have provided some additional help for 
doctors who will voluntarily participate in improvements in their 
office's investment in health information technology. In fact, the last 
bill that I introduced dealing with the sustainable growth rate problem 
had it in two components for a voluntary positive update for physicians 
who, again, participate on a voluntary basis in upgrades in health 
information technology and for physicians who voluntarily participate 
in quality reporting measures.
  Let me just tell you something. Mr. Speaker, it is just human nature, 
anyone who works for a living always likes to be kind of pulled into 
the process and asked to help work on a problem. Most people don't like 
to be told what to do. Most people inherently reject orders that come 
from the top down. A lot of times, it is better to build things from 
the bottom up. Now, I have to tell you, when I was a practicing 
physician, I wasn't a big advocate of electronic medical records. I 
dabbled in it a little bit. I had a run or two with electronic 
prescribing. These things were complicated. They were expensive. They 
added time to my day that wasn't reimbursed. But the reality is I have 
come to accept the concept more since I have been in Congress.
  Let me just share with you what one of my revelations was. Many of us 
who serve in this body will never forget the week that Hurricane 
Katrina roared into the gulf coast and struck the gulf coast areas of 
Mississippi, Louisiana and Alabama. It was the result of the effects of 
that hurricane and the subsequent flooding in the City of New Orleans 
and subsequent trips to that area, once just as an individual to see if 
I could be helpful, and once as part of a field hearing with my 
Subcommittee on Oversight and Investigations as part of the Energy and 
Commerce Committee.
  This is a picture that was taken on that second trip, January of 
2006. So we are now 5 months after the hurricane hit, 5 months after 
the dewatering of the City of New Orleans, if ``dewatering'' is 
actually a verb. Here is a picture of the basement of Charity Hospital. 
Charity Hospital, one of the venerable old institutions in our country 
that has been long associated with teaching doctors, teaching new 
doctors, here is the records room at Charity Hospital. You can't really 
see it from this picture, but there is still water on the floor, water 
about up to the level of the top of our shoes. Do you see these 
records? And there is just oceans and oceans of records. This is one 
stack. There are stacks that go on, 50 behind and 50 in front. There 
are a lot of records in the basement of Charity Hospital because they 
take care of a lot of patients, and they have for a lot of years.
  Look at these records. It almost looks like they have some smoke or 
soot damage on them, but, in fact, that is black mold that is growing 
on them

[[Page H15457]]

on the manila folders and growing on the paper in the charts, and as a 
consequence, you could not possibly send anyone in here to retrieve a 
chart. It would be too hazardous. In all likelihood, the ink is washed 
off the paper anyway during the couple of weeks that these things were 
submerged.
  These records are, for all intents and purposes, lost to the ages. 
There is no way of knowing what is included in those medical records. 
There may have been a treatment for leukemia here. There may have been 
a kidney transplant down here. We don't know. This may have been 
someone on a waiting list for a transplant. No way of knowing. Those 
records are lost forever.
  Here is the deal. Those individuals who were brought to the Dallas-
Fort Worth area who were displaced after Hurricane Katrina and arrived 
at Reunion Arena in sort of a little triage area set up by doctors from 
the Dallas County Medical Society, there was a small trailer outside, 
and one of the chain drugstores said, Well, for those people who had 
prescriptions at our drugstore, we can at least help you reconstruct 
what medicines they were on. It was enormously helpful to have that 
information so those patients who had their prescriptions at that 
particular pharmacy, they could go online into their master list and at 
least reconstruct the medication list. And a lot of times, if you have 
the medication list, you have a pretty good idea of the problems that 
were under treatment. Certainly, you would have a better idea than if 
you were waiting for the City of New Orleans to be evacuated of water 
and then get down to the basement of Charity Hospital, run the health 
risk of pulling out one of these records and breathing in the spores of 
the black mold.
  So I have become a believer. You have to have some way of, especially 
in times of great national upheaval, you have to have some way of 
getting that data that has been accumulated on patients over the years. 
You have to have ways of getting it into the hands of the caregivers. I 
don't know that we have the perfect system yet. I don't know if the 
Federal Government is capable of developing the perfect system, or 
perhaps that may be something that comes to us from private industry, 
but I do know this. The time for electronic medical records is nigh at 
hand, and as difficult as it is for doctors my age who did not grow up 
with this technology, it is time that we are going to have to come into 
the 21st century and acknowledge this type of technology is a benefit 
and delivers value to the interaction that occurs between the doctor 
and the patient.
  But how much better is it to bring those physicians along who are in 
practice and allow them to participate in the solution, allow them to 
participate in the construction of these platforms? Contrast that with 
the typical congressional activity, which would be a top-down approach. 
In fact, just last week we had the unveiling of an e-prescribing bill 
with a lot of fanfare over on the Senate side. And it was vaunted as a 
``carrot and a stick'' approach, that, Doctor, we will give you a 
little something if you participate, but we are going to have a little 
something to say to you if you don't participate. So the carrot was we 
are going to increase your reimbursement rate by 1 percent if you 
participate in an e-prescribing program. And what is the stick? A 10 
percent reduction if you are not participating in an e-prescribing 
program in 5 years' time. So that was seen as a way to rapidly get 
physicians' attention. Yes, we will offer them perhaps a little bit up 
front and we will have a significant penalty if they don't participate.

