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38–617 PDF 2007

S. HRG. 110–180

THE FUTURE OF MEDICARE: RECOGNIZING THE

NEED FOR CHRONIC CARE COORDINATION

HEARING

BEFORE THE

SPECIAL COMMITTEE ON AGING 

UNITED STATES SENATE

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

WASHINGTON, DC

MAY 9, 2007

Serial No. 110–7

Printed for the use of the Special Committee on Aging

(

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

SPECIAL COMMITTEE ON AGING 

HERB KOHL, Wisconsin, Chairman 

RON WYDEN, Oregon 

BLANCHE L. LINCOLN, Arkansas 

EVAN BAYH, Indiana 

THOMAS R. CARPER, Delaware 

BILL NELSON, Florida 

HILLARY RODHAM CLINTON, New York 

KEN SALAZAR, Colorado 

ROBERT P. CASEY, Jr., Pennsylvania 

CLAIRE McCASKILL, Missouri 

SHELDON WHITEHOUSE, Rhode Island 

GORDON H. SMITH, Oregon 

RICHARD SHELBY, Alabama 

SUSAN COLLINS, Maine 

MEL MARTINEZ, Florida 

LARRY E. CRAIG, Idaho 

ELIZABETH DOLE, North Carolina 

NORM COLEMAN, Minnesota 

DAVID VITTER, Louisiana 

BOB CORKER, Tennessee 

ARLEN SPECTER, Pennsylvania 

JULIE COHEN, Staff Director 

CATHERINE FINLEY, Ranking Member Staff Director 

(II) 

C O N T E N T S 

Page 

Opening Statement of Senator Herb Kohl ............................................................. 1

Statement of Senator Blanche Lincoln .................................................................. 2

Prepared Statement of Senator Gordon Smith ..................................................... 5

Prepared Statement of Senator Larry Craig ......................................................... 44

PANEL I 

Todd P. Semla, Pharm.D., president of the American Geriatrics Society; clinical pharmacy specialist, Department of Veterans Affairs; and associate 

professor, Feinberg School of Medicine, Northwestern University, Evanston, 

IL ........................................................................................................................... 6

Gerard Anderson, Ph.D., professor of Public Health and Medicine, Johns 

Hopkins Bloomsberg School of Public Health, Baltimore, MD ........................ 16

David Dorr, M.D., assistant professor, Medical Informatics and Clinical Epidemiology Joint Appointment: General Internal Medicine and Geriatrics, 

Oregon Health and Science University, Portland, OR ...................................... 29

PANEL II 

Stuart Guterman, senior program director, Program on Medicare’s Future, 

The Commonwealth Fund; former director of the Office of Research, Development and Information, Centers for Medicare and Medicaid Services, 

Washington, DC ................................................................................................... 52

Stephen McConnell, Ph.D., vice president of Advocacy and Public Policy, 

Alzheimer’s Association, Washington, DC ......................................................... 73

Ann Bowers, caregiver, Fort Smith, AR ................................................................ 80

APPENDIX 

Prepard Statement of Senator Blanche Lincoln .................................................... 95

Prepared Statement of Senator Hillary Rodham Clinton .................................... 96

Responses to Senator Smith Questions from Dr. Todd Semla ............................. 97

Responses to Senator Smith Questions from Gerard Anderson .......................... 98

Responses to Senator Smith Questions from David Dorr .................................... 100

Responses to Senator Smith Questions from Stuart Guterman .......................... 101

Statement submitted by American College of Physicians .................................... 103

Statement submitted by Center for Medicare Advocacy, Inc. .............................. 114

Statement submitted by Disease Management Association of America ............. 122

(III) 

(1)

THE FUTURE OF MEDICARE: RECOGNIZING 

THE NEED FOR CHRONIC CARE COORDINATION 

WEDNESDAY, MAY 9, 2007

U.S. SENATE, 

SPECIAL COMMITTEE ON AGING, 

Washington, DC. 

The Committee met, pursuant to notice, at 3:09 p.m., in room 

106, Dirksen Senate Office Building, Hon. Herb Kohl (chairman of 

the committee) presiding. 

Present: Senators Kohl, Lincoln, Casey, Whitehouse, Smith, 

Craig, and Corker. 

OPENING STATEMENT OF SENATOR HERB KOHL, CHAIRMAN 

The CHAIRMAN. Good afternoon. At this point, we are going to 

call this hearing to order. We welcome, of course, all of our witnesses who are with us today. 

I am pleased today to be able to turn over the gavel to Senator 

Blanche Lincoln, who will be chairing today’s hearing on the need 

for chronic care coordination under traditional Medicare. 

Today, 63 percent of our Nation’s Medicare beneficiaries suffer 

from two or more chronic conditions. Studies show that Medicare 

spends two out of every three dollars on seniors with five or more 

chronic conditions, such as diabetes, emphysema, heart disease, arthritis or osteoporosis. These chronic conditions are largely preventable, treatable, and their onset can often be delayed through 

coordinated care, nutrition and exercise. 

Unfortunately, today’s Medicare program is not designed to serve 

those elderly individuals with multiple chronic conditions that 

make up the majority of beneficiaries. Traditional Medicare doesn’t 

provide physicians with incentives to coordinate their elderly patients’ chronic care conditions. As a result, many seniors are left receiving disjointed care through multiple visits to different doctors 

every year at an unnecessarily high cost. 

Research indicates that Medicare beneficiaries with chronic conditions are more likely to have preventable, costly hospitalizations, 

experience adverse drug interactions, undergo duplicate tests, and 

receive contradictory medical information. 

At a time when our Nation is growing older, it is clear that the 

success we have in preventing and treating chronic diseases will directly affect our ability to provide quality health care and contain 

future growth in Medicare spending. 

2

Today’s hearing will shine a light on these shortcomings in Medicare and help us identify ways we can improve the care of our seniors while making Medicare more efficient. 

We will now be turning the hearing over to the Aging Committee’s greatest advocate for geriatric chronic care coordination, Senator Blanche Lincoln. 

Senator Lincoln has shown great leadership highlighting these 

issues and bringing them to the attention of this Committee. Since 

2001, she has worked on legislation to improve the care of our Nation’s elderly, and I am proud to join her as she introduces the 

Geriatric Assessment and Chronic Care Coordination Act of 2007. 

I know Senator Lincoln has assembled a distinguished panel of 

witnesses today, and we are looking forward to learning more 

about the challenges that these beneficiaries and their physicians 

face. We have an obligation to modernize the Medicare program 

and ensure that it is providing the quality care that today’s beneficiaries need. 

So, we thank Senator Lincoln for all of her work on this issue, 

and she will now take over this hearing. 

STATEMENT OF SENATOR BLANCHE LINCOLN 

Senator LINCOLN. Well, thank you, Chairman Kohl. I just want 

to say a very special thanks for your leadership in this Aging Committee. I think you, working with Senator Smith, have done a tremendous job in helping us to focus on so many of the issues that 

our American families face as their loved ones start that aging 

process. 

It is critically important for so many across this country that we 

really do look to modernize our ability to provide the kind of quality of care and the dignity of care that our aging Americans want 

to see. So I want to thank you so much for allowing me to do this 

today, and thank you again for your incredible leadership. You 

have done a wonderful, wonderful job. 

He really has done a tremendous job in helping make the opportunity for today’s hearing a reality. 

I also want to say a very special thanks to our panel, as I was 

not able to come and greet our witnesses. We had a vote immediately before this. But I want to say a special thanks to both of 

our panels of witnesses, as well as the advocacy groups that have 

worked so diligently with us. 

It is critically important that we hear from them, and hear from 

their issues relating to the constituencies that they represent. They 

have all been very, very willing to come forth with good, honest 

suggestions and proposals and ideas of how we can do this better. 

I am very proud to be a part of that team as well, in terms of working with them. 

As a member of the so-called Sandwich Generation, who cares for 

their children and aging parents simultaneously, I am keenly 

aware of so many issues affecting older Americans and have been 

an advocate for geriatric chronic care coordination for several 

years. 

Now, I am not just a part of the Sandwich Generation. My husband’s grandmother turns 110 in a couple of months, still living in 

3

her own apartment, assisted living. So I am a part of the Club 

Sandwich Generation. [Laughter.] 

But seeing her remarkable ability to still care for herself in so 

many ways and to live a very active and fulfilling life at almost 110 

is pretty remarkable. But it also shows that there is tremendous 

potential. 

There is certainly a lot of commitment that we need to make as 

Americans continue to live longer lives. We want to make sure that 

they are very, very healthy. 

Studies indicate that when patients are linked with a physician 

or other qualified health professionals to coordinate care, the results are improved quality of care, increased efficiency, and greater 

cost-effectiveness. 

That is why I am so pleased to chair today’s hearing, to raise the 

awareness of the need for chronic care coordination for Medicare 

beneficiaries and to discuss how these services can be provided in 

a cost-effective way. 

This hearing will specifically focus on chronic care coordination 

in the traditional Medicare fee-for-service program. While some 

chronic care coordination occurs in other programs—such as Medicare Advantage and the Program for All-Inclusive Care for the Elderly, which is known as PACE—nearly 85 percent of Medicare 

beneficiaries continue to receive health care from the traditional 

fee-for-service program, which lacks a care coordination component. 

As we know, obviously, our focus there is on the high cost, and 

that high-cost element of Medicare is mostly in the fee-for-service 

component. 

So why focus on chronic care coordination? Well, there are several reasons. 

First, the needs of Medicare beneficiaries have changed over 

time. When Medicare was first established in 1965, it was based 

on a health insurance model, which focused on acute care, not 

chronic conditions. But today, many of our older Americans suffer 

from multiple chronic conditions, and would benefit from care coordination. We know that about 78 percent of the Medicare population have at least one chronic condition, and 63 percent have two 

or more chronic conditions. 

Second, as our population ages, the number of older individuals 

with chronic illnesses is also expected to rise. A recent article in 

The Washington Post noted that baby boomers are more likely to 

be in worse health condition than their parents in retirement, 

which may result in a greater need for medical services. A RAND 

Corporation study estimates that half of the population will have 

a chronic condition in 2020, a total of 157 million Americans. 

Third, Medicare beneficiaries with multiple chronic care conditions are expensive to treat. We know that our costs in Medicare 

are exploding as our number of aging Americans is beginning to explode. According to the Congressional Budget Office, 43 percent of 

Medicare costs can be attributed to 5 percent of Medicare’s most 

costly beneficiaries. Medicare beneficiaries with four or more chronic conditions are 99 times more likely to experience one or more potentially preventable hospitalizations than those without chronic 

conditions. If an individual has Alzheimer’s disease or dementia, 

medical costs increase even more dramatically. 

4

Finally, multiple chronic conditions not only affect the individual 

suffering from them but also their caregivers. About 5 years ago, 

I watched my own mother devote herself to the care of the man she 

had loved for more than 52 years. She had pledged to attend to him 

and honor his life until he departed this world, even if he no longer 

remembered her name or could recognize her face. My dear father 

suffered from Alzheimer’s disease, and it was a long journey for all 

of us for almost 10 years. My mother’s strength and commitment 

to my father during his long illness remains a great source of inspiration to me. 

Unfortunately, my family’s experience with the ravages of Alzheimer’s is not unique. Millions of Medicare beneficiaries with 

chronic conditions who remain at home do so with the help of family and friends. Research shows us that family care for an older 

adult with chronic illness or disabilities, especially dementia, can 

have negative health effects, both physical and mental, on family 

members. 

To address these issues, I am pleased to announce that, today, 

Senator Collins and I have introduced the Geriatric Assessment 

and Chronic Care Coordination Act of 2007—it is S. 1340—and 

along with Senators Kohl, Kerry, Mikulski, Clinton, Boxer and 

Casey. I am also pleased that Representatives Gene Green and 

Fred Upton are sponsoring a companion bill in the House and that 

30 national organizations have endorsed our bill. 

This bill realigns Medicare to provide high-quality, cost-effective 

care to elderly individuals with multiple chronic conditions. It is an 

important step forward in recognizing and remedying the impact 

that multiple chronic conditions have on individuals, their caregivers and the Medicare program. 

Again, a special thanks to Senator Kohl, our Chairman, and to 

Senator Smith, Ranking, for all of your incredible leadership on 

this Aging Committee, and to all of the advocacy groups and our 

panelists here today for really making all of this a possibility. 

We want to go to Senator Smith first, if you are prepared and 

ready. 

Senator SMITH. In the interest of time, let me thank you, Senator 

Lincoln. It is a pleasure to work with you on this Committee, the 

Finance Committee, on health care issues. We have done so well, 

and will continue to do that. 

Thank you, Mr. Chairman, for allowing this important hearing to 

go forward. 

I think in the interest of time, I would like to put my statement 

in the record. 

I want to thank Dr. David Dorr, who is here from Oregon. 

I appreciate your taking your time and this long trip out here to 

share with us your important work on chronic care coordination. 

He is a distinguished assistant professor at Oregon Health 

Sciences University, and is the principal investigator of the Care 

Management Plus Project, which is funded by the John A. Hartford 

Foundation. 

So thanks for coming. 

[The prepared statement of Senator Smith follows:] 

5

PREPARED STATEMENT OF SENATOR GORDON SMITH

I want to thank Senator Lincoln for holding this important hearing today. I have 

had the pleasure of working with Senator Lincoln on many issues related to improving the quality of care for older Americans and look forward to exploring this topic 

with her. 

Medicare is the backbone of the healthcare system for elderly Americans. Now, 

more than 44.6 million Americans receive benefits from this important program, and 

the number is expected to grow quickly in the coming years as more and more babyboomers edge towards retirement. 

We also are a nation that is living longer than ever before. Studies tell us that 

as we live longer we are more likely to have an increased number of chronic health 

conditions. Americans are suffering from chronic conditions, and asthma, emphysema, dementia, diabetes, arthritis and mental illnesses are just a few of the most 

frequently diagnosed conditions in the elderly. When these conditions occur together, they significantly compound the daily difficulties of those they afflict. We 

also know that these conditions take a toll on those suffering. Too often, those suffering are forced by their condition to spend days in bed, become dependent upon 

family members and experience a general decrease in their quality of life. 

The good news is that Americans suffering from chronic conditions are living 

longer and healthier lives due to medical advances. Where they once would have 

been confined to their home or a hospital bed, many more are able to live much 

fuller lives. This is the direction that programs like Medicare should continue to 

move towards. 

Chronic care coordination is a practice that has been tried and tested in many 

areas of our nation. In fact, we will hear today from Dr. Dorr about work going on 

in my home state of Oregon. The purpose of chronic care coordination is to ensure 

that a patient’s care providers are working in a collaborative manner and that everyone who provides care does so in an informed way. The hope is that if care providers work closer together on the patient’s behalf, that patient will have better care 

and a better quality of life. 

As a member of the Finance Committee, as well as Ranking Member of this Committee, I am always looking at ways to encourage quality care for our elderly. With 

the skyrocketing cost of healthcare, I am also looking to provide that care more efficiently. Twenty percent of Medicare beneficiaries who have five or more chronic conditions account for about two-thirds of all Medicare expenditures. I look forward to 

hearing about the body of research today that looks at how chronic care coordination 

also can achieve the goal of increased quality for these patients as well as how it 

can improve the fiscal outlook for the ever-increasingly expensive Medicare program. 

I want to thank all of our witnesses for being here today. I know that they are 

tireless in their work to better the healthcare for our aging population, as well as 

all Americans. Those we will hear from today also include advocates for those with 

chronic conditions. I appreciate your ongoing work to ensure that their needs, and 

those of their families, are met. 

I especially want to thank Dr. David Dorr for being here today. I greatly appreciate him taking the time to come out here from Oregon and inform us of his work 

on chronic care coordination. Dr. Dorr is an assistant professor at the Oregon 

Health and Science University (OHSU), and is the principal investigator of the Care 

Management Plus project, which is funded by the John A. Hartford Foundation. 

