[Senate Hearing 111-690]
[From the U.S. Government Publishing Office]
S. Hrg. 111-690
CROSSING THE QUALITY CHASM
IN HEALTH REFORM
=======================================================================
HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
ON
EXAMINING QUALITY IN HEALTH REFORM
__________
JANUARY 29, 2009
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut MICHAEL B. ENZI, Wyoming,
TOM HARKIN, Iowa JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico RICHARD BURR, North Carolina
PATTY MURRAY, Washington JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island JOHN McCAIN, Arizona
BERNARD SANDERS (I), Vermont ORRIN G. HATCH, Utah
SHERROD BROWN, Ohio LISA MURKOWSKI, Alaska
ROBERT P. CASEY, JR., Pennsylvania TOM COBURN, M.D., Oklahoma
KAY R. HAGAN, North Carolina PAT ROBERTS, Kansas
JEFF MERKLEY, Oregon
J. Michael Myers, Staff Director and Chief Counsel
Frank Macchiarola, Republican Staff Director and Chief Counsel
(ii)
C O N T E N T S
__________
STATEMENTS
THURSDAY, JANUARY 29, 2009
Page
Mikulski, Hon. Barbara A., a U.S. Senator from the State of
Maryland, opening statement.................................... 1
Prepared statement........................................... 2
Cassel, Christine K., M.D., President, American Board of Internal
Medicine, Philadelphia, PA..................................... 4
Prepared statement........................................... 5
Teisberg, Elizabeth, Ph.D., Associate Professor, University of
Virginia's Darden School of Business, Charlottesville, VA...... 8
Prepared statement........................................... 9
Robinson-Beale, Rhonda, M.D., Chief Medical Officer, OptumHealth
Behavioral Solutions, Golden Valley, MN........................ 16
Prepared statement........................................... 18
Davis, Karen, Ph.D., President, Commonwealth Fund, New York, NY.. 23
Prepared statement........................................... 24
Davenport-Ennis, Nancy, CEO, National Patient Advocate
Foundation, Washington, DC..................................... 66
Prepared statement........................................... 67
(iii)
CROSSING THE QUALITY CHASM
IN HEALTH REFORM
----------
THURSDAY, JANUARY 29, 2009
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The committee met, pursuant to notice, at 2:00 p.m. in Room
SD-430, Dirksen Senate Office Building, Hon. Barbara A.
Mikulski presiding.
Present: Senators Mikulski, Dodd, Casey, Hagan, and
Merkley.
Opening Statement of Senator Mikulski
Senator Mikulski. Good afternoon, everyone. The U.S. Senate
Committee on Health, Education, Labor, and Pensions will come
to order. The Working Group on Quality is meeting this
afternoon, and the focus of this particular hearing is called
``Crossing the Quality Chasm in Healthcare Reform.''
This is the second of a series of hearings we will be
having to ensure that when we do our healthcare reform, we do
not only reform insurance finance, but that we also reform how
we are also going to be providing healthcare.
It is the view of the working group that by focusing on
quality we will not only improve outcomes for patients, but we
will improve the outcome in the bottom line of delivering
healthcare itself. We need to say good-bye to silo thinking in
which quality is over here, cost is there, and so on.
Even though our working groups are divided into three
categories--coverage, chaired by Senator Bingaman; prevention,
chaired by Senator Harkin; and quality, chaired by myself--we
see it as all the same story.
Today, we are going to hear from a distinguished group of
experts who will be testifying on that particular topic. I
thank the witnesses for their flexibility. We had originally
scheduled this hearing for 10 a.m., but President Obama decided
to sign the Lily Ledbetter Fair Pay Act this morning, so we
were there.
When we set this panel, we didn't realize we were going to
have an all-women's panel, a chair. It is not like we get 1
day, and this is it.
[Laughter.]
But we welcome you.
I am going to dispense with my opening statement, but know
that we believe that the work we are doing is going to focus on
an evidence-based approach to reforming healthcare. Just in the
same way we ask our clinicians to be thinking that way, we feel
that our committee should do the same. One of the most
evidence-based ways of looking at that, of course, is an
esteemed institution in our society, the Institute of Medicine.
In their ground-breaking report, ``Crossing the Quality
Chasm: A New Health System for the 21st Century,'' the IOM
outlined a variety of goals that would make our healthcare
system safe, effective, patient centered, timely, efficient,
and equitable. We will be embracing those principles as we move
ahead on the reform.
We have invited members of the original IOM quality
committee--Dr. Cassel, president of the American Board of
Internal Medicine; Dr. Rhonda Robinson-Beale, the chief medical
officer of OptumHealth.
We have also invited respective policy thinkers that are
well known in the community of healthcare innovation. Dr. Karen
Davis, president of the Commonwealth Fund, which has issued a
variety of reports that this committee has reviewed and
embraced in principle. And Professor Elizabeth Teisberg, the
professor of UVA's Darden Business School, will provide another
perspective on how we will be able to think of strategies to
improve health quality.
And finally, from the patient perspective--because we want
to have patient-centered healthcare at the end of the day--Dr.
Nancy Davenport-Ennis of the National Patient Advocate
Foundation.
I am going to ask unanimous consent that my full statement
go into the record.
[The prepared statement of Senator Mikulski follows:]
Prepared Statement of Senator Mikulski
In 2001, the Institute of Medicine (IOM) published a
groundbreaking report, ``Crossing the Quality Chasm: A new
Health System for 21st Century''. IOM's vision defined six
goals to improve health care:
Safe--Avoiding medical errors.
Effective--Providing evidence based services with
over-utilization.
Patient-Centered--Providing care that is
responsive to patient's needs.
Timely--Reducing harmful delays.
Efficient--Avoiding waste of time, energy, and
resources.
Equitable--Quality not vary due to income, age,
race, gender, or geography.
These goals remain essential to improving the quality of
our Nation's health system. Goals should be part of any reform
proposal that moves through Congress.
The purpose of today's hearing is to identify quality
initiatives that should be considered as part of health reform.
We have invited back members of the original IOM Quality
Committee, Dr. Christine Cassel, President of the American
Board of Internal Medicine and Dr. Rhonda Richardson Beale,
Chief Medical Officer of OptumHealth.
We've also invited two respected policy thinkers, Karen
Davis, President of the Commonwealth Fund and Elizabeth
Teisberg, Professor at UVA's Darden Business School who will
help update our thinking on strategies to improve health
quality.
Finally, from the patient perspective, we have Nancy
Davenport-Ennis of the National Patient Advocate Foundation.
My hope is that we can learn from these witnesses how
theory has been put into practice, about promising quality
initiatives that have moved from bench to bedside, and discuss
what quality initiatives should be a part of reform.
There's no question it is time for Congress to act on
comprehensive health quality initiatives. While IOM's report
shaped the thinking and actions of health policy gurus,
providers, and patients, the Federal Government has been slow
to act.
The United States leads the world in health spending but
lags behind when it comes to quality. It's time taxpayers and
patients got better value for their health dollar by improving,
not limiting, health care.
U.S. life expectancy is the same as countries that spend
far less per capita. Billions of dollars are wasted each year
through medical overuse, underuse, misuse, and inefficiencies.
Annual human cost is 98,000 deaths and 1 million injured
from medical errors.
Despite the work of the IOM and today's panel members the
United States still does a poor job of applying evidence to
health delivery. There is no effective policy to research and
disseminate best practices. The United States still does a poor
job of using Health Information Technology and lack nationwide
infrastructure to collect and share information.
The United States still does a poor job of care
coordination and has not yet appropriately aligned payment
policies with quality. The United States still has not prepared
a sufficient healthcare workforce capable of caring for large
numbers of retiring baby boomers.
By failing to adopt quality initiatives, it's obvious why
we lag behind the industrialized world.
We can do better and it is my goal to make sure we do
better.
I look forward to today's discussion and the development of
consensus around key recommendations.
Senator Mikulski. Also, I will ask unanimous consent that
any of our colleagues who have statements they would like to
put in the record on this hearing that they be so included, and
any questions that they might have that they also be submitted.
I know, speaking for Senator Enzi, we are really busy today
with SCHIP on the floor and so on. Know that he has been an
active participant at all of our many discussions and know that
he wanted very much to be here.
His staff is here, and I am going to say that in the Q and
A, if you all have questions in particular that you and Senator
Enzi would like to ask me verbally, I would be happy to ask
them on his behalf. I will also ensure that any of the members
of the other party who have questions to submit to the
witnesses can do so.
Having said that, why don't we start with you, Dr. Cassel?
And then just move down the line and let us hear what insights
you have to share with the committee.
STATEMENT OF CHRISTINE K. CASSEL, M.D., PRESIDENT, AMERICAN
BOARD OF INTERNAL MEDICINE, PHILADELPHIA, PA
Dr. Cassel. Thank you, Madam Chair, for the invitation to
testify today about improving healthcare quality.
My name is Christine Cassel. I am a board-certified
internist and geriatrician and the president of the American
Board of Internal Medicine.
ABIM is an independent nonprofit organization that is of
the profession and for the public. We assure, by board
certification, that physicians in internal medicine and 17
different subspecialties have the knowledge and skills to
practice within their specialty.
We certify about a third of the Nation's practicing
physicians, and we are the largest of the 24 boards that
constitute the American Board of Medical Specialties. Our
standards shape medical training and physician practices
throughout the country in many varied settings.
As you mentioned, I had the privilege of serving on the
Institute of Medicine committee that produced the quality chasm
report, and I believe we can point to many accomplishments
since it was published in 2001.
The development and reporting of performance measures is a
particularly visible achievement, but all of these measures are
not really coordinated or linked enough with clinical practice
to really have the big impact that they ought to have on
quality and affordability. The National Quality Forum is trying
to fix this, bringing leaders of a broad range of groups to set
priorities for improvement and to facilitate consensus on
performance measures.
As we now invest in health information technology to make
all this data available, there is still another critical
ingredient that is missing. We need to ensure that the
clinicians who are using it have the skills needed to use this
data effectively and to modernize their care around the
patient's needs.
My training in geriatric medicine gives me insight into
what is needed to take good care of patients who have complex
and multiple chronic conditions, something we are going to have
more and more of as the baby boomers age.
Doctors need to have the knowledge and judgment to make the
right diagnosis and to manage complex care, and they also need
skills less commonly taught, like working in clinical teams,
care coordination, integration with other specialists, and
linking community and clinical services.
My patients didn't just have one condition. They had five
or six and were often taking 10 to 15 medications a day. They
came to the doctor not with the diagnosis on their forehead,
but feeling weak or dizzy or mentally confused.
These symptoms could result from anything--cancer to
Alzheimer's disease. Or it might be caused by all these
medications having side effects, or even over-the-counter
remedies. There might be a pneumonia brewing, or it could be
the loss of a spouse or another close caregiver.
The physician alone can't sort all this out and address all
these different issues. If there isn't a team to help, the
patient could have many unnecessary tests, end up in the
hospital, or, worse, fall and break a hip.
A case in point is the understandable excitement now about
the patient-centered medical home. Most of the discussion is
focused on practice infrastructure to facilitate integrated and
coordinated care--electronic records, etc.--but without
considering the doctor and the team.
If the doctor doesn't have the extensive knowledge and
management skills, the promise of the medical home won't be
fulfilled. You can't just order a medical home kit from a
catalog and expect to produce results without also major
changes in how we practice.
The profession has ways to help with this challenge. At
ABIM, we provide Internet-based tools that are available to
almost 200,000 physicians around the country that can help them
to assess their practice strengths and weaknesses and offer
links to tools and strategies for improvement.
Using physicians' intrinsic motivation to help their
patients, the certifying boards have demonstrated that with
trusted and actionable data, doctors actually do engage in
improving quality of care. These very same data can be used if
they want for reporting to health plans, NCQA, hospitals, or
Medicare. This alignment reduces the burden of redundant data
collection and the hassle for a busy office practice.
We evaluate physician performance and practice using NQF-
endorsed measure sets as well as the doctor's knowledge,
diagnostic ability, and medical judgment. In our survey, 73
percent of physicians changed their practice as a result of
going through board certification.
The HELP Committee has already taken important steps in the
stimulus bill--and you are to be thanked for that--by
supporting both HIT and comparative effectiveness. These
important investments will not reach their full potential
unless physicians and other clinicians actually use the
information they provide to inform their treatment decisions or
to change their practice patterns.
Thank you for the opportunity to reflect on the progress
made and the challenges that remain. We welcome the chance to
partner with you as you consider the reforms ahead.
Thank you.
Senator Mikulski. Thank you, Dr. Cassel.
You know, your entire statement is very content rich. So we
are going to have that in the record, too.
[The prepared statement of Dr. Cassel follows:]
Prepared Statement of Christine K. Cassel, M.D.
summary
ABIM is an independent, non-profit organization that assures via
board certification that physicians have the knowledge, skills and
attitudes to practice in a given specialty. ABIM certifies about one-
third of the Nation's practicing physicians in varied settings and
practice sizes. Since the 2001 publication of the Institute of
Medicine's Quality Chasm report, many strides have been made to improve
quality of care, with the development and reporting of performance
measures as a particularly visible accomplishment. Yet, we have a long
road ahead of us because individual performance measures will never be
able to reflect, the complexity of medical practice. As we build a more
scientifically robust performance measurement and reporting system with
appropriate, valid measures linked to payment, we need to
simultaneously focus on assessing and enhancing the skills and
competencies that clinicians need to practice in a 21st century system.
The patient-centered medical home is a case in point. Discussions
about this model have largely focused on practice infrastructure,
select clinical measures and related payment mechanisms, with the goal
of facilitating integrated and coordinated care. However, these
discussions fail to recognize the importance of the competencies that
physicians and other clinicians need to effectively practice in this
redesigned system. These competencies must be at the core of primary
care residencies and physicians in practice need support to work
effectively in teams, engage patients in managing chronic conditions
and effectively coordinate and manage the care of patients with
multiple conditions, among other skills. ABIM's certification process
helps drive the attainment of such knowledge and skills in training and
practice.
ABIM's assessment ``tool box'' includes internet-based modules,
which are available to over 200,000 physicians, that use National
Quality Forum (NQF) measures to assess clinical care, a Consumer
Assessment of Health Providers and Systems (CAHPS) patient experience
survey and a mini version of the National Committee for Quality
Assurance's (NCQA) Physician Practice Connections module. ABIM's tools
also assess a physician's clinical knowledge base, diagnostic ability
and medical judgment in a given medical specialty.
ABIM has aligned its certification program with the quality efforts
of numerous organizations. In fact, at the request of a physician, ABIM
will transfer certification results and data to NCQA, health plans,
hospitals or Medicare with the goal of reducing redundant data requests
and accelerating improvement.
ABIM stands ready to work with members of the HELP Committee as you
embark on reforming the healthcare system and ask that you strongly
consider the crucial role of clinician competencies in the reform
landscape.
______
Chairman Kennedy, Senator Enzi and members of the Health,
Education, Labor and Pensions Committee, thank you for the invitation
to testify about improving health care quality. My name is Christine
Cassel, and I am a board certified internist and geriatrician, and the
President/CEO of the American Board of Internal Medicine (ABIM).
ABIM is an independent, non-profit organization that is ``of the
profession but for the public.'' We assure via board certification that
physicians who practice internal medicine and 17 different
subspecialties have the knowledge, skills and attitudes to practice
within their specialty. ABIM certifies about a third of the Nation's
practicing physicians and is the largest of the 24 boards that
constitute the American Board of Medical Specialties (ABMS). The
standards that we set shape both medical residency training programs
and physician practices of all sizes in many varied settings.
Since the publication of the Institute of Medicine (IOM) Quality
Chasm report in 2001, many strides have been made to improve the
quality of care, with the development and reporting of performance
measures as a particularly visible accomplishment. Having had the
privilege of serving on the committee that produced the IOM report, I
derive satisfaction from those gains while acknowledging that we have a
long way to go. Specific, select accomplishments over the last 8 years
include:
The healthcare community, under the auspices of the
National Quality Forum's (NQF) National Priorities Partners, has set
national priorities for improvement--including patient and family
engagement, reducing overuse of inappropriate services, and enhancing
end of life and palliative care, which are key areas to focus on from
my vantage point;
The medical community is developing and implementing a
broader array of evidence-based clinical guidelines, which translate
research into practice recommendations, and they are beginning to
enhance them with the integration of appropriateness criteria. These
guidelines are then translated into performance measures;
There is growing agreement about using standardized
performance measures--focused on both clinical conditions and on
patient experience--and the role that the NQF plays in facilitating
consensus in this arena;
There is some evidence that reporting of performance
measures is driving improvement at hospitals and health plans, although
that is less clear at the individual clinician level. For example, the
Healthcare Effectiveness Data and Information Set (HEDIS) data, used at
the health plan level, has shown improvements across multiple
dimensions over the 9 years that the National Committee for Quality
Assurance (NCQA) has been publicly reporting results.
As we build a more scientifically robust performance measurement
and reporting system with appropriate, valid measures linked to
payment, we must simultaneously focus on assessing and enhancing the
skills and competencies that clinicians need to practice in an
increasingly complex 21st century healthcare system.
My training in geriatric medicine emphasized a set of competencies
that are necessary for the provision of high quality care. These
competencies focused on the importance of making the right diagnosis
(particularly with patients that have multiple, complex problems),
working in clinical teams, care coordination, integration with other
specialists, management of multiple chronic conditions and linking
community and clinical services. But these skills are not utilized by
many clinicians for a number of reasons: our training and education
systems do not adequately focus on such competencies; such knowledge
and skills are not supported by the systems in which clinicians work;
and perhaps because these more complex areas do not easily lend
themselves to performance measurement.
A case in point are the policy discussions about the patient-
centered medical home, which are largely focused on practice
infrastructure and related payment models that can facilitate
integrated and coordinated care, but fail to emphasize the competencies
that physicians and other clinicians need to effectively meet the
promise of the medical home concept. These competencies must be a part
of primary care residencies and physicians in practice need support to
work effectively in teams and engage patients in managing their chronic
conditions, among other skills that the vision of the patient-centered
medical home model requires.
At ABIM, we provide internet-based tools that are available to
close to 200,000 physicians that can help them assess their practice
strengths and weaknesses and offer links that guide them towards
improvement. By tapping into most physicians' intrinsic motivation to
do well by their patients, the certifying boards have demonstrated that
with trusted and actionable data, physicians engage in improving the
quality of care. These very same data can then be used--if the
physician so chooses--for reporting to health plans, NCQA, hospitals
and to the Centers for Medicare & Medicaid Services. This alignment
reduces redundant data collection, lessening the administrative burden
on physicians (particularly in smaller practices), and can help in
accelerating improvement.
ABIM's tools assess physician's performance in practice--using
standardized NQF clinical measures, Consumer Assessment of Health
Providers and Systems (CAHPS) patient experience surveys and a
condensed version of NCQA's Physician Practice Connections (PPC)--as
well as his or her knowledge base, diagnostic ability and medical
judgment in a given medical specialty.
In a survey of over 5,000 physicians who have used ABIM's
performance assessment tools, 70 percent of respondents reported that
they found these tools valuable in identifying strengths and weaknesses
in the care they provide. More importantly, 73 percent of respondents
changed their practice as a result of completing one of ABIM's
performance assessment modules.
Yet, there are aspects of practice that do not easily lend
themselves to being assessed via performance measures. Therefore, other
types of assessment tools are needed. Key examples include:
Our current performance measurement system assumes that a
correct diagnosis has been made and may even result in performance
payments that stem from faulty diagnoses. This is not an outlier
problem. The literature suggests that diagnostic errors account for 5-
15 percent of medical errors, depending upon the specialty, and they
are not declining over time. Certifying board examinations include
clinical scenarios that test diagnostic acumen.
Further, making the correct diagnosis and recommending an
appropriate treatment plan requires up-to-date knowledge of new
therapies, an ever-evolving understanding of the strengths and
weaknesses of existing therapies and, often, the skill to know how to
manage and integrate multiple therapies. Certifying board examinations
test medical knowledge and provide scenarios to assess clinical
judgment and management.
Finally, it is less likely that performance measurement
bundles will be developed for less common illnesses, such as thyroid
disease, viral meningitis or rheumatoid arthritis. Yet patients will,
and should, expect that physicians can diagnose and treat such
conditions. Instead, clinical scenarios involving rare conditions lend
themselves to board examinations and online point of care tools.
As members of the HELP Committee contemplate shaping a reformed
health care system, you have already taken important steps in the
stimulus bill by articulating the importance of both health information
technology (HIT) and comparative effectiveness research. These
investments can help deliver to physicians and other clinicians
important data and information that they need to understand ``how they
are doing'' to help in facilitating care coordination and integration;
aid in reducing wasteful, redundant testing; and provide a resource
that objectively compares treatment options. But these important
investments in a 21st century healthcare system will not reach their
full potential unless physicians and other clinicians actually use the
information they provide to inform their treatment decisions or to
change their practice patterns. ABIM--and very likely other certifying
boards--would be happy to work with the HELP Committee to facilitate
physician engagement related to both HIT and comparative effectiveness.
Going forward, the HELP Committee might also want to consider how
community health centers (CHCs) define their services, making sure that
the definition allows for the effective delivery of and payment for
comprehensive care to patients with complex and multiple conditions--
the kind of care that geriatricians are trained to provide and that
many patients beyond the elderly need. CHCs will also serve as patient-
centered medical home sites, and will be most effective if the
definition of provided services is expansive and staff is supported in
learning new competencies to effectively practice in a redesigned
model.
Finally, there are two other important, and related, areas of
intersection: revitalizing primary care and providing better care for
underserved populations. In both arenas, ABIM Board-level committees
have been working to define, implement, test and evaluate new tools to
assess related competencies. We would welcome the opportunity to share
our learnings with you and others as you consider how to advance
primary care and to close disparities gaps as part of a reformed
healthcare system. For example, in the underserved area physicians
using our tools in large and small practices will eventually be able to
compare the quality of care they deliver across various sub-
populations.
Thank you for the opportunity to reflect on what the quality
community has and has not yet accomplished over the 8 years since the
Quality Chasm report was published. We would welcome the chance to
partner with you as you consider how to shape the reforms that lie
ahead. In the process, we ask that you consider the skills and
competencies of the Nation's clinicians as essential to achieving the
vision of a dramatically reformed system as laid out in that landmark
report.
