[Congressional Record Volume 154, Number 56 (Wednesday, April 9, 2008)]
[House]
[Pages H2140-H2145]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                              HEALTH CARE

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 18, 2007, the gentleman from Texas (Mr. Burgess) is recognized 
for 60 minutes.
  Mr. BURGESS. Madam Speaker, I come to the floor tonight to do what I 
often do, spend a little time talking about health care. The hour spent 
in this way, I think, delivers for the Speaker and other Members of the 
House perhaps perspectives on health care that you wouldn't hear in any 
other location. I've heard the hour that I spend down here talking 
about health care referred to as the ``House call.'' So perhaps that's 
a good way to look at it.
  Madam Speaker, we have got a big job ahead of us here in this 
Congress and the next Congress. We are going to be talking about health 
care from all sorts of different perspectives. And really where we 
ought to be focusing our efforts, where we really ought to be 
channeling our efforts is delivering better care at a lower cost. And 
you know what? The good news is there are some examples out there in 
the real world. There are some examples in the real world that this 
House can embrace and expand upon and maybe accomplish this thing that 
we all want to accomplish, which is delivering more care to more people 
in our country at a better price. But we don't need to do it at the 
sacrifice of freedom because freedom is the foundation of life here in 
America. Without our liberty, we aren't America. So unlimited options, 
the unlimited opportunity that people have in this country, that's what 
makes this country great.
  I always feel a little inadequate when I go into Starbucks because 
all I can do is order a cup of coffee. But other people go into 
Starbucks and are able to order from a wide variety of menu options. 
Who would have believed, when I was growing up, that there can be 57 
different ways to spend your money in a coffee shop all to purchase a 
cup of coffee?

                              {time}  2145

  Madam Speaker, innovation goes hand in hand with the ability to make 
choices. The combinations that are available for all of us to choose 
from have, in fact, engendered that market, and the young folks of 
today wouldn't have it any other way. And I think that is exactly as it 
should be. The same kind of options, the same kind of inventive 
technology and the same kind of innovation should be what makes health 
care great, as well.
  And, Madam Speaker, when it comes to innovation in health care, the 
United States is the world's leader in health care. Now in October of 
2006, in the New York Times, no less, and please don't tell anyone back 
in my district that I read the New York Times, but in October of 2006 
in the New York Times a piece by Tyler Cowen talked about just that 
issue. He talked about how 17 of the last 25 Nobel prizes in medicine 
have been awarded to American scientists. He talked about four of the 
six most significant breakthroughs in the last 25 years having been 
developed in the United States of America, things like the CAT scan, 
things like neuro treatments for hypertension, statins to lower 
cholesterol, coronary artery bypass surgery, all the product of the 
inventive American mind. And, as we all know, American scientists are 
not done with advances in medicine. And we are now counting on the next 
generation of doctors and scientists, a whole new generation, to 
produce whole new generations of breakthroughs, things like single gene 
therapy, advancements in protein science, and the incredible revolution 
in the way information is transmitted and handled. All of that is on 
the threshold. All of that is just over the horizon and going to have a 
significant impact on the delivery of health care in this country.
  And these breakthroughs occurred because there was an environment 
that encouraged innovation, an environment that embraced innovation, 
and yes, an environment that sometimes tolerated a little bit of chaos 
because that, after all, drove some of that creative energy. And this 
environment is better known as a competitive environment and one based 
on individual choice. Innovation and choice are the hallmarks of our 
health care system. But it doesn't mean that we can't make a good thing 
better.
  Now, Madam Speaker, as someone who has spent 25 years in the practice 
of medicine, I do believe I have a unique perspective on some of the 
issues that face our Nation's physician workforce, and certainly some 
of the

[[Page H2141]]

