Hearing of the Senate Finance Committee - The Right Care at the Right
Statement
SEN. CHUCK GRASSLEY (R-IA): Thank you, Senator Baucus. Our healthcare summit that we had a couple weeks ago -- I made the point that any reform we work for has to address three areas; increase access for uninsured, the rate of increases in the cost of healthcare, and improving quality. Today's hearing focuses upon that quality aspect.
In April of 2008, Dartmouth published, quote, "Tracking Care of Patients with Severe Chronic Illness." The researchers made this statement: Quote, "In healthcare, it matters where you get your care." And I think Senator Baucus has covered that issue, but I can add to what he said because I've heard people from Minnesota and Iowa make these statements, that if medicine was practiced like it is in the Mid-West, you'd save that 29 percent. Now, maybe there's other parts of the country that can say exactly the same thing, but I've heard that over a long period of time in my state of Iowa.
And in addition to that, there's widespread agreement on the potential of health information technology to improve quality, and when you improve quality, doing things right the first time, you control cost. If there was widespread adoption of that powerful tool, most everyone would be getting the right care at the right time.
Health information technology will play a major role in moving the nation towards being able to compare treatments. If the nation can wire every hospital and every physician's office, it will be that much easier to see what treatment works and what doesn't. It will also reduce duplicative testing and enable clinicians to share information.
While it's clear that electronic patient records will improve efficiency of healthcare, the economics have not proven attractive to doctors. They say that the systems are expensive to install, and that their practices suffer while they get used to having the electronic systems. Savings that result from increased efficiencies accrue to insurers and other payers and not the doctors. So we need to think about how to make adoption of electronic records more attractive to those who will use them.
And I had a conversation with Dr. Coburn yesterday where he says it would be very inexpensive to get at least half of the doctors covered. So I think we ought to have a conversation with him, Mr. Chairman, as well. He's studied this. I'll put the rest of my statement in the record, or I think I want to put a full statement in the record.
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SEN. GRASSLEY: Dr. Orszag and Mr. Halvorson, we in Congress have not been very successful in tweaking Medicare's reimbursement system to -- and in our efforts to reduce geographic variation in medical practice.
A question to Dr. Orszag, and then I'm going to ask the question right away of Dr. Halvorson, so you know what I'm going to ask you.
Dr. Orszag, do you think that Medicare payment structure actually encourages geographical variation, and Dr. Halvorson, Kaiser uses salaried physicians in an integrated model. What lessons could Medicare learn from the way Kaiser reimburses?
DR. ORSZAG: I would say the Medicare reimbursement methodology facilitates geographic variation because we pay for basically for whatever the doctor orders. And even if it's very low value or zero value care, we pay for it. And, of course, that does encourage more of that kind of care.
SEN. GRASSLEY: Dr. Halvorson.
MR. HALVORSON: What we're doing within Kaiser Permanente is we've put an electronic medical record in place for all of our doctors who've created a single database about all patients. And we're not putting on top of that electronic medical record care support tools, panel support tools that help remind each doctor at the point of care what each patient needs. And we're finding that to be a very powerful and effective tool. It's very useful. And one of the things we're doing -- we're doing it a little bit differently state-to-state to get a sense of what works best for asthma patients, for example, with the goal of standardizing back to the best practice as we do the (learning ?).
One of the things that's true about medical science today is that not everything is known, and so we need to do our own internal research on something like asthma care to identify the best possible pathway. But the goal is to do it consistently to track the results to know what happened, and then to embed those advisories into the computer support system so the doctor gets that information when they deliver care.
SEN. GRASSLEY: But then could I follow up, because I think the key point I want to have you express is the difference a salary makes, paying doctors by salary.
MR. HALVORSON: Paying doctors by salary removes all disincentives relative to do doing unnecessary and inappropriate procedures. So the procedures that are done are done because they're medically appropriate, not because there's a financial consideration.
SEN. GRASSLEY: Okay. Dr. Wilensky, some stakeholders suggest that by the time comparative effectiveness research would be completed, it would be outdated and a poor basis for clinical decision making.
Would you address the challenges of getting this comparative effectiveness research from the journals to the bedside in a timely manner that minimizes the likelihood of it being outdated?
MS. WILENSKY: Health IT is an obvious answer. If you can access information quickly, that would cut down the process. It needs to be understood that comparative clinical effectiveness is not a one time -- you make an investment, you find out what is true as of that moment in time and you're done forever. It is going to require continually doing research, as goes on in biomedical research at the NIH.
But it is too important to say we don't have the time to understand better about what will work more effectively. Physicians have to make decisions when they need to make decisions. The rest of us need to help provide them with the best ongoing information and make it available to them as quickly as possible.