Care Management Plus is a project that uses information technology and care managers based in primary care clinics to improve coordination and quality of care for 

older adults and those with complex chronic illness. I look forward to hearing all 

of your testimony today.

Senator LINCOLN. Great. Thank you, Senator Smith. 

We have two panels of very distinguished witnesses with us 

today, so we will get started, as Senator Smith said, in the sake 

of time. We will ask our witnesses to present their testimony, and 

then we will open it up for questions and move to panel two. 

On our first panel, we will hear from Dr. Todd Semla, president 

of the American Geriatrics Society, a clinical pharmacy specialist 

at the Department of Veterans Affairs and an associate professor 

at Northwestern University at the Feinberg School of Medicine. 

6

Next we will hear from Dr. Gerard Anderson, a professor of public health and medicine at the Johns Hopkins Bloomberg School of 

Public Health. 

He will be followed by Dr. David Dorr, the principal investigator 

of Care Management Plus and an assistant professor of medical 

informatics and clinical epidemiology with a joint appointment in 

general internal medicine and geriatrics at the Oregon Health and 

Science University. 

Thanks to all of you gentlemen for being here today, and we look 

forward to continuing our work with you. 

Dr. Semla. 

STATEMENT OF TODD P. SEMLA, PHARM.D., PRESIDENT OF 

THE AMERICAN GERIATRICS SOCIETY; CLINICAL PHARMACY 

SPECIALIST, DEPARTMENT OF VETERANS AFFAIRS; AND ASSOCIATE PROFESSOR, FEINBERG SCHOOL OF MEDICINE, 

NORTHWESTERN UNIVERSITY, EVANSTON, IL 

Dr. SEMLA. Good afternoon. I am Todd Semla, president of the 

American Geriatric Society. I am a doctor of pharmacy with more 

than 25 years of experience in the field of geriatrics. 

The American Geriatric Society is a nonprofit organization of 

over 6,700 health professionals devoted to improving the health 

and quality of life of older Americans. Geriatric medicine emphasizes primary care for older persons. It promotes preventive care, 

with a focus on care management, and coordination that helps patients maintain functional independence in performing daily activities and improves their overall quality of life. 

I thank you, Chairman Kohl, Ranking Member Smith and the 

Members of the Special Committee on Aging, for having this hearing during Older Americans Month. It is a time to celebrate this 

fastest-growing segment of our population and also a time to look 

toward the future of the Medicare program. 

Today, I will outline the need for the coordination of care and the 

many benefits, particularly the increasing number of older Americans with multiple chronic conditions. 

As Committee Members know, America is on the threshold of a 

historic population shift upward. It is no surprise that the prevalence of chronic conditions—conditions that typically last more than 

one year, such as arthritis, cancer and hypertension—increases 

with age. 

Therefore, as life expectancy increases, so does the number of 

people living with multiple chronic conditions, conditions whose 

symptoms and treatment often interact in very complex ways. Currently, about 20 percent of the Medicare beneficiaries have five or 

more chronic conditions, and these individuals account for almost 

70 percent of all Medicare spending. 

It is clear that we must find better ways to treat this population, 

and providers have increasingly recognized the need for care coordination in order to properly manage the health of individuals 

with complex and multiple chronic health conditions. 

Simply put, care coordination puts the patient at the center of 

care. It holistically views the patient’s physical, cognitive and 

caregiving needs and to result in the development of a plan that 

addresses all of the patient’s medical conditions and takes into acVerDate 0ct 09 2002 15:07 Nov 15, 2007 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 H:\DOCS\38617.TXT SAGING1 PsN: JOYCE
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count the patient’s ability to self-manage his or her health care, 

and functional issues in the patient’s support system. 

A care coordinator, usually a physician, physician’s assistant, or 

nurse practitioner, oversees the plan’s implementation by the team. 

This may entail consultation with other providers, monitoring and 

managing medication, and patient and family caregiver education 

and counseling. 

Studies show that care coordination raises the quality of care, 

improves health outcomes, and reduces health care costs for individuals with chronic conditions. This means fewer hospital visits 

are needed, duplicate services and appointments are eliminated, 

sudden health crises are avoided. When a comprehensive geriatric 

assessment is combined with coordinated care, studies have shown 

even better outcomes. 

Medicare, however, is not structured for the delivery of these coordinated care services. Instead, the current Medicare fee-for-service system encourages providers to see patients frequently for short 

periods of time. 

Without a plan or a care team, the patient receives fragmented 

care by multiple providers who may or may not communicate with 

each other. This can result in duplicate tests and treatments, and 

prescribing medications without knowing what medicines the patient is already taking. In turn, this can increase the risk for hospitalizations, drug interactions, and adverse events, placing the patient at risk as well as driving up costs. 

Where do we go from here? We believe that a new chronic care 

coordination benefit needs to be fully integrated into the Medicare 

program, both in the near term and well into the future. This will 

be key to improve health outcomes, higher quality of health care, 

and greater value for every health dollar spent. 

Legislation introduced by Senator Lincoln would move us toward 

this goal. The Geriatric Assessment and Chronic Care Coordination 

Act will create a patient-centered approach under Medicare that 

will benefit patients with multiple chronic conditions and lower 

their health utilization rates. 

The bill’s establishment of a geriatric assessment and chronic 

care coordination benefit under Medicare’s fee-for-service program 

will improve the care received by the sickest and most vulnerable 

patients in the Medicare population. It also will improve the lives 

of family caregivers by providing them with resources to better care 

for their parents, grandparents, brothers, and sisters. 

Thank you, Senator Lincoln, for your leadership. We look forward to working with you and Members of the Committee to enact 

this bill, as well as advance other issues to improve the health and 

quality of life of older Americans. I will be happy to answer any 

questions as the time allows. 

[The prepared statement of Dr. Semla follows:]

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Senator LINCOLN. Dr. Anderson. 

STATEMENT OF GERARD ANDERSON, PH.D., PROFESSOR OF 

PUBLIC HEALTH AND MEDICINE, JOHNS HOPKINS 

BLOOMSBERG SCHOOL OF PUBLIC HEALTH, BALTIMORE, 

MD 

Dr. ANDERSON. The Medicare Modernization Act of 2003 was the 

first step in the transformation of the Medicare program to one better oriented to the needs of beneficiaries with chronic conditions. 

Mrs. Lincoln and Members of this Aging Committee, thank you for 

your leadership on that issue. The transformation was long overdue. 

Looking to the future, I would like to propose five additional 

steps for the Aging Committee to consider. 

First, we need an evidence base that clinicians can use when 

they treat Medicare beneficiaries with multiple chronic conditions. 

Unfortunately, most clinical trials routinely exclude people with 

multiple clinical conditions, because it is difficult to demonstrate efficacy in this population. 

This can leave a doctor treating a Medicare beneficiary with multiple chronic conditions with a difficult clinical decision. First of all, 

they could assume that the exclusions from a clinical trial just 

don’t matter, and use the new treatment. Or two, they would assume that the exclusions are important, and not use the new information. Both of these could be wrong. 

There are two ways to give the doctor the important new information. Thirty years ago, clinical trials routinely excluded women 

and minorities. Now, the Federal Government mandates that 

women and minorities be included in clinical trials. One solution is 

to mandate that clinical trials include complex patients, not just 

the simplest patients. A second is to fund follow-up studies that include the more complex patients. 

Second of all, most clinicians are never taught how to work cooperatively with a complex patient. We did a national study of physicians, and found that a majority of the physicians did not feel that 

they had the minimum level of training in care coordination or 

other skills necessary for taking care of people with multiple chronic conditions. 

Medicare is spending $10 billion a year to support graduate medical education. Medicare could use some of its leverage to put more 

emphasis on training residents to care for complex Medicare beneficiaries. 

Third of all, we need integrated electronic medical records that 

will allow clinicians to communicate easily with each other. Many 

countries will have integrated electronic medical records by the end 

of this decade. In these countries, most of the leadership and most 

of the funding has come from the Federal Government, because 

nearly all of the financial benefit accrues to the public and to the 

payers, it is appropriate for the public and the payers to pay the 

bill. 

In the U.S., we are asking the providers to purchase electronic 

medical records systems. There are two problems with this approach: First of all, it is expensive for providers to introduce electronic medical records, and the payoffs to them are relatively miniVerDate 0ct 09 2002 15:07 Nov 15, 2007 Jkt 000000 PO 00000 Frm 00020 Fmt 6633 Sfmt 6633 H:\DOCS\38617.TXT SAGING1 PsN: JOYCE
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mal. Second of all, having each provider select his or her own system dramatically reduces interoperability. What I would do is pay each provider $5 to send certain clinical 

information to a secure site maintained by the Medicare program. 

All clinicians could then access this information through a secure 

connection. Medicare beneficiaries would be able to restrict access 

to certain clinical information if they so desire. The cost of the 

Medicare program would be $4 billion a year, and it would pay for 

itself if all the clinicians participated. 

Fourth of all, we need to pay for assessment and care coordination. The legislation developed by Mrs. Lincoln, the Geriatric and 

Chronic Care Coordination Act, goes a long way to achieving this 

objective. 

My suggestion is that each Medicare beneficiary with five or 

more chronic conditions—which represents about 20, 25 percent of 

the population—and/or dementia, select this care coordinator, and 

the care coordinator would help manage the person’s care. Most 

likely, the person would choose a doctor, and the doctor would hire 

nurses to conduct the analysis and to identify potential problems. 

One example of where better care would prevent and save some 

money is adverse drug reactions. Over half of all Medicare beneficiaries with a chronic condition go to the pharmacist once a year 

and are told by that pharmacist not to fill a prescription because 

of another drug that they are already taking that could have a 

problem. I would pay the care coordinator approximately $100 per 

beneficiary per month, which is about the same as the diseasemanagement firms receive. 

In my last few seconds, I would like to expand our horizons and 

point out that chronic disease is now the major problem in every 

country in the world, including the poorest countries. Yet most 

international aid agencies focus almost exclusively on infectious 

disease such as AIDS, TB, and malaria. 

However, the three most common reasons for death and disabilities in the world, both in high- and in low-income countries, are 

circulatory disease, cancer, and injuries. More importantly, chronic 

diseases can be treated inexpensively, and once the programs are 

initiated, these programs have a history of sustaining the chronic 

disease programs. 

Thank you for the opportunity to testify. 

[The prepared statement of Mr. Anderson follows:]

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Senator LINCOLN. Dr. Dorr. 

STATEMENT OF DAVID DORR, M.D., ASSISTANT PROFESSOR, 

MEDICAL INFORMATICS AND CLINICAL EPIDEMIOLOGY 

JOINT APPOINTMENT: GENERAL INTERNAL MEDICINE AND 

GERIATRICS, OREGON HEALTH AND SCIENCE UNIVERSITY, 

PORTLAND, OR 

Dr. DORR. Thank you. Good afternoon. My name is Dr. David 

Dorr, and I am honored to present testimony here today. 

I am an internal medicine physician who works in a primary 

care clinic. I am also a medical informatics researcher on the faculty of Oregon Health and Science University. My work has focused 

on the use of information technology to improve care coordination 

for older adults with complex chronic illnesses in a program called 

Care Management Plus. 

There is a crisis in chronic illness care. Consider Ms. Viera, a 75-

year-old patient with five chronic illnesses. In most clinics, coordination of the care for her multiple chronic illnesses would be limited, leading to worsening of her conditions, unnecessary hospitalizations, and significant costs. 

Guidelines of care for her illnesses may conflict, and she and her 

husband may struggle to integrate the sometimes conflicting recommendations of six different physicians with their own values. 

With careful care coordination, as in Care Management Plus and 

other models, a care manager can help educate and guide the 

Vieras through their options. Care coordination for people with 

these complex illnesses can help limit the costs, improve health, 

and provide better quality of life for the growing number of older 

adults in our country. 

Care Management Plus is the integration of a tested information 

technology system with trained care managers in primary care clinics to treat older adults with complicated conditions respectfully 

and effectively. 

In its initial testing, Care Management Plus saved lives and improved health care outcomes by reducing hospitalizations by 24 

percent, improving patients’ experience with care, and improving 

disease status. Savings were estimated at more than $.25 million 

annually per clinic. If 2 percent of the Nation’s primary care providers adopted similar care coordination programs, Medicare would 

potentially immediately save over $100 million each year. 

We are in the process of disseminating the Care Management 

Plus model from seven clinics to more than 40 with another grant 

from the John A. Hartford Foundation. We have discovered three 

significant challenges as we do so. 

First, clinicians want to provide care coordination services, but 

especially in smaller and rural clinics, face significant unreimbursed costs if they do so. For instance, having a care manager is 

essential to many such models, but services by the care manager 

such as providing education, motivation, coaching, and monitoring 

over time, do not receive adequate payment. 

Second, the use of information technology is essential, but must 

be adapted to the needs of coordinating care. Current incentives 

have compelled most practices to use electronic health records to 

30

better capture billing documentation rather than address the needs 

of coordination over time. 

Third, models like ours and Eric Coleman’s Care Transitions 

nurse-coaching model require time and effort to learn and implement. Incentives must reflect these costs. 

We are heartened that the Committee on Aging is holding these 

hearings today. With your help, we can make sure that all persons 

with multiple chronic illnesses get health care that meets their essential needs in the most cost-effective way possible. 

I thank you for the opportunity to share some of our exciting 

work with you today. 

[The prepared statement of Dr. Dorr follows:]

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Senator LINCOLN. Thank you, Dr. Dorr. 

Thanks to all of you all for your helpful input into this issue. We 

are grateful for that. 

I will just ask a few questions and then turn it over to the Chairman and the other Members for their questions. 

Dr. Semla, Dr. Dorr brought up some of this issue, but I was 

hoping that maybe you might elaborate as well on the doctors 

working in rural areas, the capacity or the infrastructure needs 

that they have for a team approach to coordinate their care. In particular, my State, in Arkansas, is rural, and many, many areas are 

medically underserved. 

Any of you that may have recommendations—and Dr. Dorr, you 

have mentioned some in terms of reimbursements and how we 

could do that—but how we would assist rural providers with providing care coordination, considering that there is a shortage of 

medical professional providers in many of those areas. 

Obviously, in terms of reimbursement, there is a challenge as 

well. But hopefully, there is more that we can do, if you have got 

some suggestions. 

Dr. SEMLA. Yes, thank you, Senator Lincoln. 

I was fortunate enough to train at the University of Iowa and 

was there for nine years, and so have some experience in delivering 

rural health care. I would look at it from a two-pronged approach. 

First is to look at increasing the workforce that is either specializing in geriatrics or can employ the principles of geriatric medicine. There are a couple of things that are currently under way. 

One is that the Institute of Medicine is currently working on a 

report on the workforce, will come forth with recommendations in 

March of next year on how we will meet the needs of caring for 

older adults. 

Another would be the continuation of funding for things such as 

geriatric fellowship, geriatric residency programs, and Title VII, 

which funds the geriatric education center that not only trains individuals who want to specialize within their profession in geriatrics, but also teaches others in medicine and other professions 

the principles of geriatrics, so you are going to eventually get that 

down into the communities. 

The other idea I would have is another along those lines, would 

be loan forgiveness programs for people who choose to go into geriatrics as their specialty, and particularly to encourage people to go 

into rural practices. Whether that is through State or Federal funding, that would be a huge incentive. 

With regard to the delivery of care, I think looking at things such 

as telemedicine, whether that be videoconferencing or phone conferencing or some ways. When I was at Iowa, the dental school had 

a van that was actually a mobile dental office with several suites 

that went to nursing homes and provided care. 

So if a patient can’t come to the team for geriatric assessment, 

the team may be able to come there and then work with the person 

who is going to be their care coordinator, either a physician, nurse 

practitioner, physician’s assistant in that area. So those are some 

suggestions that I would offer. 