issues that face those of us in the House of Representatives here up on 
Capitol Hill. But I do have the unique perspective having lived in both 
worlds. I have had the pleasure, the opportunity and the high honor of 
sitting in an examination room and talking with a patient, being in the 
operating room or the emergency room or the delivery room with a 
patient. I have filed claims. I have filed claims with private 
insurance companies, Medicare and Medicaid, and dealt with the almost 
impossible bureaucratic nightmare that those claims have become, and 
also discovered that with the advent of electronic submissions for 
claims, some clever individuals delivered about 1,300 different codes 
for denying those claims.
  I figured out how to build my business, sometimes in an environment 
that was quite hostile to small business. I figured out how to pay my 
employees, how to keep the lights on, how to provide health insurance 
for my employees. Sometimes I have the burden of being the only one in 
my committee, the Committee on Energy and Commerce, the Health 
Subcommittee, the only one who has had experience with the practice of 
medicine, the only one who has ever picked up a pen, written a 
prescription, looked a patient in the eye, counseled them for risks and 
benefits and costs, a significant burden to carry as we go through 
bills like the FDA Reauthorization bill that we went through this 
summer.
  I have also had the benefit of some very good advisors along the way, 
some of my professors in Medical School, Jack Pritchard, who was the 
head of my residency program at Parkland Hospital, and my own mother, 
who told me, ``don't you ever let your office put me on hold on that 
telephone again. And further,'' she went on to say, ``don't let me ever 
hear that you refused to take a Medicare patient.'' And she never did 
have to hear that.
  But what does this experience give me? Practical knowledge is 
absolutely critical when you delve into trying to craft the best public 
policy. And this practical experience is invaluable, especially in an 
environment that is as rapidly changing as our health care system and 
the focus of so many across the country.
  Now, there is widespread recognition that there is some change in the 
air. You can scarcely turn on the television at night and not hear the 
word ``change'' mentioned over and over again. In fact, I told an 
audience of doctors the other day that I haven't heard the word 
``change'' so many times since I was an intern in the newborn nursery 
at Parkland Hospital. There is a widespread recognition that change is 
coming in health care. There are a lot of different ideas on how to 
accomplish it. Presidential candidates have their ideas. A lot of 
Members of Congress have their ideas. And somehow we are all going to 
have to come together with these ideas to try to get the best policy 
going forward.
  Now one of the things that has become absolutely apparent to me as I 
have spent a good deal of time studying this issue is that health care, 
not disease, but health care, the administration of health care, begins 
and ends with those who actually deliver the care. That means those 
that actually deliver the care, the doctors, the nurses, the 
technicians, really are the ones who should be on the front-lines 
leading that transformation in health care. A lot of health care 
professionals don't realize the critical role that they can play and, 
in fact, they must play in shaping the health care debate. If the 
professionals who work in health care, if the doctors and nurses are 
not active and engaged, they are going to be forced to play by the 
rules that someone in this House will set for them, someone in this 
House who may not have a clue as to what goes on in the day-to-day 
practice or administration of medicine.
  So every chance I have, I meet with doctors, nurses, physical 
therapists, technicians, either here in Washington or my district back 
in Texas, listen to them about what their concerns are, try to 
understand the problems that they are having, problems that may have 
changed in the few short years since I left the clinics, and try to 
talk to them about how to not just complain about the problems of 
today, but how to craft the solutions of tomorrow and how to 
effectively communicate that to those who are policy makers, whether it 
be in a Federal agency or here in a legislative body. I am firmly 
convinced that if our health care professionals don't lead, we are 
going to have to accept the prescription given to us by those in the 
Federal agencies and those that may be sitting in the legislature this 
year, next year or the year after.
  Now there is no sane person who would try to conduct their own 
operation. Most doctors, if they have controlling sense, wouldn't try 
to prepare their own income tax form. Doctors and nurses, health care 
professionals, need to be the ones to lead this change. And I will tell 
you something that just makes me stop dead in my tracks is when I hear 
people talk about a single payer government run system. It scares me to 
death. Now you stop and think, where is the largest single payer 
government health care system in the world? And it is here in the 
United States. It is our Medicare and Medicaid program. This body, the 
United States House of Representatives, currently controls about 50 
cents out of every dollar that is spent in health care in this country, 
and that is an enormous amount that is spent on health care, 15, 16, 17 
percent of our gross domestic product, upwards of $2 trillion a year, 
50 percent of that originates on the floor of this House of 
Representatives. So government already controls 50 percent of the 
market. When people talk about expanding that role, I have to stop and 
ask myself, well, are we doing a good job with what we are already 
controlling? And I don't think there is anyone who would stand up and 
say, yes, you are doing such a good job, we want to turn more of it 
over to you.