Senator Mikulski. Dr. Teisberg.
STATEMENT OF ELIZABETH TEISBERG, Ph.D., ASSOCIATE PROFESSOR,
UNIVERSITY OF VIRGINIA'S DARDEN SCHOOL OF BUSINESS,
CHARLOTTESVILLE, VA
Dr. Teisberg. Chairwoman Mikulski, thank you for inviting
me to talk about quality improvement and healthcare value for
every American.
My name is Elizabeth Teisberg. I am a professor at the
University of Virginia and coauthor of ``Redefining
Healthcare.'' I am also the mother of a child who was painfully
chronically ill for 6 years before his full recovery.
As a professional and as a mother, I have questioned the
conventional wisdom that causes leaders to cling to a system
that everyone agrees could be significantly improved. We can
and should drive dramatic and ongoing improvement in value for
patients, achieving far better outcomes much more efficiently.
Lack of attention to quality in healthcare drives costs up.
While the cost of employee health benefits command headlines,
U.S. employers spend three times that much on the costs of poor
health. We can't afford to ignore quality. We can and must use
attention to quality to drive costs down and to improve value.
Quality in healthcare is measured by health outcomes
achieved. The 139 heart transplant centers in the U.S. report
results--for example, the percentage of patients who live for a
year following a heart transplant. These are complex patients.
For some centers, the percentage of patients that survive the
first year is well over 90 percent.
What about the centers that report the lowest results?
Eighty percent? Fifty percent? It is zero. To be fair, that
center had performed only six transplants, but who should be
the seventh? Because there is significant variance in outcomes,
reporting is essential.
Process measures, also described as consensus measures,
have been well developed in the past decade and are widely
used. In Minnesota, effort to improve chronic care for patients
with diabetes began with measures of process. Very rapidly, 90
percent of clinics became top rated for their processes, and
someone asked, ``Are the patients better off? Are the outcomes
better? ''
So outcome measures were developed, and in the first 2
years of public reporting, the percentage of patients that
succeeded on all the measures of outcomes more than doubled
from just over 4 percent to just under 9 percent. Great
improvement, but a long way to go in spite of excellent process
performance.
Reporting on the use of good process is not enough.
Reporting outcomes drives improvement in health results. What
is measured will improve. Outcome measurement accelerates
learning by clinical teams, which, in turn, drives better
results for patients and higher healthcare value.
The point is not consumer shopping. When New York State
began publishing mortality rates for heart surgery by different
providers, studies clearly showed that consumers did not use
the data. Yet mortality dropped 41 percent in the first 4
years. Physician teams did use the data, and the dramatic
decline in mortality surely benefited patients.
Reporting can and will start with imperfect measures.
Congress need not specify the measures, just the requirement
for teams to report outcomes.
HHS can have a not-for-profit organization oversee the
registries, as they do for transplants, or HHS can ask the
existing expert medical boards. Leaders from those boards tell
me that they have clinically meaningful outcome measures, and
they can require reporting for the renewal of credentials. This
could happen quickly. This could start now.
Want to improve results and lower costs of chronic disease?
Measure results. Want to drive down disparities in healthcare?
Measure teams' results for every patient. Want to speed
adoption of best practices? Measure results so clinical teams
can compare and improve.
The fastest and most effective way to improve health
outcomes for Americans, as well as to improve the measures
themselves, is to start measuring and reporting outcomes. The
time is now.
Thank you.
[The prepared statement of Dr. Teisberg follows:]
Prepared Statement of Elizabeth Olmsted Teisberg, Ph.D.
summary
Access to health care for all Americans is essential to both equity
and economic efficiency. Dramatic improvement in value (health outcomes
per dollar spent) is necessary to provide quality care for all
Americans.
The purpose of health care is health. Successful health care reform
efforts must do more than cut costs. The real goal of health care
reform is, and must be, to drive dramatic and ongoing improvements in
the value of health care. This means improving quality--health and
health care outcomes--relative to the cost of achieving these outcomes.
The tremendous opportunity in health care is using improvements in
quality of outcomes to drive costs down. To see this, one must only
recognize that the goal is more health, not more treatment. Often,
improved quality means more effective treatment, better health, and
lower costs. The essential insight is this: Living in good health is
inherently less expensive than living in poor health. In this era of
chronic disease, costs rise when quality is low. With improvement in
value--the health outcomes per dollar spent--more people can receive
better care.
The single most important step that Congress can take to enable
improvement in health care value for Americans is to commit to
measuring results. The adage applies: what is measured will improve.
The time to begin is now.
The Senate does not need to specify the exact measures to be used.
From a national policy perspective, the task is to require outcome
measurement. The Department of Health and Human Services can give the
task of developing measures for given medical circumstances to not-for-
profit organizations, or to the existing medical boards that have deep
credibility and expertise.
The point of measurement is not shopping or report cards. The
purpose is to enable clinical teams to accelerate learning about what
improves health outcomes and what improves the efficiency of effective
care. A decade of process measurement has not yielded these desperately
needed improvements. Measuring results is essential. Health outcomes
are what drive value. At the same time, outcome measures are critical
to ending the unacceptable disparities in American health care.
Starting soon matters. Past experience with outcome reporting in
this country and in others clearly shows that the fastest way to
improve both results and the measures themselves is to begin collecting
the measurements.
Outcome measurement will spur improvements in health and health
care value for all Americans. For patients and for health care
professionals, measuring results will refocus the system on its
intended purposes of health and care.
______
Chairman Kennedy, Chairwoman Mikulski, Ranking Member Enzi and
members of this committee, thank you for inviting me here today to talk
about health care quality and improving health care value for every
American.
My name is Elizabeth Teisberg. I am a tenured professor at the
University of Virginia and co-author of Redefining Health Care.\1\
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\1\ M.E. Porter and E.O. Teisberg, 2006, Redefining Health Care,
Harvard Business School Press, Boston, MA.
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access, measurement and payment: key dimensions of health care reform
Improving our Nation's health care is an urgent priority, made more
critical by the current economic crisis.
Health is essential to productivity--if health is
undermined because of tough economic times, the Nation becomes less
productive, less competitive, and less able.
The health sector is a large and vibrant part of our
economy and the economic recovery will be stronger and faster with an
effective and efficient health sector. There is no greater short- or
long-term economic stimulus than attending to the health of Americans.
We must keep and expand meaningful jobs that create value by enabling
health.
The crisis in health care that preceded this economic
downturn remains and won't disappear simply because of a recession. The
problems are well known: costs are spiraling upward while quality in
care and outcomes suffers from wide variance; good practice is
undermined by inconsistencies in care, disjointed coordination and poor
communication hinder care and hamper health outcomes; alarming numbers
of deaths and serious injuries result from preventable medical errors,
and over 40 million Americans lack the health insurance that would
provide appropriate access to preventive and early stage care.
Action on health care reform is a critical priority for the Nation.
For over a decade, repeated efforts to contain health care costs have
met with, at best, limited success. To change that result, to create a
world-leading health care system, the Nation needs clear, new goals,
new policies that are rapidly implemented and a government structure
that prompts, supports and rewards ongoing and dramatic improvement. My
recommendations address access, measurement and payment--issues
essential for quality and for success. But first, consider the goal of
genuine health care reform.
the goal of improving health for america
The Goal of Health Care is Health, so the Goal of Health Care Reform
Must Be To Improve the Value of Health Care
I am neither a physician nor a Washington health policy insider. My
expertise in this field comes as a scholar and professor of Innovation
and Strategy, as a Ph.D. in engineering economic systems analysis, and
as the mother of a child who was chronically ill and in pain for most
of a decade before his full and complete recovery. As a professional,
and as a mother, I have questioned the conventional wisdom that has
blocked change and retained a system that everyone agrees could be
significantly improved.
The real goal of health care is health. Yet, policy discussions are
often framed as if the goal of health care delivery were cost
reduction. If the goal of health care was simply cost reduction, the
solution would be to offer pain killers and compassion. Clearly, that
is not the solution for health care in our Nation. Successful health
care reform efforts must do more than cut costs. The real goal of
health care reform is, and must be, to drive dramatic and ongoing
improvements in the value of health care. This means improving health
care outcomes relative to the cost of achieving these outcomes.
Improving value in health care means improving health care outcomes
for the money spent. This is a critical idea and an intuitive one. In
most choices, people seek value--not the lowest cost regardless of poor
quality, and not the highest quality without regard for cost. The
tremendous opportunity in health care is how powerfully improvements in
quality actually drive costs down. To see this, one must simply
recognize that Americans desire more health, not more treatment.
Improvement in health care need not mean more treatment and more cost.
Often, improved quality means more effective treatment, better health,
and lower costs. The essential insight is this: Living in good health
is inherently less expensive than living in poor health. Improving
health, improving the quality and the value of health care will save
money, not cost money.
In this era of chronic disease, there is clear evidence that costs
can be lowered through quality.
Stroke is the leading cause of long term disability.
Preventing a stroke or fully recovering from a stroke are--in every
circumstance--less expensive than long term disability.
Diabetes has become a pandemic, and people with diabetes
have four times the health care costs of people without diabetes.
Preventing disease progression and enabling people to live in ongoing
health is far less expensive than paying for the compounding problems
of amputations, heart disease and blindness. Healthy Americans work,
provide for themselves and their families and pay taxes. Those
afflicted with diabetes, and without access to effective care, can do
less of those things.
For breast cancer, early treatment enables better results
at lower costs. A woman with stage one cancer may be cured. A woman
whose disease has reached stage 2B will face more invasive, more
expensive care with less promising results.
For any disease, quality of diagnosis is critical: a wrong
diagnosis leads to care that costs time, wastes money, and adds risk
and discomfort.
In example after example, improving health outcomes reduces costs.
Some of the savings result from reduction of waste and errors in the
current fragmented organizational structures. Even more significant
gains come from restructuring care into teams, coordinated over the
full cycle of the patient care. Innovation in the structures of care
delivery can yield better prevention and improved solutions for
patients and families. In spite of the conventional wisdom, we can
afford to improve quality. Improving quality will drive dramatic
improvement in value.
Health policy reform can and should use improvement in health
outcomes to drive down costs, rather than bowing to cost pressure and
pushing down quality of health care or undertaking more efforts (and
more administrative expenses) to limit access to care.
why results-driven competition?
Results-Driven Health Care Will Improve Value More Than Government-
Driven or Consumer-Driven Approaches
In most sectors of the economy, the dynamic of competition drives
improved value. In a functioning market, both quality and efficiency
increase over time. But health care has been different. Quality has
suffered while costs have increased. Waste is rampant. Why?
The problem in health care isn't too much competition or too
little. The problem in health care is the wrong kind of competition.
Health care lacks positive sum competition to improve value in health
care. Instead, health care is replete with examples of zero sum
competition that shift costs through the exercise of bargaining power.
Today's competition occurs among systems of providers and health plans
over capturing contracts and resources, shifting costs to each other,
to employers, to the government and to consumers. This zero sum
competition destroys value, rather than creating value for patients.
Health policy reform needs to disable the gains from zero sum
competition. A key implication of this insight is that universal access
is essential to effective, value-creating competition in health care.
The right competition is competition to increase value--to improve
health care results. In positive sum competition, the patient wins with
better health outcomes, the clinical team succeeds professionally, and
the employer, government and health plans gain through more efficient
care and increased productivity. Policy needs to support positive sum
competition. This means that policy needs to require measurement of
health care outcomes. Value is created in improving the health and
health care outcomes of people.
Productive competition is one of the most powerful forces for
change, for economic stimulus and for improvement. As President Obama
stated in his inaugural address: the question before us [is not]
whether the market is a force for good or ill. The market is a powerful
force for change, and the right kinds of policy can set a dynamic of
positive competition and increasing health care value for all
Americans.
universal access
Access For All Americans is Essential not Only for Equity, but for
Economic Efficiency
The dysfunctional competition in American health care is endlessly
fueled by opportunities for one party to shift costs to another, to win
by forcing another party to lose, rather than to win by creating value,
by improving health and health care outcomes. To stop the cost shifting
games, everyone must be brought into the system. As long as parties
gain by avoiding serving the uninsured, the tremendous energies to win
at cost shifting will continue. Shifting costs does not create health
care value.
Lack of access reduces efficiency, shifts costs and, overall,
raises costs of U.S. health care.
Those without access to early stage and preventive care
tend to seek care only after problems have advanced. Treatment for
later stage disease is both more expensive and less effective. This is
part of the reason why every country with some form of universal
coverage has lower per capita health care expenditures than does the
United States. It is simultaneously more effective and less expensive
to treat early stage disease and prevent disease progression.
In this country, everyone may go to the emergency room,
but thousands lack access to care in less expensive, more effective
settings. Those who argue that U.S. emergency rooms offer access for
all must recognize that this is the highest cost way to provide access.
Emergency rooms are not the venue for treating chronic disease or
delivering preventive care. Emergency room physicians and nurses cannot
create coordinated care for people who lack access to care in other
settings. The efficiency gains from better coordinated care are
unattainable with today's limited access.
An enormous amount of effort goes into shifting and
recovering the expenses of uncompensated care. These efforts create no
value. Instead, they reduce value by increasing administrative costs.
Costs of uncompensated care end up raising the charges to employers,
the government and other patients, adding to the upward cost spiral.
There will be transitional costs in giving everyone access to more
appropriate health care settings and at earlier points. Over time,
however, it will be more efficient and more effective for all to have
access to care and to dispense with the cost shifting efforts that
consume vast amounts of resources without creating value for patients.
Achieving Universal Access Through Mandatory Coverage
Mandatory health plan coverage is the surest way to achieve
universal access. This will require vouchers or subsidies, in
appropriate amounts, for those who need them. The obvious objective is
universal coverage, not simply expanded access with the known holes and
obvious incentives to continue cost shifting. Gains from reducing
administrative costs will be largely sacrificed by expanded coverage
that is not truly universal.
Universal coverage (with measured results) will enable quality
gains. With a health plan, every person becomes a paying customer. That
creates incentives to provide quality care for all.
Universal coverage will also need rules that require all payers to
cover their fair share of the most expensive patients. Financial risk
pooling can address this, so that payers who cover more of the highest
risk members receive an allotment that is collected from those who
cover the lower risk members. This reduces the incentives for cherry
picking only healthy customers. It is worth noting that the often-
touted Swiss system has used a risk pooling mechanism for decades. The
alternative of high risk health plans that are insurance of last resort
for the sickest people leave in place the incentive for insurers to
dis-enroll or discourage potentially expensive people.
The other essential enabler of universal access is a list of what
insurance must cover. Clarity that reduces arguments about coverage
creates enormous administrative savings. Of course, health plans could
cover more than the minimum, but the minimum must be specified to make
coverage meaningful. A logical starting point is to use the
requirements for the Federal Employee Health Benefits. Simultaneously
with starting mandatory coverage, a panel of experts could be convened
to make recommendations about adjustments to the required coverage.
But universal access alone will not fix the system or contain
rising health care costs. In the current structure, quality care for
all will be difficult to achieve or afford--perhaps impossible. Neither
incremental change nor waste reduction within the current structure
will yield enough improvement. The Nation needs significant innovation
and improvement in health care delivery to achieve a dramatic increase
in value for patients. With improvement in value--the health outcomes
per dollar spent--better care will be available to more people.
Universal access must be accompanied by measures that refocus
health care on improving value for patients (and people who need not
become patients). The single most important step that Congress can take
to improve health care value for Americans is to commit to measuring
results. The adage applies: what is measured improves.
results measurement
Measuring Results Will Unleash Significant Improvement in Value
Measuring results--health outcomes and costs--is critical to enable
and drive improvements in value. Achieving universal access will be far
less expensive in a results-driven system where positive sum
competition improves value. Without improvements in the value of health
care, the Nation will face increasing health care rationing of some
form, whether it is explicit rationing of services, waiting lines or
degradation of quality. But none of that is necessary or inevitable.
The most critical policy step for enabling improvement in value is
to begin results measurement. Through meaningful outcomes measurement,
clinical teams are able to accelerate learning about what truly
improves health outcomes and what improves the efficiency of effective
care. A decade of process measurement has not yielded these desperately
needed improvements. Results--the improvement in a patient's health--
must also be measured. The health outcomes of care are what matter to
patients and families, to the professional success of clinicians, and
to the productivity of the American workforce. Health outcomes drive
value.
The Senate cannot, should not and does not need to specify the
exact measures to be used. However, the Congress must require outcome
measurement. The Department of Health and Human Services can give the
task of developing measures for given medical circumstances (e.g.
strokes, diabetes and its co-morbidities, asthma, heart disease, etc.)
to not-for-profit organizations, or to established medical boards. The
Society of Thoracic Surgeons has been measuring health outcomes for a
decade and its efforts have resulted in dramatic improvements in health
quality and value. Leaders of four medical boards have approached me
with the statements that they already know clinically meaningful
measures that could and should be collected. Because medical boards
renew accreditation for physicians, the boards are in an able position
to require reporting. They can begin simply by requiring reporting and
tying board licensure to whether or not reporting was completed, not to
the relative performance of the reported outcomes. As the measurements
are checked and refined, the system will evolve. The board leaders with
whom I've spoken can start quickly and have deep expertise and
credibility.
Starting soon matters. Past experience with outcome reporting in
this country and in others clearly shows that the fastest way to
improve both results and the measures themselves is to begin collecting
the measurements. Perfect measures and perfect risk adjustment are not
required. When government efforts launch outcome reporting, the
clinicians most affected are spurred to improve the measures and to
create new, more accurate and clinically relevant ones. The state-of-
the-art outcome measurement by the Society of Thoracic Surgeons began
as a defensive response to government (HCFA) reporting of mortality
rates for cardiac surgery (based on administrative data). The
universally collected and publicly reported outcome measures for
transplants resulted from an Act of Congress establishing an organ
sharing network and registry. Clearly, Congress can jump start results
measurement that improves health care outcomes. Congressional expertise
in the measures is not necessary. Congress simply needs to require
registries of outcome measurements and allow appropriate experts to
specify the measures.
The point of measurement is not to enable consumer shopping. Report
cards are not the goal and assertions that consumers do not use
outcomes measures is simply a distraction. The objective of requiring
measurement is to improve health care results by accelerating learning
and improvement. When the State of New York began public reporting
rudimentary mortality outcomes, mortality from CABG surgery fell 41
percent in the first 4 years. The evidence was clear that patients did
not use the data to shop. Physicians used the data to improve. The drop
in mortality vividly indicates that patients benefited.
Measuring results will help clinical teams develop the needed
insight to improve the structures and processes through which care is
delivered. Clinical teams need to know what they do well. They need to
know when they are improving and where they need further work. They
need to know when they are achieving superb results so they can share
their approaches with others. Indeed, the history of these efforts
shows that when the teams with excellent results teach others, results
improve overall and, importantly, the team doing the teaching improves
even faster.
The Nation's health depends on this. Don't accept delay, and don't
settle for only process measures.
There have been significant and laudable efforts over the
past decade to develop measures of accepted practice. These are
important to understand and to share. But the promised progression to
outcome measurement still lies ahead. Congress needs to require outcome
measurement to begin by a specified date.
The measures must go beyond process compliance. Measuring
processes and measuring health outcomes are different. Indeed, many
studies confirm that teams complying with the same process
specifications get different health outcomes for their patients.
Measuring only process compliance diverts health care down the road of
administratively managed care and ever-increasing bureaucracy. It is
easier to achieve consensus on process metrics because inputs are more
readily controlled than the output of health results. But the past
decade of process measurement has not yielded the needed improvements.
It is time to require measurement of outcomes.
Outcome measures are also critical to ending the unacceptable
disparities in American health care. Mandatory results measurement will
mean that substandard care for any group, including minorities or
people with low incomes, will be unmasked. Once unmasked, disparities
are unacceptable and most are wholly unintended. At the same time, poor
results for any patient will lower a team's outcome measures. On every
dimension, results measures, more than any other policy, will
accelerate elimination of substandard care for any group.
Outcome measurement will spur improvements in health and health
care value for all Americans. Attention to health care outcomes also
offers the potential to align interests across the health sector.
Knowledge of what a clinical team is doing well and how it is improving
restores pride and professionalism for physicians and nurses who are so
often today beaten down by reimbursement hassles and bureaucracy that
overshadow their heartfelt desire to care for patients. For patient and
for health care professionals, results measures will refocus the system
on its intended purposes of health and care.
payment
In the current system, financial success and medical success are
not aligned. There is much discussion of the fact that some of the most
effective work that physicians do is uncompensated. But the even bigger
problems is that many of the structural improvements needed to allow
greater leaps in health care value will not be supported by current
reimbursement systems. Our piecemeal system of payment by procedure, by
visit, by intervention and by hospital stay encourages poor
coordination, redundant processes and lack of attention to the
patient's full cycle of care. In addition, prices for a particular
service vary widely by payer, which shifts costs and increases
complexity, but creates no value.
Instead, payment systems can support value-enhancing innovations in
health care organizations by offering reimbursement for the full cycle
of care needed by a patient. Rather than numerous prices and bills,
comprehensive reimbursement would essentially pay the clinical team as
a whole, rather than create negotiated prices for all of the components
of care. Prices for episodes, service bundles and ultimately full
cycles of care will require teams to apportion payment, as occurs in
other services in our economy. While that might sound a bit daunting to
some teams today, the process of considering the full suite of services
needed to restore the patient's health will lead to improved
communication and improved awareness of the patient's full experience.
Some hospitals and clinics, usually with salaried medical staff, have
already begun paying teams in this way.
Today's pricing depends as much or more on who is paying than on
the services being delivered. Reduced administrative costs, improved
transparency and incentives to improve efficiency would result from
requiring prices to depend only on medical circumstances and services
and be the same for all payers. Large payer organizations find
threatening the idea of reducing their bargaining power, but their
negotiated discounts backfire by increasing the list prices and the
costs of uncompensated care. Over time, cost shifting only fuels the
spiral of increasing costs. Aligning payment with the patient's care
will refocus competition on improving health care value and bringing
down price increases over time.
Dramatic improvement in value will result from restructuring care
in ways that are genuinely patient-centric. Today's physician-focused
organizational structures deliver visits, interventions and procedures.