  Well, what does it really mean when you say we will offer a 1 percent 
increase? Well, I will just tell you that for those Medicare patients 
that I saw as an office patient, the office reimbursement visit 
typically wasn't as generous as $50, but for the sake of argument, to 
make the math easy, let's say it was a $50 reimbursement for a 
moderately complex Medicare patient return visit, which would be the 
bulk of the patient load that a physician would see during the day. And 
the average physician can probably see four of those moderately complex 
return visit appointments in an hour's time, sometimes a little bit 
more, sometimes a little bit less if those visits turn out to be more 
and more complex. That 1 percent increase that the doctor will receive 
amounts to about a $2 an hour, 50 cents per patient, four patients an 
hour. So that is a $2 an hour increase that we are willing to provide 
the physician who is willing to participate.
  Now, what happens if in 4 or 5 years' time they are not 
participating, they are not partaking? I have to tell you, you look at 
the cost of installing an e-prescribing program in your office, putting 
a handheld device of some kind in the hands of perhaps every doctor and 
perhaps every nurse that is working in that office. This program that 
was unveiled last week would allow a $2,000 credit or grant to the 
physician to buy the equipment, but the reality is the equipment costs 
many times that. But we are going to give an extra $2 an hour to that 
doctor for participating in this program. But if they don't do it 
within 4 or 5 years, the stick is going to be a 10 percent reduction, 
which doing the same math, you are going to come up with about a $20 an 
hour reduction in reimbursement.
  Now, wait a minute, this is the same doctor you said we were going to 
cut 10 percent at the end of this year, and at the end of next year and 
the year after that. How many doctors do we expect to see, going back 
to my first slide, ``Running Out of Doctors,'' how many doctors do we 
expect are going to be participating in the Medicare system if we keep 
treating them like that? Well, they would be foolish to stay. You would 
have to wonder about their mental stability if they did indeed stay.
  So we need to have a better approach. It was talked about as a 
``carrot and stick'' approach. To me, it almost seemed like spinach and 
a whooping. You know, it is not going to be that attractive on the 
front end, but it sure is going to be bad on the back end. So I can't 
see that physicians will rush out and embrace this. And I really would 
caution the Members of Congress who are working on this end-of-the-year 
Medicare fix, whatever it is, to really be careful, to really be 
cautious about including this type of language in whatever type of 
Medicare fix that we come up with at the end of the year.
  Is the theory good? Yes, it is. E-prescribing is something that 
certainly younger physicians in medical school and residency, they are 
going to be exposed to on an ongoing basis. And they are going to look 
for practices that have this to offer, or they are going to come to 
work in practices where it is not offered and wonder why it is not 
there and ask their older partners to please provide them an e-
prescribing platform because it is the right thing to do. It reduces 
errors. It reduces some of the complications of prescriptions that are 
filled poorly, of doctors' handwriting can't be read, the pharmacist 
has to call the doctor back and say, did you mean Zanax or Zantac? And 
these types of problems can be avoided with e-prescribing.
  It is not a panacea. There will be different types of errors that 
come to light as more and more people use e-prescribing, but it clearly 
is the way of the future. But do it correctly. Remember, there is not a 
single dollar that is spent in the health care system unless it is 
ordered by a physician. So our physicians are the gateway through which 
all of the medical reimbursement, all the medical pricing, all the 
medical cost flows through the physicians. So let's make sure that they 
are on our side with this. Let's not alienate them the first shot out 
of the box as we go forward with these types of programs.
  Let me just give you an example, too. And I talked a little bit about 
I am not sure if the Federal Government is exactly the correct entity 
to have involved with creating this new electronic environment that we 
want medical practices, in which we want them to exist. Perhaps it 
would be, perhaps there will be improvements from the private sector 
that we ought to investigate. Perhaps we need to remove some of the 
regulatory burden. I won't go into great detail, but they are called 
the Star clause. Maybe we ought to remove some of the regulatory 
burden. Maybe we need to have some medical justice, some medical 
liability reform so companies aren't afraid of this. But the fact of 
the matter remains, I am not sure the Federal Government is the correct 
avenue to proceed with this.
  When I came here 5 years ago, I was told that the Federal Government 
controls 50 cents of every dollar that is spent in health care and we 
are going