SEN. GRASSLEY: A follow-up for Dr. Wilkensky in a little different area. There will certainly be instances where a clinic will accept the norm that is developed through comparative effectiveness, will not work for specific patients in a specific incident. What do you think an exceptions process would look like that would allow providers to appeal the clinical accepted norm, and if a provider's reimbursement is linked to providing the clinically accepted norm, how would we create a system that allows for exceptions?
MS. WILENSKY: Let me back up and say the center I'm trying to get going is to provide the basic information that everybody will have available to them, public payers and private payers. How that information is used will be -- probably differently unless we force it otherwise by public payers and some private payers. It will simply provide a common base of information about the best that is known in terms of the likely clinical outcome if you use a drug or a device or a medical procedure in treating a medical condition.
It is the really the question of how do payers now decide whether or not they will reimburse for a particular medical condition, and it is what the standard of care suggests is appropriate. What clinical information can do is provide a better basis for making that decision, one that's much more open and transparent.
SEN. GRASSLEY: Thank you.
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SEN. GRASSLEY: Dr. Orszag, you mentioned in your opening statement that we could save or that we're spending $700 billion that's wasted on not improving outcomes. Now if we instituted policies that would reduce that, would CBO score that favorably for those policies?
MR. ORSZAG: Sir, for example the $700 billion numbers coming from regional variation calculations and others and we are exploring and putting together options to try to capture some of that money and you'll see those in December.
SEN. GRASSLEY: But --
MR. ORSZAG: So the short answer is yes but obviously how much of that you capture, first of all that number is not just federal government savings --
SEN. GRASSLEY: Yeah, I know.
MR. ORSZAG: -- -- (inaudible) -- savings and secondly how much of it you capture depends directly on how aggressive you are in attacking this problem.
SEN. GRASSLEY: Do you have any idea what some of those proposals might be?
MR. ORSZAG: Yes.
SEN. GRASSLEY: Just -- (laughter) -- just a couple examples.
MR. ORSZAG: Well let, there are a couple of different strategies. One is that you can go the route of compared to factness(?) research, and reimbursement rate changes which I think will drive some decline in the regional variation. The variation is most severe where we have the least idea of what works and what doesn't. So where there's most ambiguity about appropriate care, there's more variation.
But beyond that you can imagine for example tying, introducing some variation in the reimbursement rate under Medicare in order to try to offset some of this variation so that in more, the regions where there are services that are delivered more intensely, you try to ratchet back a little bit on the financial incentives that providers in that area face.
One hypothetical example.
SEN. GRASSLEY: Okay.
Dr. Halvorson, what was your experience in dealing with geographic variations between those states and how did you overcome those differences and I have to assume in my question that when you put together a system that covers so many different states from one end of the country to the other, you've found great differences?
MR. HALVORSON: We have had variation in our care delivery from state to state. It hasn't been in sync with the local state variation. There are some cost differences because nurses in some communities are much more expensive than nurses in others, you get those kinds of differences. But in terms of patterns of care, we haven't found that -- (inaudible) -- practices directly reflect the community practice because we're enclosed system. We work with ourselves and we have our own multispecialty group practices that perform as multispecialty group practices. And there are no fee for service incentives in our system so we don't make more money by doing unnecessary things.
SEN. GRASSLEY: Okay. So you have, I think I interpret what you're saying is you've narrowed differences but you haven't eliminated them, geographically?
MR. HALVORSON: Right, we haven't eliminated differences and in some areas we don't want to eliminate differences because medical science isn't perfect. And so we've got one program for taking care of heart patients in Northern California that's had a really good result. We have another one in Colorado that's had a spectacular result, they're slightly different. We want to learn from both of them and then incorporate into the computer support tools the best features of both.
So we don't think medicine is at the point of science when it makes sense to say there is one perfect way of doing things. But we think we need to do it in a consistent way, we need to track it, we need to support it, we need to compare it, and we do internal comparisons so we know the difference in our system of various approaches. And internally our commitment is to be an organization that learns from itself, shares that and then transplants the learning.
But we don't, right now, science and medicine isn't at a point where we could say there is only one right way of doing any single thing. We know there are some very wrong ways of doing things, they need to be gone, but there are various pathways to getting it right.
And so the congestive heart failure model in some states, it works extremely well, heavily dependent on nurse interaction with patients, other states it might be a primary care doctor that has interaction. The key is to have the interaction to anticipate when the patient is beginning to go into crisis to do an intervention, educate the patient, there are key steps that need to be done. The different people can do them, you can do them in a slightly different order.
SEN. GRASSLEY: Thank you, sir.
Thank you, Mr. Chairman.
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