Senator LINCOLN. That is great. I know we have worked with 

great programs through Easter Seals to get that same type of team 

40

delivery in to special-needs children, particularly in underserved 

areas, where we can get different therapies out there to them. That 

same van travels across the State with seven therapists for different things. 

So there are a lot of good suggestions there. Without a doubt, increasing both the workforce, but more importantly, recognizing 

that we are not training the geriatricians or the academic geriatricians that we are going to need for the enormous onslaught of seniors that we will see when the baby boomers really do hit their full 

peak. 

Dr. Anderson, the health care privacy is also a major concern in 

our country. Looking at your research on care coordination and 

health technology in other countries, I was hoping that you maybe 

could enlighten us a little bit on how they may have handled some 

privacy issues. 

Maybe you might have some recommendations for how we can 

keep patient medical information private when trying to coordinate 

care for Medicare beneficiaries with these multiple providers. 

Dr. ANDERSON. I think the easiest example is Germany, where 

essentially, they have been working on this issue for about 15 

years. They have an electronic medical record. They are moving to 

the smart card that you would be able to walk around and could 

have all your electronic medical record information on it. You 

would have the ability to take off certain things if you chose to do 

so. 

So if you were particularly concerned about a mental illness, or 

you are concerned about something on your medical record that you 

didn’t want all the physicians to know, you could take that off, and 

it would be your choice. So, essentially, it is your card, and you get 

to deal with it. So you would have control over the information very 

easily. I think that works pretty well in Germany. 

Senator LINCOLN. Well, it is interesting. In our State, we now 

have a consortium group that is working to bring greater efficiency 

and quality of care through medical records. 

Wal-Mart has partnered with Intel and the University of Arkansas Medical Sciences to really begin to develop a very similar-type 

card that gives the information in the hands of the patient the ability to transfer or take that information with them, and to control 

the information in terms of things that they may want to keep 

some privacy element with. 

Dr. ANDERSON. About a year ago, I was down in New Orleans, 

and the New Orleans City Health Department was passing out 

smart cards, because they saw during Hurricane Katrina, there 

was a huge problem when people lost all of their medical records. 

If you had it with you in your wallet, and you ended up in Arkansas, you would have that information. It was a critical thing that 

they learned as a result of Katrina. 

Senator LINCOLN. Well, Dr. Dorr, last—my time is up—but based 

on your experience with the Care Management Plus, you talked 

about some of the benefits that you have seen for patients and 

their caregivers since they have begun receiving coordinated services for their chronic illnesses. 

Is there anything else there? You talk about the information 

technology needing to be adapted, and I would think that as opVerDate 0ct 09 2002 15:07 Nov 15, 2007 Jkt 000000 PO 00000 Frm 00044 Fmt 6633 Sfmt 6633 H:\DOCS\38617.TXT SAGING1 PsN: JOYCE
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posed to just making sure that we are having this coordination of 

information and care for the purposes of efficiency and cost-effectiveness, there are also other benefits too. 

Dr. DORR. Yes, thank you. That is an excellent question about information technology and its use. I think that we have highlighted 

health information exchange as a very important part of the care 

coordination that really has to occur, and keeping privacy carefully 

monitored as we do that. 

I think there is one core way we could do that, while still allowing a fair amount of choice, which is to continue to divine the core 

functions and standards that are necessary to be able to share care 

plans and coordinated care between physicians so that it is easy to 

keep track, and keep track of the six different components as well 

as the patient’s preferences. 

Senator LINCOLN. That is great. Thank you very much. 

Mr. Chairman. 

The CHAIRMAN. Thank you very much, Senator Lincoln. 

Dr. Semla, will you tell us more, as specifically as you can, which 

I believe you touched on, why it is that a direct physician involvement in the care plan rather than the use of disease management 

companies is more productive and more efficient? 

Dr. SEMLA. The demonstration project that CMS has done has 

largely focused on disease management companies, more focused on 

a specific disease as opposed to multiple illnesses and chronic conditions that all interact, so that their interventions are designed 

specifically for that particular intervention. 

They may be targeting heart failure, but they are not taking into 

account the patient’s diabetes, their arthritis, all of which can lead 

to complications in terms of managing their heart failure, or lead 

to drug interactions, as one of the reasons. 

So having care coordination, some patient-centered focus on all 

of those chronic conditions, will help to make that system more efficient and lead to better outcomes for the patient. 

The CHAIRMAN. You don’t believe a disease management company can do that? 

Dr. SEMLA. I don’t believe that they have demonstrated it as well 

as chronic care coordination, particularly when combined with geriatric assessment, where you have an initial plan, and then you 

have the implementation of that plan. You have to have multiple 

chronic disease management systems for the patient, and sort of 

what we have now. 

The CHAIRMAN. Dr. Anderson, what role do you believe that the 

Federal Government will have to play, or should play, in implementing electronic systems nationwide? 

Dr. ANDERSON. As I said in my testimony, I think it is the benefit of electronic medical records accrue pretty much only to the 

payers. They don’t accrue to the providers. 

If I look at other countries, almost all of the expenditures come 

from the Federal Government, come from whoever is paying for 

care. They are the ones who benefit from fewer drug interactions, 

fewer hospitalizations, fewer readmissions, all these things that 

occur because you have an electronic medical record. 

The hospital gets fewer admissions, so they don’t benefit from 

this. The doctor gets fewer admissions. They don’t benefit from 

42

this, but yet we are asking them in the United States to pay for 

this electronic medical record. The benefits accrue to the payer, because you get fewer hospitalizations. 

If I may take a second, in terms of your previous question, the 

evidence base, as I said, doesn’t exist right now for taking care of 

people with multiple chronic conditions. So, a disease management 

firm going by the book doesn’t know how to take care of somebody 

with multiple problems. 

Medicine is an art, not a science, in many of these people, with 

multiple chronic conditions until we have got a better scientific 

basis, disease management, as much as it tries, doesn’t have the 

evidence to take care of these complex patients. 

The CHAIRMAN. All right. Thank you so much. 

Dr. Dorr, implementing a program like Care Management Plus, 

as you know, may cost clinics upwards of as much as $100,000. 

Small rural clinics, such as those in my State as well as across the 

country, may not be able to afford that investment. 

So what other options exist for small clinics that may assist them 

in coordinating patient care? 

Dr. DORR. That is a great question. We are actually working with 

the Oregon Rural Practice Research Network to come up with an 

answer to that question. 

I will tell you our general approach, which we started in Utah, 

which was to invoke more of community support for the kinds of 

people who do care management in the community, to broaden the 

concept of the care team with the primary care clinics, as a center, 

but not necessarily providing all the care. To do that, developing 

relationships with the other resources that are available in that 

community, to help fill out the care as well. 

Health information exchange about care plans, about the nature 

of a person’s needs, need to be able to be spread more broadly. So 

one of the ways we have done this, just on the ground, is have a 

nurse that is shared between multiple clinics who actually might 

otherwise be competing. Basically, she goes to two different clinics, 

and sees the patient specifically for care coordination. 

That is one example. Might not work in all places. But I don’t 

think we have the answer to that yet, except to look to the broader 

rural communities and try and enhance the workforce, as Dr. 

Semla mentioned. 

The CHAIRMAN. Thank you, Dr. Dorr. 

Madam Chairwoman. 

Senator LINCOLN. Thank you, Mr. Chairman. 

Senator Whitehouse. 

Senator WHITEHOUSE. Thank you. 

Dr. Anderson, I would like to follow up a little bit on the comments you just made about health information technology. This is 

something that interests me a great deal, entirely apart from the 

question of where, within the health care system, the benefits of 

HIT accrue. 

I would agree with you that they accrue first to payers, second 

to patients, and third to providers, perhaps even not at all to providers, or perhaps even at cost to providers overall. 

Nobody contests that it is a wise idea to expend taxpayer money 

maintaining a national highway system, because we are all very 

43

pleased that goods can travel rapidly around, and we can drive to 

visit our grandmothers and family. 

Should we be looking at the national highway system as a model 

for a federally managed health information network? 

Dr. ANDERSON. I think if we look at other countries, we see in 

fact that that is exactly what they have done, they use that model. 

Now, the difference is that I think that the national highway system has both Federal money and State money. 

I think this is really a Federal responsibility, because many of 

the people spend 6 months in New York, or Rhode Island, and then 

they spend 6 months in Florida. Which State should pay for that 

cost? 

So you have got to have an information system that is in fact national. So with that slight modification to your idea, I think it 

makes complete sense to make it a nationally funded system. 

So I would prefer that, recognizing the health care system. I 

think my second choice is to have the payers pay for it, with Medicare taking the lead. 

Senator WHITEHOUSE. Before you can fund something like this, 

there has to be some agreement on what it is going to look like. 

The sort of simple analytical model I have is back when we were 

a much more primitive country, and the railways were the technology of the future. 

One thing Uncle Sam had to do, in a hurry, was decide how far 

apart the rails were going to be from each other. Simple decision, 

but once you made it, then the boxcar could get from Providence 

all the way down to Arkansas. If you don’t make that decision, and 

you have got different track widths all over the country, you really 

don’t have a railway system that can work. 

In the health information technology world, it seems to me that 

there are some similar rail-width issues having to do with interoperability, with what goes in an electronic health record, with 

what the privacy and confidentiality requirements are going to be. 

Are you comfortable that we are making enough progress on that 

in this country right now, when you consider the potential savings 

that are awaiting us if we can build out adequate health information technology? 

Dr. ANDERSON. No, I am not. I think we are in fact doing it the 

wrong way. We are essentially, by putting all the responsibility on 

the providers to develop these electronic medical records. We are 

making it almost impossible to have interoperability. 

At Johns Hopkins, we have one electronic medical record. The 

University of Maryland has a different one. A doctor doesn’t know 

which one to use. So it is exactly like your railroad analogy here. 

They are dealing with two different, three different, five different 

electronic systems to try to connect with all of the things. 

Each one of them, Johns Hopkins wants to get as many doctors 

into their system as possible. That is how the competitive system 

would work. But in this regard, the competitive system may make 

it more difficult. 

So we do need that standardization of rails. There is some work 

at AHRQ and other places on that issue that I don’t think is nearly 

enough. Until we decide we are going to put some real money into 

this activity, it is a lot of academic exercise. 

44

Senator WHITEHOUSE. In terms of talking about the real money 

in this activity, I have come across three studies. The RAND Corporation study shows that the minimum likely level of savings is 

about $81 billion a year from adequate HIT investment. Before 

David Brailer left ONCHIT, he said it was about $100 billion a 

year. There is a Massachusetts group CITL which said $75 billion 

a year. That is a pretty good set of numbers. In fact, the RAND 

Corporation high-end number estimates $346 billion a year in savings. 

Are you aware of other work that has been done to cost out the 

benefits of adequate HIT investment? Those are the three studies 

that come to mind. Are you aware of others that are out there? 

Dr. ANDERSON. There are others, but I think those are for me 

very reputable ones. They all show about the same number in 

terms of savings. Really, it depends on how many physicians actually participate into the system. 

The higher number, I think, is potentially achievable, by RAND. 

If we got nearly universal working on this system, and that physicians started to really accept the interoperability of it. In other 

countries, they are seeing significant savings. 

Senator WHITEHOUSE. For the record, Madam Chair, in the context of these, the annual budget for the Office of the National Coordinator of Health Information Technology in the Federal Government has just been doubled, nearly, to $112 million a year. If you 

took the $81 billion, and you divided it down to days, that is $220 

million a day in savings. So we are investing about 12 hours’ worth 

of the potential savings in trying to achieve them. 

My time has expired. 

Senator LINCOLN. Thank you, Senator Whitehouse. It is really 

difficult to mention those kind of savings around Senators, because 

we all can think of the many places we would like to see them invested. 

Senator Craig. 

Senator CRAIG. First of all, Madam Chairman, thank you very 

much for this hearing, and to Chairman Kohl and Ranking Member Smith. 

Thank you all. 

Let me ask unanimous consent that my full statement become a 

part of the record. 

Senator LINCOLN. Without objection. 

[The prepared statement of Senator Craig follows:] 

PREPARED STATEMENT OF SENATOR LARRY CRAIG

Good afternoon Madam Chairman. I want to thank you as well as Chairman Kohl 

and Ranking Member Smith for calling this hearing today. 

Madam Chairman, as the baby boom generation ages, we will see an enormous 

growth in the number of Medicare beneficiaries with multiple chronic conditions. By 

some estimates, this relatively small population of patients consumes nearly 2/3 of 

all our Medicare expenditures. Candidly Madam Chairman, that statistic is too startling to ignore. 

This hearing will allow us to focus on this important aspect of Medicare. We all 

agree that Medicare is in need of reform. Medicare’s inability to properly handle the 

needs of seniors with chronic illnesses is only one of the problems with the program. 

The current system is unstainable—both financially and its ability to maintain quality care. 

In the testimony they provided, our witnesses have highlighted a variety of problems that the current structure of Medicare presents to beneficiaries with chronic 

45

conditions. While it is important to identify the problems, I also appreciate hearing 

about solutions. 

America’s heavy reliance on third party payers to finance health care presents a 

number of challenges. One of those—all of the experts on the first panel recognize—

is that better coordination of care suffers because providers have little financial incentive to change care delivery based on the needs and wants of their patients. Put 

simply, their patients aren’t paying much of the bill. The federal government is. 

Still, ideas are beginning to surface in this important area. I was pleased to see 

that in his testimony Dr. Semla points out that the delivery of health care to chronically ill patients is focused more on the way physicians are paid, not on what is 

in the best interest of a patient. 

Every year I meet with more physicians from Idaho than I can count. I’m sure 

that Senator Lincoln and other members of the House and Senate meet with physicians from the States and Districts as often as I do. When these various physician 

groups are all put together, it is clear that they are a well-represented profession. 

While I enjoy learning about the new innovations in health care or the issues important to a particular specialty, I can’t help but notice that there are always a few 

common themes when any doctor visits my office on Capitol Hill. 

First, most of them recognize that the current Medicare system is not ideal for 

the needs of their patients. Then, that recognition is followed by a request that Congress increase Medicare payments for their particular specialty or cover some additional treatment service they would like to provide. In short, most of them identify 

the problem and then request something that will exacerbate the problem. 

I would like to hear more physicians come in with ideas for a new business model 

for how they practice medicine and then offer some suggestions as to how we could 

change Medicare to meet the new business model. I am pleased, Madam Chairman, 

that this distinguished group of witnesses seems to be heading down that road. 

When doctors begin to say they have a new business model that will better serve 

the health care needs of their patients, I think we in Congress will get at the business of reforming Medicare. But, when all we hear is that physicians believe Medicare payments need to increase, it is natural that we in Congress focus on that as 

the problem. 

Madam Chairman, I am pleased that we will have the opportunity to discuss one 

important facet of the challenge of the future of Medicare today. Individuals with 

chronic conditions stand to significantly benefit from a re-examination of Medicare’s 

payment structure. I hope we move on some of these innovative ideas and more importantly that we begin to change Medicare into a more patients focused system. 

Again, I want to thank you Senator Lincoln as well as Chairman Kohl for calling 

today’s hearing on this important issue and I look forward to hearing from our witnesses.

Senator CRAIG. Obviously, to our panelists, with two-thirds of our 

Medicare expenditures being into the area that you are focusing on, 

this is a bit of a statistic too big to ignore. Now, we have moved 

over to one of the tools, and that is as important. 

Let me suggest to all of you, there is a model out there that the 

Federal Government owns today that is working phenomenally 

well. In fact, Dr. Anderson, when Katrina hit, we didn’t lose a 

record. We didn’t lose a patient. We didn’t lose the pharmaceuticals. We didn’t lose a staff person or the staff person’s families 

or the staff person’s pets. It was called the VA system. 

We got them all out on time, on schedule, deployed them to other 

VA facilities around the country. The moment they walked through 

the door and their ID number was put into the system, their record 

was there. 