[[Page H15458]]

to develop a platform. We are going to develop what electronic medical 
records should look like, and private industry will follow our lead. 
Five years later, where is it? I don't know.
  But I do know this. Do you remember a year ago all the trouble we had 
out at Walter Reed Hospital and all the negative headlines that were 
coming out in the Washington Post? And yes, there were some real 
physical problems in a place out there called building 18. But here is 
the real problem. Master Sergeant Blaine, who was kind enough to give 
me a tour through that area at the end of showing me the peeling paint 
in the building under question which was no longer at that point 
occupied by our soldiers out there on medical hold, he said, Here is 
the real problem. I have guys who have been in the service for 
sometimes 20 years. They are trying to decide whether or not they are 
kept in the service, whether they can be returned to their unit, or 
whether they need to be discharged because of whatever their medical 
condition is, and if they are discharged, what is the disability, what 
is the correct disability designation to give them? And how can we put 
that information in the hands of the VA system so that patient's 
transition to retirement status is made easier?
  The problem is, the master sergeant told me, that someone who has 
been in the service for a number of years is going to have a great big, 
thick medical record. And the problem is, that even the part of the 
Department of Defense records that are electronic don't talk to the 
electronic medical records that are kept by the VA system.

                              {time}  1645

  So the result is they have got to go through a paper interface to go 
from one platform to the other, and there is this great stack of papers 
that the soldier will collect themselves, go through with a yellow 
marker, yellow highlighter, and mark and identify those things that 
will perhaps make their case for themselves, as to whether or not they 
should go back to their unit, be discharged on a disability, transition 
to the VA system. All of that data has to be done by hand by the 
soldier, and it may take many man-hours to accumulate that data.
  The real problem, the master sergeant said, was after collecting this 
voluminous data that may look like the Washington, D.C. phonebook, when 
it's all said and done, that goes and sits on someone's desk for two 
weeks' time, and then it's lost and the soldier has to start all over 
again. So their time in medical hold is increased, their frustration 
level is certainly increased, and, yeah, the peeling paint and crickets 
were a problem, because the building was a crummy building.
  But the real problem was the difficulty that the soldiers were 
experiencing because one electronic medical records system within the 
Federal Government didn't talk to the other medical record system 
within the Federal Government. Just an indication of, to me, perhaps 
government doesn't have the entire solution here.
  Mr. Speaker, a couple of other things that I just want to touch on, 
and I know time is growing short. The medical liability condition in 
this country is something that really adds to the frustration list. 
When you talk to doctors about what are some of the things that really 
bug you, what would be some of the things that shorten perhaps your 
number of years in practice, your number of years in service, certainly 
the medical liability issue will come front and center.
  Mr. Speaker, our Founding Fathers were very wise, and they talked of 
States as being great laboratories where different ideas can be tried 
and tested; and I am happy to say within the arena of medical 
liability, my home State of Texas made some changes a little over 4 
years ago that have resulted in a significant, a dramatic improvement 
in the medical-justice environment in the State of Texas.
  Consider this: my last year of active practice was 2002. We had gone 
from 17 medical liability insurers in the State down to two. I am here 
to tell you, you don't get much competitive advantage when you only 
have two medical liability insurers. But the claims are going up, the 
amounts of dollars awarded in claims is going up, and you only have two 
insurers. Guess what is happening? Premiums for doctors, doctors who 