  But government can play a role by encouraging coverage and helping 
create programs that people actually want and empowering them to choose 
between options. And really, we just have to go back a year or 2 or 3 
to look at the experience with the part D part of the Medicare program 
signed into law late in 2003. The prescription benefit became available 
in January 2006, and now we are coming into the beginning of our third 
year of experience with that program. And sure, there were some bugs 
early on. But if you look at some of the numbers now, and probably 90 
percent of eligible seniors now have some type of health care coverage, 
which is an incredible change from when I took office in 2003. Eighty 
percent are happy with the program. Well, those are numbers that I will 
just tell you controlling practitioner would love to have.
  When we crafted that program, the smart people over at the Center for 
Medicaid and Medicare Services put their sharpest pencils to the 
program and said, okay, here it is. We can devise a program that will 
provide coverage for seniors for $37 a month in premiums.
  Well, now the average plan costs $24 a month. So what happened on the 
way to that $37 a month premium? Well, I will tell you what happened. 
The plans were opened up for competition and bidding. And guess what? 
The private sector found they could do things a little cheaper, faster 
and safer than those in the Federal agency. And I say more power to 
them. They have crafted different plans. Not everyone needs the same 
prescription drug plan. There is the ability to buy a prescription drug 
plan and change it once a year if your coverage needs change. It is a 
phenomenal tool to put at the hands of our seniors who are covered 
under Medicare.
  Again, who is going to argue with something that delivers more health 
care, lower cost and better quality? It is just too simple to argue 
with. That is the type of program on which we need to be focused. But 
you hear so many people talking about, well, people won't do the right 
thing if you leave them to their own devices. You have to put a mandate 
on it. You have to put an individual mandate, or we have to put a State 
mandate, or we will have to put an employer mandate where we require 
people to take up this coverage; as opposed to creating programs that 
people actually want, pricing them in a reasonable range, making them 
available, and helping people understand the wisdom of taking up that 
coverage.
  There are a variety of studies that have been done on mandates. Most 
recently there was one in Health Affairs

[[Page H2142]]

in November of 2007 looking at the experience and the history with 
mandates. I think the title of the article was ``Consider It Done'' 
because it was the opinion of the article that mandates would just 
simply have to be the next step.
  But in this country, we have 50 percent of people with no health 
insurance and a voluntary program. Well, you say, we could do better 
with mandates, couldn't we? Well, for mandates to work, you have to 
have, of course, a widespread dissemination of knowledge that the 
mandate is required. You have to have widespread dissemination of the 
knowledge of the penalty for not taking up the good, service or product 
that has been mandated, and you have got to have a pretty strict 
enforcement mechanism, and people have to be aware that that 
enforcement is going to be swift, sure, and it is going to be painful 
when it happens. Well, where in real life in America today is there 
such a system? Hey, we are coming up on April 15. How about the 
Internal Revenue Service, for example? With the Internal Revenue 
Service, there is broad understanding throughout the population that 
you have to pay your taxes. There is a broad understanding of what will 
happen to you if you don't pay your taxes. Now there may be nuances, 
fine nuances to the Federal law, whether it is prison term or a fine, 
but people do understand there are a plethora of unpleasant 
circumstances for those who don't pay their taxes.
  And what is the take-up rate, if you will, on this generous offer 
from the Internal Revenue Service? Well, it is about 85 percent. You 
have about 15 percent of people who don't comply, even with those 
relatively draconian and well-known practices within the IRS if you 
don't comply. So it does beg the question, if we simply go up there and 
say, you have to buy an individual insurance policy or there are going 
to be consequences to that behavior which will cost you, how do we know 
we are going to get up-take greater than the 85 percent up-take that we 
have today? And indeed, some of the experience early on with some of 
the States who have experimented with this have found that some people 
look at the cost of the insurance, and since it is now required, guess 
what? The cost went up because it is no longer a free market where you 
have a willing seller and a willing buyer. You have a buyer who is 
being coerced to buy that product, so the price goes up. And so some 
people look at that and say, that is pretty costly, I will just pay the 
fine, thank you very much. So then we are in a very difficult 
situation. We have someone paying a fine for not carrying health 
insurance. And if they get sick on top of it, then they are still a 
burden on the hospital, doctor, the State, whoever has to pick up the 
cost for that hospitalization.
  So I would just urge my colleagues to be circumspect, to be careful 
when we talk about mandates and also look to the experience we had with 
Medicare part D where then a program was created that didn't exist 
before, and it was created in such a way as to put something out there 
that people actually wanted, put something out there that people 
actually saw as adding value to their health care coverage, put 
something up there that would be useful to people.

