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47–121 PDF 2010

S. HRG. 111–690 

CROSSING THE QUALITY CHASM 

IN HEALTH REFORM 

HEARING 

OF THE

COMMITTEE ON HEALTH, EDUCATION, 

LABOR, AND PENSIONS 

UNITED STATES SENATE 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

ON

EXAMINING QUALITY IN HEALTH REFORM 

JANUARY 29, 2009 

Printed for the use of the Committee on Health, Education, Labor, and Pensions 

( 

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

COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS 

EDWARD M. KENNEDY, Massachusetts, Chairman 

CHRISTOPHER J. DODD, Connecticut 

TOM HARKIN, Iowa 

BARBARA A. MIKULSKI, Maryland 

JEFF BINGAMAN, New Mexico 

PATTY MURRAY, Washington 

JACK REED, Rhode Island 

BERNARD SANDERS (I), Vermont 

SHERROD BROWN, Ohio 

ROBERT P. CASEY, JR., Pennsylvania 

KAY R. HAGAN, North Carolina 

JEFF MERKLEY, Oregon 

MICHAEL B. ENZI, Wyoming, 

JUDD GREGG, New Hampshire 

LAMAR ALEXANDER, Tennessee 

RICHARD BURR, North Carolina 

JOHNNY ISAKSON, Georgia 

JOHN MCCAIN, Arizona 

ORRIN G. HATCH, Utah 

LISA MURKOWSKI, Alaska 

TOM COBURN, M.D., Oklahoma 

PAT ROBERTS, Kansas 

J. MICHAEL MYERS, Staff Director and Chief Counsel 

FRANK MACCHIAROLA, Republican Staff Director and Chief Counsel 

(II) 

C O N T E N T S 

STATEMENTS 

THURSDAY, JANUARY 29, 2009 

Page 

Mikulski, Hon. Barbara A., a U.S. Senator from the State of Maryland, 

opening statement ................................................................................................ 1 

Prepared statement .......................................................................................... 2 

Cassel, Christine K., M.D., President, American Board of Internal Medicine, 

Philadelphia, PA .................................................................................................. 4 

Prepared statement .......................................................................................... 5 

Teisberg, Elizabeth, Ph.D., Associate Professor, University of Virginia’s Darden School of Business, Charlottesville, VA ...................................................... 8 

Prepared statement .......................................................................................... 9 

Robinson-Beale, Rhonda, M.D., Chief Medical Officer, OptumHealth Behavioral Solutions, Golden Valley, MN .................................................................... 16 

Prepared statement .......................................................................................... 18 

Davis, Karen, Ph.D., President, Commonwealth Fund, New York, NY .............. 23 

Prepared statement .......................................................................................... 24 

Davenport-Ennis, Nancy, CEO, National Patient Advocate Foundation, Washington, DC ............................................................................................................. 66 

Prepared statement .......................................................................................... 67 

(III) 

(1) 

CROSSING THE QUALITY CHASM 

IN HEALTH REFORM 

THURSDAY, JANUARY 29, 2009 

U.S. SENATE, 

COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS, 

Washington, DC. 

The committee met, pursuant to notice, at 2:00 p.m. in Room 

SD–430, Dirksen Senate Office Building, Hon. Barbara A. Mikulski 

presiding. 

Present: Senators Mikulski, Dodd, Casey, Hagan, and Merkley. 

OPENING STATEMENT OF SENATOR MIKULSKI

Senator MIKULSKI. Good afternoon, everyone. The U.S. Senate 

Committee on Health, Education, Labor, and Pensions will come to 

order. The Working Group on Quality is meeting this afternoon, 

and the focus of this particular hearing is called ‘‘Crossing the 

Quality Chasm in Healthcare Reform.’’ 

This is the second of a series of hearings we will be having to 

ensure that when we do our healthcare reform, we do not only reform insurance finance, but that we also reform how we are also 

going to be providing healthcare. 

It is the view of the working group that by focusing on quality 

we will not only improve outcomes for patients, but we will improve the outcome in the bottom line of delivering healthcare itself. 

We need to say good-bye to silo thinking in which quality is over 

here, cost is there, and so on. 

Even though our working groups are divided into three categories—coverage, chaired by Senator Bingaman; prevention, 

chaired by Senator Harkin; and quality, chaired by myself—we see 

it as all the same story. 

Today, we are going to hear from a distinguished group of experts who will be testifying on that particular topic. I thank the 

witnesses for their flexibility. We had originally scheduled this 

hearing for 10 a.m., but President Obama decided to sign the Lily 

Ledbetter Fair Pay Act this morning, so we were there. 

When we set this panel, we didn’t realize we were going to have 

an all-women’s panel, a chair. It is not like we get 1 day, and this 

is it. 

[Laughter.] 

But we welcome you. 

I am going to dispense with my opening statement, but know 

that we believe that the work we are doing is going to focus on an 

evidence-based approach to reforming healthcare. Just in the same 

2 

way we ask our clinicians to be thinking that way, we feel that our 

committee should do the same. One of the most evidence-based 

ways of looking at that, of course, is an esteemed institution in our 

society, the Institute of Medicine. 

In their ground-breaking report, ‘‘Crossing the Quality Chasm: A 

New Health System for the 21st Century,’’ the IOM outlined a variety of goals that would make our healthcare system safe, effective, 

patient centered, timely, efficient, and equitable. We will be embracing those principles as we move ahead on the reform. 

We have invited members of the original IOM quality committee—Dr. Cassel, president of the American Board of Internal 

Medicine; Dr. Rhonda Robinson-Beale, the chief medical officer of 

OptumHealth. 

We have also invited respective policy thinkers that are well 

known in the community of healthcare innovation. Dr. Karen 

Davis, president of the Commonwealth Fund, which has issued a 

variety of reports that this committee has reviewed and embraced 

in principle. And Professor Elizabeth Teisberg, the professor of 

UVA’s Darden Business School, will provide another perspective on 

how we will be able to think of strategies to improve health quality. 

And finally, from the patient perspective—because we want to 

have patient-centered healthcare at the end of the day—Dr. Nancy 

Davenport-Ennis of the National Patient Advocate Foundation. 

I am going to ask unanimous consent that my full statement go 

into the record. 

[The prepared statement of Senator Mikulski follows:] 

PREPARED STATEMENT OF SENATOR MIKULSKI

In 2001, the Institute of Medicine (IOM) published a 

groundbreaking report, ‘‘Crossing the Quality Chasm: A new 

Health System for 21st Century’’. IOM’s vision defined six goals to 

improve health care: 

• Safe—Avoiding medical errors. 

• Effective—Providing evidence based services with over-utilization. 

• Patient-Centered—Providing care that is responsive to patient’s needs. 

• Timely—Reducing harmful delays. 

• Efficient—Avoiding waste of time, energy, and resources. 

• Equitable—Quality not vary due to income, age, race, gender, 

or geography. 

These goals remain essential to improving the quality of our Nation’s health system. Goals should be part of any reform proposal 

that moves through Congress. 

The purpose of today’s hearing is to identify quality initiatives 

that should be considered as part of health reform. 

We have invited back members of the original IOM Quality Committee, Dr. Christine Cassel, President of the American Board of 

Internal Medicine and Dr. Rhonda Richardson Beale, Chief Medical 

Officer of OptumHealth. 

We’ve also invited two respected policy thinkers, Karen Davis, 

President of the Commonwealth Fund and Elizabeth Teisberg, ProVerDate Nov 24 2008 13:47 Dec 03, 2010 Jkt 035165 PO 00000 Frm 00006 Fmt 6633 Sfmt 6601 S:\DOCS\47121.TXT DENISE
3 

fessor at UVA’s Darden Business School who will help update our 

thinking on strategies to improve health quality. 

Finally, from the patient perspective, we have Nancy DavenportEnnis of the National Patient Advocate Foundation. 

My hope is that we can learn from these witnesses how theory 

has been put into practice, about promising quality initiatives that 

have moved from bench to bedside, and discuss what quality initiatives should be a part of reform. 

There’s no question it is time for Congress to act on comprehensive health quality initiatives. While IOM’s report shaped the 

thinking and actions of health policy gurus, providers, and patients, the Federal Government has been slow to act. 

The United States leads the world in health spending but lags 

behind when it comes to quality. It’s time taxpayers and patients 

got better value for their health dollar by improving, not limiting, 

health care. 

U.S. life expectancy is the same as countries that spend far less 

per capita. Billions of dollars are wasted each year through medical 

overuse, underuse, misuse, and inefficiencies. 

Annual human cost is 98,000 deaths and 1 million injured from 

medical errors. 

Despite the work of the IOM and today’s panel members the 

United States still does a poor job of applying evidence to health 

delivery. There is no effective policy to research and disseminate 

best practices. The United States still does a poor job of using 

Health Information Technology and lack nationwide infrastructure 

to collect and share information. 

The United States still does a poor job of care coordination and 

has not yet appropriately aligned payment policies with quality. 

The United States still has not prepared a sufficient healthcare 

workforce capable of caring for large numbers of retiring baby 

boomers. 

By failing to adopt quality initiatives, it’s obvious why we lag behind the industrialized world. 

We can do better and it is my goal to make sure we do better. 

I look forward to today’s discussion and the development of consensus around key recommendations. 

Senator MIKULSKI. Also, I will ask unanimous consent that any 

of our colleagues who have statements they would like to put in the 

record on this hearing that they be so included, and any questions 

that they might have that they also be submitted. 

I know, speaking for Senator Enzi, we are really busy today with 

SCHIP on the floor and so on. Know that he has been an active 

participant at all of our many discussions and know that he wanted very much to be here. 

His staff is here, and I am going to say that in the Q and A, if 

you all have questions in particular that you and Senator Enzi 

would like to ask me verbally, I would be happy to ask them on 

his behalf. I will also ensure that any of the members of the other 

party who have questions to submit to the witnesses can do so. 

Having said that, why don’t we start with you, Dr. Cassel? And 

then just move down the line and let us hear what insights you 

have to share with the committee. 

4 

STATEMENT OF CHRISTINE K. CASSEL, M.D., PRESIDENT, 

AMERICAN BOARD OF INTERNAL MEDICINE, PHILADELPHIA, 

PA 

Dr. CASSEL. Thank you, Madam Chair, for the invitation to testify today about improving healthcare quality. 

My name is Christine Cassel. I am a board-certified internist and 

geriatrician and the president of the American Board of Internal 

Medicine. 

ABIM is an independent nonprofit organization that is of the profession and for the public. We assure, by board certification, that 

physicians in internal medicine and 17 different subspecialties 

have the knowledge and skills to practice within their specialty. 

We certify about a third of the Nation’s practicing physicians, 

and we are the largest of the 24 boards that constitute the American Board of Medical Specialties. Our standards shape medical 

training and physician practices throughout the country in many 

varied settings. 

As you mentioned, I had the privilege of serving on the Institute 

of Medicine committee that produced the quality chasm report, and 

I believe we can point to many accomplishments since it was published in 2001. 

The development and reporting of performance measures is a 

particularly visible achievement, but all of these measures are not 

really coordinated or linked enough with clinical practice to really 

have the big impact that they ought to have on quality and affordability. The National Quality Forum is trying to fix this, bringing 

leaders of a broad range of groups to set priorities for improvement 

and to facilitate consensus on performance measures. 

As we now invest in health information technology to make all 

this data available, there is still another critical ingredient that is 

missing. We need to ensure that the clinicians who are using it 

have the skills needed to use this data effectively and to modernize 

their care around the patient’s needs. 

My training in geriatric medicine gives me insight into what is 

needed to take good care of patients who have complex and multiple chronic conditions, something we are going to have more and 

more of as the baby boomers age. 

Doctors need to have the knowledge and judgment to make the 

right diagnosis and to manage complex care, and they also need 

skills less commonly taught, like working in clinical teams, care coordination, integration with other specialists, and linking community and clinical services. 

My patients didn’t just have one condition. They had five or six 

and were often taking 10 to 15 medications a day. They came to 

the doctor not with the diagnosis on their forehead, but feeling 

weak or dizzy or mentally confused. 

These symptoms could result from anything—cancer to Alzheimer’s disease. Or it might be caused by all these medications 

having side effects, or even over-the-counter remedies. There might 

be a pneumonia brewing, or it could be the loss of a spouse or another close caregiver. 

The physician alone can’t sort all this out and address all these 

different issues. If there isn’t a team to help, the patient could have 

5 

many unnecessary tests, end up in the hospital, or, worse, fall and 

break a hip. 

A case in point is the understandable excitement now about the 

patient-centered medical home. Most of the discussion is focused on 

practice infrastructure to facilitate integrated and coordinated 

care—electronic records, etc.—but without considering the doctor 

and the team. 

If the doctor doesn’t have the extensive knowledge and management skills, the promise of the medical home won’t be fulfilled. You 

can’t just order a medical home kit from a catalog and expect to 

produce results without also major changes in how we practice. 

The profession has ways to help with this challenge. At ABIM, 

we provide Internet-based tools that are available to almost 

200,000 physicians around the country that can help them to assess their practice strengths and weaknesses and offer links to 

tools and strategies for improvement. 

Using physicians’ intrinsic motivation to help their patients, the 

certifying boards have demonstrated that with trusted and actionable data, doctors actually do engage in improving quality of care. 

