Health Care Reform

Floor Speech

HEALTH CARE REFORM -- (Senate - June 11, 2009)

Ms. KLOBUCHAR. Madam President, the time for health care reform is now. We cannot afford to wait any longer. For some time, Peter Orszag, now President Obama's Budget Director, has warned that rising health costs are unsustainable and represent the central fiscal challenge facing the country.

At $2.4 trillion per year, health care spending represents close to 17 percent of the American economy, and it will exceed 20 percent by 2018 if current trends continue. Hospitals and clinics are also providing an estimated $56 billion in uncompensated care. Meanwhile, businesses are squeezed on the bottom line, forced to reduce or drop health coverage for their employees. Without action, costs will continue to rise and waste will proliferate.

We need to make health care affordable for everyone, and we need to reduce the waste and fraud that plagues the current system.

To my colleagues who are conjuring up reasons not to pass reform this year, using scare tactics about nationalized health care and engaging in fear mongering, I say we cannot stay where we are. We cannot stay where we are. They must be getting different mail than I am. I am getting mail, and I am getting people coming up to me all over the State. Even though our State has some of the most affordable health care in the country, people know their money is being spent in other States that are not as efficient. They know health care coverage when the economy is tough is very difficult to come by, and that is what they are coming up to me and talking about. They are not saying let's stay the way we are. They are saying reform this system.

In 2008, employee health premiums increased by 5 percent, two times the rate of inflation, and the annual premium for an employer health plan covering a family of four averaged nearly $12,700.

Families cannot continue to bear the burden of runaway health costs. If we do not act, these costs are going to break the backs of the American people. We must remain committed to enacting a uniquely American solution to our Nation's health care problem. We must keep what works and fix what is broken.

As Congress prepares to take up landmark health care legislation, many in Washington are looking to my State, the State of Minnesota, as a leader. Among them is the President of the United States. President Obama has provided leadership and vision on this issue, and in a recent weekly radio address, he has highlighted how the Mayo Clinic and other innovative health care organizations succeed in providing high-quality care at relatively low cost. As he has said, we should learn from the successes and promote the best practices, not the most expensive ones.

In Minnesota, the Mayo Clinic is not alone. Health partners Park Nicollet and Essensia Health are already among those working to deliver the best health care at the least price. At 92 percent of the State covered by some kind of health care insurance, Minnesota has a strong history making sure the health care system promotes both quality care and access--92 percent coverage.

Minnesota, Washington, Wisconsin, Iowa, Utah, and North Dakota are just a few of the States that can help provide leadership to help Congress and the administration as we work to develop a quality integrated health care system that reduces cost to the taxpayer and improves health care outcomes.

It is no coincidence that as we speak, the President is in Wisconsin, another State that understands to have high-quality care, you do not necessarily have to have high prices. In fact, it is the opposite.

I will distill this cost issue into some understandable language. I grew up watching the Minnesota Vikings. Year after year, our State has waited for the Vikings to win the Super Bowl. We have been to the Super Bowl four times, and we have never won the Super Bowl. All during that same amount of time, the people of our country have been waiting for health care reform. They have been waiting for something to happen to make health care more affordable. The people of this country cannot wait any longer. We might be able to wait on the Vikings; the people cannot wait any longer.

The importance of Minnesota's best practices can be outlined in a game plan for national health care reform with a few key pointers: rewarding quality, not quantity; promoting coordinated, integrated care; and focusing on prevention and disease management.

We are never going to be able to move the ball for that next first down unless we start talking about costs; otherwise, we are simply going to have different people pay for the same expensive health care but not do anything to reduce the cost.

First, our game plan for health care reform to reduce costs is to be sure to keep score. That means measuring outcomes and rewarding providers who deliver quality results. Right now in many places, we are not getting our money's worth from our health care dollars. In Miami, Medicare spends twice as much on the average patient as it does in Minneapolis, even though quality is much better in Minnesota--twice as much.

If we look at this chart, we will see that the areas in dark blue are the higher spending regions of the country. They receive the lion's share of Medicare payments. The light blue areas--States such as Minnesota, Montana, and Iowa--are areas where Medicare spending is low but quality of care is often high.