                              {time}  2200

  Not simply putting a requirement out there, a penalty if you don't 
comply, and then people are constantly gauging, well, would it be 
better just to pay the penalty and not comply and not have the more 
expensive health insurance, which I, after all, don't need, because I 
will never get sick.
  So the part D program provides us a model that we could use when we 
are trying to see about developing those types of programs. And in a 
few minutes, let me cover with you some of the other models, some of 
the experience that has recently been gathered from the private sector, 
because I think that is useful to instruct, that is useful to inform 
this debate as well.
  But the experience of part D in Medicare showed us that sometimes the 
best thing that government can do for health care is just simply get 
out of the way and let people, providers, third-party payers, work this 
out between themselves. If we create the right conditions, the right 
environment, the right set of circumstances and let the private sector 
develop the innovation, sometimes the cost savings can be substantial, 
the quality can be increased. And, after all, isn't that what we want, 
more care, better quality, lower cost? Who can be against those three 
things?
  Now, Madam Speaker, I can remember a time when I was growing up that 
you could only have one kind of telephone. It was black, it was 
tethered to the wall and had a rotary dial. Over 10 or 15 or 20 years 
time we saw some technical innovation. It was still black, it was still 
tethered to the wall, but it had push buttons instead of a rotary dial.
  Then came deregulation. Then came many phone companies that were able 
to compete on the open market, compete for the individual phone user's 
business. And the story tells itself, because nowadays you have cell 
phones on every belt buckle and hip pocket. You have text messages. You 
have a whole generation of young people who know how to text better 
than they know how to communicate with the king's English.
  So change has come to this industry, not because the government said 
it would be a good idea for everyone to have a cell phone on their belt 
buckle or a cell phone in their hip pocket. It came about because 
industry, the private sector, was allowed to innovate, it was allowed 
to experiment, it was allowed to sometimes fail, and produce these 
products that people actually wanted and that deliver value, real 
value, to people's lives.
  Many, many years ago I got a pilot's license. A lot of people learned 
to fly in a Piper Cub. The Piper Cub is truly a marvel of engineering 
science. But would anyone argue that the 737, the 787 that is new this 
year, would anyone argue that that is not a better way to move large 
numbers of people from one end of the country to another, rather than 
having each of us fly our own individual Piper Cub?
  You know, you can't help but when you have this kind of discussion 
recognize that the invention of the Internet really changed a lot of 
things. Of course, now we have the Internet, we have e-mail, we have 
Web sites, we have YouTube, all of which were absolutely unimaginable 
as short as 20 years ago.
  Here is the secret. Here is the secret to that success. The private 
sector, with its ability to tolerate innovation, with its ability to 
tolerate risk and reward, its ability to tolerate a little bit of 
experimentation, and, again, a little bit of chaos, can deliver that 
kind of value. I have personally experienced this in my years 
practicing medicine, and I have learned more about it since I have come 
here and worked legislatively.
  Last fall, last November, I believe, there was a big health care 
symposium put on downtown by the periodical Health Affairs, and the 
morning panel was going to be four smart people. But one of them was a 
CEO of a large insurance company, an insurance company, quite honestly, 
that I had some trouble with when I was a practicing physician. So I 
thought, well, I want to go hear what Dr. McClellan has to say. I want 
to hear what Dr. Sarhuni from the National Institutes of Health has to 
say. But I will probably go for coffee when this CEO gets up to talk. 
But the CEO gave the most important part of the talk that morning.
  This particular individual talked about running his large insurance 
company. He talked about his 45,000 employees, 15 percent of whom were 
devoted to the development of information technology. If that 15 
percent had been a stand-alone software company, they would have been 
one of the largest in the United States of America.
  Well, that is a pretty powerful notion. I stopped and did a little 
quick mental calculation of my own and I thought about my five or six 
physician practice back in Louisville, Texas. We were faced with the 
specter of Y2K and I had to upgrade my ancient and ailing computer 
system, and although at the time I thought it cost an incredible amount 
to do that, just doing a quick back-of-the-envelope calculation, I 
spent about .015 percent of my annual budget on information technology. 
So was it any wonder that that particular insurance company could run 
rings around a small practice when it came to the managing, the flow of 
information, the speed with which they could process information?

