[Congressional Record Volume 155, Number 164 (Thursday, November 5, 2009)]
[Senate]
[Pages S11132-S11139]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                           HEALTH CARE REFORM

  Mrs. HAGAN. Mr. President, the United States spends $2.3 trillion 
each year on health care--the most per capita of all industrialized 
nations. Yet we still have higher infant mortality and lower life 
expectancy than many of the other industrialized nations. Moreover, 
medical errors kill 100,000 patients per year and cost the system tens 
of billions of dollars, and $700 billion is spent each year on 
treatments that do not lead to improved patient health.
  Today, my freshman Senate colleagues and I are going to speak about

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the need to reform our health care delivery systems. You will hear from 
all of us about innovative initiatives that are successfully bringing 
down the cost of health care and at the same time improving the quality 
of care.
  Mr. President, I would like to yield 5 minutes to my colleague from 
Colorado, Senator Mark Udall, to discuss accountable care 
organizations.
  The ACTING PRESIDENT pro tempore. Without objection, the Senator from 
Colorado is recognized.
  Mr. UDALL of Colorado. Mr. President, I thank my colleague from North 
Carolina, Senator Hagan, for convening this important session this 
morning where we will talk about the urgent need to reform health care 
in our country.
  The unsustainable growth in health care costs and lack of stable, 
affordable coverage for millions of Americans continue to jeopardize 
not only our Nation's fiscal well-being but also the physical well-
being of our families and neighbors. One of the key ways we can help 
put our health care system and our economy on the right track is by 
encouraging value in the delivery of health care.
  I have cited these numbers before--I know many of us have--but I want 
to emphasize them again. As a nation, we spend over $2 trillion per 
year on health care--that is nearly one-fifth of our economy. Yet 
between 30 and 50 percent of these dollars are not contributing to 
better patient health. That is not a good deal for the American people.
  Health reform is designed to address this staggering amount of waste 
in a number of ways. One way is to encourage providers to focus on the 
quality of care they provide and not just on the volume. And we can 
start with Medicare.
  I think the American people would agree that taxpayer dollars are 
better spent rewarding doctors for keeping patients healthy and not for 
performing more tests or more procedures. Health reform legislation can 
move us in this direction through the development of what are known as 
accountable care organizations, or ACOs. These organizations would 
encourage groups of health care professionals to team up and provide 
more coordinated, streamlined care to Medicare patients. The idea is to 
have these ACOs take responsibility for improving patient care while 
lowering cost and then sharing the savings that accrue. Research 
indicates that this idea of shared savings would help eliminate waste 
and spur changes in our health care delivery system to emphasize 
patient outcomes and value.
  The idea for ACOs no doubt came from the great work being done by a 
patchwork of physician groups. Groups such as the Physician Health 
Partners, or PHP, in my home State of Colorado, and others across the 
country focused on care coordination and quality.
  For example, PHP has seen great success in improving care for kids 
suffering from asthma--the No. 1 cause of child hospitalization and 
school absence. They developed treatment guidelines and promoted 
collaboration among doctors, the Children's Hospital in Denver, and the 
Colorado Allergy and Asthma Centers. As a result, they have reduced 
emergency room visits and improved families' ability to manage asthma 
on their own.
  PHP also has the Practice Health Project. This comprehensive effort 
brings doctors together to share best practices and encourage the 
adoption of commonsense guidelines to improve quality and efficiency. 
The goal of this team effort is to raise the standard and value of care 
and allow these physician groups to act as a model for Denver's 
physician community as a whole.
  I would also like to tout the PHP's Transitions of Care Program in 
collaboration with Denver's St. Anthony Hospital and other local care 
providers. The program dispatches nurse coaches to help Medicare 
patients make the transition from the hospital to their homes. The 
period immediately following a hospital stay is a very confusing time, 
particularly for our seniors. Having someone help with this transition 
is crucial. PHP has had tremendous early success with this program, 
showing the potential to reduce costly hospital readmissions by 40 to 
50 percent. At the same time, this program keeps patients healthy and 
it saves money.
  The successes of groups such as Physician Health Partners demonstrate 
that we already have the will and the know-how to change our system for 
the better. But under our existing system there is no incentive for 
programs like PHP to even exist. Under the status quo, a hospital 
stands to lose money if it decreases its admission rates. Primary care 
doctors would be at a financial disadvantage if they spent time in the 
development and implementation of effective treatment plans for their 
asthmatic patients.
  This is why health reform includes commonsense proposals such as 
encouraging groups such as Physician Health Partners to form 
accountable care organizations and paying them to coordinate care for 
Medicare patients. Promoting ACOs and other creative pro-consumer ideas 
will increase quality for patients and value for the taxpayer.
  Only by reshaping the way we do business in our health care system 
can we truly change health care delivery in our country. I look forward 
to working with my colleagues here today and other Senators in the 
coming weeks to promote the many ways we can accomplish that goal.
  I thank Senator Hagan, and I yield the floor.
  Mrs. HAGAN. I thank Senator Udall. Accountable care organizations are 
extremely important in health care reform.
  Mr. President, I would like to yield 5 minutes to my colleague from 
Delaware, Senator Ted Kaufman, to discuss Delaware's health information 
network.