A patient-focused organizational structure delivers coordinated
solutions for improving health results. Teams could accelerate
improvements in value by addressing clusters of medical circumstances
that patients commonly face--what Prof. Michael E. Porter and I called
``medical conditions'' in Redefining Health Care. There is ample
evidence that coordinated teams delivering care for patients with
shared medical circumstances improve health outcomes and efficiency
faster. They would be best supported by a system that includes all
Americans with universal coverage for preventive, early and essential
care, that has measured outcomes to enable learning and improvement,
and that pays for the bundle of services needed to provide patient
solutions.
conclusion
Access to health care for all Americans is essential to both equity
and efficiency. Dramatic improvement in value (health outcomes per
dollar spent) is necessary to provide quality care for all Americans.
Health outcomes will improve faster and more dramatically if they are
widely measured. Coordination of care that improves both outcomes and
efficiency will progress more readily if payment becomes team-based for
cycles of care. Congress can make huge strides by requiring mandatory
health plan coverage and setting outcome measurement in motion. The
time to begin is now.
My thanks to the members of the committee and to its diligent and
knowledgeable staff for the opportunity to share my thoughts with you.
Senator Mikulski. Thank you very much, Dr. Teisberg.
Dr. Robinson-Beale, before we go on, I want to acknowledge
that Senator Dodd has come. He is next in line behind Senator
Kennedy on the committee. Also our newest member, Senator Kay
Hagan of North Carolina. We have got you way down there.
We have Senator Dodd and Senator Hagan. Senator Hagan, we
don't know how many people are coming. Senator Dodd, do I have
unanimous consent that we have her jump the seniority system
for today?
Senator Dodd. Well, let us discuss it for an hour or so.
[Laughter.]
Come on up here, Kay.
I have got a very bad voice, and I apologize. I have got a
cold. I have got a 3-year-old and a 7-year-old. I don't have to
say anything more probably. I am living in a petri dish, and so
I apologize.
Let me thank Senator Mikulski for the tremendous work she
is doing in this area. In fact, I just got off the phone with
Senator Kennedy and Mrs. Kennedy, and he is doing well. He is
sorry he is not here today to participate in this, but deeply
grateful for the work that Senator Mikulski is doing, along
with our other colleagues, Senator Bingaman, I know as well,
and Tom Harkin, in looking at various issues here as we get
ready for what we hope is going to be a major effort on health
reform.
We are grateful as well to Mike Enzi and other members of
the committee who care about these issues as well. So we thank
you very much, Senator, for what you are doing.
Senator Mikulski. Dr. Robinson-Beale. Please.
STATEMENT OF RHONDA ROBINSON-BEALE, M.D., CHIEF MEDICAL
OFFICER, OPTUMHEALTH BEHAVIORAL SOLUTIONS, GOLDEN VALLEY, MN
Dr. Robinson-Beale. Thank you, Madam Chairman. Thank you
for inviting me to speak with you today about behavioral
healthcare today in the context of the IOM reports ``Crossing
the Quality Chasm'' and ``Improving the Quality of Healthcare
for Mental and Substance Use Conditions,'' the subsequent
report that was put out after ``Crossing the Quality Chasm.''
I am honored to have the opportunity to communicate with
you the heightened relevance of the recommendations from these
reports, given the tremendous change in our economic
environment we are now in, and we are challenged with facing a
new construct of healthcare reform.
I hope to give you something to consider, some things that
will be doable next steps to significantly move the status of
behavioral health alone as a significant factor in healthcare
reform.
I speak to you as a committee member of the ``Chasm''
report, as well as a sponsor of the ``Improving the Quality of
Healthcare for Mental Health and Substance Use Conditions.'' I
am also the chief medical officer of the largest behavioral
health organization in the country. We currently insure over 42
million people.
I am also the past chairman of the board of directors for
the Association of Health and Wellness, the trade organization
for managed behavioral health organizations, which does insure
over 147 million people across the country.
The IOM ``Chasm'' and ``Improving the Quality'' reports
clearly define the problems in both healthcare delivery
systems, medical and behavioral, and offer a set of solutions
for change. Despite the many issues and the solutions that were
similar between the two systems, behavioral health reformation
still lags behind its medical counterpart in the implementation
of those recommendations.
Clear examples are this. The National Quality Forum, which
has been designated as one of the entities that will drive
consensus on performance measures, at this point has approved
around 17 measures out of the plethora of measures that they
have approved that are specific to behavioral health.
Fifteen of those are directed toward primary care
management of behavioral health, which is leaving outside of
that scope the measures of care for those individuals who have
chronic mental illness.
Since 2006, at the time of the report ``Improving the
Quality of Healthcare,'' our country's landscape has changed
dramatically. And in light of healthcare reform, there are new
questions that need to be asked.
The questions now are how and what are the necessary
changes in the behavioral health delivery system that we will
need to make in order to be affordable, so that we can
accommodate the larger number of individuals who will be able
to seek care in an already overburdened and short-staffed
delivery system and still provide quality of care?
Where the recommendations from the IOM ``Chasm'' report and
``Improving the Quality'' reports are still relevant and
important, it is difficult to know which recommendations to
initiate and which ones are essential to be implemented at this
time. It is clear that a well-constructed strategy, concise
execution, and having the buy-in and the inclusion of major
stakeholders is needed to address this daunting task.
These are the recommendations. No. 1, it is important to
adopt the culture that behavioral health is essential to
health. It is key to effective medical care and greatly
influences overall cost of medical care.
We know from looking at our stats and our data that
behavioral health has a tremendous impact on medical cost. For
example, we know that 39 percent to 40 percent of those who
have chronic medical illnesses also have a behavioral co-
morbidity.
We also know that or at least most people believe that
behavioral health has a 3 percent to 5 percent impact on the
medical dollar. When you begin to look at the impact of
behavioral co-morbidities, that number rises to as high as 36
percent of the medical dollar.
When we look at the prevalence and the incidence of
behavioral health across the board and we look at one
indicator, and that one indicator would be the prescription
rate for antidepressant medications, we see in our population
anywhere from 9 percent to 17 percent of the medical population
is on an antidepressant.
That is larger than any other chronic medical illness. It
is larger than diabetes. It is larger than asthma, and it is
larger than the incidence of cardiac disease.
With that being said, keep in mind that behavioral health
still lags behind medical health in terms of having the
infrastructure and the inclusion in many of the recommendations
that have been put forth and actualized by the ``Chasm''
report.
Behavioral health is smaller. It is more organized--it is
not as organized, but it is smaller so it is more doable. With
that being in mind, it is necessary to create an organized
approach to be concise.
I am suggesting that we would be able to put together a
collaborative that would be accountable for convening the major
stakeholders, prioritizing initiatives, monitoring those
initiatives, and facilitating goals. By doing that, we can
concisely and quickly begin to bring behavioral health up to
play.
It is also important that there is governmental
recognition. Just as parity has brought forth behavioral health
to the forefront, governmental recognition and financial
backing of initiatives is crucial to keep behavioral health in
the forefront in importance in the healthcare reform.
Thank you.
[The prepared statement of Dr. Robinson-Beale follows:]
Prepared Statement of Rhonda Robinson-Beale, M.D.
summary
The IOM reports, ``Crossing the Quality Chasm'' ( 2001) and
``Improving the Quality of Mental and Substance-Use Conditions'' (2006)
addressed the same fundamental question of what needs to occur to
transform our current fragmented and unsafe health system to one that
meets the needs of health consumers and our communities and assures
quality of care. Quality is defined in these reports as ``the degree to
which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current
professional knowledge.'' In a health care system this links to the
concept of reducing variation and increasing the delivery of effective
care on a patient, provider and system level. In the IOM Improving the
Quality report, recommendations, based on the Chasm 6 aims and 10
rules, were constructed with the goal of addressing the core quality
elements needed to increase the likelihood of successful reformation of
the behavioral health organization.
Since the start of this series of reports on behavioral health
reform, some forward movement in the behavioral health agenda has
occurred toward implementing recommendations. While these
accomplishments are important, it is a common opinion among
stakeholders in behavioral health, that there is more advancement
needed in fulfilling recommendations in order to make significant
progress and to move behavioral health closer to a quality model.
Since 2006, the date of the last behavioral health policy report,
our country's landscape has drastically changed with economic
devastation beyond any one's prediction. With the rising number of
unemployed and the financial burdens citizens are experiencing, there
is more urgency than ever to address our health care crisis. In today's
environment, there are larger than ever numbers of individuals who are
uninsured, Federal, States and employers are in extreme budget crisis
and available funding for change is limited due to important competing
interest. The question now is ``how'' and ``what'' are the necessary
changes in the behavioral health care delivery system that will also be
affordable, can accommodate larger numbers of individuals seeking
services in an already overburdened system with limiting workforce and
still provide quality. Where the recommendations from the IOM Chasm and
Improving the Quality reports are still relevant and important, it is
difficult to know which recommendations or initiatives are the key
essential ones to be implemented. It is clear that a well constructed
strategy, concise execution and having the buy-in and inclusion of the
major stakeholders is needed to address this daunting task and to do so
expeditiously.
recommendations
Adopt the culture that ``behavioral health is essential to
health,'' key to effective medical care and greatly influences overall
cost of medical care.
Make any behavioral health project funding contingent on
clear demonstration of private-public involvement.
Create and fund a behavioral health ``czar'' an entity,
person, existing agency (ies) or a collaborative that can assume the
role of creating a behavioral health reform agenda.
The role of the behavioral health ``czar'' is accountable
for convening stakeholders, prioritization, monitoring and facilitating
goals.
The IOM Chasm and ``Improving the Quality'' reports clearly define
the problems in both health care delivery systems and offer a set of
solutions for change. Despite the fact many of the issues and the
solutions are similar between the two systems, behavioral health
reformation still lags behind its counterpart in the implementation of
recommendations. Just as parity was enacted as a legislative act,
governmental guidance and financial backing is crucial to continue to
keep behavioral health in the fore front of importance in the health
care reform.
______
introduction
Mr. Chairman, members of the committee, thank you for inviting me
to speak with you today about behavioral health care today in the
context of the IOM reports Crossing the Quality Chasm (2001) \1\ and
Improving the Quality of Health Care for Mental and Substance--Use
Conditions (2006).\2\ I am honored to have this opportunity to
communicate with you the heightened relevance of the recommendations
from these reports, given the tremendously changed economic environment
we are in now and the challenges we are facing within the construct of
health care reform. I hope to give you for your consideration doable
next steps to significantly move the status of behavioral health along
as a significant factor in health care reform. I speak to you as a
committee member of the Chasm report, and IOM Health Services Board
member, as a Chief Medical Officer for the largest behavioral health
organization in the country that currently insures over 42 million
people and as the past chairman of the board of directors for the
Association for Health and Wellness (ABHW), the trade organization for
managed behavioral health organization for which its members cover over
147 million people. My statements are my own drawn from my experience
in all these venues and not as an official position statement from any
organization with whom I have affiliation. As a point of reference I
will use the term ``behavioral health'' as a comprehensive term
representing both mental illness and substance-use conditions.
background
Significant reports that have influenced and reflected the need for
change in the delivery of behavioral health historically has included:
Mental Health: A Report of the Surgeon General \3\--
established the basic understanding that behavioral health was
important and that treatment works.
2001 IOM Crossing the Quality Chasm \1\--architectural map
to fundamental change in the general health care system to drive
quality in care.
2003--Achieving the Promise: Transforming Mental Health
Care in America \4\--laid out the values of patient-centered and
consumer-driven systems of care.
2006--IOM Improving Quality of Health Care for Mental and
Substance-Use Conditions \2\--built on the chassis of the Chasm report,
it specifically lays out the architecture specific to behavioral health
for transforming to a quality-driven system.
All these reports addressed the same fundamental question of what
needs to occur to transform our current fragmented and unsafe
behavioral health system to one that meets the needs of behavioral
health consumers and our communities and assures quality of care.
definition of quality
Quality is defined by the IOM as ``the degree to which health
services for individuals and populations increase the likelihood of
desired health outcomes and are consistent with current professional
knowledge.'' \5\ In a health care system this links to the concept of
reducing variation and increasing the delivery of effective care on a
patient, provider and system level. In the IOM Improving the Quality
report, recommendations, based on the Chasm 6 aims and 10 rules, were
constructed with the goal of addressing the core quality elements
needed to increase the likelihood of successful reformation of the
behavioral health organization. Some of those core elements were:
Applying the infrastructure changes outlined in the Chasm
report to behavioral health (IOM rec 2). This recommendation
specifically addresses the application of the general Chasm aims, rules
and strategies to a behavioral health agenda.
Designate an entity to collect and make ready for wider
distribution of best practices. (IOM rec 4-1--4-2)
Funding of ``NQF''-like functions to establishing national
behavioral health consensus measures and priorities (IOM rec 4-3),
facilitating quality improvement practices. (IOM rec 4-4) and reporting
of measures (IOM rec 5-4)
Expect the integrating medical and behavioral health care
into primary care initiatives and models. (IOM rec 5-2)
Information technology systems needs to address behavioral
health data needs as fully as general health. (IOM rec 6-1)
Link funding mechanisms across many venues to measures of
quality. (IOM rec 8-4)
Collaborative innovative research strategies to address
priority areas. (IOM rec 9-2)
progress in reforming the behavioral health care system
Since the start of this series of reports on behavioral health
reform, some forward movement in the behavioral health agenda has
occurred toward implementing recommendations. To highlight a few:
NQF adopted 15 behavioral health measures as a part of the
Ambulatory Care Standards \6\ which is focused on behavioral health
commonly found in primary care setting. Most behavioral health measures
are applicable to primary care management of behavioral health
conditions and not specific to the scope of measurement needs for
chronically mentally ill populations managed by behavioral health
clinicians. (IOM rec 4-3)
Substance Abuse and Mental Health Services Administration
(SAMHSA) organized the Federal Executive Steering Committee,\7\ an
unprecedented collaborative effort among more that 20 Federal agencies
and offices, to develop a specific agenda for driving a quality-based
care system for the public sector. (New Freedom Commission report
recommendation).
Federal parity was passed Oct. 3 2008. ( IOM rec 8-1)
While these accomplishments are important, it is a common opinion
among stakeholders in behavioral health, that there is more advancement
needed in fulfilling recommendations in order to make significant
progress and to move behavioral health closer to a quality model. Many
reasons have been sited for the lack of progress that is distinctive to
behavioral health.\2\ They consist of having more diverse stakeholder
groups (consumers, different provider disciplines, Federal, State,
employer purchasers) split between public and private systems, unclear
locus of accountability on a provider, organizational and systems level
and limited funding. The lag behind is telling in the limited number of
pilots and size of programs implementing pay-for-performance
initiatives in behavioral health. A recent study examining behavioral
health pay-for-performance found that there were only 24 behavioral
health pay-for-performance programs operating and among them was a
clear need for a strong quality infrastructure for behavioral health in
order to implement well.\8\ This is concerning since one of the major
initiatives posed to be a part of health care reform is provider
profiling and pay-for-performance reward programs.
behavioral health care reform in today's environment
Since 2006, the date of the last behavioral health policy report,
our country's landscape has drastically changed with economic
devastation beyond any one's prediction. With the rising number of
unemployed and the financial burdens citizens are experiencing, there
is more urgency than ever to address our health care crisis. The
questions posed to organizations like the IOM and others thought leader
organization around the identification of the necessary changes needed
to improve behavioral health care are still relevant and important.
Now, however, there are additional serious issues that must be taken
into account in constructing health care reform. In today's
environment, there are larger than ever numbers of individuals who are
uninsured, Federal, States and employers are in extreme budget crisis
and available funding for change is limited due to important competing
interest. The question now is ``how'' and ``what'' are the necessary
changes in the behavioral health care delivery system that will also be
affordable, can accommodate larger numbers of individuals seeking
services in an already overburdened system with limiting workforce and
still provide quality.
Where the recommendations from the IOM Chasm and Improving the
Quality reports are still relevant and important, it is difficult to
know which recommendations or initiatives are the key essential threads
to pull on to be successful and not cause a catastrophic unraveling of
the existing behavioral health structure. In this environment, there is
an increased need now to be mindfully cautious and cost conscience to
avoid wasteful spending on initiatives that is well-intended but
executed poorly. There is an increased need to be precise in the
construction of the behavioral health reform plan going forward. It is
clear that a well-constructed strategy, concise execution and having
the buy-in and inclusion of the major stakeholders is needed to address
this daunting task and to do so expeditiously. Lawrence Bossidy in
``Execution: The Discipline of Getting Things Done'' identifies a
construct for the effective execution of a plan: \9\
1. Create the framework for change;
2. Know the people, capacities and industry;
3. Set clear goals and priorities;
4. Follow through and perform on-going monitoring; and
5. Reward doing and results.
With this as an outline, these are some recommendations that appear
to be fundamental to an efficient execution of a behavioral health
reformation in this era of economic crisis.
I. Execution: Set a Framework For Cultural Change
1. As a part of cultural change there are basic values that guide
the nexus of change. For behavioral health reformation they are:
Facilitate the expectation that behavioral health
initiatives should be planned along side of and/or integrated within
medical demonstration pilots with distinct articulated behavioral
health goals, performance measures and funding. Not providing for major
inclusion of behavioral health in health reform is counter productive.
Here are some reasons why:
a. Incidence of behavioral health co-morbidities among
patients with chronic medical illness varies from 39 percent-44
percent.\10\
b. The existence of behavioral co-morbidities raises the cost
of medical care by 50-150 percent.\11\
c. Effective care does reduce medical cost and early
identification and intervention can improve workplace
productivity.\12\
d. Commonly 9 percent to 17 percent of medical patients are on
an antidepress-
ant and only around 27 percent receive evidence-based care.\13\
e. Despite the common belief that behavioral health cost
consumes 3-5 percent of the medical dollar, with the prevalence
of co-morbidities, behavioral health spend is close to 36
percent of the medical dollar.\14\
Recommendation: Adopt the culture that ``behavioral health is essential
to health,'' key to effective medical care and greatly influences over
all cost of medical care.
2. Behavioral health initiatives, to be the most effective, must
include a public-
private partnership especially in areas that involve interface with
clinicians and service delivery systems. Leveraging change with all the
purchasers of care aligned is more powerful and effective in getting
provider buy-in. (i.e. Leapfrog)
Recommendation: Make any project funding contingent on clear
demonstration of private public involvement.
II. Execution: Know the People, Capabilities And Industry
3. Consider commissioning an IOM symposium, workshop or report
(depending on timeframe for the needed deliverable) with the goal of
revisiting recommendations to modify, refine, edit and most importantly
prioritize them in light of health care reform and the realities of
today's environmental climate. The commissioned activity should include
major public/private stakeholders, consumers, providers, and health
care economist to draft an updated behavioral health strategy and
refine recommendations that considers the need for increased access,
affordability and quality as drivers.
Recommendation: Commission the IOM or another impartial body to conduct
a behavioral health symposium workshop or report involving all the
major stake holders with the intent of refining the Improving the
Quality recommendations to construct a targeted road map that can be
effectively executed.
4. Create and fund a behavioral health ``czar'' an entity, person,
existing agency (ies) or a collaborative that can assume the role of
creating a behavioral health reform agenda and organizing the structure
to convening all the major stakeholders to drive initiatives relevant
to today's needs.
Recommendation: Create and fund a behavioral health ``Czar''.
III. Execution: Set Clear Goals and Priorities
The role of the behavioral health ``czar'' is accountable for:
5. Establishing a national set of priorities for behavioral health
and commitment by stakeholders to participate in process improvement.
6. Establishing a national set of goals with measurements that are
relevant to public and private agendas.
7. Establishing strategic and integrated partnerships with medical
health reformation groups that are the key drivers of medical care
modeling and other quality initiatives.
8. Routinely designate a portion of Federal funding ear marked for
medical quality initiatives for a behavioral health component. For
example, funding to AHRQ or NQF to establish national care priorities
should have funds set aside for a behavioral consensus forum to
establish behavioral health priorities.
Recommendation: establish priorities, measurements, and medical
partnerships.
IV. Execution: Follow Through and Monitor
Through the behavioral health ``czar'':
9. Establish an oversite process and facilitate the necessary
change to the plan as results indicate.
10. Monitor, report and communicate results and outcomes of the
initiatives which were designed to address stated goals in a manner
that widely disseminates learnings and creates an atmosphere of
transparency.
11. Continue to fund and operationalize the recommendations from
the ``Chasm'' report as they are reprioritized or reformatted.
Recommendation: establish an oversite, monitoring and transparent
reporting.
closing remarks
The IOM ``Chasm'' and ``Improving the Quality'' reports clearly
define the problems in both our health care delivery systems and offer
a set of solutions for change. Despite the fact many of the issues and
the solutions are similar between the two systems, behavioral health
reformation still lags behind its counterpart in the implementation of
recommendations. The unique challenges of our economic environment and
the rising number of uninsured Americans brings a new twist to the
context of health care reform and the recommendations. This environment
puts in jeopardy the possibilities of implementing reform and
especially behavioral health. Just as parity was enacted as a
legislative act, governmental guidance and financial backing is crucial
to keep behavioral health in the fore front of importance in the health
care reform. In closing, ``Knowing is not enough, we must apply;
Willing is not enough, we must do''--Goethe.
References
1. IOM 2001, ``Crossing the Quality Chasm''. Washington, DC:
National Academy Press.
2. IOM 2006, ``Improving the Quality of Health Care for Mental and
Substance-Use Conditions: Quality Chasm. Washington, DC: National
Academy Press.
3. Satcher, D. Mental Health: A Surgeons General Report.
www.surgeongeneral
.gov/library/mentalhealth.
4. President Commissioners Report, Achieving the Promise:
Transforming Mental Health Care in America. 2003.
5. IOM 2009--Crossing the Quality Chasm: The IOM Health Care
Quality Initiative, www.iom.edu/CMS.
6. NQF, National Voluntary Consensus Standards for Ambulatory Care
Part 1, www.qualityforum.org/projects. 2009.
7. SAMHSA--Transforming Mental Health Care in America.
www.samhsa.gov/federalactionagenda.
8. Brenner, R.: Pay For Performance in Behavioral Health,
Psychiatric Services Dec. 2008, 1419-1429.
9. Leape, L; Berwick, D. Five Years After To Err Is Human; What
Have We Learned?'' JAMA May 2005; vol. 293 no. 19.
10. Moussavei, S., Depression, Chronic Disease and Decrements in
Health: Results From the World Health Surveys. Lancet Sept. 2007,
370:851-58.