These very same data can be used if they want for reporting to 

health plans, NCQA, hospitals, or Medicare. This alignment reduces the burden of redundant data collection and the hassle for 

a busy office practice. 

We evaluate physician performance and practice using NQFendorsed measure sets as well as the doctor’s knowledge, diagnostic 

ability, and medical judgment. In our survey, 73 percent of physicians changed their practice as a result of going through board certification. 

The HELP Committee has already taken important steps in the 

stimulus bill—and you are to be thanked for that—by supporting 

both HIT and comparative effectiveness. These important investments will not reach their full potential unless physicians and 

other clinicians actually use the information they provide to inform 

their treatment decisions or to change their practice patterns. 

Thank you for the opportunity to reflect on the progress made 

and the challenges that remain. We welcome the chance to partner 

with you as you consider the reforms ahead. 

Thank you. 

Senator MIKULSKI. Thank you, Dr. Cassel. 

You know, your entire statement is very content rich. So we are 

going to have that in the record, too. 

[The prepared statement of Dr. Cassel follows:] 

PREPARED STATEMENT OF CHRISTINE K. CASSEL, M.D. 

SUMMARY

ABIM is an independent, non-profit organization that assures via board certification that physicians have the knowledge, skills and attitudes to practice in a given 

specialty. ABIM certifies about one-third of the Nation’s practicing physicians in 

varied settings and practice sizes. Since the 2001 publication of the Institute of 

Medicine’s Quality Chasm report, many strides have been made to improve quality 

of care, with the development and reporting of performance measures as a particularly visible accomplishment. Yet, we have a long road ahead of us because individual performance measures will never be able to reflect, the complexity of medical 

practice. As we build a more scientifically robust performance measurement and reporting system with appropriate, valid measures linked to payment, we need to siVerDate Nov 24 2008 13:47 Dec 03, 2010 Jkt 035165 PO 00000 Frm 00009 Fmt 6633 Sfmt 6621 S:\DOCS\47121.TXT DENISE
6 

multaneously focus on assessing and enhancing the skills and competencies that clinicians need to practice in a 21st century system. 

The patient-centered medical home is a case in point. Discussions about this 

model have largely focused on practice infrastructure, select clinical measures and 

related payment mechanisms, with the goal of facilitating integrated and coordinated care. However, these discussions fail to recognize the importance of the competencies that physicians and other clinicians need to effectively practice in this redesigned system. These competencies must be at the core of primary care 

residencies and physicians in practice need support to work effectively in teams, engage patients in managing chronic conditions and effectively coordinate and manage 

the care of patients with multiple conditions, among other skills. ABIM’s certification process helps drive the attainment of such knowledge and skills in training 

and practice. 

ABIM’s assessment ‘‘tool box’’ includes internet-based modules, which are available to over 200,000 physicians, that use National Quality Forum (NQF) measures 

to assess clinical care, a Consumer Assessment of Health Providers and Systems 

(CAHPS) patient experience survey and a mini version of the National Committee 

for Quality Assurance’s (NCQA) Physician Practice Connections module. ABIM’s 

tools also assess a physician’s clinical knowledge base, diagnostic ability and medical judgment in a given medical specialty. 

ABIM has aligned its certification program with the quality efforts of numerous 

organizations. In fact, at the request of a physician, ABIM will transfer certification 

results and data to NCQA, health plans, hospitals or Medicare with the goal of reducing redundant data requests and accelerating improvement. 

ABIM stands ready to work with members of the HELP Committee as you embark on reforming the healthcare system and ask that you strongly consider the crucial role of clinician competencies in the reform landscape. 

Chairman Kennedy, Senator Enzi and members of the Health, Education, Labor 

and Pensions Committee, thank you for the invitation to testify about improving 

health care quality. My name is Christine Cassel, and I am a board certified internist and geriatrician, and the President/CEO of the American Board of Internal 

Medicine (ABIM). 

ABIM is an independent, non-profit organization that is ‘‘of the profession but for 

the public.’’ We assure via board certification that physicians who practice internal 

medicine and 17 different subspecialties have the knowledge, skills and attitudes to 

practice within their specialty. ABIM certifies about a third of the Nation’s practicing physicians and is the largest of the 24 boards that constitute the American 

Board of Medical Specialties (ABMS). The standards that we set shape both medical 

residency training programs and physician practices of all sizes in many varied settings. 

Since the publication of the Institute of Medicine (IOM) Quality Chasm report in 

2001, many strides have been made to improve the quality of care, with the development and reporting of performance measures as a particularly visible accomplishment. Having had the privilege of serving on the committee that produced the IOM 

report, I derive satisfaction from those gains while acknowledging that we have a 

long way to go. Specific, select accomplishments over the last 8 years include: 

• The healthcare community, under the auspices of the National Quality Forum’s 

(NQF) National Priorities Partners, has set national priorities for improvement—including patient and family engagement, reducing overuse of inappropriate services, 

and enhancing end of life and palliative care, which are key areas to focus on from 

my vantage point; 

• The medical community is developing and implementing a broader array of evidence-based clinical guidelines, which translate research into practice recommendations, and they are beginning to enhance them with the integration of appropriateness criteria. These guidelines are then translated into performance measures; 

• There is growing agreement about using standardized performance measures— 

focused on both clinical conditions and on patient experience—and the role that the 

NQF plays in facilitating consensus in this arena; 

• There is some evidence that reporting of performance measures is driving improvement at hospitals and health plans, although that is less clear at the individual clinician level. For example, the Healthcare Effectiveness Data and Information Set (HEDIS) data, used at the health plan level, has shown improvements 

across multiple dimensions over the 9 years that the National Committee for Quality Assurance (NCQA) has been publicly reporting results. 

7 

As we build a more scientifically robust performance measurement and reporting 

system with appropriate, valid measures linked to payment, we must simultaneously focus on assessing and enhancing the skills and competencies that clinicians 

need to practice in an increasingly complex 21st century healthcare system. 

My training in geriatric medicine emphasized a set of competencies that are necessary for the provision of high quality care. These competencies focused on the importance of making the right diagnosis (particularly with patients that have multiple, complex problems), working in clinical teams, care coordination, integration 

with other specialists, management of multiple chronic conditions and linking community and clinical services. But these skills are not utilized by many clinicians for 

a number of reasons: our training and education systems do not adequately focus 

on such competencies; such knowledge and skills are not supported by the systems 

in which clinicians work; and perhaps because these more complex areas do not easily lend themselves to performance measurement. 

A case in point are the policy discussions about the patient-centered medical 

home, which are largely focused on practice infrastructure and related payment 

models that can facilitate integrated and coordinated care, but fail to emphasize the 

competencies that physicians and other clinicians need to effectively meet the promise of the medical home concept. These competencies must be a part of primary care 

residencies and physicians in practice need support to work effectively in teams and 

engage patients in managing their chronic conditions, among other skills that the 

vision of the patient-centered medical home model requires. 

At ABIM, we provide internet-based tools that are available to close to 200,000 

physicians that can help them assess their practice strengths and weaknesses and 

offer links that guide them towards improvement. By tapping into most physicians’ 

intrinsic motivation to do well by their patients, the certifying boards have demonstrated that with trusted and actionable data, physicians engage in improving the 

quality of care. These very same data can then be used—if the physician so chooses—for reporting to health plans, NCQA, hospitals and to the Centers for Medicare 

& Medicaid Services. This alignment reduces redundant data collection, lessening 

the administrative burden on physicians (particularly in smaller practices), and can 

help in accelerating improvement. 

ABIM’s tools assess physician’s performance in practice—using standardized NQF 

clinical measures, Consumer Assessment of Health Providers and Systems (CAHPS) 

patient experience surveys and a condensed version of NCQA’s Physician Practice 

Connections (PPC)—as well as his or her knowledge base, diagnostic ability and 

medical judgment in a given medical specialty. 

In a survey of over 5,000 physicians who have used ABIM’s performance assessment tools, 70 percent of respondents reported that they found these tools valuable 

in identifying strengths and weaknesses in the care they provide. More importantly, 

73 percent of respondents changed their practice as a result of completing one of 

ABIM’s performance assessment modules. 

Yet, there are aspects of practice that do not easily lend themselves to being assessed via performance measures. Therefore, other types of assessment tools are 

needed. Key examples include: 

• Our current performance measurement system assumes that a correct diagnosis 

has been made and may even result in performance payments that stem from faulty 

diagnoses. This is not an outlier problem. The literature suggests that diagnostic errors account for 5–15 percent of medical errors, depending upon the specialty, and 

they are not declining over time. Certifying board examinations include clinical scenarios that test diagnostic acumen. 

• Further, making the correct diagnosis and recommending an appropriate treatment plan requires up-to-date knowledge of new therapies, an ever-evolving understanding of the strengths and weaknesses of existing therapies and, often, the skill 

to know how to manage and integrate multiple therapies. Certifying board examinations test medical knowledge and provide scenarios to assess clinical judgment and 

management. 

• Finally, it is less likely that performance measurement bundles will be developed for less common illnesses, such as thyroid disease, viral meningitis or rheumatoid arthritis. Yet patients will, and should, expect that physicians can diagnose 

and treat such conditions. Instead, clinical scenarios involving rare conditions lend 

themselves to board examinations and online point of care tools. 

As members of the HELP Committee contemplate shaping a reformed health care 

system, you have already taken important steps in the stimulus bill by articulating 

the importance of both health information technology (HIT) and comparative effectiveness research. These investments can help deliver to physicians and other clinicians important data and information that they need to understand ‘‘how they are 

8 

doing’’ to help in facilitating care coordination and integration; aid in reducing 

wasteful, redundant testing; and provide a resource that objectively compares treatment options. But these important investments in a 21st century healthcare system 

will not reach their full potential unless physicians and other clinicians actually use 

the information they provide to inform their treatment decisions or to change their 

practice patterns. ABIM—and very likely other certifying boards—would be happy 

to work with the HELP Committee to facilitate physician engagement related to 

both HIT and comparative effectiveness. 

Going forward, the HELP Committee might also want to consider how community 

health centers (CHCs) define their services, making sure that the definition allows 

for the effective delivery of and payment for comprehensive care to patients with 

complex and multiple conditions—the kind of care that geriatricians are trained to 

provide and that many patients beyond the elderly need. CHCs will also serve as 

patient-centered medical home sites, and will be most effective if the definition of 

provided services is expansive and staff is supported in learning new competencies 

to effectively practice in a redesigned model. 

Finally, there are two other important, and related, areas of intersection: revitalizing primary care and providing better care for underserved populations. In both 

arenas, ABIM Board-level committees have been working to define, implement, test 

and evaluate new tools to assess related competencies. We would welcome the opportunity to share our learnings with you and others as you consider how to advance primary care and to close disparities gaps as part of a reformed healthcare 

system. For example, in the underserved area physicians using our tools in large 

and small practices will eventually be able to compare the quality of care they deliver across various sub-populations. 

Thank you for the opportunity to reflect on what the quality community has and 

has not yet accomplished over the 8 years since the Quality Chasm report was published. We would welcome the chance to partner with you as you consider how to 

shape the reforms that lie ahead. In the process, we ask that you consider the skills 

and competencies of the Nation’s clinicians as essential to achieving the vision of 

a dramatically reformed system as laid out in that landmark report. 

Senator MIKULSKI. Dr. Teisberg. 

STATEMENT OF ELIZABETH TEISBERG, Ph.D., ASSOCIATE PROFESSOR, UNIVERSITY OF VIRGINIA’S DARDEN SCHOOL OF 

BUSINESS, CHARLOTTESVILLE, VA 

Dr. TEISBERG. Chairwoman Mikulski, thank you for inviting me 

to talk about quality improvement and healthcare value for every 

American. 

My name is Elizabeth Teisberg. I am a professor at the University of Virginia and coauthor of ‘‘Redefining Healthcare.’’ I am also 

the mother of a child who was painfully chronically ill for 6 years 

before his full recovery. 

As a professional and as a mother, I have questioned the conventional wisdom that causes leaders to cling to a system that everyone agrees could be significantly improved. We can and should 

drive dramatic and ongoing improvement in value for patients, 

achieving far better outcomes much more efficiently. 

Lack of attention to quality in healthcare drives costs up. While 

the cost of employee health benefits command headlines, U.S. employers spend three times that much on the costs of poor health. 

We can’t afford to ignore quality. We can and must use attention 

to quality to drive costs down and to improve value. 

Quality in healthcare is measured by health outcomes achieved. 

The 139 heart transplant centers in the U.S. report results—for example, the percentage of patients who live for a year following a 

heart transplant. These are complex patients. For some centers, 

the percentage of patients that survive the first year is well over 

90 percent. 

9 

What about the centers that report the lowest results? Eighty 

percent? Fifty percent? It is zero. To be fair, that center had performed only six transplants, but who should be the seventh? Because there is significant variance in outcomes, reporting is essential. 

Process measures, also described as consensus measures, have 

been well developed in the past decade and are widely used. In 

Minnesota, effort to improve chronic care for patients with diabetes 

began with measures of process. Very rapidly, 90 percent of clinics 

became top rated for their processes, and someone asked, ‘‘Are the 

patients better off? Are the outcomes better? ’’ 

So outcome measures were developed, and in the first 2 years of 

public reporting, the percentage of patients that succeeded on all 

the measures of outcomes more than doubled from just over 4 percent to just under 9 percent. Great improvement, but a long way 

to go in spite of excellent process performance. 