historically had not had much in the way of any activity, still, those 
doctors were being asked to fork over increasing amounts of premiums, 
and we are talking about significant increases year over year, such 
that my premium might go up from $18,000 one year, $25,000 the next 
year. My last year in practice, it was likely to be $28,000. You 
multiply that by five doctors in a practice, and that is a pretty hefty 
check to have to write at the beginning of every year. In an OB/GYN 
practice, as I was in, that's a lot of babies that you have got to 
deliver just to pay the freight, to pay the tab on medical liability.
  The State of Texas recognized that they were in crisis. The State 
legislature in 2003, at the end of their legislative session, passed a 
medical liability reform bill, and it was patterned after what was 
called the Medical Injury Compensation Reform Act of 1975, passed out 
in California. It essentially was a cap on non-economic damages, 
patterned after the California law from 1975; but it was a little bit 
different, a little bit different in that there was a cap on non-
economic damages as applied to the physician, a cap on non-economic 
damages as applied to the hospital, and a cap on non-economic damages 
as applied to a second hospital, or nursing home, if one was involved.
  So the cap was trifurcated, each maximum being fixed at $250,000, but 
an aggregate of $750,000 for non-economic damages. Punitive damages and 
actual damages were not affected by the law and the subsequent 
constitutional amendment that was passed in Texas that allowed this law 
to go into effect. Indeed, it went into effect on September 12, 2003; 
and since that time, Texas Medical Liability Trust, my old insurer of 
record, doctors who were insured with Texas Medical Liability Trust, 
between dividends and reductions in premiums, have seen a return of 
about 22 percent, a reduction of 22 percent of their premiums that they 
paid with Texas Medical Liability Trust. Remember, this was an 
environment that was going up by 10 or 15 percent or more a year. So a 
significant reduction for the physician.
  The other unintended beneficiary was the small, not-for-profit 
hospital that typically was self-insured and had to put vast sums of 
money in reserve against the unknown aspect of what they might be hit 
with in a medical liability suit where the non-economic damages were 
not capped. These small not-for-profit hospitals were able to move some 
of that money that they were holding against a loss in a legal action 
and put that into the very things you want your small, not-for-profit 
community hospital to be doing, like capital improvements, paying 
nurses, hiring more nurses; perhaps doing some of the very things that 
would result in better care that would reduce the number of medical-
legal claims. So this was a good thing across the spectrum for 
physicians, for hospitals, for patients in the State of Texas.
  Now, we have tried several times to do that similar sort of law here 
on the floor of the House. We have never managed to quite get it done. 
But House bill 3509 is a bill that is patterned after the Texas law. 
Again, Mr. Speaker, I know I need to speak directly to you and not to 
other Members of the House of Representatives, but if I could speak to 
them directly, I would ask them to have their staffs seriously look at 
H.R. 3509 and see if there wouldn't be some way for them to cosponsor 
it. Because, again, I think the weight of significant cosponsors, 
taking it to the House leadership both on my side and the Democratic 
side of the aisle, might help tip the balance that we really want 
something done on this issue. We will still have a tall order in the 
Senate, which has always been the stumbling block, but the time has 
come to do some type of sensible medical liability reform, medical 
justice reform.
  Well, I have spent a lot of time talking about physician workforce. 
Let me touch on the other two problems that I alluded to as I began 
this. Certainly, the second problem we always hear a lot about is the 
uninsured, and we can argue about what the number is, and the census 
number will come up with different numbers and different people will 
have different figures. But by anyone's estimation, it is higher than 
it should be in this country.