11. Simon, G. Recovery From Depression Predicts Lower Health
Services Cost. J Clin Psych 67:8, Aug. 2006.
12. Wang, P., Azocar, F. Telephone Screening, Outreach, and Care
Management for Depressed Worker and Impact on Clinical and Work
Productivity Outcomes. JAMA Sept 2007; 298:12 1401-1411.
13. Kessler, R., Wang, P. The Prevalence and Distribution of Major
Depression in a National Community Sample: The National Co-morbidity
Survey. Arch of Psych 2005.
14. Sources: CDC; Milliman; U.S. Dept. of Health & Human Services,
SAMHSA; ChapterHouse analysis.
15. IOM 1999, ``Too Err Is Human''. Washington, DC: National
Academy Press.
16. Baucus, M. Nov 2008. ``Call To Action Health Reform, 2009.
www.finance
.senate.gov.
17. Lewin, J. 2009. ACC Corner ``Quality First'' in Health Care
Reform Debate,'' www.cardiovascularbusiness.com .
18. Engelberg Center for Health Care Reform Nov 2008. ``Real Health
Care reform in 2009: Getting to Better Quality, Higher Value and
Sustainable Coverage,'' www.brooking.edu.
Senator Mikulski. Well, we could hold just a whole hearing
on, first of all, each and every one of your testimonies, and I
think all of my colleagues would acknowledge that. That was a
stunning statistic, Doctor, and we are going to come back to
that.
I want to acknowledge that Senator Casey of Pennsylvania is
here.
Also one other item before we go to Dr. Davis. There will
be three votes at approximately 3:10 p.m., which means we will
have about 15 minutes. When we have to leave for the votes,
that will conclude the hearing. Because by the time we go for
three votes, it will be an hour, and we don't want to
inconvenience you more.
So we are going to move right along with our testimony. We
will keep our questions to the 5-minute rule, and then if we
have time for a second round, we will do it.
Dr. Davis, hit it.
[Laughter.]
STATEMENT OF KAREN DAVIS, Ph.D., PRESIDENT, COMMONWEALTH FUND,
NEW YORK, NY
Ms. Davis. Thank you, Madam Chairman and members of the
committee, for this opportunity to join you today.
As the Nation turns to the issue of reforming our health
insurance system, it is important to address simultaneously the
way we organize and deliver healthcare services to ensure that
we are getting the very best possible outcomes for Americans
and the most value for the money we spend on healthcare.
I agree completely with the statement that the Chairman
made at the beginning of this hearing that access, quality, and
cost are interrelated, and we need to address all of them
simultaneously.
According to a recent national scorecard published by the
Commonwealth Fund, the U.S. healthcare system scored 65 out of
100 possible points on 37 indicators of performance, capturing
key dimensions of health outcomes, quality, access, equity, and
efficiency. The scorecard shows that the United States is not
making consistent progress in reducing the variability of
healthcare quality and is failing to keep pace with gains in
health outcomes achieved by our industrialized peers.
We are fortunate, however, that even within our imperfect
system, models exist for each of the components that if
properly organized, reformed, and financed it can enable the
Nation to provide high-quality, affordable care to every
American.
Examples of excellence from across the United States and
around the world offer insight into what it takes to achieve
high performance, including the Geisinger Health System in
Senator Casey's district and Denver Health, which are
integrated health systems that achieve high performance using
electronic health records and a culture of continuous
innovation and improvement.
State initiatives in Iowa and Vermont have made them
leaders on our State scorecards. Regional associations, like
the Massachusetts Health Quality Partners and the Wisconsin
Collaborative for Healthcare Quality, have been innovative
leaders in transparency and engaging providers in quality
improvement. Denmark and The Netherlands are international
leaders with accessible primary care and electronic information
systems.
The specific policies that will both lead to better
outcomes and bend the curve of our Nation's unsustainable
healthcare spending revolve around five strategies that are
amenable to action at the Federal level.
Provide affordable health coverage for all. Reform provider
payment. Organize our care delivery systems, including raising
community health centers, the exemplar models of patient-
centered care. Invest in a modern health system, including the
information technology and information on comparative
effectiveness of treatments. And ensure strong national
leadership.
By applying these policies simultaneously, the Nation would
be able to capture the synergistic benefits of specific changes
that would put the United States on the path to a high-
performance health system.
Thank you.
[The prepared statement of Dr. Davis follows:]
Prepared Statement of Karen Davis, Ph.D.*
executive summary
As the Nation turns to the issue of reforming our health insurance
system, it is important simultaneously to address how we organize and
deliver health services, to ensure that we are obtaining the best
health outcomes for Americans and value for the money we are spending
on health care. Unfortunately, the care we receive falls short of the
care it is possible to deliver, and the gap is not narrowing. According
to the most recent National Scorecard published by the Commonwealth
Fund Commission on a High Performance Health System, the U.S. health
system scored 65 out of 100 possible points in 2008 on 37 indicators of
performance that capture key dimensions of health outcomes, quality,
access, equity, and efficiency.
---------------------------------------------------------------------------
* The co-authorship and research assistance of Kristof Stremikis
and editorial assistance of Chris Hollander are gratefully
acknowledged.
The views presented here are those of the authors and not
necessarily those of The Commonwealth Fund or its directors, officers,
or staff. This and other Fund publications are available online at
www.commonwealthfund.org. To learn more about new publications when
they become available, visit the Fund's Website and register to receive
e-mail alerts. Commonwealth Fund pub. no. xxxx.
---------------------------------------------------------------------------
The Scorecard shows that the United States is not making consistent
progress in reducing the variability of care quality and is failing to
keep pace with gains in health outcomes achieved by our industrialized
peers.
The Nation now ranks last out of 19 countries on a measure
of mortality amenable to medical care, falling from 15th in 5 years as
other countries raised the bar on performance.
The widening quality chasm is having real effects on real
lives--up to 101,000 deaths could be prevented each year if the U.S.-
raised standards of care to benchmark performance levels achieved
abroad.
While we spend more than twice of what other nations spend
on health, there is overwhelming evidence of inappropriate care, missed
opportunities, and waste within the U.S. health system.
We are fortunate that within our imperfect system there are
examples of all the components that, properly organized, reformed, and
financed, can enable the Nation to provide high-quality, affordable
care to every American. Insight into what it takes to achieve high
performance is provided by some examples of excellence within the
United States and around the world:
The Geisinger Health System, on whose board I am pleased
to serve, is a leader in innovation and quality improvement that
demonstrates the importance of simultaneously aligning incentives,
utilizing electronic health records, and creating policies to encourage
coordination of care.
Denver Health, a comprehensive and integrated medical
system that is Colorado's largest health care safety-net provider, has
succeeded by promoting a culture of continuous quality improvement and
lean efficiency, adopting information technology, and providing
organization-wide leadership.
State initiatives in Iowa and Vermont have achieved better
health outcomes and increased access to needed health services by
encouraging adoption of the medical home model, disseminating
performance information and best practices, and launching focused
campaigns to cover young children.
Regional associations like Massachusetts Health Quality
Partners and the Wisconsin Collaborative for Healthcare Quality have
been leaders in quality improvement efforts by collecting and
disseminating performance data on hospitals and physician groups and
educating providers and patients to use that information to facilitate
quality improvement activities.
Denmark and the Netherlands have become international
leaders in patient-centered, coordinated care by placing great emphasis
on accessible primary care and developing information systems that
assist primary care physicians in coordinating health care services.
The specific policies that will both lead to better health outcomes
and bend the curve of our Nation's unsustainable spending on health
revolve around five strategies amenable to action at the Federal level:
Provide affordable health coverage for all;
Reform provider payment;
Organize our care delivery systems;
Invest in a modern health system; and,
Ensure strong national leadership.
Congress can continue to develop the infrastructure for improving
quality by making investments in health information technology and
information exchange networks. If the United States is serious about
closing the quality chasm, it will also need a strong primary care
system, which requires fundamental provider payment reform, encouraging
all patients to enroll in a patient-centered medical home, and
supporting those physician practices with IT and technical assistance
in care process design. Funding for comparative effectiveness research
and the establishment of a center for comparative effectiveness is also
crucial to value-based purchasing and performance improvement
initiatives. Finally, the Federal Government can raise the bar for
health system performance by setting explicit goals and priorities for
improvement--particularly with regard to the most prevalent chronic
conditions, which account for a large majority of health care costs.
By applying these policies collectively, the Nation would be able
to capture the synergistic benefits of specific changes that, if
implemented individually, would yield more modest improvements in
quality and less reduction in projected spending trends. The reforms
must support providers in their efforts to deliver the best care
possible for their patients. Armed with the knowledge that the status
quo is no longer acceptable, we have entered a new era ripe with
opportunity to close the quality chasm and improve the health and well-
being of American families. Working together we can change course--and
move the U.S. health system on a path to high performance.
______
the commonwealth fund
Thank you, Senator Mikulski, for this opportunity to testify on
health care quality and delivery system reform in the United States. As
the Nation turns to the issue of reforming our health insurance system,
it is important simultaneously to address how we organize and deliver
health services, to ensure that we are obtaining the best health
outcomes for Americans and value for the money we are spending on
health care.
Unfortunately, the care we receive falls short of the care it is
possible to deliver, and the gap is not narrowing. According to the
most recent National Scorecard published by the Commonwealth Fund
Commission on a High Performance Health System, the U.S. health system
scored 65 out of 100 possible points in 2008, on 37 indicators of
performance that capture key dimensions of health outcomes, quality,
access, equity, and efficiency.\1\ This is down slightly from 67 out of
100 in 2006--we are not on the right path.
---------------------------------------------------------------------------
\1\ The Commonwealth Fund Commission on a High Performance Health
System, Why Not the Best? Results from the National Scorecard on U.S.
Health System Performance, 2008, (New York: The Commonwealth Fund, July
2008); C. Schoen, K. Davis, S.K.H. How, and S.C. Schoenbaum, ``U.S.
Health System Performance: A National Scorecard,'' Health Affairs,
November/December 2006; 25(6): w457-w475.
---------------------------------------------------------------------------
The good news is that we no longer simply assert that we have the
best health system in the world,\2\ and instead are beginning to take a
clear-eyed look at how our system performs overall, across States, and
in comparison with other countries. We are beginning to have the
information that shows where we are gaining ground, and where there are
opportunities to improve. Public reporting of data on quality of
hospital care and focused campaigns to improve quality are spurring
improvement. Many health care professionals and organizations are
responding to the challenge and adopting information technology,
redesigning care processes, and mobilizing efforts to improve results.
Examples of excellence within the United States, as well as around the
world, demonstrate what can be achieved.
---------------------------------------------------------------------------
\2\ E.J. Emanuel, ``What Cannot Be Said on Television About Health
Care,'' JAMA 2007; 297:2131-2133.
---------------------------------------------------------------------------
But the United States will not have the health system we want for
ourselves and our families if the Federal Government does not lead and
implement a series of strategies that taken together can close the
quality chasm. These include, most importantly, extending health
insurance to all; aligning financial incentives to reward the outcomes
we want to achieve; changing the organization and delivery of care to
ensure that it is accessible, coordinated, and patient-centered;
investing in the infrastructure and support necessary to reach
attainable levels of quality and efficiency; and exercising the
leadership and collaboration among all parts of the health system
necessary to achieve health goals for the Nation.
By applying these policies collectively, the Nation would be able
to capture the synergistic benefits of specific changes that, if
implemented individually, would yield more modest improvements in
quality and less reduction in projected spending trends. The reforms
must support providers in their efforts to deliver the best care
possible for their patients. Armed with the knowledge that the status
quo is no longer acceptable, we have entered a new era ripe with
opportunity to close the quality chasm and improve the health and well-
being of American families. Working together we can change course--and
move the U.S. health system on a path to high performance.
i. headed in the wrong direction: evidence of a widening quality chasm
Despite the best efforts of millions of talented and dedicated
health care professionals, the United States is not making consistent
progress in reducing the variability of care quality and is failing to
keep pace with gains in health outcomes achieved by our industrialized
peers.\3\ The Nation now ranks last out of 19 countries on a measure of
mortality amenable to medical care, falling from 15th in 5 years as
other countries raised the bar on performance.\4\ This widening quality
chasm is having real effects on real lives--up to 101,000 deaths could
be prevented each year if the United States raised standards of care to
benchmark performance levels achieved abroad.
---------------------------------------------------------------------------
\3\ Commonwealth Fund Commission, Ibid.
\4\ E. Nolte and C. McKee, ``Measuring The Health Of Nations:
Updating An Earlier Analysis,'' Health Affairs, January/February 2008;
27(1): 58-71.
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A focus on preventive care and proper management of chronic disease
are key strategies to increase the effectiveness of health care
delivery, an area where lack of progress is undermining the Nation's
efforts to improve quality. While the benefits of prevention are well
documented,\5\ the national scorecard report found that only half of
adults receive all age-appropriate preventive care services such as
immunizations, cancer screenings, and blood pressure and cholesterol
tests. There was no improvement on this indicator between the 2006 and
2008 scorecards. Meanwhile, troubling variation in chronic disease
management is evident across health plans and insurance status despite
slight improvements in the control of diabetes and hypertension. A
recent National Committee for Quality Assurance study found that
eliminating this variance would prevent up to 46,000 premature deaths
and save up to $2.4 billion in medical costs.\6\
---------------------------------------------------------------------------
\5\ T. Kottke, et al., ``The Comparative Effectiveness of Heart
Prevention and Treatment Strategies,'' Am J Prev Med 2009; 36(1): 82-
88.
\6\ National Committee for Quality Assurance, The State of Health
Care Quality 2008, (Washington, DC: NCQA, 2008).
---------------------------------------------------------------------------
Indicators of patient safety are also important measures of overall
quality within the health care system. One bright spot is that the
United States showed progress on hospital standardized mortality
ratios, which declined by 19 percent on the 2008 scorecard from the
earlier report. This measure was the focus of a 100,000 Lives campaign
led by the Institute for Healthcare Improvement. Other organizations
that are working to improve patient safety include the World Health
Organization, the Joint Commission National Patient Safety Goals, the
Leapfrog Group's Hospital Quality and Safety Survey, the National
Surgical Quality Improvement Program, the American Medical
Association's National Patient Safety Foundation, and the Center for
Disease Control and Prevention's National Health Safety Network.\7\
---------------------------------------------------------------------------
\7\ Commonwealth Fund Commission, Ibid.
---------------------------------------------------------------------------
There also have been gains in acute hospital care for heart attack,
heart failure, and pneumonia patients--based on quality metrics
reported to Medicare. Yet, gaps in the receipt of recommended care for
pneumonia and heart failure were particularly wide, with spreads of 20
to 30 percentage points between the bottom and top 10th percentiles.
Standardized Federal reporting has shown top hospitals are achieving
100 percent on basic process measures, indicating that full adherence
to a set of best practice guidelines is possible. Researchers estimate
that if hospitals in the bottom quartile of performance improved to the
level of the top quartile, more than 2,000 deaths could be avoided each
year.\8\
---------------------------------------------------------------------------
\8\ A. Jha, et al., ``The Inverse Relationship Between Mortality
Rates and Performance in the Hospital Quality Alliance Measures,''
Health Affairs, July/August 2007; 26(4): 1104-1110.
---------------------------------------------------------------------------
Substantial variation was also found among risk-adjusted mortality
rates for several serious conditions and risk-adjusted costs for
Medicare beneficiaries, demonstrating both inefficiency and a vast
quality chasm throughout the country. Updated analysis of Medicare data
shows that 1-year risk-adjusted mortality rates for heart attacks, hip
fractures, and colon cancer varied between 27 and 33 percent among the
best- and worst-performing regions, while risk-adjusted cost ranged
from $25,000 to $30,000. A significant number of those regions with
lower risk-adjusted mortality rates also utilized lower total
resources, suggesting significant inefficiency among higher spending
regions.\9\ If all areas of the country achieved the performance levels
of the benchmark regions, Medicare could save more than 9,000 lives and
reduce annual costs by nearly $1 billion a year for these three
conditions alone.
---------------------------------------------------------------------------
\9\ E. Fisher, D. Wennberg, et al., ``The Implications of Regional
Variations in Medicare Spending. Part 1: The Content, Quality, and
Accessibility of Care,'' Annals of Internal Medicine, February 18,
2003; 138(4): 273-287; E. Fisher, D. Wennberg, et al., ``The
Implications of Regional Variations in Medicare Spending. Part 2:
Health Outcomes and Satisfaction with Care,'' Annals of Internal
Medicine, February 18, 2003; 138(4): 288-298.
---------------------------------------------------------------------------
Providing quality care during a hospital stay and giving
appropriate discharge planning, follow-up, and post-acute care can help
prevent patients from being re-admitted to the hospital, thus improving
the patient experience and reducing the total costs of care.\10\
However, no improvement in the Medicare 30-day hospital re-admission
rate was seen in the 2008 scorecard, and regional variation remained
stark. Nearly one of five Medicare patients initially hospitalized with
one set of selected conditions was re-admitted to the hospital within
30 days, with rates in the worst performing regions 50 percent higher
than those in the better performing areas of the country. A Medicare
Payment Advisory Commission analysis indicates that three-quarters of
re-admissions may be preventable at a potential savings of $12 billion
a year for Medicare.\11\
---------------------------------------------------------------------------
\10\ Medicare Payment Advisory Commission, ``Payment Policy for
Inpatient Re-admissions,'' Report to the Congress: Promoting Greater
Efficiency in Medicare, (Washington: MedPAC, June 2007).
\11\ MedPAC, Ibid.
---------------------------------------------------------------------------
The 2008 scorecard also showed increases in the rate of
hospitalization and 30-day hospital re-admission of nursing home
residents, two indicators of poor coordination and poor quality for one
of the most vulnerable populations within the United States. Nearly one
of five nursing home long-stay residents was hospitalized according to
the most recent analysis of Medicare claims data, up from 17 percent in
the previous study. The frequency of hospitalization and 30-day
hospital re-admission of nursing home residents increased among both
high- and low-performing States.
Rates of potentially preventable hospitalizations for ambulatory
care-sensitive (ACS) conditions are another key measure of quality
within the U.S. health care system. Widespread variation was again the
theme, with two- to four-fold differences across States and hospital
referral regions along with associated discrepancies in costs and
resource use. At least $4 billion annually could be saved if these
rates fell to benchmark levels.
The 2008 scorecard reported 15 to 24 percentage point differences
on important indicators of hospital patient-centered care, including
how well staff managed pain, responded when patients pressed a call
button, or explained medications and their possible side effects. The
best hospitals achieved very high rates of patient ratings on these
questions, illustrating that it is possible for hospitals to do much
better in meeting patients' needs.
The rate of medical, medication, and lab errors is yet another
important quality indicator where the United States has failed to keep
pace with gains made by benchmark performers in the international
community. Nearly one-third of U.S. patients surveyed in 2007 said
that, in the last 2 years, a medical mistake or a medication or lab
test error was made during their care. There was little to no
improvement on this metric since it was reported in the 2006 scorecard.
It would take a 40 percent reduction in the medical, medication, and
lab test error rate in the United States to reach the low level
reported in Germany, the benchmark country.
Aggregate scores on dimensions of care coordination fell between
2006 and 2008, demonstrating that fragmentation and misaligned
incentives continue to plague the U.S. health system. The percentage of
adults who reported access to a regular source of primary care failed
to improve, a particularly disturbing finding given that those who lack
a usual source of primary care are more likely to have unmet health
care needs and higher costs of care while being less likely to adhere
to treatment and receive preventive care.\12\ Differing rates of
coordination for hospital patients was similarly distressing, with
nearly three-fold variation among high and low performers on the
percentage of heart failure patients who received complete written
instructions at discharge. Proper coordination of care at the time of
hospital discharge helps prevent subsequent complications and re-
admissions, especially for patients with complex or chronic
conditions.\13\
---------------------------------------------------------------------------
\12\ B. Starfield, Primary Care: Balancing Health Needs, Services,
and Technology (New York: Oxford University Press, 1998).
\13\ E. Coleman, ``Falling Through the Cracks: Challenges and
Opportunities for Improving Transitional Care for Persons with
Continuous Complex Care Needs,'' Journal of the American Geriatrics
Society, April 2003; 51(4): 549-555.
---------------------------------------------------------------------------
Finally, while studies have shown that expansion of health
information technology is a means of facilitating quality reporting and
improvement, analysis of the 2006 Commonwealth Fund Survey of Primary
Care Physicians demonstrates that the United States falls far behind
the Netherlands, New Zealand, the United Kingdom, Australia, and
Germany on the utilization and functionality of health IT. The contrast
between the United States and the Netherlands is particularly stark,
with 98 percent of Dutch primary care physicians reporting the use of
electronic medical records compared with only 28 percent of their
American counterparts. This general pattern persists when examining the
prevalence of other IT functions such as electronic prescribing,
decision support, and computerized access to test results.\14\
---------------------------------------------------------------------------
\14\ C. Schoen, R. Osborn, P. Trang Huynh, M. Doty, J. Peugh, K.
Zapert, ``On The Front Lines of Care: Primary Care Doctors' Office
Systems, Experiences, and Views in Seven Countries,'' Health Affairs,
November/December 2006; 25(6): w555-w571; K. Davis , M. Doty, K. Shea,
and K. Stremikis, ``Health Information Technology and Physician
Perceptions of Quality of Care and Satisfaction,'' Health Policy,
forthcoming 2009.
---------------------------------------------------------------------------
ii. impediments in the current system
In short, the U.S. health care system is plagued by significant
variability in quality and is failing to match the gains seen among its
industrialized peers. Impediments to improvement include a lack of
affordable health coverage for all, a wasteful and inefficient provider
payment system, a fragmented and disorganized care delivery system,
widespread failure to adopt health information technology, and limited
Federal oversight and leadership. A recent Commonwealth Fund study
found that the United States ranked last among six industrialized
nations on health system performance.\15\ Despite spending more than
twice what other nations spend on health, there is overwhelming
evidence of inappropriate care, missed opportunities, and waste within
the U.S. health system.
---------------------------------------------------------------------------
\15\ K. Davis, C. Schoen, S.C. Schoenbaum, M.M. Doty, A.L.
Holmgren, J.L. Kriss, and K.K. Shea, Mirror, Mirror on the Wall: An
International Update on the Comparative Performance of American Health
Care, (New York: The Commonwealth Fund, May 2007).