Reporting on the use of good process is not enough. Reporting 

outcomes drives improvement in health results. What is measured 

will improve. Outcome measurement accelerates learning by clinical teams, which, in turn, drives better results for patients and 

higher healthcare value. 

The point is not consumer shopping. When New York State 

began publishing mortality rates for heart surgery by different providers, studies clearly showed that consumers did not use the data. 

Yet mortality dropped 41 percent in the first 4 years. Physician 

teams did use the data, and the dramatic decline in mortality surely benefited patients. 

Reporting can and will start with imperfect measures. Congress 

need not specify the measures, just the requirement for teams to 

report outcomes. 

HHS can have a not-for-profit organization oversee the registries, 

as they do for transplants, or HHS can ask the existing expert 

medical boards. Leaders from those boards tell me that they have 

clinically meaningful outcome measures, and they can require reporting for the renewal of credentials. This could happen quickly. 

This could start now. 

Want to improve results and lower costs of chronic disease? 

Measure results. Want to drive down disparities in healthcare? 

Measure teams’ results for every patient. Want to speed adoption 

of best practices? Measure results so clinical teams can compare 

and improve. 

The fastest and most effective way to improve health outcomes 

for Americans, as well as to improve the measures themselves, is 

to start measuring and reporting outcomes. The time is now. 

Thank you. 

[The prepared statement of Dr. Teisberg follows:] 

PREPARED STATEMENT OF ELIZABETH OLMSTED TEISBERG, PH.D. 

SUMMARY

Access to health care for all Americans is essential to both equity and economic 

efficiency. Dramatic improvement in value (health outcomes per dollar spent) is necessary to provide quality care for all Americans. 

The purpose of health care is health. Successful health care reform efforts must 

do more than cut costs. The real goal of health care reform is, and must be, to drive 

dramatic and ongoing improvements in the value of health care. This means improvVerDate Nov 24 2008 13:47 Dec 03, 2010 Jkt 035165 PO 00000 Frm 00013 Fmt 6633 Sfmt 6621 S:\DOCS\47121.TXT DENISE
10 

1M.E. Porter and E.O. Teisberg, 2006, Redefining Health Care, Harvard Business School 

Press, Boston, MA. 

ing quality—health and health care outcomes—relative to the cost of achieving 

these outcomes. 

The tremendous opportunity in health care is using improvements in quality of 

outcomes to drive costs down. To see this, one must only recognize that the goal 

is more health, not more treatment. Often, improved quality means more effective 

treatment, better health, and lower costs. The essential insight is this: Living in 

good health is inherently less expensive than living in poor health. In this era of 

chronic disease, costs rise when quality is low. With improvement in value—the 

health outcomes per dollar spent—more people can receive better care. 

The single most important step that Congress can take to enable improvement in 

health care value for Americans is to commit to measuring results. The adage applies: what is measured will improve. The time to begin is now. 

The Senate does not need to specify the exact measures to be used. From a national policy perspective, the task is to require outcome measurement. The Department of Health and Human Services can give the task of developing measures for 

given medical circumstances to not-for-profit organizations, or to the existing medical boards that have deep credibility and expertise. 

The point of measurement is not shopping or report cards. The purpose is to enable clinical teams to accelerate learning about what improves health outcomes and 

what improves the efficiency of effective care. A decade of process measurement has 

not yielded these desperately needed improvements. Measuring results is essential. 

Health outcomes are what drive value. At the same time, outcome measures are 

critical to ending the unacceptable disparities in American health care. 

Starting soon matters. Past experience with outcome reporting in this country and 

in others clearly shows that the fastest way to improve both results and the measures themselves is to begin collecting the measurements. 

Outcome measurement will spur improvements in health and health care value 

for all Americans. For patients and for health care professionals, measuring results 

will refocus the system on its intended purposes of health and care. 

Chairman Kennedy, Chairwoman Mikulski, Ranking Member Enzi and members 

of this committee, thank you for inviting me here today to talk about health care 

quality and improving health care value for every American. 

My name is Elizabeth Teisberg. I am a tenured professor at the University of Virginia and co-author of Redefining Health Care.1

ACCESS, MEASUREMENT AND PAYMENT: KEY DIMENSIONS OF HEALTH CARE REFORM

Improving our Nation’s health care is an urgent priority, made more critical by 

the current economic crisis. 

• Health is essential to productivity—if health is undermined because of tough 

economic times, the Nation becomes less productive, less competitive, and less able. 

• The health sector is a large and vibrant part of our economy and the economic 

recovery will be stronger and faster with an effective and efficient health sector. 

There is no greater short- or long-term economic stimulus than attending to the 

health of Americans. We must keep and expand meaningful jobs that create value 

by enabling health. 

• The crisis in health care that preceded this economic downturn remains and 

won’t disappear simply because of a recession. The problems are well known: costs 

are spiraling upward while quality in care and outcomes suffers from wide variance; 

good practice is undermined by inconsistencies in care, disjointed coordination and 

poor communication hinder care and hamper health outcomes; alarming numbers of 

deaths and serious injuries result from preventable medical errors, and over 40 million Americans lack the health insurance that would provide appropriate access to 

preventive and early stage care. 

Action on health care reform is a critical priority for the Nation. For over a decade, repeated efforts to contain health care costs have met with, at best, limited success. To change that result, to create a world-leading health care system, the Nation 

needs clear, new goals, new policies that are rapidly implemented and a government 

structure that prompts, supports and rewards ongoing and dramatic improvement. 

My recommendations address access, measurement and payment—issues essential for quality and for success. But first, consider the goal of genuine health care 

reform. 

11 

THE GOAL OF IMPROVING HEALTH FOR AMERICA

The Goal of Health Care is Health, so the Goal of Health Care Reform Must Be To 

Improve the Value of Health Care 

I am neither a physician nor a Washington health policy insider. My expertise in 

this field comes as a scholar and professor of Innovation and Strategy, as a Ph.D. 

in engineering economic systems analysis, and as the mother of a child who was 

chronically ill and in pain for most of a decade before his full and complete recovery. 

As a professional, and as a mother, I have questioned the conventional wisdom that 

has blocked change and retained a system that everyone agrees could be significantly improved. 

The real goal of health care is health. Yet, policy discussions are often 

framed as if the goal of health care delivery were cost reduction. If the goal 

of health care was simply cost reduction, the solution would be to offer pain killers 

and compassion. Clearly, that is not the solution for health care in our Nation. Successful health care reform efforts must do more than cut costs. The real goal of 

health care reform is, and must be, to drive dramatic and ongoing improvements in the value of health care. This means improving health care outcomes 

relative to the cost of achieving these outcomes. 

Improving value in health care means improving health care outcomes 

for the money spent. This is a critical idea and an intuitive one. In most choices, 

people seek value—not the lowest cost regardless of poor quality, and not the highest quality without regard for cost. The tremendous opportunity in health care is 

how powerfully improvements in quality actually drive costs down. To see this, one 

must simply recognize that Americans desire more health, not more treatment. Improvement in health care need not mean more treatment and more cost. 

Often, improved quality means more effective treatment, better health, and lower 

costs. The essential insight is this: Living in good health is inherently less expensive than living in poor health. Improving health, improving the quality and 

the value of health care will save money, not cost money. 

In this era of chronic disease, there is clear evidence that costs can be 

lowered through quality. 

• Stroke is the leading cause of long term disability. Preventing a stroke or fully 

recovering from a stroke are—in every circumstance—less expensive than long term 

disability. • Diabetes has become a pandemic, and people with diabetes have four times the 

health care costs of people without diabetes. Preventing disease progression and enabling people to live in ongoing health is far less expensive than paying for the 

compounding problems of amputations, heart disease and blindness. Healthy Americans work, provide for themselves and their families and pay taxes. Those afflicted 

with diabetes, and without access to effective care, can do less of those things. • For breast cancer, early treatment enables better results at lower costs. A 

woman with stage one cancer may be cured. A woman whose disease has reached 

stage 2B will face more invasive, more expensive care with less promising results. 

• For any disease, quality of diagnosis is critical: a wrong diagnosis leads to care 

that costs time, wastes money, and adds risk and discomfort. 

In example after example, improving health outcomes reduces costs. Some 

of the savings result from reduction of waste and errors in the current fragmented 

organizational structures. Even more significant gains come from restructuring care 

into teams, coordinated over the full cycle of the patient care. Innovation in the 

structures of care delivery can yield better prevention and improved solutions for 

patients and families. In spite of the conventional wisdom, we can afford to improve 

quality. Improving quality will drive dramatic improvement in value. 

Health policy reform can and should use improvement in health outcomes to drive 

down costs, rather than bowing to cost pressure and pushing down quality of health 

care or undertaking more efforts (and more administrative expenses) to limit access 

to care. 

WHY RESULTS-DRIVEN COMPETITION?

Results-Driven Health Care Will Improve Value More Than Government-Driven or 

Consumer-Driven Approaches 

In most sectors of the economy, the dynamic of competition drives improved value. 

In a functioning market, both quality and efficiency increase over time. But health 

care has been different. Quality has suffered while costs have increased. Waste is 

rampant. Why? 

The problem in health care isn’t too much competition or too little. The 

problem in health care is the wrong kind of competition. Health care lacks 

12 

positive sum competition to improve value in health care. Instead, health care is replete with examples of zero sum competition that shift costs through the exercise 

of bargaining power. Today’s competition occurs among systems of providers and 

health plans over capturing contracts and resources, shifting costs to each other, to 

employers, to the government and to consumers. This zero sum competition destroys 

value, rather than creating value for patients. Health policy reform needs to disable 

the gains from zero sum competition. A key implication of this insight is that universal access is essential to effective, value-creating competition in health care. 

The right competition is competition to increase value—to improve 

health care results. In positive sum competition, the patient wins with better 

health outcomes, the clinical team succeeds professionally, and the employer, government and health plans gain through more efficient care and increased productivity. Policy needs to support positive sum competition. This means that policy needs to require measurement of health care outcomes. Value is created in improving the health and health care outcomes of people. 

Productive competition is one of the most powerful forces for change, for economic 

stimulus and for improvement. As President Obama stated in his inaugural address: 

the question before us [is not] whether the market is a force for good or ill. The market is a powerful force for change, and the right kinds of policy can set a dynamic 

of positive competition and increasing health care value for all Americans. 

UNIVERSAL ACCESS

Access For All Americans is Essential not Only for Equity, but for Economic Efficiency 

The dysfunctional competition in American health care is endlessly fueled by opportunities for one party to shift costs to another, to win by forcing another party 

to lose, rather than to win by creating value, by improving health and health care 

outcomes. To stop the cost shifting games, everyone must be brought into the system. As long as parties gain by avoiding serving the uninsured, the tremendous energies to win at cost shifting will continue. Shifting costs does not create health 

care value. 

Lack of access reduces efficiency, shifts costs and, overall, raises costs of 

U.S. health care. 

• Those without access to early stage and preventive care tend to seek care only 

after problems have advanced. Treatment for later stage disease is both more 

expensive and less effective. This is part of the reason why every country with 

some form of universal coverage has lower per capita health care expenditures than 

does the United States. It is simultaneously more effective and less expensive to 

treat early stage disease and prevent disease progression. 

• In this country, everyone may go to the emergency room, but thousands 

lack access to care in less expensive, more effective settings. Those who 

argue that U.S. emergency rooms offer access for all must recognize that this is the 

highest cost way to provide access. Emergency rooms are not the venue for treating 

chronic disease or delivering preventive care. Emergency room physicians and 

nurses cannot create coordinated care for people who lack access to care in other 

settings. The efficiency gains from better coordinated care are unattainable with today’s limited access. 

• An enormous amount of effort goes into shifting and recovering the expenses 

of uncompensated care. These efforts create no value. Instead, they reduce value by 

increasing administrative costs. Costs of uncompensated care end up raising the 

charges to employers, the government and other patients, adding to the upward cost 

spiral. 

There will be transitional costs in giving everyone access to more appropriate 

health care settings and at earlier points. Over time, however, it will be more efficient and more effective for all to have access to care and to dispense with the cost 

shifting efforts that consume vast amounts of resources without creating value for 

patients. 

Achieving Universal Access Through Mandatory Coverage 

Mandatory health plan coverage is the surest way to achieve universal 

access. This will require vouchers or subsidies, in appropriate amounts, for those 

who need them. The obvious objective is universal coverage, not simply expanded 

access with the known holes and obvious incentives to continue cost shifting. Gains 

from reducing administrative costs will be largely sacrificed by expanded coverage 

that is not truly universal. 

13 

Universal coverage (with measured results) will enable quality gains. With a 

health plan, every person becomes a paying customer. That creates incentives to 

provide quality care for all. 

Universal coverage will also need rules that require all payers to cover their fair 

share of the most expensive patients. Financial risk pooling can address this, so that 

payers who cover more of the highest risk members receive an allotment that is collected from those who cover the lower risk members. This reduces the incentives for 

cherry picking only healthy customers. It is worth noting that the often-touted 

Swiss system has used a risk pooling mechanism for decades. The alternative of 

high risk health plans that are insurance of last resort for the sickest people leave 

in place the incentive for insurers to dis-enroll or discourage potentially expensive 

people. 