In a recent New York Times article, some explained these differences in spending as they were trying to explain how can this happen that you have twice the Medicare, twice the taxpayers' dollars for the same kind of medical treatments as you would in another part of the country. Some said it is a difference in cost of living, sicker people, more teaching hospitals. But research shows those factors only explain 18 percent of the variation in spending.

It is no surprise. Most health care is purchased on a fee-for-service basis, so more tests and more surgeries mean more money. Quantity, not quality, pays.

According to research at Dartmouth Medical School, nearly $700 billion per year is wasted on unnecessary or ineffective health care--$700 billion per year. That is 30 percent of total health care spending. So to my colleagues who are fear mongering and saying we should do nothing, I say how about $700 billion, 30 percent of total health care spending that we have the opportunity to change around to benefit the people of this country?

Just look at this fact, if you want to look at quality care. The Mayo Clinic ranked as one of the highest quality institutions in this country. If you look at the last 4 years of the lives of chronically ill patients, some of the most difficult times for people in this country, an independent study from Dartmouth came out after they looked at what the Mayo Clinic did. They have a team of doctors working together with quality ratings incredibly high. Then they looked at what was going on in other regions of the country.

If all the hospitals in this country used the same protocol that Mayo Clinic used in the last 4 years of a patient's life, where the quality rating is incredibly high, we would save $50 billion every 5 years in Medicare spending--$50 billion.

So, no, I don't think the answer is just to throw away health care reform and do a lot of fear mongering. I think the answer is to work together to bring this kind of cost savings to the rest of the country.

There is general consensus that Medicare should reward value, and value consists of both quality and efficiency. However, value is not taken into account when Medicare determines payment for providers.

To begin reining in costs, we need to have all health care providers aiming for high quality, cost-effective results. That is why I plan to introduce legislation with Senator Cantwell and others that would authorize the U.S. Health and Human Services Secretary to create a value index

as part of a formula used to determine Medicare's fee schedule--paying for value. This indexing will help regulate overutilization because those who produce more volume will need to also improve care or the increased volume will negatively impact fees. You have to have those incentives in place in how you do the payments or you are never going to reduce costs.

In adding a value index, my bill would give physicians a financial incentive to maximize quality and value of their services instead of volume. Linking rewards to the outcomes for the entire payment area creates the incentive for physicians and hospitals to work together to improve quality and efficiency.

I am also interested in the idea that the President has proposed to give increased consideration to recommendations made by the Medicare Payment Advisory Committee, MedPAC, a commission created by a Republican Congress. MedPAC's recommendations for payment reform include bundling, which has potential significant cost savings. Giving the recommendations made by experts increased authority could be a valuable tool to help rein in health care spending and improve quality in a responsible way.

So the first part of our game plan for reducing costs for health care is focusing on value. The second part of the game plan for making health care more affordable is to focus on teamwork.

Understandably, patients like it when their health care providers talk with one another and even work together. This means higher quality care, as well as more efficient care. In too many places, however, patients must struggle against a fragmented delivery system where providers duplicate services and sometimes work at cross-purposes--an x ray here, an x ray there, an expert here, an expert there. It is like a football team with 11 quarterbacks but no wide receivers, no running backs and no offensive line. This does not work in football, and it is not going to work in health care.

The beauty of integrated care systems is that a patient's overall care is managed by a primary care physician in coordination with specialists, nurses, and other care providers as needed. It is one-stop shopping. In our rural communities, critical access hospitals utilize this model and provide quality health care for residents in their community with a team of providers.

To better reward and encourage this collaboration, we also need to have better coordination of care and less incentive to bill Medicare by volume. Increasing the bundling of services in Medicare's payment system has the potential to deliver savings and start encouraging quality, integrated care.

When it comes to improving care, changing who pays a doctor will make no more difference. The lesson of high-quality, efficient States such as Minnesota and Wisconsin is that someone has to be responsible for the care of the patient from start to finish, from one goal line to the other. Bundling will ensure that practice is rewarded.

This is a very interesting chart. It does not look interesting, but it is. A lot of people think the more you pay, the better quality care you get. This was a MedPAC analysis of county level fee-for-service expenditures, a national study.

Do you know what they found? They found that those areas of the country, those counties that had low utilization--in other words, maybe someone called a nurse line or a doctor referred them to one specialist instead of them going to three on their own--they found they had the highest quality care. Why is that? It makes sense. You have one primary doctor who knows exactly what is going on, is checking your charts and can send them to one specialist so mistakes are not make. You go to one specialist who does not know you are taking a certain medication and you are allergic to another. High-quality care with low utilization; lowest quality care with high utilization.