  The ACTING PRESIDENT pro tempore. The Senator from Delaware.
  Mr. KAUFMAN. First, Mr. President, I want to thank Senator Hagan not 
just for putting this on but for her leadership all along on health 
care reform, and I look forward to working with her because of her 
great leadership. I appreciate the opportunity to join my colleagues on 
the floor to highlight health care innovations in our home States that 
can serve as models for national reform.
  Delaware is a national leader in health care IT--information 
technology--and I want to take a couple of minutes this morning to talk 
about a truly innovative approach to health care record keeping in my 
State. It is called the Delaware Health Information Network.
  The Delaware Health Information Network, which we call DHIN, was 
authorized 12 years ago and went live in 2007, becoming the first 
operational statewide health information exchange. A public-private 
partnership of physicians, hospitals, laboratories, community 
organizations, and patients, the DHIN provides for the fast, secure, 
and reliable exchange of health information among the State's many 
medical providers. As a result of its early success, the DHIN was one 
of the nine initial health information exchanges selected to 
participate in the U.S. Department of Health and Human Services' 
national health information network trial implementations. Among those 
nine, it was the first State to successfully establish a connection 
with the trial.
  Right now, more than 50 percent of all providers in the State--nearly 
1,300--participate in the DHIN. More than 85 percent of all lab tests 
are entered into the network, and 81 percent of all hospitalizations 
are captured by the exchange. As of June of this year, the DHIN held 
over 648,000 patient records, and it conducts 40 million transactions a 
year.
  Participating providers have a choice of three options to receive 
lab, pathology, and radiology reports, as well as admission face 
sheets: they can have them sent directly into a secure in-box, similar 
to an e-mail account, they can have them faxed to their office, or they 
can get the results from an electronic medical records interface on the 
Web. All three provide information in a timely manner that protects the 
privacy of the patient.
  Our State of Delaware receives four very tangible benefits from DHIN, 
and these are listed on this chart.
  First, the DHIN provides a communication system between providers and 
organizations--something that did not exist previously. Individual 
physician offices can now easily discover if hospitals, such as 
Christiana, Bayhealth, and Beebe Medical Center, have admitted their 
patients. Doctors and hospitals can also get lab results back

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from the State's clinical laboratories in a timely manner.
  Second, the information exchanged electronically through DHIN helps 
improve the quality of care being delivered in the State. When 
providers have access to better, faster information at the time and 
place of care, either in a doctor's office or an emergency room, those 
providers can make better decisions and reduce the chance of medical 
errors. Knowing what medications a patient is on or what coexisting 
conditions a patient may have can give the provider more complete 
information when delivering care, reducing the chance of an adverse 
outcome.
  Third, the DHIN can help reduce the cost of care within the health 
care system. That is what we are all looking for out of health care 
reform--cost reduction. With nearly 650,000 patient records in the 
system, providers can know what tests and procedures have already been 
ordered, cutting out inadvertent test duplication. In addition, the 
DHIN can help improve disease management by allowing multiple providers 
treating a person to communicate and better align the treatments and 
prescriptions for a particular patient.
  Finally, No. 4, the DHIN can enhance privacy within the medical 
health care system. The DHIN is a secure system that can only be 
accessed by participating providers and organizations. It contains 
access controls, regulating who can use the network, and it contains 
audit requirements to ensure there are no breaches in patient privacy.
  While the DHIN is still growing, it has already helped the patient 
care delivery system in Delaware. As it moves to include all providers 
in the State and works with other States' information exchanges to 
share ideas and successes, the DHIN will help lead our country to a 
widespread adoption of health information technology.
  The stimulus act contained $19 billion to promote the adoption of 
health IT nationwide, and the health reform effort promises to build on 
this momentum with even more resources. I believe it is essential that 
health reform boost the integration of information technology such as 
that provided by the DHIN throughout the health care system.
  As I have said many times, it is time to gather our collective will 
and do the right thing during this historic opportunity by passing 
health care reform. We must include incentives to expand the 
utilization of health information technology. We can do no less. The 
American people deserve no less.
  Mrs. HAGAN. I thank Senator Kaufman. A health information network is 
critical to improving patient care and reducing health care costs.
  Now I would like to yield 5 minutes to my colleague from Alaska, 
Senator Mark Begich, to discuss customer-driven care.
  The ACTING PRESIDENT pro tempore. Without objection, the Senator from 
Alaska is recognized.
  Mr. BEGICH. Mr. President, I thank Senator Hagan for allowing me time 
this morning. I am pleased to join my freshman colleagues to once again 
state our case for health insurance reform in this country. It is truly 
long overdue and very much needed.
  I also wish to make a point. I have listened closely to the comments 
of my colleagues from the other side of the aisle over the last several 
weeks. A few weeks ago, I heard the Senator from North Carolina, Mr. 
Burr, talking on this floor about health reform. He acknowledged that 
we need to change the health delivery system, which I agree with, but 
then he said our Democratic ideas won't work. He said one reason is 
because government programs don't do enough innovation and wellness and 
they won't help people make the lifestyle changes needed to get true 
savings in the health system.