The other essential enabler of universal access is a list of what insurance must 

cover. Clarity that reduces arguments about coverage creates enormous administrative savings. Of course, health plans could cover more than the minimum, but the 

minimum must be specified to make coverage meaningful. A logical starting point 

is to use the requirements for the Federal Employee Health Benefits. Simultaneously with starting mandatory coverage, a panel of experts could be convened to 

make recommendations about adjustments to the required coverage. 

But universal access alone will not fix the system or contain rising health care 

costs. In the current structure, quality care for all will be difficult to achieve or afford—perhaps impossible. Neither incremental change nor waste reduction within 

the current structure will yield enough improvement. The Nation needs significant 

innovation and improvement in health care delivery to achieve a dramatic increase 

in value for patients. With improvement in value—the health outcomes per 

dollar spent—better care will be available to more people. 

Universal access must be accompanied by measures that refocus health care on 

improving value for patients (and people who need not become patients). The single 

most important step that Congress can take to improve health care value for 

Americans is to commit to measuring results. The adage applies: what is 

measured improves. 

RESULTS MEASUREMENT

Measuring Results Will Unleash Significant Improvement in Value 

Measuring results—health outcomes and costs—is critical to enable and drive improvements in value. Achieving universal access will be far less expensive in 

a results-driven system where positive sum competition improves value. 

Without improvements in the value of health care, the Nation will face increasing 

health care rationing of some form, whether it is explicit rationing of services, waiting lines or degradation of quality. But none of that is necessary or inevitable. 

The most critical policy step for enabling improvement in value is to 

begin results measurement. Through meaningful outcomes measurement, clinical 

teams are able to accelerate learning about what truly improves health outcomes 

and what improves the efficiency of effective care. A decade of process measurement 

has not yielded these desperately needed improvements. Results—the improvement 

in a patient’s health—must also be measured. The health outcomes of care are what 

matter to patients and families, to the professional success of clinicians, and to the 

productivity of the American workforce. Health outcomes drive value. 

The Senate cannot, should not and does not need to specify the exact measures 

to be used. However, the Congress must require outcome measurement. The 

Department of Health and Human Services can give the task of developing measures for given medical circumstances (e.g. strokes, diabetes and its co-morbidities, 

asthma, heart disease, etc.) to not-for-profit organizations, or to established medical 

boards. The Society of Thoracic Surgeons has been measuring health outcomes for 

a decade and its efforts have resulted in dramatic improvements in health quality 

and value. Leaders of four medical boards have approached me with the statements 

that they already know clinically meaningful measures that could and should be collected. Because medical boards renew accreditation for physicians, the boards are 

in an able position to require reporting. They can begin simply by requiring reporting and tying board licensure to whether or not reporting was completed, not to the 

relative performance of the reported outcomes. As the measurements are checked 

and refined, the system will evolve. The board leaders with whom I’ve spoken can 

start quickly and have deep expertise and credibility. 

Starting soon matters. Past experience with outcome reporting in this country 

and in others clearly shows that the fastest way to improve both results and 

the measures themselves is to begin collecting the measurements. Perfect 

measures and perfect risk adjustment are not required. When government efforts 

14 

launch outcome reporting, the clinicians most affected are spurred to improve the 

measures and to create new, more accurate and clinically relevant ones. The stateof-the-art outcome measurement by the Society of Thoracic Surgeons began as a defensive response to government (HCFA) reporting of mortality rates for cardiac surgery (based on administrative data). The universally collected and publicly reported 

outcome measures for transplants resulted from an Act of Congress establishing an 

organ sharing network and registry. Clearly, Congress can jump start results measurement that improves health care outcomes. Congressional expertise in the measures is not necessary. Congress simply needs to require registries of outcome 

measurements and allow appropriate experts to specify the measures. 

The point of measurement is not to enable consumer shopping. Report 

cards are not the goal and assertions that consumers do not use outcomes measures 

is simply a distraction. The objective of requiring measurement is to improve 

health care results by accelerating learning and improvement. When the 

State of New York began public reporting rudimentary mortality outcomes, mortality from CABG surgery fell 41 percent in the first 4 years. The evidence was clear 

that patients did not use the data to shop. Physicians used the data to improve. 

The drop in mortality vividly indicates that patients benefited. 

Measuring results will help clinical teams develop the needed insight to 

improve the structures and processes through which care is delivered. Clinical 

teams need to know what they do well. They need to know when they are improving 

and where they need further work. They need to know when they are achieving superb results so they can share their approaches with others. Indeed, the history of 

these efforts shows that when the teams with excellent results teach others, results 

improve overall and, importantly, the team doing the teaching improves even faster. 

The Nation’s health depends on this. Don’t accept delay, and don’t settle for 

only process measures. 

• There have been significant and laudable efforts over the past decade to develop 

measures of accepted practice. These are important to understand and to share. But 

the promised progression to outcome measurement still lies ahead. Congress needs 

to require outcome measurement to begin by a specified date. 

• The measures must go beyond process compliance. Measuring processes 

and measuring health outcomes are different. Indeed, many studies confirm that 

teams complying with the same process specifications get different health outcomes 

for their patients. Measuring only process compliance diverts health care down the 

road of administratively managed care and ever-increasing bureaucracy. It is easier 

to achieve consensus on process metrics because inputs are more readily controlled 

than the output of health results. But the past decade of process measurement has 

not yielded the needed improvements. It is time to require measurement of outcomes. 

Outcome measures are also critical to ending the unacceptable disparities in American health care. Mandatory results measurement will mean that 

substandard care for any group, including minorities or people with low incomes, 

will be unmasked. Once unmasked, disparities are unacceptable and most are wholly unintended. At the same time, poor results for any patient will lower a team’s 

outcome measures. On every dimension, results measures, more than any other policy, will accelerate elimination of substandard care for any group. 

Outcome measurement will spur improvements in health and health care 

value for all Americans. Attention to health care outcomes also offers the potential to align interests across the health sector. Knowledge of what a clinical team 

is doing well and how it is improving restores pride and professionalism for physicians and nurses who are so often today beaten down by reimbursement hassles and 

bureaucracy that overshadow their heartfelt desire to care for patients. For patient 

and for health care professionals, results measures will refocus the system on its 

intended purposes of health and care. 

PAYMENT

In the current system, financial success and medical success are not 

aligned. There is much discussion of the fact that some of the most effective work 

that physicians do is uncompensated. But the even bigger problems is that many 

of the structural improvements needed to allow greater leaps in health care value 

will not be supported by current reimbursement systems. Our piecemeal system of 

payment by procedure, by visit, by intervention and by hospital stay encourages 

poor coordination, redundant processes and lack of attention to the patient’s full 

cycle of care. In addition, prices for a particular service vary widely by payer, which 

shifts costs and increases complexity, but creates no value. 

15 

Instead, payment systems can support value-enhancing innovations in 

health care organizations by offering reimbursement for the full cycle of 

care needed by a patient. Rather than numerous prices and bills, comprehensive 

reimbursement would essentially pay the clinical team as a whole, rather than create negotiated prices for all of the components of care. Prices for episodes, service 

bundles and ultimately full cycles of care will require teams to apportion payment, 

as occurs in other services in our economy. While that might sound a bit daunting 

to some teams today, the process of considering the full suite of services needed to 

restore the patient’s health will lead to improved communication and improved 

awareness of the patient’s full experience. Some hospitals and clinics, usually with 

salaried medical staff, have already begun paying teams in this way. 

Today’s pricing depends as much or more on who is paying than on the 

services being delivered. Reduced administrative costs, improved transparency 

and incentives to improve efficiency would result from requiring prices to depend 

only on medical circumstances and services and be the same for all payers. Large 

payer organizations find threatening the idea of reducing their bargaining power, 

but their negotiated discounts backfire by increasing the list prices and the costs 

of uncompensated care. Over time, cost shifting only fuels the spiral of increasing 

costs. Aligning payment with the patient’s care will refocus competition on 

improving health care value and bringing down price increases over time. 

Dramatic improvement in value will result from restructuring care in 

ways that are genuinely patient-centric. Today’s physician-focused organizational structures deliver visits, interventions and procedures. A patient-focused 

organizational structure delivers coordinated solutions for improving 

health results. Teams could accelerate improvements in value by addressing clusters of medical circumstances that patients commonly face—what Prof. Michael E. 

Porter and I called ‘‘medical conditions’’ in Redefining Health Care. There is ample 

evidence that coordinated teams delivering care for patients with shared medical 

circumstances improve health outcomes and efficiency faster. They would be best 

supported by a system that includes all Americans with universal coverage for preventive, early and essential care, that has measured outcomes to enable learning 

and improvement, and that pays for the bundle of services needed to provide patient 

solutions. 

CONCLUSION

Access to health care for all Americans is essential to both equity and efficiency. 

Dramatic improvement in value (health outcomes per dollar spent) is necessary to 

provide quality care for all Americans. Health outcomes will improve faster and 

more dramatically if they are widely measured. Coordination of care that improves 

both outcomes and efficiency will progress more readily if payment becomes teambased for cycles of care. Congress can make huge strides by requiring mandatory 

health plan coverage and setting outcome measurement in motion. The time to 

begin is now. 

My thanks to the members of the committee and to its diligent and knowledgeable 

staff for the opportunity to share my thoughts with you. 

Senator MIKULSKI. Thank you very much, Dr. Teisberg. 

Dr. Robinson-Beale, before we go on, I want to acknowledge that 

Senator Dodd has come. He is next in line behind Senator Kennedy 

on the committee. Also our newest member, Senator Kay Hagan of 

North Carolina. We have got you way down there. 

We have Senator Dodd and Senator Hagan. Senator Hagan, we 

don’t know how many people are coming. Senator Dodd, do I have 

unanimous consent that we have her jump the seniority system for 

today? 

Senator DODD. Well, let us discuss it for an hour or so. 

[Laughter.] 

Come on up here, Kay. 

I have got a very bad voice, and I apologize. I have got a cold. 

I have got a 3-year-old and a 7-year-old. I don’t have to say anything more probably. I am living in a petri dish, and so I apologize. 

Let me thank Senator Mikulski for the tremendous work she is 

doing in this area. In fact, I just got off the phone with Senator 

Kennedy and Mrs. Kennedy, and he is doing well. He is sorry he 

16 

is not here today to participate in this, but deeply grateful for the 

work that Senator Mikulski is doing, along with our other colleagues, Senator Bingaman, I know as well, and Tom Harkin, in 

looking at various issues here as we get ready for what we hope 

is going to be a major effort on health reform. 

We are grateful as well to Mike Enzi and other members of the 

committee who care about these issues as well. So we thank you 

very much, Senator, for what you are doing. 

Senator MIKULSKI. Dr. Robinson-Beale. Please. 

STATEMENT OF RHONDA ROBINSON-BEALE, M.D., CHIEF MEDICAL OFFICER, OPTUMHEALTH BEHAVIORAL SOLUTIONS, 

GOLDEN VALLEY, MN 

Dr. ROBINSON-BEALE. Thank you, Madam Chairman. Thank you 

for inviting me to speak with you today about behavioral 

healthcare today in the context of the IOM reports ‘‘Crossing the 

Quality Chasm’’ and ‘‘Improving the Quality of Healthcare for Mental and Substance Use Conditions,’’ the subsequent report that was 

put out after ‘‘Crossing the Quality Chasm.’’ 

I am honored to have the opportunity to communicate with you 

the heightened relevance of the recommendations from these reports, given the tremendous change in our economic environment 

we are now in, and we are challenged with facing a new construct 

of healthcare reform. 

I hope to give you something to consider, some things that will 

be doable next steps to significantly move the status of behavioral 

health alone as a significant factor in healthcare reform. 

I speak to you as a committee member of the ‘‘Chasm’’ report, as 

well as a sponsor of the ‘‘Improving the Quality of Healthcare for 

Mental Health and Substance Use Conditions.’’ I am also the chief 

medical officer of the largest behavioral health organization in the 

country. We currently insure over 42 million people. 

I am also the past chairman of the board of directors for the Association of Health and Wellness, the trade organization for managed behavioral health organizations, which does insure over 147 

million people across the country. 

The IOM ‘‘Chasm’’ and ‘‘Improving the Quality’’ reports clearly 

define the problems in both healthcare delivery systems, medical 

and behavioral, and offer a set of solutions for change. Despite the 

many issues and the solutions that were similar between the two 

systems, behavioral health reformation still lags behind its medical 

counterpart in the implementation of those recommendations. 

Clear examples are this. The National Quality Forum, which has 

been designated as one of the entities that will drive consensus on 

performance measures, at this point has approved around 17 measures out of the plethora of measures that they have approved that 

are specific to behavioral health. 

Fifteen of those are directed toward primary care management of 

behavioral health, which is leaving outside of that scope the measures of care for those individuals who have chronic mental illness. 

Since 2006, at the time of the report ‘‘Improving the Quality of 

Healthcare,’’ our country’s landscape has changed dramatically. 

And in light of healthcare reform, there are new questions that 

need to be asked. 

17 

The questions now are how and what are the necessary changes 

in the behavioral health delivery system that we will need to make 

in order to be affordable, so that we can accommodate the larger 

number of individuals who will be able to seek care in an already 

overburdened and short-staffed delivery system and still provide 

quality of care? 