[[Page H15459]]

  If you look at kind of the breakdown of the uninsured, one of the big 
problems I think we make is we always approach that as some sort of 
amorphous demographic, where everyone is identical throughout the 
spectrum of the patients who are uninsured in this country, and the 
reality is there are vastly different groups contained within that 
number.
  Now, a bill that I introduced just a couple of weeks ago that, again, 
Mr. Speaker, I will address to you, but if I was able to talk to other 
Members of the House of Representatives, I would suggest they have 
their staff look at H.R. 4190. Now this is a simple little bill 
that actually takes Members of Congress and takes them out of the 
Federal Employees Health Benefit Plan, in other words, makes Members of 
Congress uninsured. How else are we going to be able to really 
understand and really deal with the problems of the uninsured when we 
have very good health insurance?

  So if every Member of Congress suddenly found themselves without 
health insurance and placed into that demographic, however large it is, 
perhaps we could think of some more creative solutions, whether it be a 
change in the Tax Code, perhaps a tax credit, whether it be some 
additional help, whatever. Members of Congress would have a renewed 
vigor with approaching the problems and providing solutions and options 
for patients who find themselves uninsured.
  Perhaps it is a health savings account, perhaps an individually owned 
insurance policy. And, oh, by the way, the tax treatment for that for 
those provided by an employer and those provided by an individual, the 
tax treatment is vastly different. Maybe we could come up with some 
creative ways of looking at that if we ourselves were not kept in this 
cocoon and anesthetized by the Federal Employees Health Benefit 
Program.
  Suffice to say, Mr. Speaker, I have not had a lot of people showing 
up outside my office to sign on as cosponsors, but it is an intriguing 
idea, and I do ask Members, I will not ask them to necessarily sign up 
as cosponsors, but realistically, Mr. Speaker, if I could speak to my 
colleagues about this, I would ask them to give some thought to how 
they would approach the problem if they themselves or their families 
were actually members of the group in this country that did not have 
health insurance.
  You break the number down, and the individual demographics, suddenly 
you start looking at numbers of people where perhaps there are some 
choices and options. There are some things we could do. Some people 
tell me that as many as 10 percent of that uninsured demographic are 
people in universities or just recently graduated university students 
who, for whatever reasons, don't have health coverage.
  Well, there is a group of individuals that is fairly easy to insure 
because they tend to be healthy. Yes, they can have some bad things and 
they tend to be very expensive when they occur, but almost the ideal 
population to think about some type of catastrophic coverage, again 
along the lines of the HSAs that we expanded a few years ago.
  Perhaps if we equaled out the tax treatment a little bit, because a 
lot of these individuals are entering the workforce for the first time, 
they are finding what it is like to pay taxes for the first time, maybe 
we could get their attention with a little bit more favorable tax 
treatment. Certainly that is one option we could look at.
  A number of people in this country actually make enough money to 
purchase health insurance, but choose not to. Perhaps there would be 
ways of pricing health insurance so the costs were not so daunting, 
that the cost was not such a barrier to entry for those individuals; 
and there are a variety of ways of perhaps approaching that. Congress 
just simply again perhaps needs to remove some regulations, needs to 
provide a little bit more level playing field between some of the 
States and allow this to occur.
  There is no question that there is a lot of people in this country 
who are here without the benefit of having a valid Social Security 
number. That is a large number of our uninsured. Perhaps there are ways 
that we need to be thinking about how to address and how to approach 
that population, because clearly it is a difficult issue that we can't 
just keep putting in the too-hard box and we are going to think about 
it later. If we don't address that issue, we will never solve the 
problem.
  Mr. Speaker, let's not forget, we had a hearing on the Federally 
Qualified Health Centers in my committee on Energy and Commerce earlier 
this month. Fifteen million people actually get their health care 
through a Federally Qualified Health Center. Well, they have a medical 
home. For all intents and purposes, although they may lack an actual 
insurance policy on paper, they have access to medical care, they have 
access to a medical home through a Federally Qualified Health Center. 
So let's stop counting those as members of the uninsured, because they 
all obviously do have access to care.
  One final point that I do need to make, Mr. Speaker, and, again, I 