---------------------------------------------------------------------------
Lack of affordable health coverage is a proven barrier to obtaining
quality care and improving the value of the country's significant
expenditure on health services. The United States stands alone among
its industrialized peers in failing to provide universal coverage, and
ranked last among six nations in a recent Commonwealth Fund study on an
aggregate measure of health care access.\16\ Cost-related problems are
widespread, with more than half of respondents to a 2005 survey
reporting problems getting recommended tests, treatments, or follow-up
care, filling prescriptions, or visiting a doctor when they had medical
problems because of cost. Not surprisingly, lack of affordable coverage
and the attendant financial barriers to care contributed to underuse of
health services among the uninsured, a group much less likely to obtain
preventive care, fill prescriptions, and have chronic conditions under
control.\17\ This phenomenon drives disparities in outcomes, decreases
the proportion of the population receiving appropriate primary care to
prevent illness, and puts the health of the millions of Americans
living with chronic conditions in peril.
---------------------------------------------------------------------------
\16\ Davis, ``Mirror, Mirror,'' Ibid.
\17\ Commonwealth Fund Commission, Ibid.
---------------------------------------------------------------------------
Misalignment of financial incentives is also a significant
impediment to successful quality improvement in the United States. The
2006 Commonwealth Fund International Health Policy Survey showed that
only 30 percent of American primary care physicians received any
financial incentive to improve quality, contrasted with their
counterparts in the United Kingdom nearly all of whom reported
financial bonuses--the result of a bonus system which can account for
up to 30 percent of their income based on a broad array of quality
measures covering preventive and chronic care and patient
experiences.\18\ Commonwealth Fund studies have also found the
predominance of the fee-for-service payment system in the United
States--an arrangement that rewards volume over value--to be a
significant barrier to streamlined and more efficient delivery
models.\19\ Analysis has shown that doctors and hospitals practicing in
the same community and caring for the same patients have little or no
incentive or capacity to connect to one another, contributing to
unnecessary duplication of tests and procedures, wasteful deployment of
resources, and substandard outcomes.\20\
---------------------------------------------------------------------------
\18\ Davis, ``Mirror, Mirror,'' Ibid.
\19\ K. Stremikis, S. Guterman, and K. Davis, Health Care Opinion
Leaders' Views on Payment System Reform, (New York: The Commonwealth
Fund, November 2008).
\20\ MedPAC, ``Payment Policy for Inpatient Re-admissions,'' Ibid.;
D. Grabowski, ``Medicare and Medicaid: Conflicting Incentives for Long-
Term Care,'' Milbank Q., December 2007; 85(4): 579-610; T. Bodenheimer,
``Coordinating Care--A Perilous Journey Through the Health Care
System,'' N Engl J Med., March 6, 2008; 358(10):1064-1071.
---------------------------------------------------------------------------
Fragmentation of the American care delivery system drives low-
quality, inappropriate, and inefficient service in a country filled
with highly skilled health care professionals. A disjointed mix of
private insurers and public programs, each with its own set of rules
and payment methods, fuels fragmentation, generating waste and high
administrative costs.\21\ Moreover, widespread failure to adopt the
patient-
centered medical home model, especially among community health centers
serving low-income and minority patients, has contributed to uneven
performance and exacerbated disparities in quality along racial and
socioeconomic lines.\22\
---------------------------------------------------------------------------
\21\ A. Shih, K. Davis, S. Schoenbaum, A. Gauthier, R. Nuzum, and
D. McCarthy, Organizing the U.S. Health Care Delivery System for High
Performance, (New York: The Commonwealth Fund, August 2008).
\22\ M. Abrams, ``Achieving Person-Centered Primary Care: The
Patient-Centered Medical Home,'' Invited Testimony, Special Senate
Committee on Aging Hearing on ``Person-Centered Care: Reforming
Services and Bringing Older Citizens Back to the Heart of Society,''
(New York: The Commonwealth Fund, July 2008).
---------------------------------------------------------------------------
Data from high performing health systems across the country show
that moving towards more integrated models of care is a proven strategy
for increasing quality of care while simultaneously reducing costs and
inefficiencies.\23\ Over 80 percent of respondents to a recent
Commonwealth Fund Health Care Opinion Leaders Survey say that
strengthening the primary care system, encouraging care coordination,
and facilitating the integration of providers within and across care
settings are important steps to improving health system
performance.\24\
---------------------------------------------------------------------------
\23\ R.A. Paulus, K. Davis, and G.D. Steele, ``Continuous
Innovation in Health Care: Implications of the Geisinger Experience,''
Health Affairs, September/October 2008; 27(5): 1235-1245.
\24\ K.K. Shea, A. Shih, and K. Davis, Commonwealth Fund Commission
on a High Performance Health System Data Brief: Health Care Opinion
Leaders' Views on Health Care Delivery System Reform, (New York: The
Commonwealth Fund, April 2008).
---------------------------------------------------------------------------
Substandard outcomes and insufficient value are also driven by
insufficient adoption of health information technology (IT) and the
absence of information exchange systems. Analysis of the 2006
Commonwealth Fund Survey of Primary Care Physicians demonstrates that
the United States has fallen far behind the Netherlands, New Zealand,
the United Kingdom, Australia, and Germany on a number of measures
related to the utilization of health IT.\25\ The contrast between the
United States and the Netherlands is particularly stark, with 98
percent of Dutch primary care physicians reporting the use of
electronic medical records compared with only 28 percent of their
American counterparts. This general pattern persists when examining the
prevalence of other IT functions such as electronic prescribing,
decision support, and computerized access to test results. A recent
Commonwealth Fund-supported study suggests that linking health IT to
performance improvement efforts has the potential to both improve the
quality of care and significantly reduce costs.\26\ If automated
decision support was utilized among the 37 million hospital admissions
in the United States in 2005, facilities across the country would stand
to save almost $20 billion a year.
---------------------------------------------------------------------------
\25\ C. Schoen, ``On The Front Lines of Care,'' Ibid.
\26\ R. Amarasingham, et al., ``Clinical Information Technologies
and Inpatient Outcomes,'' Arch Intern Med. 2009; 169(2):1-7.
---------------------------------------------------------------------------
Finally, limited Federal leadership has contributed to uneven
application of quality improvement initiatives and widespread variance
in health outcomes. To date, Federal leaders have not clearly
identified national priorities and targets for improvement, and have
not implemented a Federal system for monitoring and reporting
performance on those metrics. Similarly, no Federal all-payer database
exists for patients who want to know, for example, the survival and
complication rate of their surgeon. In the United Kingdom, this type of
information is available through the Internet.\27\ The U.S. Federal
Government is not currently funding comparative effectiveness research
and has not created a national institute to synthesize research, inform
benefit design, and guide clinical practice. Such steps have been
crucial in value-based purchasing and performance improvement
initiatives in other industrialized countries.
---------------------------------------------------------------------------
\27\ K. Davis, Learning From High Performance Health Systems Around
the Globe, Invited Testimony: Senate Health, Education, Labor, and
Pensions Committee Hearing, (New York: The Commonwealth Fund, January
2007).
---------------------------------------------------------------------------
iii. opportunities and progress
We are fortunate that within our imperfect health care system are
examples of all the components that, properly organized, reformed, and
financed, can enable the Nation to provide high-quality, affordable
care to every American. Systematically applying and disseminating what
we know works would help put the United States on the path to a high-
performance health system.
Several ongoing quality improvement initiatives are contributing to
improving performance in hospitals, physician practices, health plans,
and public programs in the United States. Over the last 15 years, The
Commonwealth Fund has been pleased to support, assess, and disseminate
information on a number of efforts to improve quality. It is impossible
to give a comprehensive catalog of these efforts, here, but I would
like to highlight just a few to give the committee a sense of the
richness of activities underway.
Public Awareness. The Institute of Medicine launched the
modern quality movement with its report, To Err is Human followed by
its report on The Quality Chasm.\28\
---------------------------------------------------------------------------
\28\ Institute of Medicine, To Err is Human: Building a Safer
Health System, (Washington: National Academy Press, 2000); J. Corrigan,
et al., Crossing the Quality Chasm: A New Health System for the 21st
Century, (Washington: National Academy Press, 2001).
---------------------------------------------------------------------------
Measurement of Quality. The National Center for Quality
Assurance has been a leader in the development of measures of quality,
beginning with a HEDIS set of clinical quality measures, collected and
made available at the health plan level. The Agency for HealthCare
Quality and Research has added measures of patient experiences with
care (CAHPS) to the quality measurement toolkit. Specialty and
professional societies have also contributed substantially to the
development of an armamentarium of quality measures.
Endorsement of Measures. The National Quality Forum has
brought an overarching framework to quality measurement through its
endorsement of measures with rigorous standards and its process for
expert input.
Public Reporting. The Congress accelerated public
reporting of quality information by giving the Medicare program
authority to base payment on reporting quality data by hospitals, and
more recently by physicians. The National Center for Quality Assurance
reports on health plan performance on HEDIS clinical quality measures
and patient experiences with care (CAHPS). Its annual state of the
Nation's Health report is a valuable source of information on quality
of care provided to health plan enrollees, including those in
commercial, Medicare, and Medicaid health plans. State and regional
collaboratives have also led in generating publicly available data on
provider performance to be used for three purposes: provider quality
improvement, patient choice, and payer rewards.
Quality Improvement. The Institute for HealthCare
Improvement has pioneered efforts to improve quality of care through
national campaigns and quality improvement breakthrough series. The
Medicare Quality Improvement Organizations have provided technical
assistance and support to hospitals, physician practices, and nursing
homes to improve quality of care. The Commonwealth Fund is striving to
make data and tools useful to quality improvement efforts within
hospitals available through its WhyNotTheBest.org Website.
Pay for Performance. The Leapfrog Group initiated the
first major purchaser effort to reward hospitals and other providers
who met high standards of quality, and maintains a comprehensive
inventory of pay-for-performance initiatives. The Integrated Healthcare
Association (IHA) is a statewide leadership group that promotes quality
improvement, accountability, and affordability of health care in
California, including instituting a system of pay-for-performance to
reward medical groups for improving quality, patient experiences, and
adoption of health information technology. More than half of State
Medicaid programs have elements of paying for performance.\29\ Medicare
demonstrations including the Hospital Quality Demonstration Initiative
and the Physician Group Practice demonstration have implemented and
assessed the impact of financial incentives to improve quality.\30\
---------------------------------------------------------------------------
\29\ K. Kuhmerker and T. Hartman, Pay-for-Performance in State
Medicaid Programs: A Survey of State Medicaid Directors and Programs,
(New York: The Commonwealth Fund, April 2007).
\30\ S. Guterman and M.P. Serber, Enhancing Value in Medicare:
Demonstrations and Other Initiatives to Improve the Program, (New York:
The Commonwealth Fund, January 2007).
As a result of these and many other activities, we have made
extraordinary progress over the last decade in learning about and
improving quality. As noted above, these efforts have borne fruit in
improved quality on selected aspects of care that have been the focus
of improvement efforts--such as reduced hospital standardized mortality
rates which were the focus of the IHI 100,000 Lives Campaign; improved
control of chronic conditions which have been reported at the health
plan level by NCQA for over a decade; and the Medicare-reported
hospital quality measures for heart attacks, congestive heart failure,
and pneumonia.
Yet, wide variation in quality and efficiency across States,
hospital service areas, and providers persists. Nor is there a
systematic all-patient data base that contains the information that
would help patients make informed choices. For example, a patient who
wants to know the cancer survival rate of cancer centers across the
United States for his or her form of cancer has no data base to which
to turn. A patient who wants to know the survival and complication
rates of their surgeon before surgery compared to other surgeons, has
no place to turn in most parts of the United States.
Nonetheless, insight into what it takes to achieve high performance
is provided by examples of excellence within the United States and
around the world. I'd like to highlight some specific examples that
point the way to give the committee a flavor of the innovation that is
currently going on. This includes a description of what two health care
systems in the United States--Geisinger Health System and Denver
Health--are doing to achieve high performance; followed by the
activities of Iowa and Vermont, two States that score well on the
Commonwealth Fund State scorecard; two regional collaboratives which
report quality data and work with providers to improve performance--the
Massachusetts Health Quality Partners and the Wisconsin Collaborative
for Healthcare Quality; and finally health system innovations in the
Netherlands and Denmark.
Geisinger Health System and Denver Health
The Geisinger Health System, on whose board I am pleased to serve,
is a leader in innovation and quality improvement--contributing to its
ranking in this year's NCQA State of the Nation's Health report in the
top five health plans in the Nation and top three participating in
Medicare. In a September 2008 article in the health policy journal,
Health Affairs, Geisinger CEO Glenn Steele, M.D., chief innovation
officer, Ron Paulus, M.D., and I summarized how Geisinger achieves
continuous innovation in health care.\31\ Geisinger is an integrated
delivery system in northeastern Pennsylvania with clinical leadership
that focuses on value creation, measures innovation returns, and is
appropriately rewarded in the market both because it has its own
Medicare Advantage plan and because it is participating in the Medicare
physician group practice demonstration for Medicare patients not
enrolled in plans. Its pilot test of patient-centered medical homes in
two primary care group practice sites has reduced hospital admissions
of Medicare patients by 20 percent. Its erythropoietin pharmacist-
driven care management model for anemia associated with chronic kidney
disease resulted in $3,800/patient/year in drug cost savings. It has
redesigned its care process for coronary artery bypass graft surgery
(``CABG'') to provide ``proven care'' and offered insurers a global fee
with a ``warranty.''
---------------------------------------------------------------------------
\31\ R. Paulus, ``Continuous Innovation,'' Ibid.
---------------------------------------------------------------------------
Geisinger's mission, dedicated innovation and quality improvement
units, electronic health information system, and alignment of financial
incentives through its own health plan contribute to its record of
innovation. Its innovation experience has three implications for
national policy: (1) aligning incentives to reward enhanced healthcare
value creation; (2) recognizing that electronic health records are
absolutely necessary, but not sufficient to create sustainable change
in care delivery; and (3) creating policies that encourage greater
organization of care delivery and collaboration among payers and
providers to foster propagation of innovation that enhances value.
Denver Health, a comprehensive and integrated medical system that
is Colorado's largest health care safety-net provider, has a national
reputation as a high-performance organization. Members of The
Commonwealth Fund Commission on a High Performance Health System
observed Denver Health during a site visit in March 2006, to assess its
operation and determine whether it might serve as a model for other
public and private health care systems around the country.\32\ The
Commission concluded that Denver Health is indeed a ``learning
laboratory.'' It has succeeded at providing coordinated care to the
community, promoting a culture of continuous quality improvement,
adopting new technology and incorporating it into everyday practice,
taking risks and making mid-course corrections, and providing
leadership and support to its staff.
---------------------------------------------------------------------------
\32\ R. Nuzum, D. McCarthy, A. Gauthier, and C. Beck, Denver
Health: A High-Performance Public Health Care System, (New York: The
Commonwealth Fund, July 2007).
---------------------------------------------------------------------------
Since 2003, Denver Health has transformed itself and created a
culture of deliberate improvement. As a result, the organization
adopted specific new processes and tools. For example, it
systematically applied the principles of ``lean manufacturing'' based
on Toyota's approach to streamlining its operations and eliminating
waste. Denver Health has also focused on building its infrastructure
for high performance in two important areas: information technology
(IT) and workforce. The organization's investment in health-oriented
IT, which has totaled $275 million since 1997, has enabled the
establishment of a centralized data warehouse that integrates both
clinical and financial data and allows for standardized reporting. A
single imaged electronic-record format is used across the entire system
so that a patient's information can be retrieved in ``real time'' by
any of his or her providers. To ensure that it has a capable workforce,
Denver Health has restructured its hiring practices to recruit and
retain the ``right people.''
While there are many factors contributing to the overall high
quality of care that Denver Health provides to its patients, the
Commission highlighted several:
Denver Health is an integrated system, endowed with
appropriate tools including an electronic information system and
infrastructure to provide coordinated care to the community.
It has its own Medicaid-managed care plan, and State
officials have been supportive of policies that permit it to use
surpluses from its plan to provide care to a large uninsured and
indigent patient population.
Denver Health promotes a culture of improvement, peopled
by dedicated staff. The decisions are data-driven and feedback loops
allow for continuous quality improvement. Innovation at Denver Health
has strong support at the top.
Geisinger Health System and Denver Health differ in major respects:
one is a nonprofit integrated delivery system in a rural area with a
disproportionate concentration of elderly Medicare patients; the other
is a public integrated delivery system in a large metropolitan area
with a disproportionate concentration of low-
income uninsured and Medicaid patients. But both receive at least a
portion of their revenues on a ``bundled'' capitated rate per person
enrolled and their public/nonprofit, mission-driven organization leads
them to dedicate surpluses gained from eliminating waste and preventing
avoidable complications to improving care. They both have invested
extensively in health information systems. They have dedicated
innovation and quality improvement units that lead the organizations in
continuous innovation and improvement. They are led by clinician
leaders with a commitment to excellence in patient care, while
maintaining fiscal stability of the organization.
Iowa and Vermont
In June 2007 the Commonwealth Fund Commission on a High Performance
Health System released a State scorecard on health system
performance.\33\ This was followed in May 2008 with a child health
State scorecard on health system performance. There was wide variation
across States on health outcomes, quality, access, equity, and cost.
Iowa ranked first on performance of its health system for children and
second on the overall State scorecard. Vermont was second on the
children's health scorecard and fourth on the overall scorecard.
---------------------------------------------------------------------------
\33\ J.C. Cantor, C. Schoen, D. Belloff, S.K.H. How, and D.
McCarthy, Aiming Higher: Results from a State Scorecard on Health
System Performance, (New York: The Commonwealth Fund, June 2007).
---------------------------------------------------------------------------
Many factors help explain why these States stand out. Both have
high rates of health insurance coverage as a result of State Medicaid
and SCHIP policies. They rank highly on children and adults cared for
in patient-centered medical homes. Both have medical schools with an
emphasis on training primary care physicians. And both have a long
history of collaboration to promote quality. Both have public health
departments that are strongly linked to their communities and that have
a mission to serve communities. In both States, public health partners
well with Medicaid and with the private sector, especially in terms of
outreach to pregnant women and young children.
Iowa has a longstanding commitment to children. In the past decade,
the State paid particular attention to the needs of its youngest
residents, from birth to age 5. After piloting a variety of early
childhood preventive programs in the early 1990s to identify and serve
at-risk children and families, the Iowa Legislature established a
statewide initiative to fund designated ``local empowerment areas''
across the State to create local partnerships among clinicians,
parents, child care representatives, and educators focused on
preventive services. The University of Iowa and a substantial portion
of practices in the State have all voluntarily adopted the same EMR
system, which is streamlining referral processes.
The Iowa Healthcare Collaborative (IHC) has also been a key means
through which the State's healthcare community has come together to
improve quality, patient safety, and the value of health care.\34\ By
focusing on transparency and accountability, sharing performance
information and best practices among both health care providers and the
general public, the IHC has driven important progress in clinical
improvement and empowered patients and families across the State. The
collaborative has actively facilitated gains in efficiency by
distributing the tools and principles of the Toyota Production System,
better known as ``Lean,'' on its Website. The group also serves as the
Iowa field office, or ``node,'' for IHI's 5 million lives campaign to
reduce incidents of medical harm. Further quality improvement efforts
include medical home initiatives, establishment of a community advisory
council, reduction of healthcare-associated infections, and support of
rapid response teams.
---------------------------------------------------------------------------
\34\ Iowa Healthcare Collaborative, 2008 Annual Report, (Des
Moines: Iowa Healthcare Collaborative, 2008).
---------------------------------------------------------------------------
The Vermont legislature, in collaboration with public health,
Medicaid and the private sector developed a blueprint for health care
in Vermont. It builds on the Wagner chronic care model, using
measurement and direct support to practices. They have bought into the
medical home idea using NCQA criteria. The State is trying to use
payment reform to drive quality, and is encouraging adoption of EMR and
supporting outreach to help practices implement changes in their micro-
processes (appointments, handling messages, tracking laboratory
results, creating registries). Also, Medicaid and the health plans have
agreed on common measures of quality, which helps the practices focus
on a few things, rather than responding to multiple different
expectations.
Vermont also has long placed a high priority on children. In 1989,
the State enacted the Dr. Dynasaur program, which expanded health
insurance coverage to children up to age 17 in families earning less
than 225 percent of the Federal poverty level, as well as pregnant
women in families earning less than 200 percent of poverty.
In 2006, Vermont expanded SCHIP income eligibility levels for
children in families with incomes up to 300 percent of the Federal
poverty level. Vermont is also home to the Vermont Child Health
Improvement Project (VCHIP), a regional partnership of professional
society chapters; the Department of Public Health; the State's Medicaid
agency; the University of Vermont's Department of Pediatrics faculty;
the Banking, Insurance, Securities and Health Care Administration; and
three Vermont-managed care organizations. These public and private
partners use measurement-based efforts and a systems approach to
improve the quality of children's health care. VCHIP shares lessons
learned and other findings with public health agencies and policymakers
to inform decisionmaking, enhance services, and target resources.
Disease management programs are also being introduced into public
insurance plans.
Massachusetts Health Quality Partners and Wisconsin Collaborative for
Healthcare Quality
Commonwealth Fund-sponsored work shows that open sharing of quality
performance data through public reporting can be effective as an
impetus to quality improvement. Massachusetts Health Quality Partners
has been a leader in collecting and disseminating quality data on
hospitals and physician groups, and educating providers and patients to
use that information to facilitate quality improvement activities.\35\
Formed in 1995, Massachusetts Health Quality Partners (MHQP) pioneered
the collection and public release of data on patient experiences with
hospital care. In the mid-2000s it collected information from the
State's five largest private health plans on the quality of care
provided by 150 medical groups on 15 measures of clinical quality
developed by the National Committee on Quality Assurance (the Health
Plan Employer Data and Information Set, or HEDIS). The coalition then
posted this data in 2006 on its Website to encourage consumers to
search for high-quality providers and guide physicians looking to
improve their performance.\36\ It followed with data on patient
experiences with physician care at the medical group level.
---------------------------------------------------------------------------
\35\ M.W. Friedberg, D.G. Safran, K.L. Coltin, et al., ``Readiness
for the Patient-Centered Medical Home: Structural Capabilities of
Massachusetts Primary Care Practices,'' Journal of General Internal
Medicine, published online December 3, 2008.