Where the recommendations from the IOM ‘‘Chasm’’ report and 

‘‘Improving the Quality’’ reports are still relevant and important, it 

is difficult to know which recommendations to initiate and which 

ones are essential to be implemented at this time. It is clear that 

a well-constructed strategy, concise execution, and having the buyin and the inclusion of major stakeholders is needed to address this 

daunting task. 

These are the recommendations. No. 1, it is important to adopt 

the culture that behavioral health is essential to health. It is key 

to effective medical care and greatly influences overall cost of medical care. 

We know from looking at our stats and our data that behavioral 

health has a tremendous impact on medical cost. For example, we 

know that 39 percent to 40 percent of those who have chronic medical illnesses also have a behavioral co-morbidity. 

We also know that or at least most people believe that behavioral 

health has a 3 percent to 5 percent impact on the medical dollar. 

When you begin to look at the impact of behavioral co-morbidities, 

that number rises to as high as 36 percent of the medical dollar. 

When we look at the prevalence and the incidence of behavioral 

health across the board and we look at one indicator, and that one 

indicator would be the prescription rate for antidepressant medications, we see in our population anywhere from 9 percent to 17 percent of the medical population is on an antidepressant. 

That is larger than any other chronic medical illness. It is larger 

than diabetes. It is larger than asthma, and it is larger than the 

incidence of cardiac disease. 

With that being said, keep in mind that behavioral health still 

lags behind medical health in terms of having the infrastructure 

and the inclusion in many of the recommendations that have been 

put forth and actualized by the ‘‘Chasm’’ report. 

Behavioral health is smaller. It is more organized—it is not as 

organized, but it is smaller so it is more doable. With that being 

in mind, it is necessary to create an organized approach to be concise. 

I am suggesting that we would be able to put together a collaborative that would be accountable for convening the major stakeholders, prioritizing initiatives, monitoring those initiatives, and facilitating goals. By doing that, we can concisely and quickly begin 

to bring behavioral health up to play. 

It is also important that there is governmental recognition. Just 

as parity has brought forth behavioral health to the forefront, governmental recognition and financial backing of initiatives is crucial 

to keep behavioral health in the forefront in importance in the 

healthcare reform. 

Thank you. 

[The prepared statement of Dr. Robinson-Beale follows:] 

18 

PREPARED STATEMENT OF RHONDA ROBINSON-BEALE, M.D. 

SUMMARY

The IOM reports, ‘‘Crossing the Quality Chasm’’ ( 2001) and ‘‘Improving the Quality of Mental and Substance-Use Conditions’’ (2006) addressed the same fundamental question of what needs to occur to transform our current fragmented and 

unsafe health system to one that meets the needs of health consumers and our communities and assures quality of care. Quality is defined in these reports as ‘‘the degree to which health services for individuals and populations increase the likelihood 

of desired health outcomes and are consistent with current professional knowledge.’’ 

In a health care system this links to the concept of reducing variation and increasing the delivery of effective care on a patient, provider and system level. In the IOM 

Improving the Quality report, recommendations, based on the Chasm 6 aims and 10 

rules, were constructed with the goal of addressing the core quality elements needed 

to increase the likelihood of successful reformation of the behavioral health organization. 

Since the start of this series of reports on behavioral health reform, some forward 

movement in the behavioral health agenda has occurred toward implementing recommendations. While these accomplishments are important, it is a common opinion 

among stakeholders in behavioral health, that there is more advancement needed 

in fulfilling recommendations in order to make significant progress and to move behavioral health closer to a quality model. 

Since 2006, the date of the last behavioral health policy report, our country’s landscape has drastically changed with economic devastation beyond any one’s prediction. With the rising number of unemployed and the financial burdens citizens 

are experiencing, there is more urgency than ever to address our health care crisis. 

In today’s environment, there are larger than ever numbers of individuals who are 

uninsured, Federal, States and employers are in extreme budget crisis and available 

funding for change is limited due to important competing interest. The question now 

is ‘‘how’’ and ‘‘what’’ are the necessary changes in the behavioral health care delivery system that will also be affordable, can accommodate larger numbers of individuals seeking services in an already overburdened system with limiting workforce 

and still provide quality. Where the recommendations from the IOM Chasm and Improving the Quality reports are still relevant and important, it is difficult to know 

which recommendations or initiatives are the key essential ones to be implemented. 

It is clear that a well constructed strategy, concise execution and having the buyin and inclusion of the major stakeholders is needed to address this daunting task 

and to do so expeditiously. 

RECOMMENDATIONS

• Adopt the culture that ‘‘behavioral health is essential to health,’’ key to effective 

medical care and greatly influences overall cost of medical care. 

• Make any behavioral health project funding contingent on clear demonstration 

of private-public involvement. 

• Create and fund a behavioral health ‘‘czar’’ an entity, person, existing agency 

(ies) or a collaborative that can assume the role of creating a behavioral health reform agenda. 

• The role of the behavioral health ‘‘czar’’ is accountable for convening stakeholders, prioritization, monitoring and facilitating goals. 

The IOM Chasm and ‘‘Improving the Quality’’ reports clearly define the problems 

in both health care delivery systems and offer a set of solutions for change. Despite 

the fact many of the issues and the solutions are similar between the two systems, 

behavioral health reformation still lags behind its counterpart in the implementation of recommendations. Just as parity was enacted as a legislative act, governmental guidance and financial backing is crucial to continue to keep behavioral 

health in the fore front of importance in the health care reform. 

INTRODUCTION

Mr. Chairman, members of the committee, thank you for inviting me to speak 

with you today about behavioral health care today in the context of the IOM reports 

Crossing the Quality Chasm (2001) 1 and Improving the Quality of Health Care for 

Mental and Substance—Use Conditions (2006).2 I am honored to have this opportunity to communicate with you the heightened relevance of the recommendations 

from these reports, given the tremendously changed economic environment we are 

in now and the challenges we are facing within the construct of health care reform. 

19 

I hope to give you for your consideration doable next steps to significantly move the 

status of behavioral health along as a significant factor in health care reform. I 

speak to you as a committee member of the Chasm report, and IOM Health Services 

Board member, as a Chief Medical Officer for the largest behavioral health organization in the country that currently insures over 42 million people and as the past 

chairman of the board of directors for the Association for Health and Wellness 

(ABHW), the trade organization for managed behavioral health organization for 

which its members cover over 147 million people. My statements are my own drawn 

from my experience in all these venues and not as an official position statement 

from any organization with whom I have affiliation. As a point of reference I will 

use the term ‘‘behavioral health’’ as a comprehensive term representing both mental 

illness and substance-use conditions. 

BACKGROUND

Significant reports that have influenced and reflected the need for change in the 

delivery of behavioral health historically has included: 

• Mental Health: A Report of the Surgeon General 3—established the basic understanding that behavioral health was important and that treatment works. • 2001 IOM Crossing the Quality Chasm 1—architectural map to fundamental 

change in the general health care system to drive quality in care. • 2003—Achieving the Promise: Transforming Mental Health Care in America 4— laid out the values of patient-centered and consumer-driven systems of care. • 2006—IOM Improving Quality of Health Care for Mental and Substance-Use 

Conditions 2—built on the chassis of the Chasm report, it specifically lays out the 

architecture specific to behavioral health for transforming to a quality-driven system. 

All these reports addressed the same fundamental question of what needs to occur 

to transform our current fragmented and unsafe behavioral health system to one 

that meets the needs of behavioral health consumers and our communities and 

assures quality of care. 

DEFINITION OF QUALITY

Quality is defined by the IOM as ‘‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.’’ 5 In a health care system this links to 

the concept of reducing variation and increasing the delivery of effective care on a 

patient, provider and system level. In the IOM Improving the Quality report, recommendations, based on the Chasm 6 aims and 10 rules, were constructed with the 

goal of addressing the core quality elements needed to increase the likelihood of successful reformation of the behavioral health organization. Some of those core elements were: 

• Applying the infrastructure changes outlined in the Chasm report to behavioral 

health (IOM rec 2). This recommendation specifically addresses the application of 

the general Chasm aims, rules and strategies to a behavioral health agenda. • Designate an entity to collect and make ready for wider distribution of best 

practices. (IOM rec 4–1—4–2) • Funding of ‘‘NQF’’-like functions to establishing national behavioral health consensus measures and priorities (IOM rec 4–3), facilitating quality improvement 

practices. (IOM rec 4–4) and reporting of measures (IOM rec 5–4) • Expect the integrating medical and behavioral health care into primary care initiatives and models. (IOM rec 5–2) • Information technology systems needs to address behavioral health data needs 

as fully as general health. (IOM rec 6–1) 

• Link funding mechanisms across many venues to measures of quality. (IOM rec 

8–4) 

• Collaborative innovative research strategies to address priority areas. (IOM rec 

9–2) 

PROGRESS IN REFORMING THE BEHAVIORAL HEALTH CARE SYSTEM

Since the start of this series of reports on behavioral health reform, some forward 

movement in the behavioral health agenda has occurred toward implementing recommendations. To highlight a few: 

• NQF adopted 15 behavioral health measures as a part of the Ambulatory Care 

Standards 6 which is focused on behavioral health commonly found in primary care 

setting. Most behavioral health measures are applicable to primary care management of behavioral health conditions and not specific to the scope of measurement 

20 

needs for chronically mentally ill populations managed by behavioral health clinicians. (IOM rec 4–3) • Substance Abuse and Mental Health Services Administration (SAMHSA) organized the Federal Executive Steering Committee,7 an unprecedented collaborative 

effort among more that 20 Federal agencies and offices, to develop a specific agenda 

for driving a quality-based care system for the public sector. (New Freedom Commission report recommendation). • Federal parity was passed Oct. 3 2008. ( IOM rec 8–1) 

While these accomplishments are important, it is a common opinion among stakeholders in behavioral health, that there is more advancement needed in fulfilling 

recommendations in order to make significant progress and to move behavioral 

health closer to a quality model. Many reasons have been sited for the lack of 

progress that is distinctive to behavioral health.2 They consist of having more diverse stakeholder groups (consumers, different provider disciplines, Federal, State, 

employer purchasers) split between public and private systems, unclear locus of accountability on a provider, organizational and systems level and limited funding. 

The lag behind is telling in the limited number of pilots and size of programs implementing pay-for-performance initiatives in behavioral health. A recent study examining behavioral health pay-for-performance found that there were only 24 behavioral health pay-for-performance programs operating and among them was a clear 

need for a strong quality infrastructure for behavioral health in order to implement 

well.8 This is concerning since one of the major initiatives posed to be a part of 

health care reform is provider profiling and pay-for-performance reward programs. 

BEHAVIORAL HEALTH CARE REFORM IN TODAY’S ENVIRONMENT

Since 2006, the date of the last behavioral health policy report, our country’s landscape has drastically changed with economic devastation beyond any one’s prediction. With the rising number of unemployed and the financial burdens citizens 

are experiencing, there is more urgency than ever to address our health care crisis. 

The questions posed to organizations like the IOM and others thought leader organization around the identification of the necessary changes needed to improve behavioral health care are still relevant and important. Now, however, there are additional serious issues that must be taken into account in constructing health care reform. In today’s environment, there are larger than ever numbers of individuals who 

are uninsured, Federal, States and employers are in extreme budget crisis and 

available funding for change is limited due to important competing interest. The 

question now is ‘‘how’’ and ‘‘what’’ are the necessary changes in the behavioral 

health care delivery system that will also be affordable, can accommodate larger 

numbers of individuals seeking services in an already overburdened system with 

limiting workforce and still provide quality. 

Where the recommendations from the IOM Chasm and Improving the Quality re- ports are still relevant and important, it is difficult to know which recommendations 

or initiatives are the key essential threads to pull on to be successful and not cause 

a catastrophic unraveling of the existing behavioral health structure. In this environment, there is an increased need now to be mindfully cautious and cost conscience to avoid wasteful spending on initiatives that is well-intended but executed 

poorly. There is an increased need to be precise in the construction of the behavioral 

health reform plan going forward. It is clear that a well-constructed strategy, concise execution and having the buy-in and inclusion of the major stakeholders is 

needed to address this daunting task and to do so expeditiously. Lawrence Bossidy 

in ‘‘Execution: The Discipline of Getting Things Done’’ identifies a construct for the 

effective execution of a plan: 9

1. Create the framework for change; 

2. Know the people, capacities and industry; 

3. Set clear goals and priorities; 

4. Follow through and perform on-going monitoring; and 

5. Reward doing and results. 

With this as an outline, these are some recommendations that appear to be fundamental to an efficient execution of a behavioral health reformation in this era of economic crisis. 

I. Execution: Set a Framework For Cultural Change 

1. As a part of cultural change there are basic values that guide the nexus of 

change. For behavioral health reformation they are: 

• Facilitate the expectation that behavioral health initiatives should be planned 

along side of and/or integrated within medical demonstration pilots with distinct articulated behavioral health goals, performance measures and funding. Not providing 

21 

for major inclusion of behavioral health in health reform is counter productive. Here 

are some reasons why: 

a. Incidence of behavioral health co-morbidities among patients with chronic 

medical illness varies from 39 percent–44 percent.10

b. The existence of behavioral co-morbidities raises the cost of medical care by 

50–150 percent.11

c. Effective care does reduce medical cost and early identification and intervention can improve workplace productivity.12

d. Commonly 9 percent to 17 percent of medical patients are on an antidepressant and only around 27 percent receive evidence-based care.13

e. Despite the common belief that behavioral health cost consumes 3–5 percent 

of the medical dollar, with the prevalence of co-morbidities, behavioral health 

spend is close to 36 percent of the medical dollar.14

Recommendation: Adopt the culture that ‘‘behavioral health is essential to 

health,’’ key to effective medical care and greatly influences over all cost of medical 

care. 

