[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
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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
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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
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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
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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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