That is probably the opposite of what most people in this country think. But, literally, you get the highest quality care in those parts of the country where you are paying less money.

As I said, if people start to say our area of the country is so expensive, only 18 percent of that difference with the high-quality, low-cost States and the low-quality, high-cost States can be attributed to cost of living.

Research has shown that moving toward a better integrated and coordinated delivery system would save Medicare alone up to $100 billion per year. So if people don't want to talk about reform and they want to make a bunch of fear-mongering statements, let them explain to the American people why we are not going to save $100 billion per year.

Finally, the last game pointer is that the best offense is a good defense. My dad covered football his whole life for the newspaper, and this is what he would always say to me: It works on the football field and it works in health care. It is a lot better for both the patient and the patient's pocketbook if a chronic medical problem can be prevented or managed early to stave off complications and the need for costly care. Right now, physicians are paid to treat diseases, not prevent them. Yet a payment system that encourages prevention and disease management could generate enormous savings because a large portion of health care spending is devoted to treating a relatively small number of people with chronic medical conditions.

Let me give an example of this. This is Health Partners, which is a clinic in Minnesota--all over our State. A lot of patients are members of it. They started looking at how can we do a better job with diabetes. They did this back in the fourth quarter of 2004 compared to the fourth quarter of 2008. You see here an increase in quality for the patients, an increase in percentage of patients with optimal diabetes control, because they put in some practical protocols.

What do you see with costs? You see an actual major decrease in the cost per patient. That is the green line. The yellow line is an increase in the patients with optimal diabetes control, as the doctors determined. The green line is a decrease in cost. The red line is patients with diabetes who had asked that they recommend Health Partners clinics. So even as they saw this dramatic reduction in cost, they were still on the up in terms of recommending using Health Partners clinics. Most people don't like their HMOs very much. They always have reasons to complain. So I think this is amazing that they were able to show this kind of result.

At Park Nicollet in Minnesota, they have implemented a congestive heart failure program with Medicare. In the 3 years since the program began, Park Nicollet has saved nearly $5,000 per patient, per year.

Diabetes, congestive heart disease, and back problems all contribute to the excessive cost and growth in our health care system and cause decreased productivity in our economy. One study found that the most costly 20 percent of Medicare patients in a given year account for 84 percent of total Medicare spending. By contrast, the least costly 40 percent of Medicare patients accounted for just 1 percent of overall spending. As the examples from Minnesota and other places demonstrate, effectively managing these and other chronic illnesses is essential to health care reform.

A recent New Yorker magazine article showcased the Mayo Clinic in the context of health care's cost conundrum.

Madam President, I ask unanimous consent for 3 more minutes.

The PRESIDING OFFICER. Without objection, it is so ordered.

Ms. KLOBUCHAR. According to the author, a physician, we are in ``a battle for the soul of American medicine.'' On one side is a fragmented, volume-driven model that too often crosses into profiteering. There are good parts about our health care system, believe me. I know this because I live in Minnesota. We have to maintain those. But we have to fix this broken cost structure. On the other side, you see this model offered by Mayo and other peer institutions across the country where doctors collaborate to provide the best, most efficient care for their patients.

On one side is more of the same, which is both financially and morally unsustainable; on the other side is a new direction that promises to curb cost while expanding affordable coverage. It is time to choose sides. For the sake of our fiscal health and for the sake of millions of Americans struggling to afford the care they need, I urge my colleagues to choose the latter.

Yesterday, I met with a bipartisan group of Senators, and I have to tell you I still have hope that we are going to get this done and I have hope that there will be bipartisan support for this. What I am talking about today--cost reduction, putting these incentives in place--isn't a Democratic issue or a Republican issue. It is an American issue. This is an American cause, and we can find a uniquely American solution to this problem so that we can reduce costs and make health care better quality. I can tell you, having spent my entire life in the State of Minnesota and having a daughter who was born very sick, who couldn't even swallow when she was born, I know we can get high-quality health care at lower cost. They do it every day in my State, and we can do it in the rest of the country.

Madam President, I yield the floor.

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