\36\ http://www.mhqp.org.
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The Wisconsin Collaborative for Healthcare Quality (WCHQ), founded
in 2003, involves physician groups, hospitals, health plans, employers,
and labor organizations that want to enhance transparency and promote
quality in the health care system.\37\ WCHQ publicly reports
comparative information on its member physician practices, hospitals,
and health plans through an interactive Web-based tool.\38\ The WCHQ
has earned credibility among health care providers because the measures
are reported in ways that allow member groups to identify variation by
physician practice and target areas for improvement. WCHQ also
developed and unveiled a quadrant analysis to demonstrate the
relationship between quality outcomes and risk-adjusted charges. This
innovative approach to quantifying the value each member hospital
provides when caring for patients with specific conditions was
developed in response to the business community's desire for a more
sophisticated measure of a hospital's efficiency.
---------------------------------------------------------------------------
\37\ A.L. Greer, Embracing Accountability: Physician Leadership,
Public Reporting, and Teamwork in the Wisconsin Collaborative for
Healthcare Quality, (New York: The Commonwealth Fund, June 2008).
\38\ http://wchq.org/Reporting/.
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Netherlands and Denmark
A Commonwealth Fund survey of chronically ill adults in eight
countries found that the Netherlands consistently outperformed other
countries, while the United States typically fared worst.\39\ The Dutch
had the highest satisfaction with their health system, the best access
to needed care, the longest relationship with a regular doctor, the
easiest time getting a same-day appointment with their doctor, the
least difficulty getting care on nights and weekends, the best care
coordination and least duplicate tests or missing records, and the
lowest reported rates of medical errors--while the United States fared
worst on all these measures.
---------------------------------------------------------------------------
\39\ C. Schoen, R. Osborn, S.K.H. How, M.M. Doty, and J. Peugh,
``In Chronic Condition: Experiences of Patients with Complex Health
Care Needs, in Eight Countries, 2008,'' Health Affairs, January/
February 2009; 28(1): w1-w16.
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The Netherlands has historically had a strong primary care system
that requires primary care referrals for specialized care. They have an
organized system of off-hours care. Over 90 percent of primary care
physicians have electronic medical records. Peer physicians visit and
audit each others' practices every 3 years. They have an advanced
system of public reporting of quality.
Denmark also places great emphasis on patient-centered primary
care, which is highly accessible and has an outstanding information
system that assists primary care physicians in coordinating care.
Denmark, like most European countries, has a universal health insurance
system with no patient cost-sharing for physician or hospital services.
Every Dane selects a primary care physician who receives a monthly
payment per patient for serving as the patient's medical home, in
addition to fees for services provided. Incomes of primary care
physicians are slightly higher than those of specialists, who are
salaried and employed by hospitals. Patients can easily obtain care on
the same day if they are sick or need medical attention, and an
organized ``off-hours service'' provides telephone consultations (for
which they are paid a fee) and clinic services on nights and weekends.
The patient's own primary care physician receives an e-mail the next
day with a record of the off-hours consultation.
All primary care physicians (except a few near retirement) are
required to have an electronic medical record system, and 98 percent
do. Danish physicians are now paid about $8 for e-mail consultations
with patients, a service that is growing rapidly. The easy
accessibility of physician advice by phone or e-mail, and electronic
systems for prescriptions and refills cuts down markedly on both
physician time and patient time. Primary care physicians save an
estimated 50 minutes a day from information systems that simplify their
tasks, a return that easily justifies their investment in a practice
information technology system.\40\
---------------------------------------------------------------------------
\40\ I. Johansen, ``What Makes a High Performance Health Care
System and How Do We Get There? Denmark,'' Presentation to the
Commonwealth Fund International Symposium, November 3, 2006.
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Primary care physicians prescribe electronically and information
systems provide information at the point of prescribing on the lowest
cost drug available in a given class. Patients pay the difference if
physicians prescribe a more expensive drug. Drug prices are updated
automatically every 2 weeks in physician and pharmacy electronic
information systems.
In many ways what the Netherlands and Denmark have done is not
remarkable--they emphasize primary care and patients are enrolled with
a physician and typically maintain that relationship over a long period
of time. Primary care physicians are paid well, they have reasonable
working hours since they are supported by off-hours systems of care on
nights and weekends, and they have information systems that make it
possible for them to provide highly coordinated care. They are
committed to providing the best quality care for the resources
available. Yet, they spend less than half per capita what the United
States spends. The United States has made other choices--a payment
system that rewards highly specialized care and procedures, financial
barriers that deter patients from seeking care or filling prescriptions
written by their physicians to manage their conditions, no organized
system of care on nights and weekends other than emergency rooms, lack
of investment in health information technology, and inadequate
commitment to transparency and quality improvement.
iv. policy solutions
Health care reform is a unique opportunity to transform the U.S.
health care system. The Commonwealth Fund Commission on a High
Performance Health System has identified five strategies for improving
access, quality, and efficiency:
Provide affordable health coverage for all. The most
important factor determining the ability to obtain health care is
adequate health insurance coverage. The uninsured are much less likely
to obtain preventive care. They are much less likely to fill
prescriptions and to have their chronic conditions controlled, with the
consequence that opportunities are missed to save lives and prevent
disability. In Commonwealth Fund international surveys, the United
States stands out for reported difficulties obtaining needed care. It
is time that all Americans receive the security of health care coverage
enjoyed by citizens of every other major industrialized country.
Providing everyone--regardless of age or employment status--with
affordable insurance options, including a comprehensive package of
benefits, will enhance access to care. This, in turn, will help reduce
disparities in care, increase the proportion of people receiving
appropriate primary care to prevent illness, and improve the care and
health of millions of Americans living with chronic conditions.
Reform provider payment. Our open-ended fee-for-service
payment system must be overhauled to reduce wasteful and ineffective
care and to spur innovations that can save lives and increase the value
of our health care dollars. We need to revamp our system for paying
health care providers--reform that will reward high-quality care and
prudent stewardship of resources, move toward shared provider
accountability for the total care of patients, and correct the
imbalance in payment whereby specialty care is rewarded more than
primary or preventive care.
Organize our care delivery systems. We need to reorganize
the delivery of care, moving from our current fragmented system to one
where physicians and other care providers are rewarded for banding
together into integrated or virtual organizations capable of delivering
21st-century health care. Patients need to have easy access to
appropriate care and treatment information, and providers need to be
responsive to the needs of all their patients. Providers must also
collaborate in delivering high-quality, high-value care, and they
should receive the support needed for continuous improvement. Community
health centers--a major source of care in many low-
income communities--should be assisted in meeting the standards of
patient-centered medical homes.
Invest in a modern health system. The United States lags
behind other countries in the adoption of health information technology
and a system of health information exchange. In such a system, patient
information would be available to all providers at the point of care,
as well as to patients themselves through electronic health record
systems, helping to ensure that care is well coordinated. Early
investment in the infrastructure of a high performance health system--
including information technology, research on comparative effectiveness
of drugs, devices, and procedures, data on provider performance on
quality and affordability, and a workforce that ensures a team approach
to care--is an essential building block.
Ensure strong national leadership. None of the above will
be possible if government does not take the lead. The Federal
Government--the Nation's largest purchaser of health care services--has
tremendous leverage to effect changes in coverage, care delivery, and
payment. National leadership can encourage the collaboration and
coordination among private-sector leaders and government officials that
are necessary to set and achieve national goals for a high performance
health system. It can also help set priorities and targets for
improvement, create a system for monitoring and reporting on
performance
information technology
Congress has already begun to make important investments in the
infrastructure required to improve quality and efficiency in
consideration of the economic stimulus package. While some have
questioned whether information technology will generate significant
health system savings, The Commonwealth Fund report, Bending the Curve,
put the aggregate systemwide savings of promoting health information
technology at $88 billion over 10 years.\41\ The authors estimated that
the cost reductions would result from a lower rate of medical errors,
more efficient use of diagnostic testing, more effective drug
utilization, and decreased provider costs, among other improvements.
Additional savings would likely flow from better care coordination
among multiple providers--and improved chronic care management--that
would lead to a decrease in provider utilization and better health
outcomes. Financial benefits accrue to all payers, with investments in
health IT estimated to result in substantial cumulative net savings to
all levels of government and households over 10 years and cumulative
savings to private insurers after 11 years.
---------------------------------------------------------------------------
\41\ C. Schoen, S. Guterman, A. Shih, J. Lau, S. Kasimow, A.
Gauthier, and K. Davis, Bending the Curve: Options for Achieving
Savings and Improving Value in U.S. Health Spending, (New York: The
Commonwealth Fund, December 2007).
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A recent Commonwealth Fund-sponsored study of health IT in Texas
hospitals led by Ruben Amarasingham of the University of Texas
Southwestern Medical Center has shown that hospitals with more advanced
information technology capacity have fewer complications and decreased
mortality rates.\42\ Amarasingham and his colleagues' findings
importantly show that utilizing IT to automate test results, order
entry, and decision support was not only associated with better quality
but also lower average adjusted costs for hospital admissions and lower
mean hospital costs for a variety of clinical conditions, including
heart failure and coronary artery bypass grafting. Computerized
decision support was particularly effective at generating savings.
Higher degrees of decision support automation was associated with lower
average adjusted costs of $538 for all conditions. If these reductions
were realized among the 37 million hospital admissions in the United
States in 2005, hospitals across the country would stand to save almost
$20 billion a year.
---------------------------------------------------------------------------
\42\ R. Amarasingham, ``Clinical Information Technologies,'' Ibid.
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Modern health care also requires replacing antiquated paper-based
medical records with systems that take advantage of modern health
information technology. Medicare can do its share by joining with
private payers in contributing funds to help those who cannot afford to
purchase such technology on their own--especially safety-net clinics
and hospitals serving uninsured and low-income patients. It can also
create incentives for the adoption of information systems meeting
approved standards, and help establish ``health information networks''
that allow patients and the health professionals that care for them to
have all relevant medical information available at their fingertips.
While such a change requires upfront investment, it would begin to pay
dividends in the future.
primary care
If the United States is serious about closing the quality chasm, it
will need to build a strong primary care system. This will require
fundamental provider payment reform, encouraging all patients to enroll
with a patient-centered medical home that is accessible and accountable
for patient outcomes, and supporting those physician practices with
information technology and technical assistance in care process design
to improve quality and reliability of care.
One important place to start is to ensure that all the Nation's
community health centers meet the standards of a patient-centered
medical home, and have the information tools and technical assistance
necessary to reach benchmark levels of quality. Work by staff at the
Commonwealth Fund has found that racial/ethnic disparities in access to
needed care can be eliminated if patients are enrolled in such systems
of care.\43\
---------------------------------------------------------------------------
\43\ A.C. Beal, M.M. Doty, S.E. Hernandez, K.K. Shea, and K. Davis,
Closing the Divide: How Medical Homes Promote Equity in Health Care:
Results From The Commonwealth Fund 2006 Health Care Quality Survey,
(New York: The Commonwealth Fund, June 2007).
---------------------------------------------------------------------------
comparative effectiveness
Medicare, Medicaid, and private insurers can also ensure that the
care they cover is based on the best and latest research findings on
effectiveness. Insurers should cover all medications, devices, and
procedures that have been scientifically shown to improve patient
outcomes and quality of life. But insurers also should be prudent
purchasers, paying no more for a device or treatment than they would
for another that is equally effective. The Bending the Curve report
estimates that a center on medical effectiveness and health care
decisionmaking could save $368 billion over 10 years, if insurance
benefit design and payment were tied to evidence on cost-
effectiveness.
health goals and targets for improvement
The Federal Government can also raise the bar for health system
performance and help providers get the tools they need to reach the
highest attainable levels of performance. This should start with
setting explicit goals and priorities for improvement--including a
focus on the most prevalent chronic conditions, which account for a
large majority of health care costs.
For example, Medicare could join with private insurers and other
payers to develop a database that lets providers and the public know
how they are doing relative to what is possible. Having reliable
comparative data, adjusted for differences in patient characteristics,
is the first step along the path to improvement. Such a database should
provide timely feedback on how each and every provider--whether health
system, hospital, physician, or long-term care facility--is doing on
quality and health outcome metrics that are tied to achievable
benchmarks. The Commonwealth Fund is helping to support such a tool
through its WhyNotTheBest.org Website with data and tools to improve
hospital clinical quality and patients' experiences.
In sum, experience shows that policies to alleviate the quality
chasm and improve the performance of our health care system must be
multifaceted and mutually re-
inforcing. Work by the Commonwealth Fund demonstrates that it is not
only possible--but critical--to employ strategies that simultaneously
improve quality, reduce costs, and increase access for all Americans.
Armed with the knowledge that the status quo is no longer
acceptable, we have entered a new era ripe with opportunity to close
the quality chasm and improve the health and well-being of American
families. Working together we can change course--and move the U.S.
health system on a path to high performance.
Senator Mikulski. Wow, all that in 5 minutes.
Ms. Davenport-Ennis.
STATEMENT OF NANCY DAVENPORT-ENNIS, CEO, NATIONAL PATIENT
ADVOCATE FOUNDATION, WASHINGTON, DC
Ms. Davenport-Ennis. Thank you, Madam Chairwoman, for the
opportunity to be with you today. Thank you, members of the
panel.
I am Nancy Davenport-Ennis, and I am the founder of the
National Patient Advocate Foundation, which is a policy
organization whose mission is to try to remove and work with
legislators and regulators to inform and improve healthcare
access in America. Our heart lives in Patient Advocate
Foundation, founded at the same time, that provides direct
patient services to patients in each of the 50 States in the
United States.
My testimony is grounded in more than 12 years of
documentation across more than 350,000 closed patient cases,
reporting the concrete gaps and failures in our current
healthcare delivery systems.
I would like to share that my testimony today will focus on
how the use of three specific tools, we feel, could help to
improve the level of quality care that patients receive in our
healthcare system and lead to improved outcomes and better
coordinated care for patients.
They are health information technology, widespread use and
adoption of medical guidelines across all disease areas, and
comparative effectiveness research.
In the area of health information technology, it is known
to reduce medical errors and to improve patient safety.
However, only 25 percent of healthcare providers in the United
States today, as reported in a study released in January, are
currently using health information technology. In other
countries, such as the United Kingdom and Australia, adoption
is at about 75 percent.
In 2006, one-third of patients reported a medical,
medication, or laboratory error during the previous 2 years.
These errors resulted in the unnecessary deaths of nearly
100,000 patients annually, as reported by the Commonwealth
Fund.
NPAF does support health IT funding in the stimulus and
believes that it should be available to all providers
regardless of practice size. We are pleased that today we do
have, through the Certification Commission for Healthcare
Information, 55 electronic health records that have been
certified.
There is no better example of how health information
technology can benefit patients than a story of a 13-year-old
patient whose parents reached out to us. The child had terrific
headaches and uncontrollable vomiting. When she went to her
primary care physician, after X-rays and several tests, they
could not determine what the problem was with the child.
They electronically transmitted her records to a specialist
in a nearby city, where there was a research center. And within
hours, the records were reviewed, and the child was scheduled
to be there the next morning. The child was diagnosed with
Chiari syndrome.
We also feel that medical guidelines afford some degree of
consistency in care that can be delivered routinely and
uniformly. Within the cancer community, guidelines are fairly
routine. The guidelines are developed by panels of experts, and
these guidelines provide us some system to know that when a
treating physician, perhaps in a smaller community, is deciding
what is the best course of care, the guideline can give them
recommendation.
We would also like to say that guidelines provide a process
through which these treatments have been well vetted. We feel
that medical guidelines are based upon clinical trials'
research. A story of a 45-year-old patient who came to us with
a disease that had been diagnosed as incurable. We enrolled her
in a clinical trial at the National Institutes of Health.
Today, Mary Schwartz is disease free 3\1/2\ years after being
told that she had approximately 6 years to live.
This clinical trial information also, we feel, is what is
going to drive the comparative effectiveness research in the
United States of America. We strongly support comparative
effectiveness research and would ask that the panel join us in
supporting clinical focus in that area.
We are pleased to take additional questions.
Thank you, Madam Chairperson and members of the panel.
[The prepared statement of Ms. Davenport-Ennis follows:]
Prepared Statement of Nancy Davenport-Ennis
summary
National Patient Advocate Foundation believes our healthcare system
should incent quality and promote transparency to encourage patients to
be better purchasers of health care. The use of health information
technology, medical guidelines, clinical trials, and comparative
effectiveness research are tools that should be utilized to help
improve the level of quality care Americans receive in our health care
system.
Quality healthcare coverage leads to improved outcomes and better
coordinated care for patients. One tool that has proven valuable to
patients and providers is health information technology. In the United
States, the Veterans Administration (VA) leads in complete adoption of
health information technology (HIT); however, only 10-30 percent of
U.S. primary care providers utilize electronic medical records.
The IOM report, Crossing the Quality Chasm, explains that re-
designing the health care delivery system will require many changes.
One of which, applying evidence to health care delivery, can be
partially addressed with adoption of proven medical guidelines such as
those developed by the National Comprehensive Cancer Network (NCCN).
Clinical research has improved the treatment of various diseases
and has helped doctors make well-informed decisions about what
particular therapy is best for their patients. In cancer, clinical
trial research has vastly improved survival rates for many cancers and
led to improved cancer care. However, according to the National Cancer
Institute, less than 5 percent of adults diagnosed with cancer annually
enroll in a clinical trial.\1\ Broader enrollment in cancer clinical
trials will enable researchers to discover new and better ways to treat
and prevent cancer leading to higher quality cancer care for patients.
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\1\ Boosting Cancer Trial Participation. National Cancer Institute,
February 2006.
---------------------------------------------------------------------------
National Patient Advocate Foundation supports comparative
effectiveness research to determine the comparative clinical
effectiveness of various treatment options for those with chronic and
debilitating diseases. However, it is our belief that using comparative
effectiveness research findings to limit access, deny treatment or
reimbursement will not benefit patients or our healthcare system as a
whole. One-size-fits-all will not help us achieve a high quality
healthcare system since we know that patients can have very different
reactions to certain medications or therapies.
National Patient Advocate Foundation supports the IOM report's
premise that ``narrowing the quality chasm will make it possible to
bring the benefits of medical science and technology to all Americans
in every community, and this in turn will mean less pain and suffering,
less disability, greater longevity, and a more productive workforce.''
______
Prepared Statement of Nancy Davenport-Ennis
Good morning. Thank you, Mr. Chairman and members of the committee,
for the opportunity to testify before you. My name is Nancy Davenport-
Ennis, and I am the Founder of the National Patient Advocate Foundation
and the Patient Advocate Foundation. National Patient Advocate
Foundation is a policy organization based in Washington, DC that is
dedicated to providing the patient's voice in order to improve access
to health care at the Federal and State levels. Patient Advocate
Foundation is a direct patient services organization which provides
case management services to patients throughout the country seeking
information and assistance for access to care issues resulting from a
diagnosis of a chronic, debilitating or life-threatening disease. My
testimony is grounded in more than 12 years of documentation across
300,000 closed patient cases reporting the concrete gaps and failures
in our current healthcare delivery and financing systems.
When the Institute of Medicine published their report, ``Crossing
the Quality Chasm: A New Health System for the 21st Century,'' back in
March 2001, the hope was that doctors, elected officials and patients
would demand that we fix our payment policies which have been
reimbursing for unnecessary and ineffective care, adopt electronic
medical records to help coordinate care in our complex healthcare
system, and provide doctors with independent clinical research to help
guide them when prescribing a treatment protocol. Unfortunately, almost
8 years have passed and progress is moving very slowly. In health
information technology, only 10-30 percent of primary care providers
utilize electronic medical records (EMRs). In other countries, such as
the United Kingdom and Australia, adoption is around 75 percent.\1\ In
terms of treatment guidelines, while we have very specific and notable
guidelines in cancer, that is not the case for many other chronic
diseases in the country where we still lack good scientific and
evidence-based research to guide many clinical diagnoses. There are
gaps in the utilization of treatment guidelines and in the availability
of guidelines for specific patient and/or disease populations, such as
the pediatric population. These gaps impact all healthcare
stakeholders, including the patients I am here to represent.
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\1\ R Atkinson, D Castro & S Ezell. The Digital Road to Recovery: A
Stimulus Plan to Create Jobs, Boost Productivity and Revitalize
America. The Information Technology & Innovation Foundation, January
2009.
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Even though the United States spends 16 percent of GDP on
healthcare, which is more than any other industrialized country, there
is significant evidence that the quality of medical care trails other
developed nations. The United States continues to fall behind other
industrialized countries when comparing various dimensions of health
system performance including: healthy lives, quality, access,
efficiency, and equity. In The Commonwealth Fund's National Scorecard
on U.S. Health System Performance, the United States achieved an
overall score of 65 out of 100. Compared to 19 countries, the United
States now ranks last on a measure of mortality amenable to medical
care. However, the report did show that hospitals are showing
``measureable improvement on basic treatment guidelines for which data
are collected and reported nationally on Federal Websites.''\2\
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\2\ Why Not the Best? Results from the National Scorecard on U.S.
Health System Performance. The Commonwealth Fund Commission on a High
Performance Health System, July 2008.
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Our system often reimburses for services independent of quality
measurements. Currently, many providers lack incentive to promote and
prescribe preventive care for their patients. Addressing these systemic
reimbursement issues could greatly improve the quality of medical care
patients receive. NPAF recommends we undertake reimbursement reform and
include direct processes to incent providers to provide quality care.
In 2006, a study by The Commonwealth Fund found that one-third of
patients reported a medical, medication or laboratory error during the
previous 2 years.\3\ These errors result in the unnecessary deaths of
nearly 100,000 patients annually.\4\ In addition to the deaths that
medical errors impose, the total financial cost of preventable adverse
events, including lost income, lost household functioning, disability,
etc., are estimated to be $35 billion a year.\5\
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\3\ The Commonwealth Fund Commission on a High Performance Health
System, Why Not the Best? Results from a National Scorecard on U.S.
Health System Performance. The Commonwealth Fund, September 2006.
\4\ J Corrigan, L Kohn, M Donaldson, eds. To Err is Human: Building
a Safer Health System. Committee on Quality of Health Care in America,
Institute of Medicine, The National Academies Press, 1999.
\5\ J Corrigan, L Kohn, M Donaldson, eds. To Err is Human: Building
a Safer Health System. Committee on Quality of Health Care in America,
Institute of Medicine, The National Academies Press, 1999.