It is by far, by almost every public and private estimation today, 

the best records system in this country. It was federally funded. It 

is uniform. We are now moving the DOD into a similar system, so 

there is connectivity. 

I don’t disagree with anything you are saying. The sporadic efforts out in the private sector to build a system is not working, not 

working the way it ought to work. There is no question, when I 

46

look at the quality of health care delivery that the VA system now 

brings to us. 

Harvard, Michigan, their surveys, consumer satisfaction is higher than almost any private or other public system, and so on and 

so forth. Why? It is the records system. It is the uniformity of it. 

It is a phenomenally good system. 

Madam Chairman, we have spent a few billion dollars getting 

there. It is available. It is a publicly owned system. Anybody can 

replicate it if we were to choose to do that. But there is no single 

force causing that to happen, or allowing it to happen. 

Privacy becomes a frustrating issue, as it relates to that kind of 

connectivity. I voice my concern about smart cards, and the need 

for uniformity even for a smart card to work, while that card 

houses all of the information current. 

In fact, I saw a demonstration of it today where in the card was 

also the X-rays, and so if you have got a hip that is metal, and you 

are going through a detector at the security at the airport, well, 

that system could have a system that accepts a smart card, and 

boom, up comes your X-ray to prove if you needed to. 

So all of that is doable, but there is no national coordinated effort. With a smart card, there would need to be a uniformity, 

though, of at least software to accept it at individual providers’ locations. Would that not be true? 

Dr. ANDERSON. That would definitely be true. But I think that 

is something that AHRQ and other Federal agencies have worked 

on. There is a fair amount of work that has been done. So I think 

we are close to that. 

I think it is the Medicare program that should take the lead, because the people who would benefit most from the smart card are 

the people with multiple chronic conditions, and that tends to be 

the Medicare program. 

Senator CRAIG. What about that chronic condition that says, 

‘‘When I get to my provider, I forgot my smart card’’? How do we 

deal with that? 

Dr. ANDERSON. That is clearly a problem, that we do lose information. We might have to have a backup——

Senator CRAIG. ‘‘Oh, it is back home, laying on my dresser. I forgot to bring it.’’ 

Dr. ANDERSON. Right, and that happens. I sometimes forget my 

Blue Cross card when I go to the doctor as well. They give me a 

little bit of information. 

You could have a backup system there that is available as well, 

where you just put the smart card in at the doctor’s office and it 

connects to some very large server, if you chose to do that. I was 

just trying to make sure that we didn’t really intrude too much on 

the privacy thing. 

But personally, I think the VA system works incredibly well. I 

think the smart card would be in addition to that. But the VA system works incredibly well. 

Senator CRAIG. Well, I thank you. I have no questions. 

But I do believe, Madam Chairman, we have something that we 

may not necessarily want to replicate, but we have a model that 

is working. It is right in front of us every day. The taxpayers of 

America paid for it. 

47

We spent many years investing it, and in it, and improving it, 

and we continually do work on it today. It is without question a 

very effective system. It has brought savings. It has brought quality of delivery, and all kinds of things that are something that we 

are striving for. 

Thank you very much for this hearing. 

Senator LINCOLN. Thank you, Senator Craig. 

It brings consistency, as you have mentioned with the victims of 

Katrina, to be able to have portability. 

Senator CRAIG. In fact, Madam Chairman, it was fascinating, in 

talking with the managers of those hospitals, as I have. They didn’t 

worry about the records, because the records were in the mainframe, outside of Katrina. They just knew that when they got the 

patient, they worried about the patient. 

In fact, the great tragedy is that the public sector performed very 

well in that instance, and the private sector, in some instances, 

failed, even to the point of losing patients. Therein lies a great 

tragedy. But beyond that, they didn’t worry about the records, because they knew when they got to wherever they were going, they 

would be there. 

Dr. ANDERSON. I had an opportunity to go to see it, and almost 

all the doctors’ offices lost all of their records. The hospitals lost all 

of their records. It was only the VA that was able to maintain, because they had it on a remote site. 

Senator CRAIG. That is right. Thank you. 

Senator LINCOLN. Thank you. 

Senator Casey. 

Senator CASEY. Thank you, Senator Lincoln. I appreciate you 

getting us together today here. 

Senator Kohl, thank you for your chairmanship and the great 

hearing you have provided and the great panels, today being one 

of those. 

I want to say first that one of the things that I am proudest of 

in the last couple of days is to be a co-sponsor of the Geriatric Assessment and Chronic Care Coordination Act of 2007. Senator Lincoln has shown great leadership on that issue, and we are just beginning that process. 

Your testimony today helps us to understand better the kind of 

coordination that we need, and the real urgency to do that when 

it comes to chronic conditions and in other challenges we have in 

our health care system, particularly with regard to Medicare. 

I come from a State where we are right now second in the country in terms of the population over the age of 65, second only to 

Florida. Eighty-five and up is our fastest-growing population, and 

your heads are 90, and you know this well. I think these issues 

that you have given testimony about, we are exploring this particular bill that I mentioned, will bring some light too, I think. 

All these issues come under the broad umbrella of how do we pay 

for Medicare in the future, and it is among the two or three most 

urgent domestic challenges we have for the next 50 or 100 years. 

We all know that. This is one of the few efforts in Washington, DC, 

today, I think, to really deal with it. 

If we don’t deal with the coordination of care in chronic disease 

or illness, we are not dealing with the cost of Medicare. So it is not 

48

just about dollars and cents, it is about whether we can deal with 

those costs. 

There are two data points or statistics that I want to read, and 

I think they are particularly compelling. One is, this comes from 

the summary that Senator Lincoln had for the bill, and it is just 

startling. The witnesses know this, but I think we can’t say this 

enough. 

Twenty percent of Medicare beneficiaries have five or more 

chronic conditions, and these individuals account for almost 70 percent of all Medicare spending. I mean, it is just staggering, the 

kind of money that is being expended. We have no strategy to deal 

with that at present, no strategy to take better advantage of the 

technology, and take better advantage of the care plans that we are 

talking about. 

I think also, the other number, or the other data point that 

jumped out at me, was just the impacts of this on our entire population, that by the year 2020, a quarter of the American population—not the American elderly or older citizens, the entire population—will be living with multiple chronic conditions. Costs from 

managing these conditions will reach more than $1.1 trillion, by 

one estimate. 

So whether those numbers are exactly accurate or not, even if 

they are in the ballpark, we are in big trouble right now. Washington is not dealing with this. I think this bill and this hearing 

is a step in the right direction. 

It seems that we have made a decision over many years in both 

parties, in lots of administrations and Congresses, to say that for 

someone who has a chronic condition or a long-term problem like 

diabetes, that we have made the decision we will pay for an amputation down the road decades later, but we won’t pay for a care 

plan that leads to the prevention that is necessary, or a plan to 

prevent that amputation from taking place. It is real madness in 

terms of care, but it is fiscal madness in terms of the money. So 

that is my statement. 

But let me get to some questions. I would ask, I did have a 

longer statement, which I will submit for the record, and I would 

ask consent to do that. 

Senator LINCOLN. Without objection. 

Senator CASEY. One of the concerns that I have with the direction we are taking is whether or not this coordination—and this is 

for any one of the three of you—this coordination and the kind of 

chronic care coordination that we are talking about can lead to the 

elimination or the reduction of the kind of independence that people want. 

I know that is always a tension between helping someone and coordinating their care and a lot of the independence. I don’t know 

if any of you have any opinions about that. 

Doctor. 

Dr. ANDERSON. What I think you want to do is to allow the patient to choose their own care coordinator. So, if I have cancer as 

my major concern, maybe it is my oncologist that is the care coordinator. If diabetes is my major concern, maybe it is my 

endocrinologist that is my care coordinator. 

49

If I get to choose who my care coordinator is, I am going to feel 

very comfortable with that. If somebody else chooses it for me, then 

I am not going to be comfortable. So I think it is really just giving 

that person the choice. 

Senator CASEY. Anyone else have, on that question? 

Dr. DORR. Absolutely. The most patients in the country do seek 

care from a primary care physician, a geriatrician. That what 

makes sense, at least from our perspective, is that they are still 

able to choose any primary care team that they would like, but that 

unfortunately, that to learn how to do these models takes time and 

effort. 

That somehow, if a way to understand the value of that and to 

document it more carefully through a series of standards that were 

implemented, that that would help as well. So patients could 

choose somebody who has by reputation had that opportunity. 

Senator CASEY. I know I am out of time, but, Doctor? 

Dr. SEMLA. Well, I would just say that choice is good, and letting 

the patients choose would be a goal. Most patients are probably 

going to choose a geriatrician or a primary care provider, particularly if they have multiple chronic illnesses. 

Senator CASEY. Thank you. 

Thank you, Mr. Chairman, Madam Chair, as well. 

Senator LINCOLN. Thank you. 

Senator Corker. 

Senator CORKER. Madam Chairman, thank you for this great 

hearing. 

I think the testimony has been very, very good, along with the 

comments that other Senators have made. I know that the subject 

matter was selected for each of you, and we kind of honed in on 

Mr. Anderson a great deal, not to take away from the two of you. 

But I think the focus of the records and the smart card itself are 

dead-on. 

I come from a State, Tennessee, that has a lot of entrepreneurs, 

a lot of people involved in health care. What I find—and I really 

appreciate the great work that they do, and they have done a lot 

to advance medical care in America—but it is like we have silos of 

people that are doing exceptional things, but not talking with each 

other. 

I think that tying that together with technology truly is the 

only—we really do not have a health care system in America. We 

have a lot of people who are doing what they do well. I think that 

the technology has the ability to really cause us to have a system 

where people are actually communicating with each other. 

I think your comments have been dead-on, along with others up 

here. I really want to work with our Madam Chairman and others 

to make sure that we do focus on the public sector taking the lead 

in making sure we have a technology platform. 

I would like to move to another subject, and I think Senator 

Casey’s comments about focusing on the end issue instead of prevention—obviously, all the money exists in the chronic conditions. 

That is where all of the prevention needs to even take place with 

younger populations. 

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But if you will, describe to me, if we went this route, sort of the 

upfront investment that might take place. Financially, again, I realize we are seeking bigger savings down the road. 

But talk a little bit about how we would go about paying for this, 

through this Medicare program. Also if you would differentiate that 

from what now happens with Medicare Advantage and that type of 

thing. I would love to have an explanation from each of you that 

want to discuss it. 

Dr. ANDERSON. What I propose is that the Medicare program pays $5 for a physician, for a hospital, for whoever has the medical 

records to submit it. Then, that is the payment system, and that 

would cost about $4 billion. 

Senator CORKER. Yes, I am actually not talking about it. I had 

heard you say that, both in your testimony and I know someone 

else asked a question. I am actually talking more now about the 

general coordinated care effort that would take place, and having 

someone coordinate that through the fee-for-service program. I am 

focusing on the bigger picture of the bill itself. 

Dr. ANDERSON. Basically, what you want to do is provide to a 

doctor, I think in most cases—whoever is the person who the patient chooses to be the care coordinator—approximately $100 per 

member per month. That person would probably hire somebody to 

do most of the care coordination activities. 

Then, where there is a difficult decision to be made clinically, it 

goes to those two, three, four doctors, and they have an actual conversation about whether or not the cardiology problem or the neurology problem is more significant. So, it would probably involve 

the geriatrician and others. 

You need money for that person to gather all the information, to 

have it in order to make a decision. I propose one more number to 

keep in your heads these Medicare beneficiaries with five or more 

chronic conditions see 13 different doctors during the year and fill 

50 prescriptions during the year. So a lot of information is flowing, 

and we need somebody paid to coordinate that. 

Senator CORKER. Let me follow up on that, if I could. I know 

there are others that want to make comments. 

I was commissioner of finance for the State of Tennessee about 

a year after we privatized Medicaid. I had nothing to do with 

privatizing it, but was there to sort of deal with some of the issues. 

What we found was that, in a lot of the HMOs, we had clerks, 

in essence, that didn’t know that much about medicine, that were 

paid like you are describing, to make major decisions, if you will, 

on behalf of patients. 

So, it turned out to be a not-so-good thing, if you have, in essence, somebody on the end of the telephone that really—so if you 

could respond to that? 

Dr. ANDERSON. Mine would be different in that it would be paid. 

The money would go to the doctor, and the doctor would be the one 

that would be supervising this nurse or this person. So the doctor 

would feel responsible for the activity, not some clerk on a telephone. 

Senator CORKER. Can I ask one more question? I know I am out 

of time, but, through an HMO, there is obviously a financial incentive. This would, in essence, be a fee paid to someone. 

51

Would there be additional incentives, if you will, to coordinate 

care and keep costs at a lower level? Or would it just be that permember per-month payment to that person? It sounds like a strict 

administrative payment without other incentives in place. 

Dr. ANDERSON. I would love to have pay for performance included in that. I think the key things that you would want to reduce are readmission rates, and you could monitor the readmission 

rates at the hospitals. 

You can monitor what are called preventable hospitalizations, 

and these are things that have been in the literature for a while, 

like you should never be hospitalized for diabetes and other kinds 

of things. You can monitor how well this care coordinator is performing on all these types of indicators. 

A third one would be drug-drug interactions. These are things 

that can be very expensive that can be relatively easily monitored 

if you have somebody who feels responsible for that activity. Right 

now, none of these 13 doctors really feel responsible. So paying for 

a care coordinator and monitoring his or her activities would make 

them feel responsible, and we can monitor their performance in 

this activity. 

Dr. SEMLA. I would like to comment that many geriatricians are 

already providing these services without receiving payment for 

them, because that is what they do and what they are committed 

to doing as part of their service. I would include others in geriatrics, such as nurse practitioners and physicians’ assistants, who 

can deliver some of these same services under the supervision of 

a physician. 

With regard to pay for performance, I think we have to be very 

careful in terms of the quality indicators that we would choose, because we are dealing with a very vulnerable and at some times 

frail population but that does get sick. But just focusing on something like drug-drug interactions is a perfect example. 

I am not sure the Committee is aware, but there is evidence that 

suggests that for every dollar that we spend in the United States 

on prescription medications, we are spending between 33 cents and 

another dollar to treat the adverse events from those medications. 

So it is not a really good bang for our buck. That would certainly 

improve with care coordination. 

Senator LINCOLN. Well, I want to thank the panel very much. 

You all have been a tremendous help, and we look forward to continuing this discussion and work, because I think there are so 

many things that we can agree will benefit all of us, all of our families, and certainly the Medicare beneficiaries in this country. So we 

look forward to working with you. Thank you so much for your 

time and for being here. 

We would like to call our second panel, if we can. 

I would like to welcome our second panel. 

We will first hear from Stuart Guterman, who is the senior program director of the Program on Medicare’s Future at the Commonwealth Fund. Mr. Guterman was also the former director of 

the Office of Research, Development, and Information at the Centers for Medicaid Services. 

52

He will be followed by Dr. Stephen McConnell, who is the vice 

president of advocacy and public policy at the Alzheimer’s Association. 

Our final witness will be Ann Bowers, who will share with us 

what it is like to be a caregiver to an individual who suffers from 

multiple chronic-care conditions. I am certainly especially pleased 

with Ann being here today, because she is from Arkansas. 

As a caregiver to a parent with Alzheimer’s disease myself, along 

with my sisters, brother, and my mother, I think it is especially important that we hear from family members who face the day-to-day 

struggles of caring for a person with multiple illnesses and in that 

chronic disease. 

So thank you all for being here. 

Mr. Guterman. 