  Quoting from the Congressional Record, here is what else he said:

       Show me a government plan that pays for prevention, 
     wellness, and chronic disease management, and I will quit 
     coming to the floor and quit talking about the lack of 
     reform.

  Mr. President, I have one. I have a great example of just such a 
government plan that pays for all of those things, almost the whole 
thing, and gets incredible results. It comes from my home State, from 
an Alaska Native program called the Nuka Model of Care. It is based in 
Anchorage at the Southcentral Foundation, a nonprofit health system 
serving about 55,000 Alaska Natives.
  The Nuka Model was developed about 10 years ago using the wisdom of 
Native leaders. They acted in response to what they saw as their own 
failing health care system. Like many other health providers in this 
country, the foundation recognized an alarming contradiction: As health 
costs continued to increase, the health status of their patients only 
got worse. More dollars going to health care only resulted in worse 
health outcomes.
  So they decided to change things. From the ground up, they built a 
system of customer-driven health care. That is their term, not mine--
``customer driven.''
  ``Nuka'' is a Native word associated with family, and that is 
certainly the approach. The Nuka model creates teams of health 
providers--doctors, nurses, medical assistants--to work with each 
patient. It requires doctors to listen to the patients, to really hear 
what customers are saying about their lifestyles, their jobs, their 
families, everything that affects their overall health.
  It makes medical access much easier, guaranteeing that you can see 
your chosen provider for anything you want--same day. In person, via 
phone or e-mail--whatever is easier for the patient--same-day 
guarantee. Let me repeat that: same-day guarantee.
  Here is another important point. Physician salaries are based on the 
team's overall performance. I want to make sure my friend, Senator Burr 
from North Carolina, hears this part. The Nuka model is funded almost 
entirely by the Federal Government--half by Indian Health Services and 
one-third by Medicaid or Medicare. It works, and it works very well.
  This chart covers some of the most amazing results since the program 
started: a 50-percent drop in urgent care and emergency room visits; a 
53-percent reduction in hospital admissions; a 65-percent drop in the 
need for expensive specialists; a childhood immunization rate of 93 
percent, well above the State and national averages; much better 
management of diabetes with 50 percent of patients kept in the 
prediabetes stage instead of worsening into full diabetes; and happy 
customers. The overall satisfaction rate among our patients for this 
program is 91 percent.
  The Nuka model has attracted attention from all over the world, as it 
should. Even as recent as last month, the former Speaker, Newt 
Gingrich, recognized this great program.
  I am sure there are similar government-backed success stories 
throughout this country. I think I have made my point, and truly my 
remarks are not intended to single out any one Senator. But I will say 
this: As we debate health insurance reform in this Chamber, let's arm 
ourselves with the facts and with open minds. Let's not say no just 
because of partisan differences. Let's celebrate examples of innovation 
and excellence that work no matter where they come from, and let's use 
the successful models to extend good, quality care to millions more 
Americans.
  I am proud of the Nuka model in Alaska, of the people who got it 
started a decade ago, and of the people who are making it work today.
  I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from North Carolina.
  Mrs. HAGAN. Mr. President, Senator Begich's comments on customer-
driven care is certainly working in Alaska.
  I now yield 5 minutes to my colleague from Colorado, Senator Michael 
Bennet, for his discussion on transitional care.
  The ACTING PRESIDENT pro tempore. The Senator from Colorado.
  Mr. BENNET. Mr. President, I thank our colleague from North Carolina 
for organizing this discussion this morning and for the other freshmen 
here yet again, week after week, to talk about the urgent need for 
health care reform in this country.
  My colleague, Senator Udall from Colorado, did a wonderful job 
talking about the models we have of transitional care in Colorado, 
where we see some providers able to have merely a 3-percent readmission 
rate just because of the way they manage patients, patient-centered 
care, unlike the way we

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do it all across the country, which is the reason we are at a 20-
percent readmission hospital rate in the United States.
  If we would put in some of these commonsense practices and worry 
about outcomes more and worry less about how many tests were given, in 
this case we could reduce the expenditure by $18 billion annually and 
provide better quality care. It is just one of the many ideas that is 
bubbling up from States all across the country.
  I wish to spend a couple minutes today talking about the absurd waste 
of time that is caused by our current system of insurance in the United 
States. We have two examples in Colorado that have recently been 
covered by the newspapers out there. The first is a story about gender 
discrimination when it comes to insurance. It is about a woman in my 
state, Peggy Robertson of Golden, CO, who was denied coverage because 
she had what was called a preexisting condition, which was the C-
section that she had when she gave birth to her son. The insurance 
company said they would not cover her unless she became sterilized.
  Peggy came and testified about this in the committee, and her story 
has been repeated by many people across the State of Colorado. But it 
got the attention of another person in our State named Matt Temme of 
Castle Rock, CO, who wrote a letter to the editor that I almost could 
not believe when I read it.
  We followed up with Matt, and it turned out that it was true. Matt 
was denied coverage because his wife, who is insured--she has her own 
insurance--was pregnant. Matt is a 40-year-old commercial pilot from 
Castle Rock. He was furloughed from his job at the end of June. His 
wife Wendy is a paralegal, and she is covered through her employer. 