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The Agency for Healthcare Research and Quality (AHRQ) estimates
that treating the Nation's 10 most expensive medical conditions cost
nearly $500 billion in 2005. The conditions beginning with the least
expensive include: normal childbirth, back problems, osteoarthritis and
other joint diseases, diabetes (type 1 & 2), hypertension, asthma and
chronic obstructive pulmonary disease (COPD), mental disorders
including depression, cancer, trauma disorders, and heart disease. Many
of them--including cancer, heart disease and diabetes--are common,
chronic conditions that may be reduced and in some instances prevented.
Promoting and rewarding high-quality health care will help reduce
unnecessary healthcare spending as we move away from acute, episodic
care needs and towards disease prevention and management.
Transforming our healthcare system into a system that incents high-
quality healthcare services is a long-term initiative, but there are
steps we can take now to improve the care patients receive throughout
the country. In the last 2 years, the World Health Organization's (WHO)
Safe Surgery Saves Lives program implemented a 19-item surgical safety
checklist in eight countries to improve patient care and reduce
complications and death associated with surgery. Similar to the
checklist a pilot runs through before takeoff, surgeons and nurses
participating in the study completed a series of basic safety checks
before and after each operation. The study found that the checklist cut
surgical deaths and complications by a third. Study authors say that
work is already underway to develop additional checklists for maternity
and childbirth, heart disease, pneumonia, HIV and mental health. This
WHO study illustrates that something as simple as a checklist can
improve quality and safety in our healthcare system in ways that will
be of enormous benefit to patients. Study authors assert that few U.S.
hospitals currently use these surgical safety checklists. While various
hospitals and physicians have developed checklists, utilization needs
to be more widespread in our health care system.
National Patient Advocate Foundation believes our healthcare system
should incent quality and promote transparency to encourage patients to
be better purchasers of health care. The use of quality measures,
comparative effectiveness research, medical guidelines and evidence-
based medicine are tools that should be utilized to help improve the
level of quality care patients receive in our healthcare system.
Quality healthcare coverage leads to improved outcomes and better
coordinated care for patients. One tool that has proven valuable to
patients and providers is health information technology. In the United
States, the Veterans Administration (VA) leads in complete adoption of
health information technology (HIT). In addition, institutions such as
the Cleveland Clinic have universally adopted HIT. The American Health
Information Community, a federally chartered advisory committee,
officially certified HIT systems and developed interoperability
standards so that with financial support, such as the funding included
in the economic stimulus, providers can adopt and use HIT thus reducing
medical errors.
The parents of a 13-year-old patient sought the assistance of
Patient Advocate Foundation after their daughter began experiencing
severe headaches that caused extreme pain and vomiting. Even after her
pediatrician ordered X-rays and other tests, no diagnosis was reached.
The family remained concerned, however, and after being provided a disc
which contained all of the tests performed as well as radiology
reports, the parents made an appointment with a pediatric neurologist.
The neurologist and a pediatric radiologist, who specialize in
neurological disorders, were able to review thoroughly the patient's
electronic medical records and all of the tests included on the disc
and to diagnose the girl with Chiari Malformation, an abnormality in
the lower part of the brain. The appointment with the specialists had
been scheduled in very short order due to the immediate availability of
the patient's health record in an electronic format. This example
illustrates how health information technology allows instant access to
medical records resulting in improved patient care.
The National Comprehensive Cancer Network (NCCN) is dedicated to
improving the quality and effectiveness of care provided to cancer
patients. Through the leadership and expertise of clinical
professionals at their member institutions, NCCN develops clinical
practice guidelines appropriate for use by patients, clinicians, and
other healthcare decisionmakers. NCCN guidelines are considered ``the
gold standard'' because they are developed by medical professionals
adhering to strict standards on conflicts of interest. Our healthcare
system should support and adhere to medical guidelines that are
independently developed by skilled medical professionals and free from
conflicts of interest. When assisting patients, case managers at
Patient Advocate Foundation frequently cite medical guidelines when
successfully appealing to insurance companies that have denied a
particular treatment protocol.
NCCN guidelines are practical, up to date, easily accessible online
at no charge, and relevant to a physicians' practice. These guidelines
are developed by panels of unpaid, multidisciplinary experts including
surgeons, nurses, patient representatives, radiation therapists,
hematologists and clinical oncologists, who to date, have developed
over 100 guidelines for therapeutic interventions covering 98 percent
of all cancers. The guidelines specify best practices from a point of
screening and diagnosis, through development of treatment plans,
including all protocols selected, as well as maintenance and follow-up
recommendations. NCCN guidelines also provide specific information
concerning supportive care needed for patients to tolerate and respond
favorably to therapeutic interventions. The American Society of
Clinical Oncology (ASCO) has also developed guidelines specific to
cancer that are focused on technology assessments, which evaluate the
appropriate use of specific therapeutic interventions.
Other disease areas, including cardiology, also develop and utilize
national guidelines. Guidelines are a tool routinely used in the field
of cancer by treating physicians, patients, nurses, social workers and
insurers. In addition, PAF case mangers use guidelines frequently when
assisting patients with pre-authorizations or when negotiating appeals.
Finally, the Centers for Medicare and Medicaid Services (CMS) uses NCCN
guidelines to make coverage determinations about the use of off-label
drugs and biologics in cancer care as well as in technology
assessments.
Patient Advocate Foundation predominantly assists patients with
healthcare access issues, but many patients also have underlying issues
with the quality of care they are receiving. Approximately 78 percent
of patients contacting Patient Advocate Foundation in 2007 had a cancer
diagnosis.\6\ After a serious diagnosis like cancer, many patients wish
to seek a second opinion, but insurance companies are increasingly
refusing to cover this important service. Research conducted by the
University of Michigan Comprehensive Cancer Center found that more than
half of breast cancer patients who sought second opinions received a
change in their recommended treatment plan.\7\ For some patients, a
change in diagnosis and/or treatment results in less-invasive and
higher-quality care.
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\6\ Patient Data Analysis Report. Patient Advocate Foundation,
February 2008.
\7\ University of Michigan Comprehensive Cancer Center, November
2006.
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Clinical research has improved the treatment of various diseases
and has helped doctors make well-informed decisions about what
particular therapy is best for their patients. In cancer, clinical
trial research has vastly improved survival rates for many cancers and
led to improved cancer care. However, according to the National Cancer
Institute, less than 5 percent of adults diagnosed annually with cancer
enroll in a clinical trial.\8\ Broader enrollment in cancer clinical
trials will enable researchers to discover new and better ways to treat
and prevent cancer leading to higher-quality cancer care for patients.
Unfortunately, access to clinical trials is decreasing here in the
United States because many companies are moving their clinical trials
abroad where it is not only less expensive, but where accrual rates are
improved thus allowing trials to close earlier. While this may seem
like a positive development because it may lower the cost of drug
development and reduce the clinical time to accrual completion, our
Nation must address disparities in outcomes from one population group
to another. These very disparities may be extrapolated to the whole
U.S. population who may ultimately engage in the treatment protocols
resulting from the trial. NPAF encourages the Federal agencies to work
collaboratively with manufacturers to address regulatory barriers that
may contribute to the exodus in recent years of these clinical trials.
---------------------------------------------------------------------------
\8\ Boosting Cancer Trial Participation. National Cancer Institute,
February 2006.
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Patient Advocate Foundation assisted a 45-year-old woman diagnosed
with an adrenal tumor who was unable to locate treatment for her rare
cancer. After accumulating nearly $10,000 in unpaid medical bills for
out-of-network care, she was told she had 6 months to live and she
should go home and prepare herself and her family. Immediately after
contacting PAF, the patient's case manager began investigating clinical
trials. PAF was successful in enrolling the patient in a clinical trial
at the National Institutes of Health (NIH); the trial was successful,
and the patient is cancer free today, 3 years after enrollment in the
clinical trial. Unfortunately, many patients are unaware that clinical
trials may be a good treatment option for them and seek less effective
and/or lower-quality care as a result.
Patients seeking the assistance of Patient Advocate Foundation
describe many reasons for not enrolling in clinical trials including:
high costs and/or lack of insurance coverage; trial location; age
restrictions; fear that the trial will reduce their quality of life;
and fear they may receive a placebo. Patient Advocate Foundation
assisted a 30-year-old man diagnosed with stage IV olfactory
neuroblastoma, a pediatric disease that is only seen in 1 percent of
adults, who had difficulty enrolling in an appropriate clinical trial.
The PAF case manager facilitated an agreement with the sponsors of a
pediatric clinical trial at Duke University so that the clinical trial
could be administered at the University of Alabama at Birmingham
Hospital where the patient was located. Enrollment in this clinical
trial ensured the greatest opportunity for control of disease for the
longest period of time.
In 2005, cancer expenditures cost patients, insurers and the
government $69 billion making it one of the top 10 most expensive
diseases. Clinical trials are critical in fighting cancer and improving
the quality of care that cancer patients receive. We must strengthen
our efforts to enroll patients in clinical trials if we wish to
understand and effectively treat some of the most costly diseases.
The IOM report, Crossing the Quality Chasm, explains that re-
designing the healthcare delivery system will require many changes. One
of which, applying evidence to healthcare delivery, can be partially
addressed with adoption of proven medical guidelines.
National Patient Advocate Foundation supports comparative
effectiveness research to determine the comparative clinical
effectiveness of various treatment options for patients with chronic
and debilitating diseases. However, it is our belief that using
comparative effectiveness research findings to limit access, or deny
treatment or reimbursement will not benefit patients or our healthcare
system as a whole. A one-size-fits-all approach will not help us
achieve a high-quality healthcare system since we know that patients
can have very different reactions to certain medications or therapies.
Moreover, denying access to some of the newer and/or more expensive
treatments will only move us further away from personalized medicine
which should be our ultimate goal. As we continue to learn more about
genetics and gene profiles, science will enable us to further tailor
medical care to an individual's needs which will benefit patients and
payers by eliminating ineffective and sometimes costly treatments.
Comparative effectiveness research should be used as a tool for doctors
and patients to determine the best course of action for individual
patients. Similar to clinical trials, comparative effectiveness
research and medical guidelines must be sensitive to different patient
populations since we know that ethnic populations react differently to
medical treatments, as do patients with multiple co-morbidities.
In addition, National Patient Advocate Foundation strongly
advocates that all relevant stakeholders, including patient and
consumer groups, representatives from the public and private sectors,
such as government, physicians and other healthcare providers, medical
specialists, insurers, and manufacturers of drugs and medical devices,
should be involved in every step of the process, from setting the
research agenda, and developing study methodology, to the translation
and dissemination of findings.
National Patient Advocate Foundation strongly supports the goal
stated in the IOM report:
``Narrowing the quality chasm will make it possible to bring
the benefits of medical science and technology to all Americans
in every community, and this in turn will mean less pain and
suffering, less disability, greater longevity, and a more
productive workforce.''
Senator Mikulski. Well, those were excellent examples, and
each one with such specific recommendations.
I am going to go to a broad-based question that perhaps all
could jump in on. Just a brief comment, and then get to my
question, because it goes to case management.
My background is that of a social worker. I was a foster
care worker, and I was a child abuse and child neglect worker.
The key to helping a family was ongoing, intrepid, and
unrelenting case management.
Here goes my question. Dr. Beale, you talked about
behavioral medicine, and often that is synonymous for mental or
emotional illness or challenges. Also the biggest thing, in no
matter what is diagnosed, is compliance with what you are
asking the patient or the family to change, even if it is the
treatment of cancer and so on.
No. 1, how do you motivate people to comply? How do you
stand sentry in a free society without being a ``health nanny?
'' Because we don't want health nannies or health nags, we want
compliance.
Also with our practitioners, no matter how dedicated and
duty-driven, given the demands of time, they will see a
patient, and they will pass them on, and nobody keeps track.
Dr. Cassel, I am going to open with you to share your
thoughts on the much talked about medical home. Tell me what
you think that means, and do you agree that compliance and
follow-through is a significant part of that? And should we
have a human being, or can we do it with HIT, which is being
talked about all the time?
Can we have a techno-case manager? Do we need a human being
as a case manager? And is a primary care physician really able
to be a case manager?
Dr. Cassel. Thank you, Madam Chair.
Those are excellent questions, and I think the one-sentence
answer is that the techno-case manager won't do it alone. You
need to have human beings enabled by technology, and then the
reach can be much farther.
I completely agree with you about the importance of
compliance, although I personally prefer other terms that
suggest that it really is a partnership between the clinicians
and the patient. There actually is research that shows that if
there is a better relationship between the doctor and the
patient, the patient is much more likely to comply with the
recommendations of the treatment.
Sometimes it is just a matter of not really understanding,
not really having somebody who can answer your questions, not
really being able to juggle the requirements of the treatment
with all of the other requirements of your life.
What the case manager helps you to do is to understand that
interface between the patient and family and their life and
what the doctor thinks they should do. And the doctor--you are
absolutely right. A primary care physician in a one- or two-
person practice is not going to be able to be a medical home
with just the addition of an electronic medical record.
That is why the emphasis on the team. You have got to have
people who can actually have that interaction, proactive
interaction, with the patient to be able to make that phone
call, and ask, ``How are you doing? Do you have any questions?
'' Respond to their needs. Understand what their situation is
in the community.
You probably know better than anyone, a social worker is
the best person to really do that. A social worker and a nurse
and a primary care physician together would be my idea of the
minimum for what would really constitute a medical home.
If they then have the technology to connect to all of the
other specialists and maybe even do e-mail with the patient and
other kinds of communications with the pharmacy, then that is a
truly empowered medical home.
Senator Mikulski. Well, Dr. Cassel, do you think that is
realistic? The whole discussion will be to expand the concept
of primary care.
Dr. Cassel. Right.
Senator Mikulski. If we look at the Massachusetts model--
and others could comment on it--do you think it is a realistic
expectation that a primary care operation, the physician's
office, would have exactly what you said?
First of all, social workers are usually not even included
in the discussion.
Dr. Cassel. Right.
Senator Mikulski. They are included because, quite frankly,
I am here.
[Laughter.]
Dr. Cassel. Well, you are talking to a geriatrician. So the
social worker is our best friend.
Senator Mikulski. And we would be a hell of a team.
Dr. Cassel. Right. But let me answer your question, because
I think that the large physician practices--and Karen Davis
will tell you this. The Commonwealth Fund Commission has really
looked into this. That is why there are great advantages to the
scale of a large, integrated system of care.
The real challenge for the medical home will be how can you
get small practices who aren't used to practicing in that
setting to have some kind of virtual team coming together even
in rural areas to offer those kinds of services to their
patients?
I believe it can be done. But I don't think that doctors
alone can do it.
Senator Mikulski. Well, my time is up. Dr. Davis, do you
think you could fill us in there?
Dr. Davis. There are some practical models. In North
Carolina, Community Care of North Carolina is a network. The
State is divided into 15 regions. The Medicaid program funds
the network, which are social workers and nurses to work with
the physician practices in that region to do exactly what you
have said about case management.
At the Geisinger Health System in Pennsylvania, they are
large enough that their health plan pays the salaries of nurses
who are embedded in physicians' practices and responsible for
working with Medicare patients who are high risk, have complex
problems.
But the key, as Dr. Cassel said, is trust in the physician,
a good relationship, and then adding to that these extra
services that can work with patients who have very difficult
problems to handle.
Senator Mikulski. Not extra, integrated? They are not extra
services. They have to be integrated services.
Dr. Davis. Right. Integrated services.
Senator Mikulski. They have to be viewed as an essential
part of primary care, not ``isn't it swell if we could afford
it? ''
Well, my time is up. Let me turn to Senator Dodd, and
hopefully, we will have time for another round. That was just
the kind of exchange I had hoped for.
Senator Dodd. Yes, that is great. Madam Chairman, thank you
very much again.
Thank you to our panel of witnesses. You are just excellent
witnesses and are providing a tremendously valuable service.
Obviously, the challenge in many ways to our healthcare
system is how we promote quality, achieve value, and ensure the
system is equitable. In many ways, those three elements will
have a lot to do with bending that curve on cost, even though I
think all of us recognize there are going to be some up-front
costs we will have to make.
If we promote the ideas of quality, value, and
equitability, I think you have a chance of really moving in
that direction.
I just want to mention, Madam Chairman, I have started last
week a series of town hall meetings in my own State on
healthcare, inviting the people of my State to come and talk
about what they anticipate and what they would hope would be
achieved with healthcare reform.
As all of us know on this side of the panel, you never know
when you hold a town meeting what is going to happen. Seven
hundred people showed up at 8:30 a.m. on a Friday to come out
and talk. We thought maybe 100 people might show up to come and
talk about it.
The issues they raised are ones you have been talking about
here today--the need for improved patient incentives for
primary care. We need to recruit and retain primary care
providers. A good deal about eliminating duplicative,
unnecessary testing, these various items that people raise all
the time.
Obviously, expansion of health information technology, and
again, the numbers from the Commonwealth Fund or others, we
have all used them. I used them last Monday. It is a staggering
number. Every time I say it, I can't believe I am accurate.
That 98,000 people lose their lives every year in this country
because of medical errors, it is just a stunning number. When
you think we are in the 21st century and this is going on in
the United States, it is really hard to believe.
I was pleased to see--and I know that Senator Mikulski and
others had a lot to do with this. I know Senator Kennedy did as
well. The $23 billion investment in health IT that is in this
stimulus package that is moving its way through here.
While people complain about various aspects, when we hear
about sod on the Mall and so forth, I wish they would talk as
much about putting resources, in the health IT area. It would
make a huge difference.
I have a number of questions, but let me focus on two
quickly, if I can. In Connecticut, we have the Help Me Grow
program. I know, Ms. Davis, you are very familiar with this,
and I want to mention it because it has been a tremendous
success.
This is a statewide program in Connecticut since 2002. It
is a comprehensive, statewide coordinated system of early
identification and referral for children at risk for
developmental or behavioral problems. We are now serving about
4,000 at-risk children in Connecticut per year as the care
coordinator so that these children access and receive
healthcare services, including preventive screenings and
treatments.
A fellow by the name of Dr. Paul Dworkin, who I know you
know, and the Connecticut Children's Health Medical Center,
among many others, are doing some tremendous work. In fact,
Commonwealth Fund has recently given them a grant to help
replicate the Help Me Grow model in five States across the
country because of their success. Polk County, IA, Orange
County, CA, already have programs that are up and running.
Dr. Dworkin and his colleagues' program is really a model,
Madam Chairman, for changing our current healthcare delivery
system for children, which is what we have been working on this
week and the votes we will be cast in a few minutes on the CHIP
program and are indicative of our interest in the subject
matter.
In doing so, they have identified two critical gaps in the
current system. First, they found that care coordination is
critical. It is the critical missing element to the current
care model for children. And second, they have cited a need to
establish and promote a mid-level assessment capacity for
screening at-risk children and intervening quickly where
necessary.
I wonder, Karen, since this is something you are so
familiar with, that you might comment on these observations and
provide your recommendations on how to implement them in the
context of healthcare reform?
Dr. Davis. Yes, the Help Me Grow program is a very
important model. That also picks up on Senator Mikulski's point
that any pediatrician, any parent can call this toll-free
number and make sure that that child gets the services that
that child needs.
It is a way of not putting all of the burden on the
pediatrician to know everything that is available in the
community, but to make it very easy to make that linkage and
then have absolute certainty that they will follow up and
connect that child or that parent with the necessary service.
It is an excellent model.
Senator Dodd. Yes. I wanted to jump quickly because the
long-term services and supports, Dr. Cassel, they are a
particular interest of Senator Kennedy's. It is an interest, I
know, of Senator Mikulski's and mine as well. There is some
debate as to whether or not--as we talk about universal
healthcare reform--whether or not long-term services are going
to be a part of that. That is an ongoing debate around here as
to whether or not it should be.
I am an advocate of it. I think it is critical if we are
going to have universal care that we provide long-term care and
services and support. I just wonder----
Senator Mikulski. Can I ask you what you mean by ``long-
term services? ''
Senator Dodd. Well, providing the kind of living conditions
where people don't need much necessarily, but need some. You
have a graduated care process as their health conditions
deteriorate, but they don't have to wait until they absolutely
reach the point where there is very little options for them.
They can have longer lives.
Senator Mikulski. You mean the continuum, all the way from
independent living----
Senator Dodd. Yes. Right.
Senator Mikulski [continuing]. Supportive at-home health
services.
Senator Dodd. Absolutely. Choices, where people have
choices, they can make as well. We have an aging population.
The great news is people are living longer, but they want the
quality of life to be there as well.
I can't imagine us having a universal healthcare reform
package and not including a long-term support and services for
people.
Senator Mikulski. Absolutely.
Senator Dodd. I wonder if you might just, in the context of
our discussion here today, comment on that as well, since I
know you have done so much work in this area.
Dr. Cassel. Well, thank you, Senator Dodd. I appreciate
that.
I have often thought it was kind of a blind spot in our
health policy world that people didn't want to include long-
term care in these discussions. Yet, I think it is also a place
where we can get tremendous advances in affordability by
coordinating acute and long-term care services.
There is a place where there is both huge redundancies and
also huge gaps in care, huge opportunities for errors to occur
when the long-term care providers aren't talking to the acute
care providers, and vice versa. There is huge amounts of data
on that.
There is both outcome reasons, but also financial reasons
to bring them together. One is Medicare. One is Medicaid. They
don't connect financially so you have the silo problem that
Senator Mikulski mentioned earlier.
In fact, I believe, if you look at models from other
countries, which the Commonwealth Fund has done, that you can
get real efficiencies as well as better quality of care if you
actually take it on as a part of the care and try to figure out
a way to do that.
Senator Dodd. Yes. You know, one point, and my time is up.
Someone made, I thought, a very wise suggestion. And that is to
begin, in Medicare, providing screening and prevention to
people at the age of 55. I know there is talk about moving the
enrollment age down to 55, but I don't know how much support
there might be for that.
But certainly to begin to provide prevention to people at
age 55 rather than waiting until they are 65 so that you begin,
you can start treating people in anticipation, before something
becomes an acute chronic illness. Having the ability to
intervene at an earlier time and save an awful lot.
If you are not impressed by the ethical question, certainly
the financial motivations ought to be there to promote that
idea.