STATEMENT OF STUART GUTERMAN, SENIOR PROGRAM DIRECTOR, PROGRAM ON MEDICARE’S FUTURE, THE COMMONWEALTH FUND; FORMER DIRECTOR OF THE OFFICE OF 

RESEARCH, DEVELOPMENT AND INFORMATION, CENTERS 

FOR MEDICARE AND MEDICAID SERVICES, WASHINGTON, DC 

Mr. GUTERMAN. I want to thank you, Chairman Kohl, and Ranking Member Smith, Senator Lincoln, and the other Members of the 

Committee for this invitation to testify on chronic care initiatives 

in Medicare. 

I am Stuart Guterman, senior program director for the Program 

on Medicare’s Future at the Commonwealth Fund. The Commonwealth Fund is a private foundation that aims to promote a highperforming health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s 

most vulnerable populations, including the elderly and disabled. 

The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health 

care practice and policy. 

Now, the Medicare program, as you have heard, was designed to 

ensure access and needed health care for first the elderly and then 

the disabled population. It has served that purpose well for more 

than 40 years. But the population it serves has grown and 

changed, and Medicare must adjust to meet the needs of its beneficiaries. 

One problem faced by Medicare, as well as the rest of the health 

care system in this country and in other countries, is that while the 

health care delivery and financing system was originally designed 

to address acute care needs, the population they serve is characterized increasingly by multiple chronic conditions. 

We have already heard from the Chairman and others, 20 percent of Medicare beneficiaries have five or more chronic conditions, 

and these beneficiaries account for two-thirds of Medicare spending 

each year. That accounts for about $300 billion next year that will 

be spent on people with multiple chronic conditions. 

The astounding fact to me in all this is that this group of 20 percent of Medicare beneficiaries sees 13 different physicians—actually not see, is treated by, sometimes they actually don’t see 

them—13 different physicians, and fills 50 prescriptions each year. 

53

So there is not only a lot of money on the table for this group 

of people, there is also a lot of care being provided. Currently, there 

is no incentive in Medicare or most other systems to coordinate 

that care. Within Medicare, I would assert that neither traditional 

fee-for-service Medicare nor necessarily the Medicare Advantage 

program currently is configured to ensure that these beneficiaries 

get the kind of coordinated care that they need. 

Fee-for-service payment emphasizes provision of individual services in the context of a single encounter for a single condition. 

Capitation provides incentives that may be more consistent with 

better coordination, but that doesn’t mean that plans respond to 

those incentives in that way. 

Capitation also provides a strong incentive to avoid chronically 

ill enrollees, even under the current risk adjustment mechanism. 

Moreover, the lucrative payment rate that plans currently receive 

under Medicare Advantage may actually diminish the power of any 

incentives, both positive and negative, that capitation otherwise 

would provide. 

CMS, though, has begun to respond to these changes in their 

population and their needs by developing a variety of initiatives 

aimed at improving the coordination of care provided to Medicare 

beneficiaries with chronic conditions. In my written testimony, I 

describe these initiatives in some detail, but I would like to mention a few of the projects that are currently underway. 

Under traditional Medicare, one of the early attempts to coordinate care was the Medicare Coordinated Care Demonstration. This 

was an attempt to see whether providing coordinated care services 

to Medicare fee-for-service beneficiaries with complex chronic conditions could yield better patient outcomes without increasing program costs. 

There were 15 sites, both in urban and rural areas, that focused 

on various complex chronic conditions. Enrollment in these programs began in April 2002, and at its maximum reached about 

21,000 patients. However, that number was concentrated; about 60 

percent of the total enrollment was in the five largest sites. 

There are initial findings from the first 2 years of that demonstration. They found that beneficiary recruitment in the fee-forservice market can be a challenge, that the most successful programs had close ties to physicians and other providers, and 

through the first 2 years of the demonstration, few effects were 

found on beneficiaries’ overall satisfaction with care, patient adherence or self-care and Medicare program expenditures. So the results are sort of mixed at best. 

Currently, there is a major project that is not a demonstration, 

but a pilot program called Medicare Health Support, which was expected to involve about 160,000 beneficiaries at eight participating 

sites. 

Unfortunately, two sites are in the process of dropping out of 

that program, LifeMasters in Oklahoma and McKesson in Mississippi. But we don’t have any good results on what the bottom 

line is going to be from that demonstration. 

I am glad to say that apparently, another demonstration project 

that was in the Medicare Modernization Act is about to be implemented, the Medicare Care Management Performance DemonstraVerDate 0ct 09 2002 15:07 Nov 15, 2007 Jkt 000000 PO 00000 Frm 00057 Fmt 6633 Sfmt 6633 H:\DOCS\38617.TXT SAGING1 PsN: JOYCE
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tion, which is a 3-year project that is scheduled to start July 1 in 

Arkansas, California, Massachusetts and Utah, to promote adoption of health care information technology to improve quality of 

care for chronically ill Medicare patients. 

Focused on the physicians, about 800 practices with one to 10 

physicians are going to be involved in that, a total of 2,800 physicians focusing on patients with diabetes, heart failure, coronary artery disease, and preventive care. The special needs plans, which 

I won’t go into, are intended to help, in the Medicare Advantage 

environment, improve coordinated care. 

So what do these initiatives tell us? They tell us, No. 1, that engaging Medicare beneficiaries in these kinds of initiatives can be 

challenging, that the more successful initiatives work more closely 

with physicians to help identify patients who can be helped most 

and to establish credibility with those patients. 

They tell us that designing approaches to reach different populations and in different circumstances and environments and successfully integrating those approaches can be complicated, and that 

improvements in health care for groups of individuals seem to be 

achievable, but the jury is still out on whether savings can be reliably achieved. 

Still, given the current lack of coordination in our health system, 

it would be hard to believe that a way can’t be found to improve 

on both quality and efficiency. The current system basically is the 

example of the worst case, and any attempt to coordinate care, I 

think, would be a move in the right direction to use this $300 billion a year that is on the table more effectively for the beneficiaries 

in the program. 

[The prepared statement of Mr. Guterman follows:]

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Senator LINCOLN. Dr. McConnell. 

STATEMENT OF STEPHEN MCCONNELL, PH.D., VICE PRESIDENT OF ADVOCACY AND PUBLIC POLICY, ALZHEIMER’S ASSOCIATION, WASHINGTON, DC 

Dr. MCCONNELL. Madam Chair, thank you for holding this hearing and for your consistent leadership in improving care for the 

Nation’s older population, especially for your leadership on behalf 

of people with Alzheimer’s disease. 

I would also like to acknowledge the terrific staff work of your 

Brenda Sulick, who is a fellow in the program named after Senator 

Heinz, who was the Chair of this great Committee in the past. 

Assessment in coordinating care is especially important for people with Alzheimer’s disease, because they have high use of Medicare services, and incur very high Medicare costs. This is not because of the problems of treating Alzheimer’s disease, it is what 

Alzheimer’s disease does to complicate the care and treatment of 

other conditions. 

Let’s take a look at some of the costs. Medicare now spends three 

times as much for beneficiaries with Alzheimer’s disease as it does 

for those who do not have the disease. About half of that is on hospital care. By 2030, there will be more than 600,000 new cases of 

Alzheimer’s disease every year, and the cost to Medicare for just 

treating those people will be $394 billion a year, which is the cost 

of the entire Medicare program today. 

What is behind the numbers? First of all, people with Alzheimer’s disease have other chronic conditions. Twenty-nine percent have heart disease, 28 percent congestive heart failure, 23 percent diabetes, 17 percent had chronic lung disease. In fact, only 5 

percent of Medicare beneficiaries aged 65 and over with Alzheimer’s disease had no comorbid medical conditions. Many had 

more than one serious condition. 

So what happens when those conditions come together? A couple 

of examples: Medicare beneficiaries with Alzheimer’s disease plus 

congestive heart failure had 50 percent more hospital stays, and 

the cost of their care was 50 percent higher than those with congestive heart failure and no Alzheimer’s disease. 

Alzheimer’s disease plus diabetes resulted in three times as 

many hospital stays, and average Medicare costs that were 150 

percent higher than for beneficiaries with diabetes but no Alzheimer’s or dementia. 

The reason for the higher hospitalization and higher costs is simple. Memory and other cognitive impairments caused by Alzheimer’s disease greatly complicate the management of comorbid 

medical conditions. The case of Ms. X was reported in the Journal 

of the American Medical Association and illustrates this point. 

Ms. X had mild Alzheimer’s disease and osteoporosis, and was 

prescribed a medication for her osteoporosis and told she had to 

take the medication with water and remain upright after taking it. 

Because of her dementia, Ms. X did not remember or follow her 

doctor’s instructions. 

Four weeks after starting the medication, she was taken to the 

local hospital emergency room with symptoms of an ulcerated 

esophagus because of taking the medication incorrectly. Despite 

74

treatment, Ms. X ultimately died when the ulcer eroded into a 

major blood vessel. Ms. X and the data I have presented make 

clear why care management is essential for beneficiaries with Alzheimer’s disease. 

For this reason, we need congressional action to create a new 

Medicare benefit targeted to the most complex patients. Without 

the adoption of a new benefit, CMS is unlikely to develop a comprehensive pilot program that ensures complex patients—that is, 

those with dementia and one or more other medical condition—are 

treated appropriately with meaningful assessments. 

We did a survey of 10 of the pilots that are being done now, and 

with the exception of one, none of the rest of them are even screening for dementia. They are managing diseases and not paying attention to the fact that many of the beneficiaries have dementia. 

The Alzheimer’s Association strongly supports the Geriatric Assessment and Chronic Care Coordination Act. This act is a very important step forward, and has the potential of substantially improving care and lowering costs for Medicare beneficiaries with Alzheimer’s disease and other dementias. 

The value of this legislation is not just the numbers. It is about 

the lives of real people. Without this legislation, people with Alzheimer’s disease and other dementias in their families will continue to struggle with a fragmented health care system, and Government will continue to pay for preventable hospitalizations that 

could be avoided with better assessment and care coordination. 

Do not forget the human faces behind all the statistics. You know 

that very well, and you have handled that incredibly well here in 

the Senate. There are real reasons to support this important legislation, and we appreciate your leadership on this issue. 

[The prepared statement of Dr. McConnell follows:]

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Senator LINCOLN. Thank you, Dr. McConnell. 

Now, I would like to welcome Ann Bowers from Arkansas. I 

won’t need an interpreter here at all, having a fellow Arkansan. 

Just to say thanks to Ann for sharing your story. I think our stories really do make all the difference in the world, because it does 

put a face, as Dr. McConnell said, on each of our families, on how 

we can do better, and hopefully we will. 

Thank you. 

STATEMENT OF ANN BOWERS, CAREGIVER, FORT SMITH, AR 

Ms. BOWERS. Yes, it does. You can provide printed versions for 

those that do need accent assistance. [Laughter.] 

Thank you first, Senator Lincoln, for inviting me and for everything you do for those of us struggling with the problems of an 

aging population—sometimes they are not even that aged—as well 

as everything you do for those of us in the great State of Arkansas. 

Thank you. 

My name is Ann Bowers, and I represent one of the millions of 

Americans caring for loved ones with Alzheimer’s. 

Seven years ago, my ex-husband Jay Sweatman, a 50-year-old divorced man with an MBA, two loving preteen daughters, and no 

family history of Alzheimer’s, became ill. At the time, he maintained joint custody of our girls, owned his own company, and 

served on State and National boards throughout the country. 

Fourteen months later, everything came crashing down. Repeated financial mistakes, misplaced money, overlooked details, 

drove his business into the ground, and our marriage ended. He 

then took and lost a succession of jobs, with the last one being a 

position as a stock boy at Sam’s Club Warehouse. 

When I realized this college graduate with an advanced degree 

couldn’t hold a job at Sam’s, I moved him from Albuquerque to 

Denver so he could be with his daughters and with me. At this 

point, he frequently struggled to find words while speaking and 

was having difficulty carrying on a coherent conversation. 

After 4 months of exhaustive neurological testing, a diagnosis of 

probable Alzheimer’s was made in March 2002. Neurologists gave 

me the phone number of the local Alzheimer’s Association chapter 

and suggested I get in touch with them to find out what help might 

be available for Jay, for our daughters and for me. 

I will always be grateful for that single gesture. The Alzheimer’s 

Association made sure I knew about day care and referred me to 

24-hour phone help and online bulletin boards where I could always find someone who had a clue what I was going through on 

any day. 

Finding help for Jay and a way to pay for services was overwhelming. Unemployment and financial mismanagement left him 

with absolutely no resources. He was admitted in April 2002 to the 

Colorado Indigent Care Program to help cover his medical expenses. 

In May, he applied for Social Security Disability Income, but was 

denied, because he didn’t appear to need help and he was under 

age 60. The following month, his lack of income and resources 

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viding $250 a month against any future Social Security benefits, as 

well as food stamps. 

During this time, Jay remained in an apartment across the 

street from our home, with the children spending several nights a 

week with him. He felt that independence and contact with the 

girls was critical to his well-being. However, by the winter of 2002, 

he could no longer reliably keep house, cook, or even groom himself 

regularly. 

In early 2003, Jay was finally approved for Social Security Disability benefits. He was also at long last approved for in-home personal assistance, but it came too late. By the time the services were 

authorized, he could no longer live independently. We moved him 

into a personal-care boarding home. 

In the midst of trying to help Jay get the help he needed, it 

never occurred to me to closely monitor his medication. We had 

been married for 20 years, and he was totally self-sufficient. I had 

no idea, due to his impaired judgment, he was hoarding the medication that kept his other health problems, glaucoma and depression, under control. 

It wasn’t until he tried to explain that something was wrong 

with his eyes that I realized he was losing vision from the sides, 

a classic exacerbation of his glaucoma symptoms. A thorough 

search of his apartment confirmed the worst. I found the pills I 

thought he was faithfully taking organized into neat piles in a 

dresser drawer, where he placed one each day. 

From that point on, every health problem quickly became a crisis. Jay’s untreated glaucoma required extensive testing, and we 

briefly considered surgery. He lost most of the sight in one eye. 

Frustration coupled with lack of medication for his depression led 

to thoughts of suicide. 

He had to be hospitalized just so we could get him on an adequate drug regimen and determine his true needs. We didn’t know 

it then, but we needed one person providing ongoing support and 

a plan of care in coordination with all of his doctors. Instead, I 

tried to hold down a full-time job, raise two preteenage girls, and 

solve all the problems myself, guessing what specialist he might 

need next and what condition we should manage on any given day. 

There has to be a better system. The Geriatric and Chronic Care 

Coordination Act will prevent other caregivers from facing the challenges that I did with my daughters. 

Maintaining Jay’s health was only part of the struggle. Multiple 

wandering incidents landed Jay in the hospital yet again for medical re-evaluation. He was then moved to assisted living, but had 

to be discharged after only 3 months because he became aggressive 

and physical, a common progression for Alzheimer’s disease. 

The next stop was a full-service nursing facility specializing in 

Alzheimer’s. Each of these moves required weeks of full-time 

searching by me to find available beds. First choice was never a 

consideration. Just finding an open bed for a male patient was the 

biggest hurdle. 

Each move also, I will add, required a minimum of 2 to 3 weeks 

of hospitalization, for reasons that we will see later. Moving from 

setting to setting was extremely hard on Jay, on myself and on the 

girls. 

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Access to a care coordination benefit would have provided us 

with critical nonmedical care, including managing these transitions 

between care settings and offering guidance on how to find the 

right facility. 

Comprehensive geriatric assessment would have properly evaluated his needs and functional status and made changes to his care 

on an ongoing basis to preserve his independence and his ability 

to remain in the community. 

Jay is now 57. He lives in a nursing home in Denver, where he 

no longer recognizes me or his daughters or any of his caregivers. 

I am managing his care long-distance, having moved back to Arkansas in 2005 so my daughters could be closer to our extended 

family. 

I work full-time and serve as Jay’s guardian. I am in charge of 

all medical decisions related to his care. He doesn’t have any other 

family members who are ready or able to take on this responsibility. I speak weekly with the doctors and nurses at his nursing 

home and visit as often as possible. It is not an ideal situation, but 

it is the best we can do for now. 