2. Behavioral health initiatives, to be the most effective, must include a publicprivate partnership especially in areas that involve interface with clinicians and 

service delivery systems. Leveraging change with all the purchasers of care aligned 

is more powerful and effective in getting provider buy-in. (i.e. Leapfrog) 

Recommendation: Make any project funding contingent on clear demonstration of 

private public involvement. 

II. Execution: Know the People, Capabilities And Industry 

3. Consider commissioning an IOM symposium, workshop or report (depending on 

timeframe for the needed deliverable) with the goal of revisiting recommendations 

to modify, refine, edit and most importantly prioritize them in light of health care 

reform and the realities of today’s environmental climate. The commissioned activity 

should include major public/private stakeholders, consumers, providers, and health 

care economist to draft an updated behavioral health strategy and refine recommendations that considers the need for increased access, affordability and quality 

as drivers. 

Recommendation: Commission the IOM or another impartial body to conduct a 

behavioral health symposium workshop or report involving all the major stake holders with the intent of refining the Improving the Quality recommendations to construct a targeted road map that can be effectively executed. 

4. Create and fund a behavioral health ‘‘czar’’ an entity, person, existing agency 

(ies) or a collaborative that can assume the role of creating a behavioral health reform agenda and organizing the structure to convening all the major stakeholders 

to drive initiatives relevant to today’s needs. 

Recommendation: Create and fund a behavioral health ‘‘Czar’’. 

III. Execution: Set Clear Goals and Priorities 

The role of the behavioral health ‘‘czar’’ is accountable for: 

5. Establishing a national set of priorities for behavioral health and commitment 

by stakeholders to participate in process improvement. 

6. Establishing a national set of goals with measurements that are relevant to 

public and private agendas. 

7. Establishing strategic and integrated partnerships with medical health reformation groups that are the key drivers of medical care modeling and other quality 

initiatives. 

8. Routinely designate a portion of Federal funding ear marked for medical quality initiatives for a behavioral health component. For example, funding to AHRQ or 

NQF to establish national care priorities should have funds set aside for a behavioral consensus forum to establish behavioral health priorities. 

Recommendation: establish priorities, measurements, and medical partnerships. 

IV. Execution: Follow Through and Monitor 

Through the behavioral health ‘‘czar’’: 

9. Establish an oversite process and facilitate the necessary change to the plan 

as results indicate. 

10. Monitor, report and communicate results and outcomes of the initiatives 

which were designed to address stated goals in a manner that widely disseminates 

learnings and creates an atmosphere of transparency. 

11. Continue to fund and operationalize the recommendations from the ‘‘Chasm’’ 

report as they are reprioritized or reformatted. 

Recommendation: establish an oversite, monitoring and transparent reporting. 

22 

CLOSING REMARKS

The IOM ‘‘Chasm’’ and ‘‘Improving the Quality’’ reports clearly define the problems in both our health care delivery systems and offer a set of solutions for change. 

Despite the fact many of the issues and the solutions are similar between the two 

systems, behavioral health reformation still lags behind its counterpart in the implementation of recommendations. The unique challenges of our economic environment and the rising number of uninsured Americans brings a new twist to the context of health care reform and the recommendations. This environment puts in jeopardy the possibilities of implementing reform and especially behavioral health. Just 

as parity was enacted as a legislative act, governmental guidance and financial 

backing is crucial to keep behavioral health in the fore front of importance in the 

health care reform. In closing, ‘‘Knowing is not enough, we must apply; Willing is 

not enough, we must do’’—Goethe. 

REFERENCES

1. IOM 2001, ‘‘Crossing the Quality Chasm’’. Washington, DC: National Academy 

Press. 

2. IOM 2006, ‘‘Improving the Quality of Health Care for Mental and SubstanceUse Conditions: Quality Chasm. Washington, DC: National Academy Press. 

3. Satcher, D. Mental Health: A Surgeons General Report. www.surgeongeneral 

.gov/library/mentalhealth. 4. President Commissioners Report, Achieving the Promise: Transforming Mental 

Health Care in America. 2003. 

5. IOM 2009—Crossing the Quality Chasm: The IOM Health Care Quality Initiative, www.iom.edu/CMS. 6. NQF, National Voluntary Consensus Standards for Ambulatory Care Part 1, 

www.qualityforum.org/projects. 2009. 

7. SAMHSA—Transforming Mental Health Care in America. www.samhsa.gov/ 

federalactionagenda. 8. Brenner, R.: Pay For Performance in Behavioral Health, Psychiatric Services 

Dec. 2008, 1419–1429. 

9. Leape, L; Berwick, D. Five Years After To Err Is Human; What Have We 

Learned?’’ JAMA May 2005; vol. 293 no. 19. 

10. Moussavei, S., Depression, Chronic Disease and Decrements in Health: Results 

From the World Health Surveys. Lancet Sept. 2007, 370:851–58. 

11. Simon, G. Recovery From Depression Predicts Lower Health Services Cost. J 

Clin Psych 67:8, Aug. 2006. 

12. Wang, P., Azocar, F. Telephone Screening, Outreach, and Care Management 

for Depressed Worker and Impact on Clinical and Work Productivity Outcomes. JAMA Sept 2007; 298:12 1401–1411. 

13. Kessler, R., Wang, P. The Prevalence and Distribution of Major Depression in 

a National Community Sample: The National Co-morbidity Survey. Arch of Psych 

2005. 

14. Sources: CDC; Milliman; U.S. Dept. of Health & Human Services, SAMHSA; 

ChapterHouse analysis. 

15. IOM 1999, ‘‘Too Err Is Human’’. Washington, DC: National Academy Press. 

16. Baucus, M. Nov 2008. ‘‘Call To Action Health Reform, 2009. www.finance 

.senate.gov. 17. Lewin, J. 2009. ACC Corner ‘‘Quality First’’ in Health Care Reform Debate,’’ 

www.cardiovascularbusiness.com . 18. Engelberg Center for Health Care Reform Nov 2008. ‘‘Real Health Care reform 

in 2009: Getting to Better Quality, Higher Value and Sustainable Coverage,’’ 

www.brooking.edu. 

Senator MIKULSKI. Well, we could hold just a whole hearing on, 

first of all, each and every one of your testimonies, and I think all 

of my colleagues would acknowledge that. That was a stunning statistic, Doctor, and we are going to come back to that. 

I want to acknowledge that Senator Casey of Pennsylvania is 

here. 

Also one other item before we go to Dr. Davis. There will be 

three votes at approximately 3:10 p.m., which means we will have 

about 15 minutes. When we have to leave for the votes, that will 

conclude the hearing. Because by the time we go for three votes, 

it will be an hour, and we don’t want to inconvenience you more. 

23 

So we are going to move right along with our testimony. We will 

keep our questions to the 5-minute rule, and then if we have time 

for a second round, we will do it. 

Dr. Davis, hit it. 

[Laughter.] 

STATEMENT OF KAREN DAVIS, Ph.D., PRESIDENT, 

COMMONWEALTH FUND, NEW YORK, NY 

Ms. DAVIS. Thank you, Madam Chairman and members of the 

committee, for this opportunity to join you today. 

As the Nation turns to the issue of reforming our health insurance system, it is important to address simultaneously the way we 

organize and deliver healthcare services to ensure that we are getting the very best possible outcomes for Americans and the most 

value for the money we spend on healthcare. 

I agree completely with the statement that the Chairman made 

at the beginning of this hearing that access, quality, and cost are 

interrelated, and we need to address all of them simultaneously. 

According to a recent national scorecard published by the Commonwealth Fund, the U.S. healthcare system scored 65 out of 100 

possible points on 37 indicators of performance, capturing key dimensions of health outcomes, quality, access, equity, and efficiency. 

The scorecard shows that the United States is not making consistent progress in reducing the variability of healthcare quality 

and is failing to keep pace with gains in health outcomes achieved 

by our industrialized peers. 

We are fortunate, however, that even within our imperfect system, models exist for each of the components that if properly organized, reformed, and financed it can enable the Nation to provide 

high-quality, affordable care to every American. 

Examples of excellence from across the United States and around 

the world offer insight into what it takes to achieve high performance, including the Geisinger Health System in Senator Casey’s 

district and Denver Health, which are integrated health systems 

that achieve high performance using electronic health records and 

a culture of continuous innovation and improvement. 

State initiatives in Iowa and Vermont have made them leaders 

on our State scorecards. Regional associations, like the Massachusetts Health Quality Partners and the Wisconsin Collaborative for 

Healthcare Quality, have been innovative leaders in transparency 

and engaging providers in quality improvement. Denmark and The 

Netherlands are international leaders with accessible primary care 

and electronic information systems. 

The specific policies that will both lead to better outcomes and 

bend the curve of our Nation’s unsustainable healthcare spending 

revolve around five strategies that are amenable to action at the 

Federal level. 

Provide affordable health coverage for all. Reform provider payment. Organize our care delivery systems, including raising community health centers, the exemplar models of patient-centered 

care. Invest in a modern health system, including the information 

technology and information on comparative effectiveness of treatments. And ensure strong national leadership. 

24 

* The co-authorship and research assistance of Kristof Stremikis and editorial assistance of 

Chris Hollander are gratefully acknowledged. 

The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. This and other Fund publications are available 

online at www.commonwealthfund.org. To learn more about new publications when they become 

available, visit the Fund’s Website and register to receive e-mail alerts. Commonwealth Fund 

pub. no. xxxx. 

By applying these policies simultaneously, the Nation would be 

able to capture the synergistic benefits of specific changes that 

would put the United States on the path to a high-performance 

health system. 

Thank you. 

[The prepared statement of Dr. Davis follows:] 

PREPARED STATEMENT OF KAREN DAVIS, PH.D.* 

EXECUTIVE SUMMARY

As the Nation turns to the issue of reforming our health insurance system, it is 

important simultaneously to address how we organize and deliver health services, 

to ensure that we are obtaining the best health outcomes for Americans and value 

for the money we are spending on health care. Unfortunately, the care we receive 

falls short of the care it is possible to deliver, and the gap is not narrowing. According to the most recent National Scorecard published by the Commonwealth Fund 

Commission on a High Performance Health System, the U.S. health system scored 

65 out of 100 possible points in 2008 on 37 indicators of performance that capture 

key dimensions of health outcomes, quality, access, equity, and efficiency. 

The Scorecard shows that the United States is not making consistent progress in 

reducing the variability of care quality and is failing to keep pace with gains in 

health outcomes achieved by our industrialized peers. 

• The Nation now ranks last out of 19 countries on a measure of mortality amenable to medical care, falling from 15th in 5 years as other countries raised the bar 

on performance. 

• The widening quality chasm is having real effects on real lives—up to 101,000 

deaths could be prevented each year if the U.S.-raised standards of care to benchmark performance levels achieved abroad. 

• While we spend more than twice of what other nations spend on health, there 

is overwhelming evidence of inappropriate care, missed opportunities, and waste 

within the U.S. health system. 

We are fortunate that within our imperfect system there are examples of all the 

components that, properly organized, reformed, and financed, can enable the Nation 

to provide high-quality, affordable care to every American. Insight into what it takes 

to achieve high performance is provided by some examples of excellence within the 

United States and around the world: 

• The Geisinger Health System, on whose board I am pleased to serve, is a leader 

in innovation and quality improvement that demonstrates the importance of simultaneously aligning incentives, utilizing electronic health records, and creating policies to encourage coordination of care. 

• Denver Health, a comprehensive and integrated medical system that is Colorado’s largest health care safety-net provider, has succeeded by promoting a culture 

of continuous quality improvement and lean efficiency, adopting information technology, and providing organization-wide leadership. 

• State initiatives in Iowa and Vermont have achieved better health outcomes 

and increased access to needed health services by encouraging adoption of the medical home model, disseminating performance information and best practices, and 

launching focused campaigns to cover young children. 

• Regional associations like Massachusetts Health Quality Partners and the Wisconsin Collaborative for Healthcare Quality have been leaders in quality improvement efforts by collecting and disseminating performance data on hospitals and physician groups and educating providers and patients to use that information to facilitate quality improvement activities. 

• Denmark and the Netherlands have become international leaders in patientcentered, coordinated care by placing great emphasis on accessible primary care and 

developing information systems that assist primary care physicians in coordinating 

health care services. 

25 

1The Commonwealth Fund Commission on a High Performance Health System, Why Not the 

Best? Results from the National Scorecard on U.S. Health System Performance, 2008, (New York: 

The Commonwealth Fund, July 2008); C. Schoen, K. Davis, S.K.H. How, and S.C. Schoenbaum, 

‘‘U.S. Health System Performance: A National Scorecard,’’ Health Affairs, November/December 

2006; 25(6): w457–w475. 2 E.J. Emanuel, ‘‘What Cannot Be Said on Television About Health Care,’’ JAMA 2007; 

297:2131–2133. 

