[Senate Hearing 111-690]
[From the U.S. Government Printing 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











  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
                                 senate




                  U.S. GOVERNMENT PRINTING OFFICE
47-121 PDF                WASHINGTON : 2010
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC 
20402-0001







          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\
---------------------------------------------------------------------------
    \1\ M.E. Porter and E.O. Teisberg, 2006, Redefining Health Care, 
Harvard Business School Press, Boston, MA.
---------------------------------------------------------------------------
 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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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/.
---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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).
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \6\ Patient Data Analysis Report. Patient Advocate Foundation, 
February 2008.
    \7\ University of Michigan Comprehensive Cancer Center, November 
2006.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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.]