I urge Congress to pass the Geriatric Assessment and Chronic 

Care Coordination Act, so that families living across the country, 

including those taking care of the 56,000 Arkansans living with 

Alzheimer’s, cannot wait any longer for this kind of help. 

Thank you. 

[The prepared statement of Ms. Bowers follows:]

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Senator LINCOLN. Thank you, Ms. Bowers, for sharing your story. 

I think that so many of us feel incredibly blessed to have grown 

up in communities and certainly surroundings—I know I did—

where I lived within walking distance of both sets of my grandparents and aunts and uncles close by. One of my grandmothers 

lived with us for the last two years of her life, and those were certainly times and experiences that I cherish and am enormously 

grateful for. 

Yet, we also find, in today’s world, that is not necessarily the 

case anymore. We don’t live next-door to family members—natural 

caregivers. Oftentimes we are miles and miles apart. 

I know that through our own experience as well, if it weren’t for 

my mother’s diligence and my sister’s unbelievable ferocious appetite of going to the Internet to find out more and more about the 

progression of Alzheimer’s and what my dad might be going 

through, it was hard for us to make those decisions as well. 

Later on, hospice came through for us in an incredible way, but 

we didn’t even know to call hospice until the very last minute. So, 

it is so important that with coordination of care we are able to get 

some of those answers and directives, and to have someone there 

who can help to make those decisions. I think you bring that to a 

great realization in your testimony, and we are grateful to you for 

sharing your story with us. 

Just a couple of questions for you all, if I may. The last panel 

mentioned once something that I thought was important, and I 

didn’t get to mention it before, and that was the issue of utilizing 

Medicare and our graduate medical education dollars. 

I know my own husband is a physician, and I never will forget, 

about four or five years ago, when I really started focusing on this 

issue, I asked him which year of medical school of residency did he 

spend a specific amount of time better understanding the coordination of care for his patients. He just looked at me and said, ‘‘That 

doesn’t happen.’’ 

So I hope that we will begin to see some focus on that. I know 

our former panel mentioned it some. It is something that I wanted 

to make sure that we were aware of. 

The other was the technology platforms, and that is the ability 

to make sure that the information and the exchange of information 

in our IT efforts to bring about greater coordination are things that 

are compatible. 

I just recently visited one of my physicians at home, and they 

had gone to electronic records. It only frustrated the practice, because everybody that came to see them did not have electronic 

records, and they were not compatible with the records systems 

they had. So they were running dual systems, which were extremely costly and unbelievably frustrating. So we have mountains 

of problems to solve. 

But without a doubt, I think today’s hearing has brought before 

us that there are some good solutions to be had. We have to have 

the will to make them happen, and certainly, make the choices of 

the investments that need to be there to see that happen. 

Mr. Guterman, even if the chronic care coordination is effective, 

which I believe it is—and I believe it can be more effective as we 

87

walk through the motions of improving it—we may not see any of 

those benefits or the cost savings for several years. 

Considering the prevalence of chronic care disease in America 

and its impact on health care utilization, it seems that at some 

point we are going to need some kind of dynamic scoring that takes 

future savings into account. I know myself and Senator Clinton 

were talking about this last week in our weekly policy meeting, 

about how critically important it is. 

But based on your research, do you have any recommendations 

for us on how we can best measure the results of a chronic care 

coordination program if it is applied to the Medicare FSS program? 

I know it is difficult to measure, but you may have some recommendations for us on how to demonstrate those overall savings 

to Medicare as a result of that chronic care program, so we can convince CBO to score us some of those savings. 

Mr. GUTERMAN. Well, Senator, I think one thing that all of the 

chronic care initiatives that Medicare is doing are teaching us is 

more about how to do these things, and more about the kinds of 

things that may work in different circumstances. There is a tendency, when people look at these various initiatives, to ask only one 

question, does it work or doesn’t it work, or sometimes even more 

narrowly, does it save money or doesn’t it save money? 

I think we are at a point now where we are really early on in 

the process. We need to move in a direction that we all feel is right. 

It is similar to the interstate highway system analogy, was brought 

up in the earlier panel. 

But when people talk about evaluations, I think evaluations are 

really crucial in any kind of public or private initiative, but I think 

we need to understand what we are evaluating and the circumstances in which we are evaluating it. 

It is similar to the interstate highway system analogy: before the 

system was built, if you were trying to estimate what the savings, 

what the benefit would be from a system like that, it would be difficult to come up with hard evidence of what that savings would 

have been. 

Similarly, to go back even further, if you were trying to estimate 

what the savings, what the benefit to this country would have been 

of the automobile in the era around 1900 or 1910, to look at the 

potential benefits of the automobile. You had an automobile that 

was running on rutted dirt roads, and you really had no ability to 

generate hard evidence on what the benefit would be. 

Sometimes you just have to do things, because you feel like 

they’re the right thing to do. Under the current circumstances, we 

couldn’t possibly do worse than we are doing. However, along the 

way, you need to be careful. You also need to have a transparent 

process. 

I mean, part of the thing that we need is accountability for these 

initiatives, so that the public can know what works and what 

doesn’t work and when it works and doesn’t work, so that we can 

keep building as we move along with more care. 

Senator LINCOLN. Well, certainly your point of greater evidence 

being needed is well taken. The problem, obviously, that without 

it, it takes us longer here to get consensus to bring about that will, 

to make those investments, and to reach out to those new techVerDate 0ct 09 2002 15:07 Nov 15, 2007 Jkt 000000 PO 00000 Frm 00091 Fmt 6633 Sfmt 6633 H:\DOCS\38617.TXT SAGING1 PsN: JOYCE
88

nologies and the new ideas, and if nothing else, force the consistency that needs to be there if they are going to be effective. 

So it takes longer, and the longer it takes us, the less effective 

we are, because we are wasting so many of those dollars and efforts 

in that timeframe. So my hope is that we can bring about a consensus, and I am pleased that this Committee is very interested, 

and I know the Finance Committee has been as well in terms of 

the investments in IT. 

You did allude to, in your statement there, the report that has 

reported on the initial findings of the chronic care demos. I would 

just say that maybe perhaps the information there may not be astounding as we would have liked to have been, because it was such 

a short period of time. It is hard to—I don’t know, maybe you disagree with that—but 2 years is not a very adequate amount time 

to demonstrate, I think, the true savings or the true benefits of 

what we might see. 

Mr. GUTERMAN. Well, I think, Senator, that that early demo was 

an example of a pretty light—there wasn’t very strong financial incentive involved in that system. It was really a sort of early attempt to see whether systems of coordinated care could be put together. 

I think the answer there is, yes, they could, and I think that we 

need to be careful when we look at those things to be able to determine what we expected to see in the first place, and how we can 

learn from what actually happened. One thing we learned was that 

it can be done. 

One thing we learned, most of these were very small attempts 

at doing this, and we need to pick out what we can use in the next 

step, rather than focus on whether, in the grand scheme of things, 

whether this was a success or a failure. I mean, the fact that it existed, and that the programs ran, I think, could be called a success. 

Then we need to draw out of that all the information we can to 

make the next attempts better. I believe that was done. The Medicare Health Support Pilot will provide more information. 

But as was mentioned earlier most of the systems that are being 

tested now are based on third-party disease management organizations. I think those organizations really do have a role, but I think 

they have a role in working with the physician in providing this 

care. 

That is actually one way to answer the question about rural 

areas in this context, is that these disease management organizations can work with doctors in rural areas on a sort of contract 

basis or itinerant basis, to able to provide the services to their patient under the physician’s coordination for physicians who have 

practices that are too small to be able to afford a full-time person 

in the practice to be able to do this. 

Senator LINCOLN. Kind of contracting it out. Well, that is interesting, and I do think that it is important for us to give the time 

that we need to see the effects of some of the good things that we 

are seeing happen. I do think it is important. Thank you. 

Dr. McConnell, your written testimony, you mention the need for 

assessments as part of chronic care coordination and how important that is. I do see that as an important part of the Chronic Care 

Coordination bill that we introduced today. 

89

Maybe you might talk a little bit more about particularly ways 

that assessments would benefit individuals with dementia and 

their caregivers. I think Ann’s story really alluded to a lot of that. 

But there may be some specifics here you would like to mention. 

Dr. MCCONNELL. Well, the assessment is the foundation. You 

can’t develop a plan, you can’t implement a plan unless you know 

what it is you are addressing. I mentioned that. One of the biggest 

problems we have in the health care system is that frequently, we 

don’t know that a person has dementia, just as an example——

Senator LINCOLN. Right. A lot of people won’t even diagnose it. 

Dr. MCCONNELL. Exactly. If you don’t know that a person has a 

condition, you can’t do anything about it. So the assessment is essential to define what the problem is, and then you develop a care 

plan. I think is an example is a perfect example of that, the example I gave. Somebody wasn’t paying attention to the whole person. 

You mentioned hospice. I think it is a very good example of coordinating somebody’s care. Hospice works so well because it is 

looking at not only the whole patient, but the whole family, and 

dealing with that whole complex unit and making sure that they 

get what they need. So it is in some ways a good model. 

I worry about some of these demonstrations and pilots, because 

there are a couple of tendencies. One, I think, the disease management approach has problems, and as I said, they are not screening 

for dementia as far as we know. We are hoping that that will happen eventually. But as far as we know, we are not doing that. 

So, in the case of trying to manage someone’s diabetes, you don’t 

have dementia, you get the doctor prescribes drugs, prescribes the 

exercise regimen and diet, and you go home and you follow it. You 

have dementia, you go home, and you don’t follow, you end up in 

the hospital. 

So some of these things may fail, because they are not really paying attention to the complex problems, particularly where dementia 

is involved. We have seen that in some previous demonstrations, 

where they haven’t focused on that. Or they have focused not on 

having the physician coordinate it. So I think the physician role is 

critical. 

The other problem is that there is a tendency in these research 

projects to define the issue so narrowly, so you can really determine, did an intervention here produce a certain kind of an outcome? 

By definition, what we are talking about here is much more complex. If we try to narrow it down to get a good solid research 

project out of it, we are in some ways taking the heart out of what 

it is your bill would do and what is needed in the welfare system. 

Senator LINCOLN. Well, it is interesting, because there is a lot of 

talk up here about pay for performance, and being able to manage 

care like that is going to be a critical component of the pay for performance. 

Because as you said, if there are instructions that patients don’t 

follow, it is hard to be able to recognize what the end performance 

is of that medical provider if, in fact the patient is not participating, or the actual instructions or prescription or prescriptive 

plan that has been given isn’t followed. 

90

So with that, a manager, looking at that overall plan, it is going 

to be really critical if we want to see that pay for performance, or 

bait outcome as a part of the tools of creating greater quality and 

efficiency in our health care delivery. 

Dr. MCCONNELL. When you mentioned the importance of family 

caregivers in this whole system, and how, even in your experience, 

and previous generations where people lived closely together, families can only do so much. 

If there isn’t a good care plan, and the physicians aren’t providing the kind of information and monitoring, no matter how 

closely the family is paying attention—and I think Ann was doing 

the best she should, but the families simply can’t do it without the 

assistance. 

The physicians won’t do it, in part, because you mentioned the 

need for geriatric training. We have really got to pay attention to 

that. Because they just don’t have the time. They aren’t incented. 

Senator LINCOLN. Well, the incentivizing, as you said, for the 

amount of time that a physician is going to spend with an aging 

parent or somebody with chronic conditions, there is no doubt they 

are going to spend more time with it. 

But the other is, in terms of rural areas and the physicians that 

you have there, that there is not more training about where we are 

going with an aging population for geriatrics and geriatricians. 

Particuarly academic geriatricians, because we are not training 

those, which means as med school goes, 10 years from now, we are 

going to have less in the academic world training the geriatricians, 

and we will be at a tremendous deficit in terms of the caregivers 

that we need out there to be managing the managers, in this opportunity. 

Just one more opportunity. You have talked about how you have 

handled coordinating your ex-husband’s care. Maybe you, in having 

looked at that and continuing to do that, could reflect on how care 

coordination services would have helped your family, or would help 

your family when your husband was first diagnosed with Alzheimer’s disease. 

Ms. BOWERS. First of all, it is such a huge thing to me to sit here 

and look at this and hear people talk about budgeting and things 

like that, because to me, this is such a clear-cut cost-cutting measure. This is——

Senator LINCOLN. We need you at CBO. [Laughter.] 

Ms. BOWERS. When I look at the times my husband had three 

hospitalizations between 14 and 21 days, those hospitalizations 

were far and away primarily for simply evaluation and placement 

needs. Those needs could have been taken care of 100 percent by 

a care coordinator, a well-trained medical background care coordinator, not a clerk at the end of a phone. 

It would have made a huge difference, not only in cost-cutting—

which he was Medicare by that point—how many tens of thousands 

of dollars were spent hospitalizing him simply because the right 

hand didn’t know what the left was doing? 

We didn’t know the progression of the disease. His depression got 

out of control. His glaucoma had gone bad. There were so many 

things that went wrong that, you know, hindsight is the perfect 

20–20 situation. I went back, and can beat myself up, ‘‘I should 

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have seen this, I should have seen this.’’ But the reality is, every 

caregiver has other responsibilities, and those of us in the Sandwich Generation invariably have lots of other responsibilities. I did 

the best I could. 

Earlier today, I was speaking with someone, and it occurred to 

me, how would someone have handled this if they were less welleducated than I was? I have been blessed with a good education 

and have the ability to understand the systems, simply getting 

through the Web sites on Social Security or Medicare. I am fairly 

technologically savvy. I have a lot of time doing that kind of stuff. 

I can’t imagine how somebody without the support of a care coordinator could even begin to find the services, much less access and 

complete the paperwork and the regimen that is required and demanded to achieve the services. A care coordinator would have 

made not only a phenomenal financial savings, but it would have 

kept him in the community longer in the early stages, when he still 

had pride. 

That kind of thing is gone now. But when he still knew what was 

happening to him, and he had to try to cover, he had coping mechanisms that he would use to cover up things, like he forgot to take 

a shower. I mean, this strictly GQ man, who all of a sudden, you 

will see when it dawns on him, all of a sudden he realizes he is 

not well-groomed, or he is not putting his best foot forward. 

Those kind of things, if we could have had the in-home help that 

a care coordinator could have helped us obtain, instead of being 

turned down because the person that came to interview him happened to hit him on a good day. ‘‘Well, he doesn’t need in-home 

help.’’ 

Well, if a physician recommended that through a care coordinator, those obstacles would be gone. It would save money, it would 

enable the patient to maintain his dignity far longer, and it would 

leave some quality of life for the hundreds of thousands of young 

children that are going to be affected by this. 

This is not a disease simply of our parents, Senator Lincoln. It 

is a disease of our peers, and our children are affected by it. I just 

feel so strongly about it, that it is not just the financial citings, 

which to me is so clear-cut, that that alone, the bill should be able 

to stand on. But in terms of dignity, ability to remain in the community, and the personal quality of life for both patients and caregivers. 

Senator LINCOLN. Well, one of the other things that comes to 

mind as you discuss those things, is that as we mentioned, many 

of us, not all of us, represent predominantly rural States, but a lot 

of us do. Me, and certainly all of us, have rural areas in our States. 

But when you think about, too, where you go in rural communities, 

that was our concern. 

We lived in a small town, my mother was there in a small town. 

Finding somebody to help her navigate the system of services that 

exists, my sisters, my brother, we were there for her. Like you, we 

have got relatively decent educations. Just learning to navigate 

those systems is unbelievable too. 

But with a care coordinator, you have somebody who is in the 

medical field and in those services fields, who can better understand where you go for those services. As you said, you access them 

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quicker, and in that fashion, you provide, again, greater savings, 

because you don’t do those hospitalizations, but you also provide 

that kind of dignity for your loved one. That is so critically important. 