The specific policies that will both lead to better health outcomes and bend the 

curve of our Nation’s unsustainable spending on health revolve around five strategies amenable to action at the Federal level: 

• Provide affordable health coverage for all; • Reform provider payment; • Organize our care delivery systems; • Invest in a modern health system; and, • Ensure strong national leadership. 

Congress can continue to develop the infrastructure for improving quality by making investments in health information technology and information exchange networks. If the United States is serious about closing the quality chasm, it will also 

need a strong primary care system, which requires fundamental provider payment 

reform, encouraging all patients to enroll in a patient-centered medical home, and 

supporting those physician practices with IT and technical assistance in care process design. Funding for comparative effectiveness research and the establishment of 

a center for comparative effectiveness is also crucial to value-based purchasing and 

performance improvement initiatives. Finally, the Federal Government can raise the 

bar for health system performance by setting explicit goals and priorities for improvement—particularly with regard to the most prevalent chronic conditions, which 

account for a large majority of health care costs. 

By applying these policies collectively, the Nation would be able to capture the 

synergistic benefits of specific changes that, if implemented individually, would yield 

more modest improvements in quality and less reduction in projected spending 

trends. The reforms must support providers in their efforts to deliver the best care 

possible for their patients. Armed with the knowledge that the status quo is no 

longer acceptable, we have entered a new era ripe with opportunity to close the 

quality chasm and improve the health and well-being of American families. Working 

together we can change course—and move the U.S. health system on a path to high 

performance. 

THE COMMONWEALTH FUND

Thank you, Senator Mikulski, for this opportunity to testify on health care quality 

and delivery system reform in the United States. As the Nation turns to the issue 

of reforming our health insurance system, it is important simultaneously to address 

how we organize and deliver health services, to ensure that we are obtaining the 

best health outcomes for Americans and value for the money we are spending on 

health care. 

Unfortunately, the care we receive falls short of the care it is possible to deliver, 

and the gap is not narrowing. According to the most recent National Scorecard published by the Commonwealth Fund Commission on a High Performance Health System, the U.S. health system scored 65 out of 100 possible points in 2008, on 37 indicators of performance that capture key dimensions of health outcomes, quality, access, equity, and efficiency.1 This is down slightly from 67 out of 100 in 2006—we 

are not on the right path. 

The good news is that we no longer simply assert that we have the best health 

system in the world,2 and instead are beginning to take a clear-eyed look at how 

our system performs overall, across States, and in comparison with other countries. 

We are beginning to have the information that shows where we are gaining ground, 

and where there are opportunities to improve. Public reporting of data on quality 

of hospital care and focused campaigns to improve quality are spurring improvement. Many health care professionals and organizations are responding to the challenge and adopting information technology, redesigning care processes, and mobilizing efforts to improve results. Examples of excellence within the United States, 

as well as around the world, demonstrate what can be achieved. 

But the United States will not have the health system we want for ourselves and 

our families if the Federal Government does not lead and implement a series of 

strategies that taken together can close the quality chasm. These include, most importantly, extending health insurance to all; aligning financial incentives to reward 

26 

3 Commonwealth Fund Commission, Ibid. 4 E. Nolte and C. McKee, ‘‘Measuring The Health Of Nations: Updating An Earlier Analysis,’’ 

Health Affairs, January/February 2008; 27(1): 58–71. 5T. Kottke, et al., ‘‘The Comparative Effectiveness of Heart Prevention and Treatment Strategies,’’ Am J Prev Med 2009; 36(1): 82–88. 6 National Committee for Quality Assurance, The State of Health Care Quality 2008, (Washington, DC: NCQA, 2008). 7 Commonwealth Fund Commission, Ibid. 8 A. Jha, et al., ‘‘The Inverse Relationship Between Mortality Rates and Performance in the 

Hospital Quality Alliance Measures,’’ Health Affairs, July/August 2007; 26(4): 1104–1110. 

the outcomes we want to achieve; changing the organization and delivery of care to 

ensure that it is accessible, coordinated, and patient-centered; investing in the infrastructure and support necessary to reach attainable levels of quality and efficiency; 

and exercising the leadership and collaboration among all parts of the health system 

necessary to achieve health goals for the Nation. 

By applying these policies collectively, the Nation would be able to capture the 

synergistic benefits of specific changes that, if implemented individually, would yield 

more modest improvements in quality and less reduction in projected spending 

trends. The reforms must support providers in their efforts to deliver the best care 

possible for their patients. Armed with the knowledge that the status quo is no 

longer acceptable, we have entered a new era ripe with opportunity to close the 

quality chasm and improve the health and well-being of American families. Working 

together we can change course—and move the U.S. health system on a path to high 

performance. 

I. HEADED IN THE WRONG DIRECTION: EVIDENCE OF A WIDENING QUALITY CHASM

Despite the best efforts of millions of talented and dedicated health care professionals, the United States is not making consistent progress in reducing the variability of care quality and is failing to keep pace with gains in health outcomes 

achieved by our industrialized peers.3 The Nation now ranks last out of 19 countries 

on a measure of mortality amenable to medical care, falling from 15th in 5 years 

as other countries raised the bar on performance.4 This widening quality chasm is 

having real effects on real lives—up to 101,000 deaths could be prevented each year 

if the United States raised standards of care to benchmark performance levels 

achieved abroad. 

A focus on preventive care and proper management of chronic disease are key 

strategies to increase the effectiveness of health care delivery, an area where lack 

of progress is undermining the Nation’s efforts to improve quality. While the benefits of prevention are well documented,5 the national scorecard report found that 

only half of adults receive all age-appropriate preventive care services such as immunizations, cancer screenings, and blood pressure and cholesterol tests. There was 

no improvement on this indicator between the 2006 and 2008 scorecards. Meanwhile, troubling variation in chronic disease management is evident across health 

plans and insurance status despite slight improvements in the control of diabetes 

and hypertension. A recent National Committee for Quality Assurance study found 

that eliminating this variance would prevent up to 46,000 premature deaths and 

save up to $2.4 billion in medical costs.6

Indicators of patient safety are also important measures of overall quality within 

the health care system. One bright spot is that the United States showed progress 

on hospital standardized mortality ratios, which declined by 19 percent on the 2008 

scorecard from the earlier report. This measure was the focus of a 100,000 Lives 

campaign led by the Institute for Healthcare Improvement. Other organizations that 

are working to improve patient safety include the World Health Organization, the 

Joint Commission National Patient Safety Goals, the Leapfrog Group’s Hospital 

Quality and Safety Survey, the National Surgical Quality Improvement Program, 

the American Medical Association’s National Patient Safety Foundation, and the 

Center for Disease Control and Prevention’s National Health Safety Network.7

There also have been gains in acute hospital care for heart attack, heart failure, 

and pneumonia patients—based on quality metrics reported to Medicare. Yet, gaps 

in the receipt of recommended care for pneumonia and heart failure were particularly wide, with spreads of 20 to 30 percentage points between the bottom and top 

10th percentiles. Standardized Federal reporting has shown top hospitals are 

achieving 100 percent on basic process measures, indicating that full adherence to 

a set of best practice guidelines is possible. Researchers estimate that if hospitals 

in the bottom quartile of performance improved to the level of the top quartile, more 

than 2,000 deaths could be avoided each year.8

27 

9 E. Fisher, D. Wennberg, et al., ‘‘The Implications of Regional Variations in Medicare Spending. Part 1: The Content, Quality, and Accessibility of Care,’’ Annals of Internal Medicine, February 18, 2003; 138(4): 273–287; E. Fisher, D. Wennberg, et al., ‘‘The Implications of Regional 

Variations in Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care,’’ Annals 

of Internal Medicine, February 18, 2003; 138(4): 288–298. 10Medicare Payment Advisory Commission, ‘‘Payment Policy for Inpatient Re-admissions,’’ Report to the Congress: Promoting Greater Efficiency in Medicare, (Washington: MedPAC, June 

2007). 11MedPAC, Ibid. 

Substantial variation was also found among risk-adjusted mortality rates for several serious conditions and risk-adjusted costs for Medicare beneficiaries, demonstrating both inefficiency and a vast quality chasm throughout the country. Updated analysis of Medicare data shows that 1-year risk-adjusted mortality rates for 

heart attacks, hip fractures, and colon cancer varied between 27 and 33 percent 

among the best- and worst-performing regions, while risk-adjusted cost ranged from 

$25,000 to $30,000. A significant number of those regions with lower risk-adjusted 

mortality rates also utilized lower total resources, suggesting significant inefficiency 

among higher spending regions.9 If all areas of the country achieved the performance levels of the benchmark regions, Medicare could save more than 9,000 lives 

and reduce annual costs by nearly $1 billion a year for these three conditions alone. 

Providing quality care during a hospital stay and giving appropriate discharge 

planning, follow-up, and post-acute care can help prevent patients from being re-admitted to the hospital, thus improving the patient experience and reducing the total 

costs of care.10 However, no improvement in the Medicare 30-day hospital re-admission rate was seen in the 2008 scorecard, and regional variation remained stark. 

Nearly one of five Medicare patients initially hospitalized with one set of selected 

conditions was re-admitted to the hospital within 30 days, with rates in the worst 

performing regions 50 percent higher than those in the better performing areas of 

the country. A Medicare Payment Advisory Commission analysis indicates that 

three-quarters of re-admissions may be preventable at a potential savings of $12 billion a year for Medicare.11

The 2008 scorecard also showed increases in the rate of hospitalization and 30- 

day hospital re-admission of nursing home residents, two indicators of poor coordination and poor quality for one of the most vulnerable populations within the 

United States. Nearly one of five nursing home long-stay residents was hospitalized 

according to the most recent analysis of Medicare claims data, up from 17 percent 

in the previous study. The frequency of hospitalization and 30-day hospital re-admission of nursing home residents increased among both high- and low-performing 

States. 

Rates of potentially preventable hospitalizations for ambulatory care-sensitive 

(ACS) conditions are another key measure of quality within the U.S. health care 

system. Widespread variation was again the theme, with two- to four-fold differences across States and hospital referral regions along with associated discrepancies in costs and resource use. At least $4 billion annually could be saved if these 

rates fell to benchmark levels. 

The 2008 scorecard reported 15 to 24 percentage point differences on important 

indicators of hospital patient-centered care, including how well staff managed pain, 

responded when patients pressed a call button, or explained medications and their 

possible side effects. The best hospitals achieved very high rates of patient ratings 

on these questions, illustrating that it is possible for hospitals to do much better 

in meeting patients’ needs. 

The rate of medical, medication, and lab errors is yet another important quality 

indicator where the United States has failed to keep pace with gains made by 

benchmark performers in the international community. Nearly one-third of U.S. patients surveyed in 2007 said that, in the last 2 years, a medical mistake or a medication or lab test error was made during their care. There was little to no improvement on this metric since it was reported in the 2006 scorecard. It would take a 

40 percent reduction in the medical, medication, and lab test error rate in the 

United States to reach the low level reported in Germany, the benchmark country. 

Aggregate scores on dimensions of care coordination fell between 2006 and 2008, 

demonstrating that fragmentation and misaligned incentives continue to plague the 

U.S. health system. The percentage of adults who reported access to a regular 

source of primary care failed to improve, a particularly disturbing finding given that 

those who lack a usual source of primary care are more likely to have unmet health 

care needs and higher costs of care while being less likely to adhere to treatment 

28 

12 B. Starfield, Primary Care: Balancing Health Needs, Services, and Technology (New York: 

Oxford University Press, 1998). 13 E. Coleman, ‘‘Falling Through the Cracks: Challenges and Opportunities for Improving 

Transitional Care for Persons with Continuous Complex Care Needs,’’ Journal of the American 

Geriatrics Society, April 2003; 51(4): 549–555. 14 C. Schoen, R. Osborn, P. Trang Huynh, M. Doty, J. Peugh, K. Zapert, ‘‘On The Front Lines 

of Care: Primary Care Doctors’ Office Systems, Experiences, and Views in Seven Countries,’’ 

Health Affairs, November/December 2006; 25(6): w555–w571; K. Davis , M. Doty, K. Shea, and 

K. Stremikis, ‘‘Health Information Technology and Physician Perceptions of Quality of Care and 

Satisfaction,’’ Health Policy, forthcoming 2009. 15K. Davis, C. Schoen, S.C. Schoenbaum, M.M. Doty, A.L. Holmgren, J.L. Kriss, and K.K. 