They have a 6-year-old son.
  As I mentioned a minute ago, Wendy is pregnant. It was too expensive 
for Matt and his son to join his wife's plan. Because he was 
furloughed, he went out shopping for a new plan on the individual 
market, which he thought would be easy. He first checked with his 
previous company's health insurance. He filled out all the paperwork 
for himself and his son. He is healthy, he is 40 years old, and he is 
not eligible for coverage because his wife found out she was pregnant. 
He told the insurance companies: My wife is already covered by another 
insurer.
  They said to him: That is true, but if she suffers a fatality while 
giving birth to her child, that child is going to become a dependent of 
yours and therefore will be on the insurance you buy and therefore we 
are not going to sell it to you.
  So now Matt had to go out to the market again. They have three plans. 
They have the plan his wife is on, already covered; they have another 
plan for his 6-year-old son; and now Matt is on a version of a public 
option that we have in Colorado called Cover Colorado.
  When I read this letter, when we heard this story, when we talked 
with Matt, it reminded me again of all the stories that I have heard--
that all of us have heard--over these many months when we have been 
discussing health care about all the wasted evenings and conversations 
and fights that people have over their telephone just to get basic 
insurance for their families so they can have the kind of stability all 
of us want to have for our kids, for our grandkids, and for our 
families.
  That is what this insurance reform is about. It is time for us to set 
aside the usual politics, the special interests that always have 
prevented us from getting something done, and deliver reform that 
creates stability for working families all across our country, deliver 
reform that allows us to consume a smaller portion of our gross 
domestic product than we are today, deliver reform that allows us to 
begin to put this Federal Government back on a path of fiscal 
stability. It is high time to put this politics aside.
  I know in this country we can do better than that. In the end, we 
will do better. Our working families and small businesses will be real 
beneficiaries of the reform that we pass.
  I thank the Senator from North Carolina for giving me the opportunity 
to be here this morning. I appreciate her very important leadership on 
this critical issue.
  I yield the floor.
  Mrs. HAGAN. Mr. President, I thank Senator Bennet for his comments on 
transitional care and certainly the need to make sure no patients are 
denied insurance coverage for preexisting conditions and in particular 
because a wife is pregnant.
  I yield 5 minutes to myself. I take this opportunity to talk about 
health care reform and how it will improve the delivery of health care 
to Americans.
  One successful delivery system that health care reform will expand 
upon is patient-centered medical homes which were pioneered in my State 
of North Carolina. Since 1998, North Carolina has been implementing an 
enhanced medical home model of care and its Medicaid Program called 
Community Care of North Carolina.
  Under this model, each patient has access to a primary care physician 
who is responsible for providing comprehensive and preventive care, 
working in collaboration with nurses, physician specialists, and other 
health care professionals.
  The primary care physician is the go-to doctor and the gatekeeper of 
a patient's information. Within each network, patients are linked to a 
primary care provider to serve as a medical home that provides acute 
and preventive care, manages chronic illness, coordinates speciality 
care, and provides round-the-clock, on-call assistance. Case managers 
are integral members of the network and work in concert with the 
physicians to identify and manage care for high-cost, high-risk 
patients.
  As of May of this year, Community Care of North Carolina was 
comprised of 14 networks that included more than 3,200 physicians and 
covered over 913,000 Medicaid patients in North Carolina, accounting 
for over 67 percent of the State's entire Medicaid population.
  As an example of the benefits of a program such as this, consider the 
impact on asthma patients because patients get to see the same doctor 
and get more consistent, coordinated care. Physicians are able to 
quickly recognize a condition such as asthma and can more quickly and 
efficiently determine the most appropriate treatment. The support 
network then educates the patients and their families about the 
management of their disease.
  Due to the increased likelihood of complications when asthma patients 
get the flu, it is very important that they receive the flu vaccine. 
Since 2004, within the Community Care of North Carolina, there has been 
a 112-percent increase in flu shots administered to asthma patients. 
More than 90 percent of patients are using the most appropriate 
medications.
  Between 2003 and 2006, asthma-related hospitalizations were decreased 
by 40 percent, and emergency room visits decreased by 17 percent. That 
saves all of us dollars.
  Community Care of North Carolina has improved patient care and saved 
the State money. An independent analysis by Mercer, which is a 
government consulting group, found that this program saved between $150 
million and $170 million in 2006.
  A University of North Carolina evaluation of asthma and diabetes 
patients found that it saved $3.3 million for asthma patients and $2.1 
million for diabetic patients between 2000 and 2002.
  In addition to asthma patients, diabetic patients also had fewer 
hospitalizations, and they visited the primary care doctors more often 
instead of specialists and had better health outcomes.
  I would like to tell a story about how access to a medical home has 
helped someone in North Carolina overcome the challenges of an illness.
  Donald from Charlotte has type 2 diabetes. This diabetic condition of 
his went untreated for a long time and, as a result, he began having 
ministrokes, had to cut back on his work in landscaping, and he ended 
up in an emergency room. He was referred to a Charlotte-based medical 
home program called Physicians Reach Out. He now has a primary care 
doctor who has helped get him on a medication regimen, returning his 
blood sugar to a normal level which allowed him to work full time 
again. His primary care physician was the key to teaching him how to 
manage his diabetes. Without his medical home, he said getting his 
condition under control would have been a ``wild goose chase.''