Ms. BOWERS. It is. I would like to just point out, one point. It 

really touched me when you mentioned about hospice. By the time 

you needed it, you didn’t even realize it was there until the very 

last minute, and available. 

That is an exact parallel to the fact that we had supposedly had 

access to some in-home help for him, an in-home health care manager that would come in once or twice a day to supervise his medications. I believe you had to lose a certain percentage of your ADLs 

in order to qualify. 

Of course, in his initial screening, he didn’t qualify, because he 

happened to be on top of his game for 30 minutes while she was 

there. The simple ability to access those type of services, and know 

that they are available through a program like this, would just in 

the quality of life, would be unbelievable. 

Dr. MCCONNELL. Senator, I think that is one provision in your 

legislation that is really important. It is about the importance of 

linking the individuals to community-based services. 

You think about just the Alzheimer’s Association chapters. There 

was a clinical study in Cleveland, where the people that were the 

caregivers were linked to an Alzheimer’s Association chapter and 

given some basic training on how to help care for somebody who 

had a medical problem. 

It resulted in significant reductions in unnecessary hospitalizations and emergency room use, just that small little intervention. 

So not only is it a comfort to caregivers, but it is a very important 

intervention that is part of your legislation. 

Senator LINCOLN. Well, without a doubt, being able to have 

someone that you can talk to and have recommendations from is 

critical. 

Mr. Guterman, just one last thing on those demonstrations. Of 

all the chronic care demonstrations that you have analyzed, which 

one do you think provides us the most promise for helping the 

chronically ill beneficiaries in the Medicare program? Would you 

pick one over the other? 

Mr. GUTERMAN. Well, I think since these are sort of a sequence, 

and since all the results aren’t in, I don’t know that there is a definitive model that I could say was the right model. 

I have my reservations about models that don’t involve physicians directly, at least coordinating. I do think there is a role for 

third-party organizations to help physicians provide the services. 

The demonstration that is starting up in your State and three others, with small practice physicians, I think is a promising one for 

two reasons. 

Senator LINCOLN. We wanted the physician oversight as well 

when we did this. 

Mr. GUTERMAN. One is that it is physician-oriented, and the 

other is that it is small-practice-oriented, which is really where the 

majority of physicians practice. There is another demonstration 

going on now called the Physician Group Practice Demonstration, 

that focuses on large multi-specialty group practices, and that has 

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some promise too. But most physicians aren’t in large organizations 

like that. 

Again, I think what we need to do is take what we can learn out 

of all of these examples, and then decide as we go along, not necessarily one model, but different models. The Medicare Health Support Pilot is going to offer some good information on what works 

in different circumstances and what doesn’t work in different circumstances. 

I think we have a lot of development to go, and we can develop 

as we go along. But as I said before, it is hard for me to believe 

that we can’t do better than we are doing now. 

Senator LINCOLN. Well, thank you so much. 

Dr. McConnell, just one more thing. You mentioned in your written testimony that disease management may not be the best way 

to go, because it focuses on specific diseases. Can you just help me 

understand your comments there? 

Dr. MCCONNELL. Well, I think, again, taking the case of Alzheimer’s disease, there is more than an additive effect here. When 

you add dementia to another condition, it really creates a whole 

new care problem. Disease——

Senator LINCOLN. You are saying that one single disease is managed, not multiple diseases——

Dr. MCCONNELL. Right. If they are doing multiple disease management, that is fine. But typically, it is focusing on one disease 

at a time, and as I said, and again, we want to work with CMS. 

We want to work with these demonstrations and pilots. 

The concern is that in the legislation, in the Medicare Modernization Act, it specifically requires physicians to assess each eligible beneficiary for conditions other than chronic conditions, such 

as impaired cognitive ability and comorbidities. It doesn’t appear, 

and we have looked at several of these, that that is happening. 

Again, it may be just that it is complicated. What the disease 

management organizations know about is how to deal with managing diabetes. The notion of dealing with someone’s cognitive impairment is not something perhaps that they are familiar with. 

Yet, it is very difficult to imagine that it will succeed without paying attention to that. 

Senator LINCOLN. Well, I just want to thank all of you. 

I appreciate this panel as well as our first panel, and I certainly 

do want to say to you, please don’t go far. This is an issue that I 

think we really owe to ourselves, to our children, and to our parents and grandparents to work hard to get it right. 

As I said, I just go back to the blessing of being able to grow up 

in a neighborhood with my grandparents and aunts and uncles, 

and my grandmother right there beside me. I know as much as I 

may want that for my children, today’s society may not fit in that 

way. But without a doubt, I want to know that my parents—let’s 

face it, we want to be cared for too. Those twin boys of mine, who 

knows where they will be when I need them, when I need that 

care? 

So I am grateful to you all for your input. 

I am also enormously grateful to my staff. I don’t remember who, 

I guess it was Dr. McConnell, who mentioned Brenda Sulick and 

Ashley Ridlon on my staff, who have been enormously immersed in 

94

this issue. I am grateful for their hard work in helping us put this 

hearing together. 

A special thanks to the Chairman and the Ranking Member. 

So, thank you all. We will look forward to working with you in 

the future. 

With that, the Committee is adjourned. 

[Whereupon, at 5:02 p.m., the Committee was adjourned.] 

(95)

A P P E N D I X 

PREPARED STATEMENT OF SENATOR BLANCHE LINCOLN

I want to thank Chairman Kohl and Ranking Member Smith for the opportunity 

to chair today’s hearing on the Future of Medicare: Recognizing the Need for Chronic Care Coordination. As a member of the so-called ‘‘Sandwich Generation’’ who 

cares for their children and aging parents simultaneously, I am keenly aware of 

many issues affecting older Americans and have been an advocate for geriatric 

chronic care coordination for several years. Studies indicate that when patients are 

linked with a physician or other qualified health professionals to coordinate care the 

results are improved quality of care, increased efficiency, and greater cost-effectiveness. 

That is why I am pleased to chair today’s hearing; to raise awareness of the need 

for chronic care coordination services for Medicare beneficiaries and to discuss how 

these services can be provided in a cost-effective way. This hearing will specifically 

focus on chronic care coordination in the traditional Medicare fee-for-service (FFS) 

program. While some chronic care coordination occurs in other programs such as 

Medicare Advantage and the Program for All Inclusive Care for the Elderly (PACE), 

nearly 85 percent of Medicare beneficiaries continue to receive healthcare from the 

traditional fee-for-service program, which lacks a chronic care coordination component. 

Why focus on chronic care coordination? Well, there are several reasons. 

First, the needs of Medicare beneficiaries have changed over time. When Medicare 

was first established in 1965, it was based on a health insurance model, which focused on acute care, not chronic conditions. But today, many older Americans suffer 

from multiple chronic conditions and would benefit from care coordination. We know 

that about 78 percent of the Medicare population have at least 1 chronic condition, 

and 63 percent have two or more chronic conditions. 

Second, as our population ages, the number of older individuals with chronic illnesses is also expected to rise. A recent article in the Washington Post noted that 

Baby Boomers are more likely to be in worse health condition than their parents 

in retirement (April 20, 2007), which may result in a greater need for medical services. A RAND Corporation study estimates that half of the population will have a 

chronic condition in 2020—a total of 157 million Americans. 

Third, Medicare beneficiaries with multiple chronic care conditions are expensive 

to treat. According to the Congressional Budget Office, 43 percent of Medicare costs 

can be attributed to 5 percent of Medicare’s most costly beneficiaries. Medicare 

beneficiaries with four or more chronic conditions are 99 times more likely to experience one or more potentially preventable hospitalizations than those without chronic 

conditions. If an individual has Alzheimer’s disease or dementia, medical costs increase even more dramatically. 

Finally, multiple chronic conditions not only affect the individuals suffering from 

them, but also their caregivers. About 5 years ago, I watched my mother devote herself to the care of the man she had loved for more than 52 years. She had pledged 

to attend to him and honor his life until he departed this world, even if he no longer 

remembered her name or could recognize her face. My dear father suffered from Alzheimer’s disease. 

My mother’s strength and commitment to my father during his long illness remains a great source of inspiration to me. Unfortunately, my family’s experience 

with the ravages of Alzheimer’s is not unique. Millions of Medicare beneficiaries 

with chronic conditions who remain at home do so with the help of family and 

friends. Research shows that family care for an older adult with chronic illness or 

disabilities, especially dementia, can have negative health effects (both physical and 

mental) on family members. 

To address these issues, I am pleased to announce that today Senator Collins and 

I introduced the Geriatric Assessment and Chronic Care Coordination Act of 2007, 

96

along with Senators Kohl, Kerry, Mukulski, Clinton, Boxer, and Casey. I am also 

pleased that Representatives Gene Green and Fred Upton are sponsoring a companion bill in the House and that 30 national organizations have endorsed the bill. 

This bill realigns Medicare to provide high-quality, cost-effective care to elderly individuals with multiple chronic conditions. It is an important step forward in recognizing and remedying the impact that multiple chronic conditions have on individuals, their caregivers, and the Medicare program. 

PREPARED STATEMENT OF SENATOR HILLARY RODHAM CLINTON

I would like to thank Chairman Kohl and Ranking Member Smith for convening 

today’s hearing on the importance of chronic care coordination for older Americans 

who rely on Medicare to pay for treatment for multiple illnesses. And I applaud Senator Lincoln for organizing today’s hearing and for her leadership on the Geriatric 

Assessment and Chronic Care Coordination Act, of which I am a proud original cosponsor. 

In less than ten years, the first wave of baby boomers will turn 65. In light of 

the growing longevity of Americans, we must consider how we will meet the increasing needs of this elder boom and the growing demands placed on our local, state, 

and federal health and social service systems in the years ahead. 

To ensure that we are prepared, we must reevaluate whether our health care system is helping or hindering those who are struggling with the burdens of age. 

Medicare has long been a vital source of health insurance for our nation’s seniors, 

providing them with access to medical treatment at a time of life when care is needed most. However, a critical weakness of Medicare that Senator Lincoln’s bill addresses is the lack of incentives to provide coordinated healthcare. It is crucial that 

we provide care coordination and geriatric assessments for older Americans who suffer from one or more chronic conditions. 

We spend more and use more services to treat catastrophic, complex, chronic care 

cases. Our lack of a system to manage the multiple, complex health care needs of 

people with chronic illness leads to higher costs and often poor quality. Chronic diseases, such as cardiovascular disease and diabetes, account for 75 percent of our 

total national health expenditures and are the leading cause of death in the U.S. 

Further, the number of Americans with at least one chronic illness is expected to 

rise 25 percent by 2020. 

Under Medicare, at least 83 percent of Medicare beneficiaries suffer from one 

chronic illness and the 23 percent of beneficiaries who suffer from five or more 

chronic illnesses account for 68 percent of costs to the program. Further, the combination of a chronic condition and Alzheimer’s disease causes Medicare costs to 

soar. According to the Alzheimer’s Association, the combination of Alzheimer’s and 

another chronic condition, such as heart disease or diabetes, approximately doubles 

the Medicare cost. All of us here realize that as the Baby Boomer generation ages, 

there will be a dramatic increase in the number of Alzheimer’s cases. By the year 

2050, if we do not make headway, up to 16 million Americans are expected to suffer 

from this devastating disease. 

For the people that will confront this disease in their own lives, this is about more 

than statistics: it represents an emotional struggle, a tremendous financial burden, 

a new strain on our already stressed healthcare system, particularly for Medicaid 

and Medicare costs. 

As co-chair of the Senate Task Force on Alzheimer’s Disease with my colleague 

Senator Collins, I have worked to address issues faced by Alzheimer’s patients and 

their caregivers. I’m pleased that Dr. Steve McConnell is here today. The Alzheimer’s Association has been a wonderful partner in raising awareness and support 

for people living with Alzheimer’s and their families. 

We know that it’s crucial to make caregiver health and well-being a priority, 

which is why I am fighting for full funding of the Lifespan Respite Care Act, which 

was signed into law last December. 

But today’s hearing is not just about improving Medicare programs for older 

Americans. It’s also about improving management conditions for all ages, including 

education on how individuals can better manage their own health in order to avoid 

further complications. 

That’s why I am a strong supporter of chronic disease management programs. The 

money we invest in prevention, early diagnosis and management programs today 

can reduce treatment costs down the road. 

Let’s take, for example, diabetes—over 20 million Americans are currently living 

with this disease. Six million of them have not yet been diagnosed. Another 54 million are classified as ‘‘pre-diabetic,’’ with a high risk of developing this condition. DiVerDate 0ct 09 2002 15:07 Nov 15, 2007 Jkt 000000 PO 00000 Frm 00100 Fmt 6601 Sfmt 6601 H:\DOCS\38617.TXT SAGING1 PsN: JOYCE
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abetes accounts for over $92 billion in direct medical costs every year, and these 

numbers are only likely to increase. 

Last year, a New York Times series focusing on diabetes spelled it out the problem. The healthcare system will pay tens of thousands of dollars for an amputation, 

but won’t pay for a low-cost visit to the podiatrist that could have saved the foot. 

The incentives inside our health care system are backwards, and the payment system is upside-down: too often paying for costly and debilitating treatment but not 

for low-cost prevention. 

Today, Senator Collins and I are introducing the Diabetes Treatment and Prevention Act of 2007, legislation that will strengthen our support for chronic disease 

management programs of the CDC and state and local health departments. 

Our bill would allow the Diabetes Prevention Program to be brought into clinical 

practice where it can be replicated at the state, local and provider level, along with 

other interventions to control diabetes. This program has shown that diet and exercise interventions were successful at preventing diabetes. 

Our bill would also establish a demonstration grant program that would help 

state and local health departments to establish disease management programs for 

individuals with diabetes and other co-occurring chronic conditions like heart disease, mental illness and HIV. In some cases, the medications for these other conditions can cause diabetes and aggravate its management. 

I believe we must do more to help people who are dealing with multiple chronic 

conditions manage them in a coordinated manner and our bill will help accomplish 

this goal. 

Again, I thank Chairman Kohl and Ranking Member Smith for convening today’s 

hearing, and Senator Lincoln for her leadership on this issue. I look forward to continuing to working with my colleagues to make progress for our seniors and families 

on these important issues. 

RESPONSES TO SENATOR SMITH QUESTIONS FROM DR. TODD P. SEMLA

Question. How would you rank the importance of better training for doctors, implementation of electronic-records keeping and utilization of chronic care coordination through case mangers? 

Answer. All three of these are critically important for providing care to chronically 

ill patients and it is hard to rank them in terms of priority. However, chronic care 

coordination is the lynchpin of the system. Without care coordination, better training and better electronic records systems would have very limited effect and the cost 

savings might be limited. Thus, we would rank chronic care coordination through 

case managers first, better training (in geriatrics) for doctors and health care professionals second, and implementation of electronic records third. 

Question. For all of our panelists, though your focus has been to institute systems 

of care management for persons with multiple chronic conditions to prevent these 

situations, aren’t many of these examples prevalent even among those who only 

enter the health care system because of an acute health need? 

Answer. America’s health care needs are changing dramatically with the aging of 

its population—from a system focusing on acute care to one that must address 

chronic care either after an acute event, such as stroke, or for ongoing conditions 

that may take years to culminate in an acute event (e.g., Type II diabetes). With 

the aging of the population, conditions that were not that prevalent 50 years ago 

are quite prevalent today; osteoporosis and all its complications is one example. 

Patients who enter the health care system because of an acute health need, such 

as a heart attack, are indeed at risk for many of negative outcomes that the chronic 

care coordination model could prevent. It is less complicated to coordinate care for 

a single condition during a specific acute care event, which is what the current 

health care system (under Medicare) is designed to do—it’s modeled for acute care. 

Many of the patients that fit your example may derive benefits from existing single 

disease management programs. The patient, however, with multiple and complex 

chronic conditions would typically benefit from a comprehensive and coordinated 

regimen of care that holistically addresses his or her health care needs. The recent 

MedPAC Commission report of June 2007 has reached many of these same conclusions. 