[[Page H2143]]

  I was very intrigued by the fact that this individual said we have 
learned a lot about the progress of disease and the course of disease, 
not by studying clinical data, but by simply analyzing the financial 
data available to us within our information technology system. For 
example, if we see A and B, we are very likely going to see C, and of 
those patients who have C, some are going to go on to D, and D costs a 
lot of money. So we are far better off intervening at A or B and not 
having to buy as many Ds as we might otherwise have to buy.
  He gave the example, and, of course, my practice was not in taking 
care of heart disease, but he gave the example of a middle-aged 
individual suffering a myocardial infarction or heart attack. He said 
we know from studying our data that this individual is very likely to 
suffer about a bout of significant depression somewhere along the line 
in their recovery, and in fact that bout of depression may be so 
significant that it precludes that individual complying with their 
exercise program, their cardiorehabilitative program, and very likely 
puts them at risk for a second cardiac event, or perhaps even 
consigning them to congestive heart failure in the future, which is 
terribly expensive to treat within and out of the hospital and lots of 
expensive medications.
  So he found that by intervening early on with an aggressive 
assessment for depression, an aggressive treatment for depression, that 
they were in fact able to get better compliance in their 
rehabilitation, and ultimately lowered their cost at the out end 
because of this very aggressive management program that they had 
developed.
  Again, that is all done with financial data. They were just beginning 
to be able to incorporate clinical data. They have got some problems 
with that because of some of the constraints, regulatory constraints 
that we here in Congress have put on them. But, nevertheless, it told a 
great story about the types of things that can be done in managing 
information in this brave new world, where so much information is 
available and so much can be assembled and analyzed at a very rapid 
rate. We are coming up on a period of rapid learning unlike anything 
ever seen before in any branch of science, and certainly medicine is 
not going to be any stranger to that.

  When I was in training in the 1970s, when I was in practice in the 
1980s and 1990s and early 2000s, it was very difficult to encounter a 
patient late in pregnancy with an elevated blood pressure. You never 
knew whether this was going to go on to a much more serious condition 
or whether in fact this was simply a transient problem that would be 
self-limited and of no consequence, and you had to treat them all as if 
they were the most serious consequences, sometimes even requiring 
hospitalization for a period of observation until things got squared 
away.
  There are tests that are just around the corner that will analyze for 
a couple of things in the bloodstream that have a very high predictive 
value as to whether or not someone will develop a condition called 
preeclampsia over the next 14 days. What a tremendously powerful tool 
to put in the hands of clinicians. And how many dollars is that going 
to save? It may well be an expensive test when it first comes out, but 
how many dollars is it going to save for unnecessary hospitalizations?
  Sometimes we would have to take someone off from work, not knowing 
whether they had a more serious disease or whether this was going to be 
a benign self-limited event. But you just couldn't take a chance. You 
just couldn't take that risk of not counseling that patient to behave 
as if this was going to be the more serious of the two conditions. How 
great it will be for the next generation of doctors who practice my 
specialty of obstetrics to be able to have that test at their disposal 
so they can adequately counsel their patients, recommend to their 
patients the correct treatment course for them, and, in the process, 
not overtreat a large group of patients, and, very importantly, not 
undertreat a much smaller but potentially much more lethal condition in 
a smaller group of patients.
  Yesterday up here on the Hill I was very fortunate to be able to host 
a panel with several speakers that included the former Speaker of our 