  The Health, Education, Labor, and Pensions Committee included two 
provisions in the health care reform bill to

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encourage patient-centered medical homes, such as we have in North 
Carolina. The Secretary of Health and Human Services will create a 
program to support the development of medical homes, and then the other 
States will apply for grants.
  The bill also provides grants for physician training programs, giving 
priority to those who educate students in these physician training 
programs that are team-based approaches, including the patient-centered 
medical home.
  I have been focused on a reform bill that prevents insurance 
companies from turning patients away who have a preexisting condition, 
that expands coverage, and ensures that if you like your insurance and 
your doctors, you keep them. This bill actually will reduce our 
deficit, and that, obviously, has been a requirement of mine all along. 
This bill also encourages innovation in the delivery of health care to 
Americans using successful programs, such as the Community Care of 
North Carolina and the Physicians Reach Out patient-centered medical 
home as a model.
  Mr. President, now I wish to yield 5 minutes to my colleague from New 
Mexico, Senator Tom Udall, to talk about a model of community health 
service delivery.
  The ACTING PRESIDENT pro tempore. The Senator from New Mexico is 
recognized.
  Mr. UDALL of New Mexico. I thank Senator Hagan very much, and thank 
her for her statement today and leading us on the floor in this 
discussion of health care.
  In my case, I want to talk a little bit about health care delivery 
systems.
  First, let me say I know when we talk about a health care delivery 
system it is a little bit of a wonky term. Most Americans' eyes 
probably glaze over when experts, politicians, or pundits describe the 
problems with our health care delivery system. They don't know what it 
has to do with their health care experience, their doctors, or their 
lives.
  The reality is health care delivery systems have everything to do 
with all of that. These delivery systems determine how Americans 
receive their care. They dictate how a doctor treats their patients, 
how long a patient must wait for treatment, how much a hospital charges 
for its services, and how the medical community is held accountable for 
its mistakes.
  As we continue working to reform health care, we must take an honest 
look at our current health care delivery system and ask ourselves some 
basic questions, questions such as: Do the systems we currently use to 
deliver health care work? Are we, as patients, businesses, and 
governments, getting the best value for our health care dollar? Do 
these systems encourage efficient, coordinated care?
  If you ask the experts on this subject, the answer you will likely 
get is a loud and resounding ``no.''
  The way I look at the role of health care delivery systems is the 
same way I look at building a house. To build a strong, solid, safe 
house, you have to start with a strong, solid, safe foundation. Our 
health care delivery systems are the foundation for all of our efforts 
in health care. If that foundation is off center or cracked or built on 
uneven ground, it does not even matter how straight the walls are or 
how efficient the electrical system is, nothing is going to work right.
  Right now, the vast majority of health care in America rests on shaky 
foundations. It is our job to rebuild these foundations before more 
Americans slip through the cracks. The good news is that across the 
country, communities are achieving success with innovative health care 
delivery programs. We should look at these models as we continue our 
work here in Washington.
  There is one example I wish to highlight today. That example comes 
from my home State of New Mexico, from a county that makes up the boot 
heel of the southwestern corner. Hidalgo County is one of the most 
rural counties of my State, with a population of 5,000 people. Hidalgo 
faces the same health care delivery problems as other rural areas. 
There are not enough doctors. Patients must travel long distances for 
care and, as a result, there are higher rates of chronic diseases and 
health problems that require specialized treatment.
  To meet these challenges, the Hidalgo County medical community had to 
think outside the box. What they came up with is the Hidalgo Health 
Commons. It uses four guiding principles in its approach to health 
care.
  First, they acknowledge that in rural areas, chronic health 
conditions are worsened by limited access to health providers and are 
often compounded by poverty.
  Second, to respond to this challenge they established a one-stop shop 
for medical and social services. At the clinic you can find doctors, 
nurses, and dentists, seek mental health treatment, fill a 
prescription, get Medicaid or Medicare, or apply for public assistance 
such as WIC.
  Third, they work with the community to identify local health 
priorities and then align their services accordingly.
  Finally, they are a source of local economic and social development 
by creating jobs, serving schools, and offering family support.
  The health commons model has worked so well that it has grown to 
serve five sites across New Mexico and they are not stopping there. The 
new Hidalgo initiative, which is still in development, will expand on 
the success of the health commons. The goal is to enroll all 5,000 
residents of Hidalgo County into the health services program.
  Hidalgo County is just one example of the innovative work going on 
across the country and it serves as a lesson to all of us that faulty 
foundations do not fix themselves. They require hard work and ingenuity 
and significant investment.
  If we are going to fully transform our Nation's ailing health care 
system, we must first focus on the foundation. We must first reform our 
health care delivery systems.
  Mr. President, I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from North Carolina is 
recognized.
  Mrs. HAGAN. Mr. President, I thank Senator Udall. His example of the 
community health service delivery in New Mexico is excellent.
  Now I yield 5 minutes to my colleague from New Hampshire, Senator 
Jeanne Shaheen, to talk about reducing overutilization of emergency 
departments and reducing hospital readmissions.