Question. Can you talk a bit more about this and explain how a more formal case 

manager or group of doctors working closely together can relieve some of the pressure on family caregivers and how this could reduce errors since most family caregivers are not trained for this type of work? 

Answer. The burden currently being placed on family caregivers is huge and frequently detracts from their ability to care for loved ones. Care managers should colVerDate 0ct 09 2002 15:07 Nov 15, 2007 Jkt 000000 PO 00000 Frm 00101 Fmt 6601 Sfmt 6601 H:\DOCS\38617.TXT SAGING1 PsN: JOYCE
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lect and maintain all health related information for the chronically ill, such as a 

list of current diagnoses, medications and treatment goals so that it is not only the 

family doing the task of conveying sometimes complex information. A care manager 

can much more effectively and efficiently communicate with other caregivers and 

can, for example, make sure that patients are getting the right medications in the 

right dose at the right time. A care manager would also see that changes in the 

patient’s care plan are communicated in a timely manner to all health care providers caring for the patient. This legislation introduced by Senator Lincoln (S. 

1340) will allow family members to do what they do best—provide day to day care 

and not force them to be responsible for communicating to an array of health professionals. 

Question. Can you talk a little more on this culture of specialties working in silos 

and its impact on patient care? What steps can be taken to break down these outdated practices? 

Answer. Historically, specialists have taken care of patients with acute illnesses, 

or single illnesses affecting one organ system, and have not provided ongoing or coordinated care. Only recently have specialists begun to take care of chronic illness, 

but even then those illnesses tend to consist of a single disease or a few diseases 

that affect a single organ system. Their practices are not set up to provide care for 

patients with multiple diseases that affect many organ systems. Neither the specialist nor their staff has the expertise to do that. It is critical to have a care coordinator, such as a physician or nurse practitioner, who can collect and coordinate care 

from multiple specialists. 

AGS believes in inculcating principles of geriatric care across all disciplines—the 

coordinated care approach. The geriatrics based whole patient approach looks at the 

different functions of each member of the team treating the whole patient. A care 

coordinator can bring in specialists to consider their areas of expertise in the context 

of the big picture. Many presently do this well and, in other cases, a care manager 

is critical, in all cases, a care manager will make it more likely that the whole patient is cared for. 

S. 1340 would be strong first step in changing the culture of medical practice 

silos. To change practice habits, changes would need to be made in medical education and residency programs for specialists. Additionally, the mere existence of 

care coordinators is likely to induce specialists to make sure their patients participate in care coordination because it will allow them to continue doing what they 

do best—take care of acute illnesses affecting a single organ system. 

RESPONSES TO SENATOR SMITH QUESTIONS FROM GERARD ANDERSON

Question. How would you rank the importance of better training for doctors, implementation of electronic-records keeping and utilization of chronic care coordination through case mangers? 

Answer. All three are critically important and they are synergistic. Better training 

for doctors is needed because most doctors currently are not being told how to coordinate care and perform other activities that would benefit people with multiple 

chronic conditions. Electronic medical records are the only feasible methods to have 

the multiple clinicians caring for the complex patient interact with one another. 

Currently most payment systems do not pay for care coordination and with payment 

many clinicians will not perform the service. Unless the clinician is trained in care 

coordination, has the information to perform care coordination, and is paid to do 

care coordination, care coordination is unlikely to happen. All three are needed. 

Question. For all of our panelists, though your focus has been to institute systems 

of care management for persons with multiple chronic conditions to prevent these 

situations, aren’t many of these examples prevalent even among those who only 

enter the health care system because of an acute health need? 

Answer. The problems are also important for people with just an acute illness. 

There is, however, one important distinction. An acute illness typically is treated 

in one location with all the clinicians able to share information and perhaps to meet 

and discuss the case. For people with multiple chronic conditions it is often that the 

clinicians are miles apart, never see each other, are unable to coordinate their care 

and as a result costs increase and quality suffers. The problems compound for people with multiple chronic diseases because the problems are ongoing instead of happening at one time. 

Question. You mention in your testimony that half of Medicare beneficiaries with 

multiple chronic conditions will be told by their pharmacist at least once a year not 

to fill a prescription because of possible interactions with other drugs that they take. 

This number strikes me as shockingly high. I assume that there could be a variety 

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of reasons for this happening, including the patient not being able to remember 

their list of medications, incomplete medical records or medical error. 

Do you think that physicians are resistant to changes in their training and why 

do you think physicians are resistant to moving to more advanced approaches such 

as electronic medical records keeping? 

Answer. I agree the number is high. I was shocked when we got the numbers from 

the Gallup Organization. I think the main reason why half of all people with multiple chronic conditions go to fill a prescription and are told of a potential drug drug 

interaction is that the physicians do not always know the drugs that other doctors 

have prescribed. An electronic medical record would make the information available. 

I do not think physicians are resistant to changing their training programs. I 

teach the importance of care coordination to all 1st year medical students at the 

Johns Hopkins School of Medicine. Medical students and the teaching physicians 

understand the importance of care coordination. However, until it is reimbursed, 

they are unlikely to emphasize it in the training programs. 

I think most physicians are resistant to electronic medical record keeping because 

we are asking them to pay for it when it does not benefit them financially and may 

actually be very expensive for them to install. Purchasing the software and the computers necessary to have an electronic medical record is only a small portion of the 

cost. The major cost is in redesigning the office’s entire information system from 

paper to electronic medical records. During the conversion the physician’s office 

must maintain two parallel information systems and this could go on for years. 

Once the electronic medical record system is implemented it is unlikely to save the 

physician much money and it could mean fewer visits. Nearly all of the benefits accrue the payors (reduced readmissions, fewer preventable hospitalizations, and 

fewer drug drug interactions). In other countries the payors are funding the diffusion and operation of electronic medical records. 

Question. In your testimony, you also mention that many physicians are not 

trained to work cooperatively to treat a patient with multiple chronic conditions. It 

seems that a lack of care coordination also is due to some gaps in training or limited 

emphasis on the importance of coordination within the profession. 

What do you think can be done to change this aspect of the culture of medicine 

and how do you think training programs can be enhanced to emphasize chronic care 

coordination? 

Answer. Currently most medical schools and residency programs emphasize acute 

care medicine and emphasize training in a particular disease. We need to emphasize 

that care coordination is important because patients often have multiple problems 

and all of the problems need to be considered not just one of the problems. Physicians are becoming increasingly aware of the need to coordinate care; however, the 

current system stifles care coordination. I propose three things: Medicare use the $10 billion it spends on graduate medical education each year 

to push medical schools and teaching hospitals to place greater emphasis on training physicians in care coordination. 

Medicare pays $5 each time a physician submits an electronic medical record. 

This will fund the creation of an integrated electronic medical record that will allow 

information to flow easily. 

Medical pays $100 per beneficiary per month for a clinician to perform care coordination activities on Medicare beneficiaries who want care coordination and who 

will benefit from care coordination. I would begin by focusing on Medicare beneficiaries with 5+ chronic conditions and/or dementia. 

Question. In your testimony, you also mention that many persons with multiple 

chronic conditions are left out of clinical trials. You state that this leads to inadequate data on evidence-based methods to treat them. 

Are patients with multiple chronic conditions being left out of these trials because 

it makes the research more difficult in that they have to account for more variables? 

Answer. Patients with multiple chronic conditions are being left out of the clinical 

trials because it makes the research more difficult. Currently the research emphasizes efficacy. Efficacy measures what works in a controlled environment. However, 

in the real world the critical term is effectiveness. Effectiveness measures how well 

the drug, device or procedure works in actual practice. Effectiveness is more important in the long run. 

Question. Given that such a large percentage of Americans have multiple conditions wouldn’t it benefit medicine to see how treatments impact people with multiple diseases? 

Answer. I totally agree that it would benefit medicine to know how treatments 

impact people with multiple diseases. There are two ways to obtain this information. 

One option is to expand the inclusion criterion in the initial clinical trail. In the 

1980s we required that women and minorities be included in all clinical trials (if 

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clinically appropriate). Previously most clinical trials were restricted to white males. 

Women and minorities wondered if the drug, device, or procedure would work equally as well for them. Now we require their inclusion. 

The second option is to require follow-up studies to include people with multiple 

chronic conditions. These studies would be performed only after the efficacy has 

been demonstrated. 

RESPONSES TO SENATOR SMITH QUESTIONS FROM DAVID DORR

Question. In your testimony you mention the savings to clinics by implementing 

chronic care coordination plans, like Care Management Plus. You state that the savings can be more than a quarter of a million dollars annually at each clinic. 

How do you see these potential savings playing out widely within Medicare and 

Medicaid? 

Answer. The Care Management Plus process focuses on prevention and patient 

education, keeping chronically ill patients healthier and out of the hospital setting. 

We anticipate that savings would accrue to the clinic from an increase in clinician 

productivity, a shift in clinical practice, and a change in overall patient utilization 

patterns. In addition, public payers such as Medicaid and Medicare would see savings from the implementation of coordinated care programs that use clinical tools 

and processes that emphasize effective and efficient patient care. Incentive structures within the reimbursement system, both public and private, must be implemented to support this change in care delivery. 

There are substantial benefits from the efficiency gains that arise from better information technology (IT) and care coordination. Many researchers have documented 

the enormous amount of waste in medical care services. Estimates vary substantially but generally suggest that 20 to 50 percent of medical care spending, including Medicare and Medicaid, could be eliminated without reductions in quality services. 

Question. We know that rural hospitals, clinics, and practices have very different 

concerns than those located in more urban areas. For instance, there is more likelihood that a person will see a general practitioner in a rural area than the specialist 

more urban patients will see. 

How do models of care coordination for patients with chronic illness differ in 

urban versus rural areas? 

Answer. Care Management Plus is designed to be flexible for the variety of clinical settings that exist. The program tools and curriculum can be used to accommodate the varying size and structure of clinics/systems, the differing amount of resource capacity within each clinic/system, and the multiple and complex patient populations in need of coordinated care. 

We will be implementing Care Management Plus in six rural clinic settings over 

the next two years in collaboration with the Oregon Rural Practice-based Research 

Network through a grant funded by the Agency for Healthcare Research and Quality (AHRQ). This project will provide important information about the gains and the 

limitations of a care management program in a rural setting. Implementing Care 

Management Plus in these rural clinics will require special attention not only to the 

information technology capacity. Its success will also depend on available specialty 

care in each clinic, available clinical staff to participate in the care management 

process, and the patient demographics served in each rural area. 

Question. In your testimony, and in some of the testimony that we will hear during the second panel, there are some very troubling stories and statistics on the lack 

of important information being given to a person with a chronic disease and the 

dangers that can arise when patients can’t or don’t tell one specialist about care 

they are receiving from another. Many of these examples and statistics lead me to 

wonder about what can be done to better train doctors in working collaboratively 

and how to improve our records systems such as through electronic records-keeping. 

How would you rank the importance of better training for doctors, implementation 

of electronic-records keeping and utilization of chronic care coordination through 

case managers? 

For all of our panelists, though your focus has been to institute systems of care 

management for persons with multiple chronic conditions to prevent these situations, aren’t many of these examples prevalent even among those who only enter 

the health care system because of an acute health need? 

Answer. Care coordination can address all three areas of improvement required 

for high quality care. Care coordination programs like Care Management Plus use 

a team-driven workforce to provide high quality care with the most appropriate information technology (IT) and clinical tools available. Training for nurses, care coorVerDate 0ct 09 2002 15:07 Nov 15, 2007 Jkt 000000 PO 00000 Frm 00104 Fmt 6601 Sfmt 6601 H:\DOCS\38617.TXT SAGING1 PsN: JOYCE
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dinators, clinic supervisors and administrators, and medical directors is necessary 

to successfully transform care for the chronically ill. IT tools and electronic-record 

keeping play an important role in helping the health care team track patient needs 

and follow the best evidence-based guidelines for a chronically ill population. Health 

care providers can also utilize appropriate IT tools to inform and educate patients 

about their conditions and teach self management strategies. Patient-centered care 

directly by a care/case manager has proven effects on disease improvement, patient 

satisfaction, physician productivity, and the resulting change in health care utilization. 

Prevention and early recognition are key components in programs like Care Management Plus. The primary care team treats patients’ chronic diseases early, trying 

to prevent problems rather than treating them after they occur. This can result in 

time and cost savings in managing care for not only the chronically ill population, 

but for those patients that have more acute/episodic health care needs. 

Many patients do enter the health care system only for acute needs. Each contact 

with the health care system can still be used to help educate and motivate people 

to think about their chronic illnesses. Health Information Technology, especially 

where information is shared readily, can help connect these often fragmented acute 

visits by reminding about the need to educate and consider their chronic needs without overly burdening the acute care team and to facilitate contacts with the primary 

care system. Our care management program was borne of the fact that so many patients have no follow-up after their acute care episode; having the care manager 

whose goal is to understand the barriers and move patients towards more preventative and chronic illness care was a solution to just the problem posed by the followup question. 

RESPONSES TO SENATOR SMITHS QUESTIONS FROM STUART GUTERMAN

Question. Mr. Guterman, in your testimony you mention research that shows that 

persons with multiple chronic conditions are more likely to have preventable hospitalizations, experience adverse drug interactions, undergo duplicate tests and receive contradictory information from doctors. 

How much of this is due to the simple fact that these persons are sicker than 

other patients so they see doctors more often and are in more acute health situations and therefore there is more change of error? 

Answer. Senator Smith, there may well be a relationship between the fact that 

persons with multiple chronic conditions are sicker than other patients and have 

more interactions with the health care system at a higher level of acuity and the 

fact that they experience more problems with their health care than other patients. 

But that relationship only emphasizes the fact that better coordination is needed 

for these patients to avoid those kinds of problems. Even if the same proportion of 

care provided results in problems for the patient who needs more care, it still means 

that the patient who receives more care is at greater risk for adverse events, and 

therefore that more needs to be done to reduce that risk. Also, it stands to reason 

that patients with multiple conditions require more coordination across those conditions, because they receive not only more care, but care from more different providers—each of whom may not be aware of what the other providers are doing to 

the patient. 

Question. Do these studies control for the fact that these persons simply have 

more opportunity for error due to the sheer number of their interactions with medical professionals in a given year? 

Answer. To my knowledge, the studies I refer to do not control for the number 

of each individual’s interactions with medical professionals. But the focus of interest 

here is the individual and his or her risk of adverse events, rather than the medical 

encounter, so the point that patients with chronic conditions are a greater risk still 

holds, I believe. 

Question. In your testimony you mention that only 67 percent of hospitalized patients in the U.S. reported having their medications reviewed at the time of a hospital discharge and that patients with congestive heart failure receive discharge instructions only 50 percent of the time. 

Question. At what point is it a question of providing incentives for chronic care 

coordination or are we at a question of doctors doing their due diligence in treating 

the patient? It seems to me that these are questions that doctors should be asking 

all patients—not just those with multiple chronic diseases. 

Answer. That is an important question. My answer would be that certainly, physicians should be providing appropriate care, not only to patients with multiple chronic conditions, but to all their patients. But part of the problem we have with the 

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quality of care across our health care system is that we have provided distorted incentives that emphasize providing more services and more complex services—sometimes to the detriment of the patient. We can blame physicians for responding to 

those very string incentives, or we can search for ways to try and fix the distorted 

incentives we’ve presented them with. Moreover, in many cases the problem that 

patients with multiple chronic conditions face is that multiple providers are responsible for their services, and many times those providers don’t communicate with 

each other—not because they are bad providers, but because the way that medicine 

is practiced in our health system doesn’t really allow for them to devote resources 

to those types of activities. My point is that if we want to see our health system 

provide coordinated, appropriate care, that is what we ought to pay for.

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