House, Newt Gingrich, who came up on the Hill to talk about change in 
health care reform and transformation in health care.
  Everyone knows that former Speaker Gingrich is a real leader when it 
comes to health care transformation. In fact, he has made that now his 
life's work here in Washington. We are certainly grateful for, first 
off, for his service in the House, but we are very grateful that he has 
devoted his enthusiasm, his considerable energy, his considerable 
ability to generate new ideas and to recognize great ideas when they 
are presented to him. We are very fortunate to have his expertise in 
Washington. So it was really a great experience to have him involved in 
this panel yesterday.
  Several companies came in. The whole premise of the seminar, the 
whole premise of the series, was, just as I started out this talk, 
better health, lower cost, examples from the real world. These were 
four individuals that came in and talked to us about real world 
experience and how they have been able to deliver their product, health 
care, in a more timely fashion, better quality, lower cost.
  Let me share with you some of what I learned. It was a very action-
packed hour-and-a-half that we had yesterday. But let me share with you 
just a little bit of what I have learned with talking to some of those 
innovative medical leaders.
  One of the central themes that kept repeating itself over and over 
again was the issue of personal responsibility. It is important to have 
someone invested in the concept that it is a good idea to take care of 
their own health and to be personally invested in their own health 
care, and a lot of the discussion came around to a concept that is 
popularly called consumer-driven health care. We have talked about that 
a lot up here on the Hill.
  The fact is that because of our third-payer system, so many people 
are actually anesthetized to the true cost of their health care. All 
they want to know is can they see the doctor when they need to, how big 
is the copay, and if I need an expensive test, well, is it covered by 
insurance? If is not, I don't want it. If it is, I will take two.
  Now, my own staff tells me that when they receive an explanation of 
benefits, that little form, that little EOB form that you get from your 
insurance company after you have a medical event or an intersection 
with the health care system, whether it be doctor or hospital, most 
people take that explanation of benefits, it says on it ``this is not a 
bill,'' so what happens to it? It goes straight into the trash. They 
never look at it. They never try to assess what is or is not on it. So 
they are consuming the health care service, but not really are 
conscious as to the cost. As a consequence, there is little or no 
incentive for anyone to take any proactive stance on the health care 
that is delivered to them, the health care that is offered to them. 
There is very little incentive for someone to actually take an active 
role in that.
  There is an old saying from P.J. O'Rourke, if you think health care 
is expensive now, just wait until it is free, and that is the concept. 
If it doesn't cost anything, then, again, yes, nothing but the best 
will do, and let's be sure we have plenty of it, and don't be too long 
about getting it to me.
  In a consumer-driven health care system, people would be more 
conscious of their health care cost, more conscientious, and more 
likely to make wiser decisions about lifestyle choices, about things 
that they might do to alter a lifestyle choice, to be able to maintain 
their health.
  There was a study take that was talked about yesterday that found 
that in one hospital group, the patients who were in a consumer-
directed health care plan were twice as likely as patients in 
traditional plans to ask about the cost, and three times as likely to 
choose a less expensive treatment option. And this is just not for 
young healthy patients. Patients with chronic conditions, chronic 
disease states, were 20 percent more likely to follow the treatment 
regimen recommended to them, to follow that regimen much more 
carefully.
  Now, there is no shortage of critics of consumer-directed health care 
up here on the Hill. People will argue that it will cause patients, 
consumers, perhaps those less wealthy, perhaps those less educated, to 
avoid needed and appropriate health care because of the cost