  The ACTING PRESIDENT pro tempore. The Senator from New Hampshire is 
recognized.
  Mrs. SHAHEEN. Mr. President, I thank Senator Hagan for organizing the 
effort today and also for her great work on the HELP Committee to 
develop a health care reform bill that can be supported by this body.
  Once again we are here to talk about health care reform and why it is 
so urgently needed. We are at a critical juncture because health care 
costs are out of control. They are a threat to our families, our small 
businesses, our economy and, despite all the money we are spending on 
health care, we are not guaranteed better health outcomes. That means 
because we are spending money doesn't mean that people are healthier. 
The truth is, we can control costs and improve quality. We can do this 
by promoting effective delivery models. Senator Udall did a great job 
of talking about what that term means in real language. We can promote 
effective delivery models that emphasize coordination and 
individualized care.
  As I have said on a number of occasions, I am proud of the 
innovations that are changing health care delivery in New Hampshire, my 
home State. One of those that has been recognized nationally is the 
Dartmouth Atlas project, based in Hanover. Because of the work of the 
Dartmouth Atlas project, we now know that there are significant 
variations in the way health care resources are used and how money is 
spent depending on where we live.
  Right now, providers are rewarded for volume rather than for value. 
There is a chart here that shows that very clearly. It shows the 
difference in spending among different regions of the country for 
Medicare patients. As you can see, the areas that are dark red are the 
most expensive, these areas. The areas that are lightest are the least 
expensive areas when it comes to cost per Medicare patient--from $5,280 
to $6,600 in the lowest spending regions all the way up to $8,600 to 
$14,360 per Medicare

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patient in these darkest regions of the country.

  Unfortunately, the sad thing about this research is not the changes 
in cost, but it is the fact that because someone lives in an area where 
the spending is higher doesn't mean they are going to have better 
health outcomes. Put very simply, more costly care does not mean better 
care. This is a fundamental problem with our health care system. The 
way our health care dollars are being spent right now is analogous to a 
medical arms race. That is not my term, that is by Dr. Elliott Fisher, 
from the Atlas Project. Too often we judge the quality of our 
hospitals, for example, based on a new expansion wing or the latest 
medical device, and not on comparing the quality of care they provide.
  Over the past several months, thousands of my constituents have 
expressed their concerns about our health care system. Last week, Dr. 
Jim Kelly, from Hollis, NH, was in my office sharing his concerns and 
frustrations. Dr. Kelly is a family physician and, like so many of our 
health care providers, he is dedicated to doing the best job he can for 
his patients. However, inefficiencies in our system often work against 
the best efforts of our providers.
  Dr. Kelly shared one of those experiences. He talked about one of his 
patients who was a 73-year-old woman with diabetes who came into his 
office on a Friday morning with a swollen, red, and tender leg. In 
addition to her own illness, she is the sole caretaker for her 79-year-
old husband who recently had a stroke. Dr. Kelly diagnosed her 
condition, a relatively common one, as cellulitis, a skin infection 
which required IV antibiotics. Dr. Kelly gave her the first dose in his 
office, but Medicare would not cover her infusion therapy at home. As a 
result, Dr. Kelly was forced to send her to the local emergency room to 
receive treatment over the weekend. As a result, she had to bring her 
disabled husband, whom she couldn't leave at home alone, to the 
emergency room. Both of them were forced to sit in the crowded ER, 
exposing them to more germs and using resources that could be used much 
more efficiently.
  Unfortunately, our system does not always facilitate efficient and 
coordinated care. This is too often true with our most vulnerable 
patients.
  But there are innovative projects across the country that have 
adapted to meet the needs of these individuals. By providing increased 
outreach and care coordination, one pilot program was able to reduce 
visits to the emergency room by almost two-thirds, after 2 years of 
participation.
  I recently introduced the REDUCE Act, which is modeled after these 
successful pilots, and which I believe will change the way care is 
delivered to these high-risk patients with multiple chronic conditions. 
I think that is very important to point out.
  The REDUCE Act will create demonstration projects in 10 States that 
are modeled off of these approaches that have been successful in places 
around the country. This is the type of delivery system reform that 
improves quality and reduces costs simultaneously.
  As I have said many times, the challenge we face is great, but we 
have the resources and the tools we need to reform our health care 
system. We can do this in a fiscally responsible way. By improving the 
way we deliver care, we can maximize efficiency and we can improve 
quality. This is the type of reform all Americans deserve. This is the 
type of reform we are working on here in the Senate. This is the type 
of reform I hope our colleagues will all support.
  I thank Senator Hagan and I yield my time back to her.
  The ACTING PRESIDENT pro tempore. The Senator from North Carolina
  Mrs. HAGAN. Mr. President, I thank my colleague. She has made it 
abundantly clear that by reducing the overutilization of emergency 
departments, at the same time reducing hospital admissions, we can 
maximize efficiencies and improve patient health and health care.
  I yield 5 minutes to my colleague from Virginia, Senator Mark Warner, 
to talk about delivery system reforms in Virginia.
  The ACTING PRESIDENT pro tempore. The Senator from Virginia is 
recognized.