realize that time is short and it has been a long week: Do we increase 
the participation of the Federal Government in health care? Is that the 
answer for us in dealing with a lot of the problems that we face today?
  Well, I would ask us to look at a couple of things. You look at what 
is still on our to-do list as Congress wraps up this year, and what are 
some of the big things you see? First off, we haven't funded the money 
for veterans services and veterans health care. That is still up there 
on the to-do list.
  I have talked about it already, but we have not dealt with the 
looming reduction in physician reimbursement rates that is out there 
and fixing to happen to doctors across the country in just a few short 
weeks' time.
  We haven't dealt with whatever our final resolution is going to be on 
continuing the State Children's Health Insurance Program, a program 
administered by States, but they receive a significant amount of money 
from the Federal Government. And we have as yet not been able to come 
to a conclusion as to what we are going to do about funding the future 
for the State Children's Health Insurance Program.
  Take a step back and look at that. We haven't funded veterans, we 
haven't figured out what we are going to do for our Medicare patients, 
because the doctors may leave because we decided not to pay them, and, 
oh, by the way, we still haven't done anything to cover our kids.
  Do we want to be giving the Federal Government an increased reach and 
grasp of our health care in this country? Are we doing such a good job 
here that you want to reward us with more?
  You see Members of Congress write op-eds in the Washington Post where 
they talk about expanding Medicare to people that are age 55. But, by 
the way, good luck on finding a doctor, because we are not paying them 
anymore and they are dropping out of the system.
  So we have people in this Congress who want to sort of drag and drop 
people into Federal programs, take people off of private health 
insurance in the State Children's Health Insurance Program. One of the 
big issues there, we want to expand the program so big that it pulls 
kids off of private insurance, because, you know what, it is too hard 
to go down and find those really poor kids that we are supposed to be 
covering. That is a lot of work. They move around a lot. They may not 
really live with their parents any more. It is just a lot of hard work 
to find them. It would be a lot easier to go get some middle-class kids 
and pull them in to have a number of 10 million and say, look, aren't 
we great, what we did with the State Children's Health Insurance 
Program.
  I don't know. I don't know. You talk to pediatricians who work in 
private practice in this country. You ask them how they are reimbursed 
in the State Children's Health Insurance Program versus private 
commercial insurance. And guess what? Private commercial insurance, for 
all its faults, is still a better reimbursement rate than the State 
Children's Health Insurance Program by about a two to one margin. So 
are we going to be helping our pediatricians by pushing more kids on to 
the state-run program and pulling them off of those private programs? I 
don't think so.
  Right now the Federal Government has control of about 50 cents out of 
every health care dollar that is spent in this country. The remainder 
of that is not all private insurance. The lion's share of it is. 
Certainly some people

[[Page H15460]]

still write a check for their health care, just like they did when my 
dad was in practice back in the 1950s. Some doctors give of their time 
willingly. They give charitable care. We never account for that in any 
of the demographic studies that we do. But half of the health care in 
this country, the dollars spent on health care in this country, 50 
cents out of every health care dollar originates right here in the 
House of Representatives.
  Are we doing a good job with what we already have? Might we not be 
asked to improve what we are doing in those programs before we are 
asking you to let us take over even more of how we deliver health care 
in this country? It is certainly food for thought as we wrap up this 
year in the United States Congress.
  I would emphasize one more time, Mr. Speaker, and again I will 
address my remarks to you, if I could talk directly to Members who are 
involved in leadership on both sides of this House of Representatives, 
Mr. Speaker, I would ask that they seriously look at fixing the problem 
with physician reimbursement rates that we are coming up on now like a 
freight train and it is going to have a significant negative impact on 
the care rendered to our seniors in the Medicare program.

                              {time}  1700

  But we have got to pay attention to what we are doing for our 
veterans. We have got to pay attention with the State Children's Health 
Insurance Program. Again, lots of areas for improvement, I think, 
before we talk about expanding the reach and grasp of the Federal 
Government.

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