[[Page H2144]]

burden and the inability to make informed appropriate choices.
  One of the companies yesterday that discussed this at the panel has 
data that they say directly contradicts that criticism. And I don't 
doubt that that is correct, because back in the late 1990s a comparison 
was done with a country that had a large component of what were then 
called medical savings accounts or consumer-directed health care, in 
contrast to the United States, which at that time had no high 
deductible consumer-directed health care options, no MSA options, and 
that was in a lead-up to the beginning of the MSA era in 1996 or 1997.

                              {time}  2215

  Experience with that country that had about a 50/50 mix of consumer 
directed plans and what might be called standard indemnity plans found 
that there was no dialing back on needed services. There was no pulling 
back on services that were critical for the maintenance of a person's 
health, but more optional types of treatments perhaps, were the ones 
that had a lower uptake.
  Now, a Midwestern health care company introduced consumer-driven 
health care plans to its 8,600 employees. They also left their 
traditional PPO plan in place.
  In the first year, 79 percent of their employees chose one of the 
four consumer-directed health care options. These health plans had 
several important features.
  Preventive care is free. Now, what a concept. That means that the 
annual visit to the doctor, required screening exams, don't cost money. 
They are provided for you free of charge.
  Employees also receive financial incentives to change behaviors like 
smoking or those who need to lose weight. They also receive financial 
incentives to manage chronic conditions like asthma and diabetes more 
carefully and become active participants in the management of their 
disease.
  The results so far have shown that they had 7 percent of health care 
dollars spent on prevention compared to a national average that was 
about a third of that.
  Nearly 40 percent of employees take an annual personal health risk 
assessment and earn $100 for their trouble. But a 40 percent uptake on 
an annual health risk assessment is a significant number. Five hundred 
employees have quit smoking, their employees have lost a total of 
13,000 pounds through their weight management programs with appropriate 
monitoring, 13,000 pounds. Talk about your biggest loser or your 
biggest winner, clearly, that's a program that is paying off.
  Now, the average claim increase of 5\1/2\ or 5.1 percent the last 2 
years is compared to a national trend of over 8 percent, so there has 
been a 3 percent savings on the average claim. The company has, again, 
collected an impressive amount of data, and we could learn from their 
example, from their experience.
  There are some other companies we can learn from as well. There was 
another very large health insurance company that was on the panel. 
Then, again, it was a health insurance company with which I used to 
have some differences, but they described their incentive-based benefit 
design. They provide or have available to their employees one of the 
high deductible plans. A high deductible plan with a large deductible 
is going to cost less than a plan with a lower deductible.
  They offer a plan with a high deductible. But without an increase in 
premium, the individuals, the families can lower that deductible to 
$1,000 by changing things like weight, smoking, serial cholesterol 
measurements complying with annual screening exams.
  A $5,000 deductible at a lower policy rate then becomes a $1,000 
deductible at the same rate. It's a significant cost savings for that 
patient or that family, that employee, where they get the benefits of a 
very high deductible plan but the deductible comes to them in a much 
more manageable size.
  We also heard about some of the very positive results driven by 
consumer-driven health plan options. Now, the speaker who talked about 
that actually took me back a little bit, because I do remember back 
1976 and 1977 the MSAs first became available. They were called the 
Archer Medical Savings Account after Bill Archer, chairman of the Ways 
and Means Committee from this body who had worked so hard on that over 
the years.
  Phil Gramm, then a Senator from Texas over on the other side of the 
rotunda, had worked on that on the Senate side. As part of a large bill 
that was passed to increase insurance portability, they got a 
demonstration project, a pilot project that was going to allow 750,000 
so-called high deductible policies or medical savings accounts to be 
sold. I heard about that, and I thought I don't know if I can sign up 
quickly enough to be in that first 750,000.
  But the reality was I needn't have worried. There were so many 
restrictions placed on that insurance that the uptake was, in fact, 
probably only one-tenth of what were available.
  There weren't many insurance companies that offered it. The premiums 
had to be paid for with after-tax dollars. Many of the things that we 
now think of as being associated with a health savings account just 
weren't available back in those early years.
  But, still, although the amount that you could put away in a medical 
IRA or a medical savings account wasn't nearly as large as what you 
could do today, still, it was a significant amount of money. I 
purchased one of those myself back in 1976 or 1977, keeping it until I 
started service here in the House of Representatives, where at that 
time it wasn't available.
  But that chunk of dollars has sat there, and with the time value of 
money, earning interest, compound interest, the miracle of compound 
interest, year over year now is a sizeable sum of money that is 
available to my wife and I for health care needs. Whether it be pre-
Medicare or post-Medicare age, that money is still going to be 
available to us as additional cash that can be spent on health 
problems.
  The doctor that talked to us about the nuances of the newer health 
savings account talked about how in his experience 88 percent, that's 
nearly nine out of ten account holders, carried a balance from 2006 to 
2007. The actual percentage of people who either did not contribute or 
used up all the money that they had contributed to their medical IRA or 
their health savings account was only about one in 10, and the average 
balance for people across all income levels was $597 at the end of that 
carryover from year to year.
  Now, you have to ask yourself how many Americans, how many families 
are encouraged to live a healthier life, conserve their health care 
dollars, like these individuals have done. These guys are making 
personal decisions about prevention, they are making personal decisions 
about life-style changes, they are managing chronic conditions, 
actively engaged in the management of those chronic conditions. As a 
consequence of those behaviors, they are holding down costs.
  Now, most other populations with regular private indemnity insurance 
are not. The key is bringing about the necessary change to effect that 
transition from an individual who is really indifferent as to the cost 
of the expenditure on health care to one that is actively managing the 
cost of their health care.
  But there are other tools we can put in the hands of people. We hear 
people talk about transparency. I have, in fact, introduced legislation 
dealing with transparency.
  We have got some good things going on back home in my home State of 
Texas as far as some of the web-based transparency information and data 
that's out there as far as hospitals are concerned. The Centers for 
Medicare & Medicaid Services has, in fact, published their own data up 
on the web.
  So as more and more information is gathered, patients, individuals, 
can have access to greater and greater amounts of information detailing 
what is available to them as far as what if the difference between one 
hospital and another is substantial as far as the cost of rendering a 
particular service, regardless of what it is. But the ability to go on 
the Internet and be able to compare the cost of those two services, 
that's a tremendous tool to put into someone's hands.
  If you can further refine that to allow an individual to put in 
information about their particular health insurance or their health 
plan, or if they are a self-pay, to make that information available, to 
then go on and compare between the institutions, where