  Mr. WARNER. Mr. President, I thank my colleague from North Carolina 
for organizing the freshmen one more time to talk about our vision for 
health care reform. We invite our colleagues not only on our side of 
the aisle but our colleagues across the aisle to join us in this 
conversation about how to get health care reform right. I also commend 
my colleague from New Hampshire, Senator Shaheen, on her comments about 
how we can fix financial incentives in our current health care system. 
I think reforming our delivery system ought to be, clearly, part of any 
overall health care reform we take on.
  I want to pick up, actually, where Senator Shaheen left off and talk 
about how we can readjust our financial incentives system in health 
care. We have them all wrong. We have a health care system right now 
that rewards bad practices. We have a health care system that rewards 
hospitals for multiple readmissions rather than a low readmission rate. 
We have a health care system that rewards volume of care rather than 
quality of care. Reforming the financial incentives in our delivery 
system has to be a key component of any health care reform going 
forward.
  I join my colleagues in citing examples of delivery system reforms 
that are happening now in my own state. I have three examples here from 
the Commonwealth of Virginia.
  In 2000, VCU Health System in Richmond, our capital, developed a 
system called Virginia Coordinated Care to manage health care services 
for the uninsured. The uninsured often rely on emergency rooms to be 
treated for their illnesses and then go back home until they get sick 
again. There is no continuity of care and oftentimes that uninsured 
person will end up back on an emergency room doorstep because, outside 
of being treated for the episodic incident, there was no management of 
that patient's care during that period.
  What VCU developed was a program that assigned a primary care 
physician to oversee each uninsured patient's health. The goal was to 
increase coordination between doctors and hospitals and, as a result, 
increase accountability, improve quality of care, and lower costs.
  The Virginia Coordinated Care program started with a few participants 
in 2000; by 2009, there were over 20,000 members. One of the most 
important outcomes of the program was a significant drop in emergency 
room visits by enrolled patients. By increasing continuity of care, 
emergency room visits dropped 14 percent between 2000 and 2005. Costs 
were reduced for Richmond area hospitals, as well as surrounding 
Virginia hospitals as fewer patients showed up at other emergency 
rooms. By treating the patient earlier in their illness the program 
achieved better quality of care, and better results for the health care 
system as a whole.
  Another example of delivery system reform took place at another end 
of our State, at Sentara Healthcare, located in Norfolk, VA. In 1999, 
Sentara studies found that intensive care units that were monitored by 
a doctor full time had lower mortality rates and shorter length of 
stays than those that were not. In order to improve quality of care, 
Sentara worked with a company called VISICU to install Web-based 
television cameras in each patient's room. With this technology, a 
single physician in a central location can follow patients in multiple 
rooms at the same time. Again, this kind of logical approach produced 
more efficient care at a lower cost. Sentara saw a 25-percent reduction 
in mortality among these patients, a 17-percent reduction in their 
length of stay, and a 150-percent return on investment in the program.
  Perhaps the best example is now being modeled by the Carilion Clinic 
in Roanoke, VA. Carilion Clinic is a multispecialty health care 
organization, with more than 600 doctors and 8 health care 
organizations.
  In 2010, next year, Carilion Clinic will join with Engelberg Center 
for Health Care Reform at Brookings and the Dartmouth Institute for 
Health Policy and Clinical Practice to implement a new and innovative 
health care model that rewards providers for improving patient outcomes 
while also lowering costs. This Accountable Care Organization will 
encourage physicians, hospitals, insurance companies, and the

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government to work together to coordinate care, improve quality, and 
reduce costs. Under this model, providers will assume greater 
responsibility not only for treating the patient's illness but for the 
overall quality and cost of care to be delivered. They will actually be 
incentivized to take steps to keep patients healthy, while avoiding 
costly medications and procedures. Additionally, this model will 
encourage, and make it affordable, for doctors to finally practice 
preventive care. Carilion Clinic is doing the right thing: moving away 
from the current, and very flawed, fee-for-service system.
  As long as our health care system--one-sixth of our economy--
continues to reward providers simply based on quantity rather than 
quality of care, we are never going to get health care reform right. By 
increasing coordination of care, and putting in place smarter financial 
incentives, we can have higher quality care at lower costs. We can 
focus on the health of patients, rather than the number of procedures. 
Changing our payment mechanisms and restructuring financial incentives 
are a key part of health care reform.
  I know my freshmen colleagues stand ready to work with our colleagues 
on this side of the aisle, and I again invite our colleagues on the 
other side of the aisle to join us in this effort. Getting it right 
will lead to improved quality of care, lower costs, and a healthier 
America.
  I thank our leader today, the Senator from North Carolina, for 
granting me this time. I look forward to working with Senator Hagan and 
all my colleagues as we move forward.
  I yield the floor.
  Mrs. HAGAN. I thank Senator Warner. It is obvious that coordinated 
care will reduce costs and at the same time provide higher quality for 
our patients.
  What Senator Warner has discussed is very similar to the patient 
centered medical homes in North Carolina where we currently cover over 
900,000 Medicaid patients.
  Finally, I yield 5 minutes of my time to my new colleague from 
Massachusetts, Senator Paul Kirk, to discuss some key national 
indicators.