Senator Mikulski. Senator Dodd, there are a couple of
issues here. One is the management of chronic illness. And that
could begin at any age.
For example, the autistic child would have, even through
early adulthood, these kinds of living arrangements, graduated
living arrangements for independence. But then there are other
kinds of challenges, such as the management of diabetes. And
all those illnesses that have the underpinnings of
inflammation, which can cause even Alzheimer's, etc.
One is the management of chronic illness, and then the
other, though, is when you are getting older and you do go from
independent living to supportive services at home to the need
for assisted living to perhaps a more substantial in-residence
thing. Those are two separate things, but they need to be
viewed as the continuum. You are onto something.
One of the things I would like to suggest, as we then move
on to our colleagues, we are coming up on the 20th anniversary
of legislation you and Senator Kennedy helped George Mitchell
and I do, which was the anti-spousal impoverishment
legislation.
Do you remember the old Reagan rules of spend down--or I
should say David Stockton rules--so you only had $3,000 left in
your bank account before you could get Medicaid. We changed
those laws so that you could keep more of an asset, as well as
your family home or your family farm.
It was meant to be a down payment. It is now the 20th
anniversary coming up, and nothing new has happened.
As we look through this, I would like to join with you and
our colleagues on both sides of the aisle to say it is nice to
have the 20th anniversary, but what is the new thinking that
can really look at not only the issues around financial assets,
but what are we going to do with people with the need for long-
term care?
It shouldn't be at home or nursing home as your only two
choices. We have got a lot of work to do and a lot of Senators
who want to ask questions.
Senator Dodd. Well, we can submit some questions.
Senator Mikulski. Absolutely. Please. Your full statements
will be included the record.
We are going to go according to seniority. Senator Casey
and then Hagan and Merkley.
Senator Casey. Chairwoman Mikulski, thank you for calling
this hearing and for your leadership on the whole host of
issues we are talking about today.
I am going to be very brief. I have to be in the chair in
the Senate. The place doesn't operate unless someone is in the
chair. I will probably be below 5 minutes.
It is difficult to choose here because we have great
questions for a wonderful panel. Dr. Cassel, if you will pardon
me, I know you have roots in Philly, but the Geisinger plan was
mentioned over here. I have got to ask a quick question about
that. Then I will run out the door.
To Karen Davis, I wanted to ask you about Geisinger in
terms of their health IT system. Dr. Steele will be glad that I
mentioned it, but I am serious about the importance of it.
How do you see that model and the methodology--the way they
set it up, the way it has been implemented and effective, I
think, very effective--how do you see that playing out on a
national scale? That is part A. Part B is the challenge on
balancing that kind of technology with privacy.
Dr. Davis. Well, thank you very much. I should say that I
am on the board of the Geisinger Health System, a nonprofit
system.
I obviously think it is a terrific model, and the IT, which
they have had for over 10 years, facilitates quality
improvement. But the fact that they have a dedicated innovation
and quality improvement unit makes all the difference.
Again, it is not up to the individual physician to figure
out how to have systems that make sure every diabetic gets
appropriate care, that makes them provide perfect care for
coronary bypass surgery. They really re-engineer their care
processes and build it in.
So the question you raise is about how do we do this on the
national basis? I think, first of all, we need to provide
incentives for integrated delivery systems to flourish and give
bonuses, as Dr. Teisberg has said, for performance on health
outcomes and results.
Second, I think many of the smaller practices are going to
need financial help with IT adoption. That is why what you are
doing in the stimulus bill is very important.
But the third point is I think they are going to need
technical assistance. A big system like Geisinger, with 750
physicians, they have an organization that helps them adopt
these changes that let them provide better care. We are going
to need either to change the way we fund the quality
improvement organizations in Medicare and charge them with this
task or to fund models like they have in North Carolina of an
infrastructure of support.
I think it is not enough to have the IT. That makes a lot
of good things happen, but you need more than that.
Senator Casey. Thank you very much.
Senator Mikulski. I am going to turn to the Senator from
North Carolina. We have been hearing so much about it.
Senator Hagan.
Senator Hagan. Thank you, Madam Chairman. I also thank you
for my offer to move up in seniority, but I was kind of worried
somebody else might come in. I had so many papers. I decided
just to stay right here.
This is an excellent panel, and actually Dr. Allen Dobson
was here last week specifically talking about the community
care centers in North Carolina. My question relates, too, to
the health information technology.
I know that in the reports I have read, we know that that
is probably a very, very important tool, and I understand that
the Veterans Administration is using that quite a bit now. I
was budget chairman in North Carolina for a number of years, so
I am very familiar with the community care centers.
One of the things that we also talked about quite a bit was
actually having physicians with a palm-held device that, as
they are prescribing medication, they can find out what other
medications the patient is currently taking, what the
contraindications are. It would reduce, No. 1, fraud, but also
any medical errors that might take place.
As sort of a roundabout question--and I guess this is
directed to Ms. Davis--can you tell us anything about what the
VA is doing in relation to this? And then if there is any very
cost-effective model such as hand-held devices, that would help
in implementation that wouldn't cost a whole lot of money
immediately? To start getting special small practices and the
individual silos actually onboard at an earlier point in time.
I think we have got to be moving toward health information
technology across the United States in order to be sure that
the quality of care can be handled in an appropriate fashion.
Dr. Davis. Well, I am sure Dr. Cassel can also comment on
the electronic prescribing. It certainly is a very powerful and
low-cost approach to eliminating medical errors, eliminating
the handwriting problems.
Decision support--suggesting to the physician a different
medication that because a patient has an allergy or because
maybe there is something at a lower cost. That is a system they
have in Denmark, where the doctor is told, when they prescribe
electronically, there is a lower cost drug that is equally
effective.
But on the VA, first of all, the records do show that their
health outcomes, quality indicators are above the rest of the
United States. They have just done an extraordinary job over
the last 10, 15 years.
One simple example, they are doing home monitoring of
patients with chronic conditions. The person at home enters
information every morning in a pad by the phone. If they don't
do it, the phone rings, and they get asked that information.
Then nurses, again, are monitoring that information, and
red lights go off if the patient is out of control or getting
into a yellow danger zone.
So, yes, there are a lot of applications that really can
improve care. I think there are others here who may be familiar
with it.
Ms. Davenport-Ennis. Senator Hagan, I would like to also
answer your question, if I may, having served on AHIC 1.0 for
the last 3 years and working in this particular area.
In the VA, I think we know there are two major advantages.
Not only do they have electronic health records domestically
and internationally where we have troops, and they do use the
hand-held devices. Literally, if a patient is injured today in
Iraq, we know within moments the medical record while our
people are standing with him to evacuate him.
In the United States, we have also moved the VA population
to the use of personal health records. By doing that, the very
example that we were citing with the home health monitoring,
through the PHRs now the patients are getting prompts of
appointments that they need to follow. Medications--if they are
having any types of side effects or adverse events these are
immediately recorded. And there is immediate intervention.
When we look at the VA model, certainly I think all of us
in the country feel it is the most complete and ideal model. I
think we have a significant step to get from there to taking
the remaining 75 percent of providers to get them into some
form of utilization, and dollars will certainly help us do that
through the stimulus.
Thank you for your consideration of that when it comes to
the Senate.
Senator Mikulski. Senator Hagan, do you have a follow-up
question?
Senator Hagan. Do we have time?
Senator Mikulski. If you have a short question.
Senator Hagan. Well, it was concerning the nursing
shortage. I think that at least in North Carolina, it is
certainly an issue that we have grappled with for quite a
while, and one of the issues has to do with the qualification
of the nursing instructors to be sure that they have either the
master's or the Ph.D.
Many people can earn more money than at that level, and it
is just sort of a compounding problem. I know that money,
obviously, will help some of it. We know, too, that nurses are
very responsible for a lot of this care. But do you have any
other ideas or suggestions on that?
Dr. Teisberg. It is a great question. In all of the follow-
up work that we have done in the 2 years since ``Redefining
Healthcare'' published, we have worked with groups implementing
the idea of how to do integrated multidisciplinary practice,
which includes, of course, nurses and social workers and
others.
One of the things we have found is there is tremendous
leverage on the pressures on nurses and doctors when you
actually put together team care around patient needs rather
than simply structuring things by medical specialty.
When Ms. Davis tells you that we need organization and
delivery done differently, she is absolutely right. If you
organize a team around the patient needs, then you have these
other roles. I call them a ``compagnie autour,'' which is what
they get called internationally.
But it can be a nurse. It can be a social worker. It can be
a family member. It can be a community member. You end up with
additional members of the team who provide a lot of those
coordination services that today fall on nurses but don't
necessarily require a nursing degree.
As we move to truly patient-centered care, truly
coordinated care around multidisciplinary teams, we have other
options, and they provide leverage. So instead of forecasting
forward shortages with a ruler, we create a different set of
possibilities.
Senator Hagan. Thank you.
Senator Mikulski. Senator Hagan, in the economic stimulus
package, along with a beginning investment in health IT, there
are also additional resources to deal with the nursing
shortage, again making the down payment in anticipation of the
changes that we hope to achieve over the next couple of years
in the area.
None of this is throwing money at anything. The health IT
is not only to get some of the investments going, but the
language to ensure interoperability so we don't have a techno
boondoggle.
In the area of nursing shortage, all the work shows that we
don't have a shortage of talent, and we don't have a shortage
of people who want to go into nursing. We have a shortage of
people who teach the people who want to go into nursing. We
make some investments in that area at our wonderful university-
level 4-year programs and also at the community college level
for our 2-year nursing graduates that, again, could perform
many of these vital functions.
We would like to visit with you even on the vote to discuss
it. So we invite you in dealing with this.
Now we are going to turn to our new Senator from Oregon,
Senator Merkley.
Senator Merkley. Thank you very much, Madam Chair.
Thank you for your presentations. Many of you have dealt in
some aspect with ``results-based'' healthcare, and there is a
pilot project in Oregon that is set up like this.
They provide a quarterly report, and the clinic receives
bonuses based on three tiers. The first tier is really for
participating in the pilot, sending the data, compiling the
data, helps compensate them for their cost.
The second is for improvement in access and in--you all can
help me with this term--but H-E-D-I-S? HEDIS? HEDIS benchmarks,
reaching those benchmarks for progress. The percent of the
population that receives preventive care. For example, are
diabetics getting their blood sugar level testing, etc?
A third is for benchmarks such as avoiding emergency room
visits, hospital visits, and so forth.
I am not sure if any of you are familiar with this model or
if it is very similar to ones you are familiar with. Is this a
type of strategy that is worth experimenting in and that makes
some sense?
Dr. Davis. I would like to learn more about it. I think the
third tier is pretty unique. I would like to learn more about
that.
In California, the Integrated Healthcare Association has
the first two tiers. All the major health plans reward medical
groups for reporting data, adopting information technology.
They give bonuses for doing the preventive care like the Pap
smears.
I haven't heard of an initiative that really rewards
avoiding ambulatory-sensitive hospitalizations, reduces re-
admissions by reducing complications, or is sufficiently
accessible 24-7 that people don't have to go to the emergency
room.
I think that is very, very interesting. I would like to
follow up with that.
Senator Merkley. Thank you. I would be delighted to follow
up with you and learn more about how that compares to other
experiments around the country.
Any other thoughts or comments on that?
Ms. Davenport-Ennis. I think the comment that I would like
to make to you, Senator Merkley, is that from the patient
perspective, if that model, indeed, can be successful, it means
that mom and dad and children can get care in the community and
with their primary care physician.
When that happens, we see there is usually greater
compliance to care and less cost involved. We hope that model
can work.
Senator Merkley. Thank you.
Dr. Teisberg. Yes, I would add that as you are looking to
measure quality to drive results-based care that you want to
make sure that you are measuring results. In Minnesota, when
they measured processes such as did the patient get their blood
sugar measured, they got very good process compliance. Then
when they checked to see whether the outcomes for patients had
actually improved, they discovered that the outcomes were not
what they were hoping for.
When they started measuring the results--was the HbA1c, the
blood sugar level, below the threshold? Once they were
measuring the result, the percentage of patients who actually
achieved the result more than doubled in the first couple of
years of reporting.
Measuring processes alone may not get the results that you
want because you actually want to get the health results so
that you do avoid the complications. You want to set up a
situation where they are not just getting to the doctor, but
they are actually not needing amputation, not going blind, not
having heart attacks. You want to get clinically meaningful
outcomes.
Senator Merkley. Thank you.
To that point, there is a former governor of Oregon, and
this governor, Governor Kitzhaber, heads a group called the
Archimedes Movement. This is about evidence-based practice, but
also about finding ways to pay for, if you will, the course of
treatment as opposed to the set of procedures. Does that fit
with what you are saying?
Dr. Teisberg. Yes, absolutely. What we have talked about is
creating payment for the cycle of care rather than for the
pieces, that there are just tremendous efficiencies in
coordinating care. This is the essence of why care needs to be
reorganized into integrated practice units around the common
sets of medical circumstances that patients face.
Senator Merkley. Can you help us get a clear vision of how
one actually does that on a practical level? A patient comes in
who has--maybe you can give us an example of a problem, and how
the difference between how you would pay for the procedures and
pay for this cycle of care?
Dr. Teisberg. Yes, think about a patient with diabetes. A
patient with diabetes would often--Type 2 diabetes would often
also have hypertension, also have vascular problems. From my
perspective, if I were a patient with diabetes--thank goodness
I am not. If I were, that would be one medical condition, not
three or four. We need to think about it from a patient
perspective.
Then we can--our DRGs right now are too narrow. We think
about these in pieces.
Senator Merkley. And DRG is? For us outside the profession.
Dr. Teisberg. I am sorry. That is the payment structure
that is used in hospitals, and then we have a payment structure
used for outpatient, RBRVS.
They are set up in these narrow buckets that you are
talking about, and what we need to do is allow for teams to be
paid for wider episodes of care. It would be common in other
services, other businesses to do it that way. If we set up
payment around the cycle of care, around the episode, rather
than around the individual procedures or interventions, then we
can do it.
One of the reasons for measuring results by teams rather
than by individuals is to pull people together that way. My
written testimony talks about restructuring payment. I didn't
talk about that orally because it is short.
Senator Merkley. I appreciate very much your input. Thank
you.
Senator Mikulski. Well, we are just concluded about 3:10
p.m., and I know the votes will be beginning shortly. This has
been a very, very informative panel.
Before I conclude, I want to go back to Dr. Robinson-Beale
and her startling statistic of the number of people on
antidepressants. Doctor, could you repeat that number? I think
it was between 9 percent and 17 percent?
Dr. Robinson-Beale. Nine percent and seventeen percent.
Again, I am basing that not only on the work that we have done
at United, but also in other venues where I have been, where it
seems to be consistent. That is what is alarming.
Where you have 9 percent to 17 percent of the medical
population--that is the population that is seeking medical
care, so there is a claim out there--that are on antidepressant
medications.
Even if you assume, and we have done a little bit of study
on that, that maybe 20 percent are on those mediations
needlessly, that is still a staggering number of individuals
who are being treated for forms of depression and anxiety in
the primary care arena.
Senator Dodd. Barbara, can I just--why is that? Why is
there such a disparity in that number? I would understand 9 to
17 is a rather large gap.
Dr. Robinson-Beale. It depends upon, one, the type of
practice that you are looking at, also the type of individuals.
We see a big difference in terms of access to behavioral
healthcare depending upon whether the person is blue collar,
white collar, whether or not they are living in certain parts
of the country.
In New York and in California, where it is stylish to seek
a mental health therapist because it is just a nice thing to
have, you have higher incidence of people accessing care. Those
variations are not uncommon. I think the staggering thing is
that it is much higher than any other chronic medical illness
that you have out there in terms of the prevalence.
Senator Mikulski. Are you saying that there are more people
on antidepressants than, say, insulin or insulin-resistant
drugs, going back as we used diabetes as an excellent example
of a chronic condition?
Dr. Robinson-Beale. What I am saying is that when we look
at those numbers, I am saying that in your diabetic population,
40 percent to 42 percent of those individuals will have
depression. We are finding more and more there is a close----
Senator Mikulski. No, no, no. Here is my question.
Dr. Robinson-Beale. OK.
Senator Mikulski. Do they have depression, or have they
been given antidepressive medication? I don't consider those to
be the same thing.
Dr. Robinson-Beale. Sure, and let me answer it this way.
The dispensing of an antidepressant medication is linked to
many times a physician who feels that they see someone who has
some symptoms of depression. It doesn't mean that they
necessarily have major depressive disorder, which is one of the
DSM-IV diagnoses, but it is very clear that they have
depressive symptomatology.
We have found that even treating mild or moderate
depression that you will get a tremendous improvement in that
individual's compliance with--for diabetes, there was a lot of
work done on that in terms of medication adherence, in terms of
their diabetic medication, also compliance in terms of
following through on their medical regimes.
It doesn't change their habits as it relates to exercise,
unfortunately, or maybe diet compliance. But it does have a
great deal to do with their compliance as it relates to medical
regimes.
Senator Mikulski. Well, that is also what Dr. Teisberg has
been talking about, which is to measure the outcome. So for a
diabetic, you can measure whether you are taking your blood
sugar every day.
One of the keys to chronic management, Dr. Cassel would
say, is aggressive testing. It is a tried and true technique.
You might have started, when you found this out, at an A1c of
8.5. That is a little scary. That is up over 200 points.
Everybody works hard. You might get your A1c down to 7.5.
Under the ADA guidelines, you want to be 7.0 or down to 6.5 or
6.0. Is that right?
Dr. Cassel. Not always.
Senator Mikulski. Not always. OK, but I want to go to this
point, which goes to the team approach. One of the things, and
again, just in reading, my general reading in some of this
testimony and others today, there are certain issues where
depression sometimes appears when people find out they either
have a problem or the circumstances in their life that are
triggering other traditionally medically diagnosed issues are
causing great either anxiety or depression.
That then takes the team approach in terms of the
appropriate medication, but without getting to the underlying
symptom. A woman could come in and have terrible symptoms of
depression, but it could be that she is a victim of wife
beating and abuse. What she needs is a shelter and a way out
along with the temporary bridge to bring her over.
There is talk of people, as you know in the geriatric
population, the issue of depression versus Alzheimer's. Many
patients who are diagnosed with Alzheimer's get depressed
because they have Alzheimer's, which is a natural reaction. So
they need a lot of help.
The point, with her statistic and your case management,
would go to this more comprehensive approach. We can't expect a
primary care physician to do it all and to do it all by him or
herself. They need to be using other specialists and other
people to work with other aspects of the patients overall
condition.
When we are talking about reforming healthcare, we have got
to really get a new paradigm, not only a new insurance
mechanism. Isn't that really what you are saying? And because
of new breakthroughs in metrics, we can actually measure
outcomes, measure results as well as process. We don't have to
make it either/or.
At the same time, success, meaning the improved quality
and, in case of chronic illness, really preventing the
deterioration into a far more serious problem. The diabetic who
is vibrant and in compliance is a lot better off than the one
who isn't, because noncompliance is going to lead to kidney
dialysis, amputation, and retina disintegration.
I think what our colleagues need to think about, and I
think this is what the challenge of quality is, is how do we
bring new thinking and not only new ways of financing?
Dr. Teisberg, and then we are going to wrap it up. The vote
has just begun.
Dr. Teisberg. Thank you.
It is a critical insight that you are identifying that we
need to have a new way of organizing healthcare, a new way of
thinking about the structure of delivery. If you think about
it, what can the Senate do, what can the Congress do to enable
that and to spur that to happen?
If we measure results by teams, you have to be on one. You
can't organize everyone into teams, but you can require the
measurement of the results so that people have to be part of
it. They have to be part of coordinated care.
It is your most powerful lever to achieve change in the
structure, and I would encourage you to use it. You have people
ready to go with it. If you say we are going to measure results
by coordinated teams, people will find their way to them.
Senator Mikulski. Go ahead, Dr. Robinson-Beale. I am
listening.
Dr. Robinson-Beale. I would also like to say, as part of
the team, to make sure that behavioral health is considered and
not forgotten. The de facto system for treating behavioral
health now is the primary care arena. Without their having the
tools to do so and being able to detect and being able to
diagnose and do it objectively--and there are tools out there--
I think we will have a very difficult problem.
Unless those measures that are out there that are
comprehensive measures so you are not just measuring, with the
diabetic, the hemoglobin A1c, but you are also measuring the
screening rate for depression, without those kind of
comprehensive approaches, I think we will still miss the ball.
Dr. Teisberg. Yes, you will need multiple measures, and if
you have multidisciplinary teams, you will get them. When you
put multidisciplinary teams together, they suggest a more
comprehensive set of measures. That is what they want to live
with.
Senator Mikulski. That is good.
Ms. Davenport-Ennis. I would like to say, Madam Chair, as a
closing statement that if we look within the cancer community,
the use of multidisciplinary teams is routine in the treatment
of cancer patients, and I think there are lessons that can be
learned from that model as you move forward.
Senator Mikulski. Well, the Institute of--I am sorry. Dr.
Cassel, did you want to say something?
Dr. Cassel. I just wanted to add to Elizabeth's point about
measures, that the measures alone can't do it. That you have
got to have the skills among the providers who know how to work
together.
It is medical knowledge and clinical nursing knowledge and
social work knowledge. It is also teamwork and management
skills, which we don't teach enough of, and I think that needs
to be a big part of the new model that you are talking about.
Dr. Teisberg. Yes, if you measure----
Senator Mikulski. Well, Thank you.
Dr. Teisberg [continuing]. Results, the team has to achieve
it together.
Senator Mikulski. Thank you, Dr. Cassel.
We are going to adjourn this committee until February 5,
when we are going to be holding another hearing on quality.
This hearing will be on the best practices. In other words,
actual case examples on the best practices.
Later on during the month, we will be holding a hearing on
integrative healthcare. We also note that when we turn to the
Institute of Medicine during the last week in February, we will
be holding a 3-day summit on integrative medicine, which I
believe is what everyone at this table is talking about.
You need integrative medicine to help create the kinds of
teams we are talking about, but you need integrative healthcare
because it is really the new paradigm.
Well, with that, we are going to go and actually vote on
expanding healthcare for children. This committee is in recess
until February 5th at the hearing on best practices.
Thank you very much for coming, being so patient and
willing to shoehorn in so much content in such a short amount
of time.
Thank you so much.
[Whereupon, at 3:19 p.m., the hearing was adjourned.]