[[Page H2145]]

would their best benefit be derived? Where can they most adequately get 
the type of care that they want and, of course, there does have to be 
quality data published alongside that.
  It can't just simply be the cheapest care at the cheapest cost. You 
want the best care at the most reasonable cost, or, as Dr. McClellan, 
former administrator of Centers for Medicare & Medicaid Services always 
talks about the four Rs, the right care for the right patient at the 
right time and the right price.
  These are going to be critical aspects of any health care policy that 
we craft in this House. We simply have to keep those basic tenets in 
mind.
  One of the speakers yesterday talked about in education the 
fundamentals of the three Rs, reading, writing and arithmetic. He went 
on to say in health care the fundamentals should be risk, 
responsibilities and reward, because, indeed, the risks are those that 
must be balanced against the possible benefit.
  The patient needs to be an active participant in that. They can no 
longer simply be passive passengers on the journey through the health 
care system. They actually have to play a role in taking responsibility 
for their own care. The rewards, the reward aspect, the incentive 
aspect is often given. Well, while we are real good about being 
punitive in this body, we are pretty stingy when it comes to rewards or 
incentives. I could give you several examples of that.
  One that comes to mind is the bill that was introduced late December 
as far as trying to encourage physicians for e-prescribing. The reward 
was a 1-percent increase in Medicare fees for a physician who 
participated in e-prescribing. The penalty 4 or 5 years later was a 10-
percent reduction if they don't.
  On a $100 procedure, and I will tell you there are not many office 
procedures under Medicare that pay $100, but let's use that number 
because it makes the math easy. In a $100 procedure administered in a 
physician's office if they utilize an e-prescribing module to 
administer that patient's care, they are going to get $1 extra for that 
$100 procedure or interaction, visit, whatever it was. That's okay, $1 
is $1, and it's better than nothing.
  But if you don't participate in 4 years time, 5 years time, that's 
going to be a 10-percent reduction. That same $100 procedure or test or 
interaction now will pay $90.
  We are so focused on the punitive in this body, and we never focus on 
the front end of the problem, which is assigning the appropriate dollar 
amount or the appropriate incentive.
  Now, go back to my earlier example of that large insurance company, 
and again an insurance company in the past which I have had great 
difficulty with, but what innovative thinking they have. They are 
offering a patient the ability to reduce from $5,000 to $1,000 their 
risk, their cost, on a deductible with no increase in premiums if they 
will do four simple things, lose a little weight, stop smoking, 
exercise regularly.
  If you have asthma or diabetes you participate in a disease 
management program, and your deductible falls from a $5,000 deductible 
down to $1,000, and, oh, by the way, that premium that was less because 
you had a $5,000 deductible, it doesn't go up. It doesn't go up when 
that policy changed. That's the kind of innovative thinking I am 
talking about when I say we must balance the risk and rewards, because 
we haven't been good about doing that.
  Everyone likes to quote the Rand study when they talk about 
information technology and programs like e-prescribing. The Rand study 
says that if we go to electronic prescribing in our health care system 
in this country, we are going to save $77 billion in 15 years, a 
tremendous amount of money.
  Now, most of that savings is, in fact, out toward the end of that 15-
year time. They don't really talk very much about who is going to pay 
for the cost of the implementation, putting the software, the hardware, 
the training, the upkeep of the software, the maintenance of the 
software, the time spent on the learning curve for all of these small 
offices across the country that have to make that investment. That's 
just going to be a given, but it will be worth while because we get a 
$77 billion savings at the end.

                              {time}  2230

  What is missed so often in this study is the last paragraph. At the 
end of a very large study, it talks about the incentives to make this 
happen, to get us to this happy place where we are saving $77 billion 
with e-prescribing.
  The incentives have to be early. The late innovators are going to be 
rewarded, so you have to have the incentives arrive early, and they 
have to have a time limit otherwise people will wait and see if the 
technology doesn't improve because, after all, they know they will have 
to pay for the hardware, software, the training, the upkeep and 
maintenance of the software.
  Finally, the third thing is the incentives must be substantial. And 
again, on both sides of the aisle, we forget that very important point. 
So while we hear the Rand study quoted over and over again, please 
remember the incentives are early, they are time limited, and they are 
substantial. That was the economic modeling that got them to the happy 
place where they were saving $77 billion in the 15th year of that 
study.
  If we concentrate on the fundamentals, getting back to the 
fundamentals, focusing on the risk, talking to our patients about 
responsibility, that is not so hard to do; but we should obviously 
compensate the health care professional for their time, for counseling 
about that responsibility, so that we don't forget the reward for the 
provider, to be sure; for the patient, to be sure; for the taxpayer, 
the American taxpayer if it is on that 50 percent of every health care 
dollar that is spent in the largest single-payer, government-run health 
care system in the world, which is Medicare and Medicaid today.
  So the right prescription for health professionals has to be focused 
on these three areas when it comes to providing the real direction for 
health care reform.
  I know I am not alone when I say that I am going to use these 
principles as my guiding star as I continue to work on health care 
policy. I hope I can convince my colleagues both in committee and here 
in the House of Representatives to focus on those same issues as well.

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