  Mr. KIRK. Mr. President, I thank the Senator from North Carolina. It 
is a privilege to be a member of her class and the class of 
distinguished colleagues of freshmen, and I commend her as well for her 
leadership in this discussion this morning, adding onto the role the 
freshman class is playing in advocating for health care reform for the 
American people.
  I would like to speak this morning about a key national indicators 
system.
  As we know, America is said to lead the world in health innovation. 
It can create the finest medical devices, the most effective drugs to 
treat diseases and advanced processes and procedures to care for 
patients. It is this wide range of remarkable innovations that has 
resulted in today's $2.3 trillion health care industry. But despite all 
of our medical achievements and technologies and the private and public 
money we spend on health care, we do not lead the world in health 
outcomes.
  We need to innovate not only in the way we treat patients but in the 
way we create and implement health care policy. For that reason, one of 
the most promising provisions in the draft health reform measures about 
to come before us is the creation of a key national indicators system.
  When illness strikes, we expect a health care team to carefully 
collect information from the patient and then consult the wide range of 
information available to them to achieve the appropriate diagnosis and 
treatment. That careful and complete process should yield the best 
possible course of treatment and recovery.
  We need the same kind of approach in the creation of wise health care 
policy. In particular, we need measures to identify what is wrong with 
our current health care system, including what is driving the 
increasingly high cost of care. Abundant research and reports have 
analyzed such questions. What is missing is a central, independent 
organization that can analyze all of the research performed by various 
organizations and make that information readily available to Congress, 
to the executive branch, and the American people. That is an 
indispensable part of successful health reform. It will give 
decisionmakers easier access to all the knowledge available and 
eliminate wasteful spending of the hard-earned dollars of American 
families.
  Senator Kennedy and Senator Enzi, in a strong, bipartisan effort, 
understood the need for this vital resource, and they designed a key 
national indicators system to provide it. It will be a nonpartisan, 
independent agency with a public-private partnership. It will foster 
better relations and relationships between members of the legislative, 
statistical, and scientific communities and will lead to greater 
transparency and accountability for spending on national health 
programs. Without such a resource, we will be at a serious disadvantage 
in fully understanding emerging health risks and in assessing whether 
the intended result is being achieved or adequate progress is being 
made on the health care challenges facing us.
  The key national indicators system will make all its data available 
on a newly created, widely accessible Web site in the health care 
context. This unprecedented accessibility of data will assist the 
public in understanding what information was used by politicians 
in creating health care policies. It will enable policymakers to see 
whether progress is being made in health reform. And it will permit 
practitioners and researchers to use the information for the greater 
benefit of patients and consumers of health and medical care.

  Significant progress in this area has already been accomplished. Over 
the years, the Institute of Medicine has been able to identify five 
drivers of health care quality and costs: first, health outcomes; 
second, health-related behaviors; third, health system performance; 
fourth, social and physical environment; and fifth, demographic 
disparities. The institute has recommended 20 specific indicators for 
measuring these five drivers of health care quality and cost. These 
indicators were carefully selected to reflect both the overall health 
of the Nation and the efficiency and effectiveness of our health care 
industry. However, the institute lacks an implementation system that 
can use these indicators effectively to guide future policy and 
practice. That is the goal and that is the mission of the new agency, 
the key national indicators system, we propose.
  Here is one example of how this legislation will improve our health 
care system. A recent study conducted by the Harvard School of Public 
Health found that using a simple checklist during surgical procedures 
resulted in a one-third reduction of complications from that surgery. 
Reports such as these are made public, but you have to know where to 
look in order to access this information. The key national indicators 
system will take these reports, compile them, disseminate them, and 
make them available to the public. So any time a bill is being 
developed, a congressional office can go to this Web site and see all 
of the research that has been conducted on the topic in order to make 
economically sound decisions for the American people.
  Currently, Congress and the executive branch continue to follow old 
habits. We tend to reinvent the wheel with every major new bill that is 
introduced. That approach leads to wasted time, wasted energy, and 
wasted money. Old habits are not good enough to achieve tomorrow's 
goals. By developing this indicator system, a process will be in place 
so that the efficiency and effectiveness of government spending on 
short-, medium-, and long-term problems can be determined quickly and 
in a fiscally responsible manner.
  Our current system is unsustainable. It creates unnecessary confusion 
when Americans can least afford it. We need a system that will provide 
insight, foresight, transparency, and accountability. We will not be 
doing our job for the American people if we allow their money to be 
spent without assessing the cost-effectiveness of the various programs 
being developed.
  By creating the key national indicators system, we can reassure all 
Americans that we did our required due diligence and that our health 
care reform bill will truly work for them.
  I yield the floor.
  Mrs. HAGAN. Mr. President, I thank Senator Kirk. I thank him for his 
comments and the discussion on the transparency and openness of the new 
key national indicators system. I think

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this is critically important so that our public can see the progress we 
are making in improving health outcomes, healthy behavior, and cost-
effectiveness.
  In this last hour, we have heard from many of our new freshman 
colleagues about the successful efforts to reform the way we deliver 
health care in our country. I thank my colleagues for sharing those 
ideas with us.
  I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from Idaho.

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