Shea, Mirror, Mirror on the Wall: An International Update on the Comparative Performance of 

American Health Care, (New York: The Commonwealth Fund, May 2007). 16Davis, ‘‘Mirror, Mirror,’’ Ibid. 17 Commonwealth Fund Commission, Ibid. 18Davis, ‘‘Mirror, Mirror,’’ Ibid. 

and receive preventive care.12 Differing rates of coordination for hospital patients 

was similarly distressing, with nearly three-fold variation among high and low performers on the percentage of heart failure patients who received complete written 

instructions at discharge. Proper coordination of care at the time of hospital discharge helps prevent subsequent complications and re-admissions, especially for patients with complex or chronic conditions.13

Finally, while studies have shown that expansion of health information technology 

is a means of facilitating quality reporting and improvement, analysis of the 2006 

Commonwealth Fund Survey of Primary Care Physicians demonstrates that the 

United States falls far behind the Netherlands, New Zealand, the United Kingdom, 

Australia, and Germany on the utilization and functionality of health IT. The contrast between the United States and the Netherlands is particularly stark, with 98 

percent of Dutch primary care physicians reporting the use of electronic medical 

records compared with only 28 percent of their American counterparts. This general 

pattern persists when examining the prevalence of other IT functions such as electronic prescribing, decision support, and computerized access to test results.14

II. IMPEDIMENTS IN THE CURRENT SYSTEM

In short, the U.S. health care system is plagued by significant variability in quality and is failing to match the gains seen among its industrialized peers. Impediments to improvement include a lack of affordable health coverage for all, a wasteful 

and inefficient provider payment system, a fragmented and disorganized care delivery system, widespread failure to adopt health information technology, and limited 

Federal oversight and leadership. A recent Commonwealth Fund study found that 

the United States ranked last among six industrialized nations on health system 

performance.15 Despite spending more than twice what other nations spend on 

health, there is overwhelming evidence of inappropriate care, missed opportunities, 

and waste within the U.S. health system. 

Lack of affordable health coverage is a proven barrier to obtaining quality care 

and improving the value of the country’s significant expenditure on health services. 

The United States stands alone among its industrialized peers in failing to provide 

universal coverage, and ranked last among six nations in a recent Commonwealth 

Fund study on an aggregate measure of health care access.16 Cost-related problems 

are widespread, with more than half of respondents to a 2005 survey reporting problems getting recommended tests, treatments, or follow-up care, filling prescriptions, 

or visiting a doctor when they had medical problems because of cost. Not surprisingly, lack of affordable coverage and the attendant financial barriers to care contributed to underuse of health services among the uninsured, a group much less 

likely to obtain preventive care, fill prescriptions, and have chronic conditions under 

control.17 This phenomenon drives disparities in outcomes, decreases the proportion 

of the population receiving appropriate primary care to prevent illness, and puts the 

health of the millions of Americans living with chronic conditions in peril. 

Misalignment of financial incentives is also a significant impediment to successful 

quality improvement in the United States. The 2006 Commonwealth Fund International Health Policy Survey showed that only 30 percent of American primary 

care physicians received any financial incentive to improve quality, contrasted with 

their counterparts in the United Kingdom nearly all of whom reported financial bonuses—the result of a bonus system which can account for up to 30 percent of their 

income based on a broad array of quality measures covering preventive and chronic 

care and patient experiences.18 Commonwealth Fund studies have also found the 

predominance of the fee-for-service payment system in the United States—an arrangement that rewards volume over value—to be a significant barrier to streamVerDate Nov 24 2008 13:47 Dec 03, 2010 Jkt 035165 PO 00000 Frm 00032 Fmt 6633 Sfmt 6621 S:\DOCS\47121.TXT DENISE
29 

19K. Stremikis, S. Guterman, and K. Davis, Health Care Opinion Leaders’ Views on Payment 

System Reform, (New York: The Commonwealth Fund, November 2008). 20MedPAC, ‘‘Payment Policy for Inpatient Re-admissions,’’ Ibid.; D. Grabowski, ‘‘Medicare and 

Medicaid: Conflicting Incentives for Long-Term Care,’’ Milbank Q., December 2007; 85(4): 579– 

610; T. Bodenheimer, ‘‘Coordinating Care—A Perilous Journey Through the Health Care System,’’ N Engl J Med., March 6, 2008; 358(10):1064–1071. 21 A. Shih, K. Davis, S. Schoenbaum, A. Gauthier, R. Nuzum, and D. McCarthy, Organizing 

the U.S. Health Care Delivery System for High Performance, (New York: The Commonwealth 

Fund, August 2008). 22M. Abrams, ‘‘Achieving Person-Centered Primary Care: The Patient-Centered Medical 

Home,’’ Invited Testimony, Special Senate Committee on Aging Hearing on ‘‘Person-Centered 

Care: Reforming Services and Bringing Older Citizens Back to the Heart of Society,’’ (New York: 

The Commonwealth Fund, July 2008). 23 R.A. Paulus, K. Davis, and G.D. Steele, ‘‘Continuous Innovation in Health Care: Implications of the Geisinger Experience,’’ Health Affairs, September/October 2008; 27(5): 1235–1245. 24K.K. Shea, A. Shih, and K. Davis, Commonwealth Fund Commission on a High Performance 

Health System Data Brief: Health Care Opinion Leaders’ Views on Health Care Delivery System 

Reform, (New York: The Commonwealth Fund, April 2008). 25 C. Schoen, ‘‘On The Front Lines of Care,’’ Ibid. 26 R. Amarasingham, et al., ‘‘Clinical Information Technologies and Inpatient Outcomes,’’ Arch 

Intern Med. 2009; 169(2):1–7. 27K. Davis, Learning From High Performance Health Systems Around the Globe, Invited Testimony: Senate Health, Education, Labor, and Pensions Committee Hearing, (New York: The Commonwealth Fund, January 2007). 

lined and more efficient delivery models.19 Analysis has shown that doctors and hospitals practicing in the same community and caring for the same patients have little 

or no incentive or capacity to connect to one another, contributing to unnecessary 

duplication of tests and procedures, wasteful deployment of resources, and substandard outcomes.20

Fragmentation of the American care delivery system drives low-quality, inappropriate, and inefficient service in a country filled with highly skilled health care professionals. A disjointed mix of private insurers and public programs, each with its 

own set of rules and payment methods, fuels fragmentation, generating waste and 

high administrative costs.21 Moreover, widespread failure to adopt the patientcentered medical home model, especially among community health centers serving 

low-income and minority patients, has contributed to uneven performance and exacerbated disparities in quality along racial and socioeconomic lines.22

Data from high performing health systems across the country show that moving 

towards more integrated models of care is a proven strategy for increasing quality 

of care while simultaneously reducing costs and inefficiencies.23 Over 80 percent of 

respondents to a recent Commonwealth Fund Health Care Opinion Leaders Survey 

say that strengthening the primary care system, encouraging care coordination, and 

facilitating the integration of providers within and across care settings are important steps to improving health system performance.24

Substandard outcomes and insufficient value are also driven by insufficient adoption of health information technology (IT) and the absence of information exchange 

systems. Analysis of the 2006 Commonwealth Fund Survey of Primary Care Physicians demonstrates that the United States has fallen far behind the Netherlands, 

New Zealand, the United Kingdom, Australia, and Germany on a number of measures related to the utilization of health IT.25 The contrast between the United 

States and the Netherlands is particularly stark, with 98 percent of Dutch primary 

care physicians reporting the use of electronic medical records compared with only 

28 percent of their American counterparts. This general pattern persists when examining the prevalence of other IT functions such as electronic prescribing, decision 

support, and computerized access to test results. A recent Commonwealth Fund-supported study suggests that linking health IT to performance improvement efforts 

has the potential to both improve the quality of care and significantly reduce 

costs.26 If automated decision support was utilized among the 37 million hospital 

admissions in the United States in 2005, facilities across the country would stand 

to save almost $20 billion a year. 

Finally, limited Federal leadership has contributed to uneven application of quality improvement initiatives and widespread variance in health outcomes. To date, 

Federal leaders have not clearly identified national priorities and targets for improvement, and have not implemented a Federal system for monitoring and reporting performance on those metrics. Similarly, no Federal all-payer database exists for 

patients who want to know, for example, the survival and complication rate of their 

surgeon. In the United Kingdom, this type of information is available through the 

Internet.27 The U.S. Federal Government is not currently funding comparative effecVerDate Nov 24 2008 13:47 Dec 03, 2010 Jkt 035165 PO 00000 Frm 00033 Fmt 6633 Sfmt 6621 S:\DOCS\47121.TXT DENISE
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28 Institute of Medicine, To Err is Human: Building a Safer Health System, (Washington: National Academy Press, 2000); J. Corrigan, et al., Crossing the Quality Chasm: A New Health System for the 21st Century, (Washington: National Academy Press, 2001). 29K. Kuhmerker and T. Hartman, Pay-for-Performance in State Medicaid Programs: A Survey 

of State Medicaid Directors and Programs, (New York: The Commonwealth Fund, April 2007). 30S. Guterman and M.P. Serber, Enhancing Value in Medicare: Demonstrations and Other 

Initiatives to Improve the Program, (New York: The Commonwealth Fund, January 2007). 

tiveness research and has not created a national institute to synthesize research, 

inform benefit design, and guide clinical practice. Such steps have been crucial in 

value-based purchasing and performance improvement initiatives in other industrialized countries. 

III. OPPORTUNITIES AND PROGRESS

We are fortunate that within our imperfect health care system are examples of 

all the components that, properly organized, reformed, and financed, can enable the 

Nation to provide high-quality, affordable care to every American. Systematically 

applying and disseminating what we know works would help put the United States 

on the path to a high-performance health system. 

Several ongoing quality improvement initiatives are contributing to improving 

performance in hospitals, physician practices, health plans, and public programs in 

the United States. Over the last 15 years, The Commonwealth Fund has been 

pleased to support, assess, and disseminate information on a number of efforts to 

improve quality. It is impossible to give a comprehensive catalog of these efforts, 

here, but I would like to highlight just a few to give the committee a sense of the 

richness of activities underway. 

• Public Awareness. The Institute of Medicine launched the modern quality 

movement with its report, To Err is Human followed by its report on The Quality 

Chasm.28

• Measurement of Quality. The National Center for Quality Assurance has 

been a leader in the development of measures of quality, beginning with a HEDIS 

set of clinical quality measures, collected and made available at the health plan 

level. The Agency for HealthCare Quality and Research has added measures of patient experiences with care (CAHPS) to the quality measurement toolkit. Specialty 

and professional societies have also contributed substantially to the development of 

an armamentarium of quality measures. 

• Endorsement of Measures. The National Quality Forum has brought an overarching framework to quality measurement through its endorsement of measures 

with rigorous standards and its process for expert input. 

• Public Reporting. The Congress accelerated public reporting of quality information by giving the Medicare program authority to base payment on reporting 

quality data by hospitals, and more recently by physicians. The National Center for 

Quality Assurance reports on health plan performance on HEDIS clinical quality 

measures and patient experiences with care (CAHPS). Its annual state of the Nation’s Health report is a valuable source of information on quality of care provided 

to health plan enrollees, including those in commercial, Medicare, and Medicaid 

health plans. State and regional collaboratives have also led in generating publicly 

available data on provider performance to be used for three purposes: provider quality improvement, patient choice, and payer rewards. 

• Quality Improvement. The Institute for HealthCare Improvement has pioneered efforts to improve quality of care through national campaigns and quality 

improvement breakthrough series. The Medicare Quality Improvement Organizations have provided technical assistance and support to hospitals, physician practices, and nursing homes to improve quality of care. The Commonwealth Fund is 

striving to make data and tools useful to quality improvement efforts within hospitals available through its WhyNotTheBest.org Website. 

• Pay for Performance. The Leapfrog Group initiated the first major purchaser 

effort to reward hospitals and other providers who met high standards of quality, 

and maintains a comprehensive inventory of pay-for-performance initiatives. The Integrated Healthcare Association (IHA) is a statewide leadership group that promotes quality improvement, accountability, and affordability of health care in California, including instituting a system of pay-for-performance to reward medical 

groups for improving quality, patient experiences, and adoption of health information technology. More than half of State Medicaid programs have elements of paying 

for performance.29 Medicare demonstrations including the Hospital Quality Demonstration Initiative and the Physician Group Practice demonstration have implemented and assessed the impact of financial incentives to improve quality.30

31 

31 R. Paulus, ‘‘Continuous Innovation,’’ Ibid. 32 R. Nuzum, D. McCarthy, A. Gauthier, and C. Beck, Denver Health: A High-Performance 

Public Health Care System, (New York: The Commonwealth Fund, July 2007). 

As a result of these and many other activities, we have made extraordinary 

progress over the last decade in learning about and improving quality. As noted 

above, these efforts have borne fruit in improved quality on selected aspects of care 

that have been the focus of improvement efforts—such as reduced hospital standardized mortality rates which were the focus of the IHI 100,000 Lives Campaign; improved control of chronic conditions which have been reported at the health plan 

level by NCQA for over a decade; and the Medicare-reported hospital quality measures for heart attacks, congestive heart failure, and pneumonia. 

Yet, wide variation in quality and efficiency across States, hospital service areas, 

and providers persists. Nor is there a systematic all-patient data base that contains 

the information that would help patients make informed choices. For example, a patient who wants to know the cancer survival rate of cancer centers across the 

United States for his or her form of cancer has no data base to which to turn. A 

patient who wants to know the survival and complication rates of their surgeon before surgery compared to other surgeons, has no place to turn in most parts of the 

United States. 

Nonetheless, insight into what it takes to achieve high performance is provided 

by examples of excellence within the United States and around the world. I’d like 

to highlight some specific examples that point the way to give the committee a flavor of the innovation that is currently going on. This includes a description of what 

two health care systems in the United States—Geisinger Health System and Denver 

Health—are doing to achieve high performance; followed by the activities of Iowa 

and Vermont, two States that score well on the Commonwealth Fund State scorecard; two regional collaboratives which report quality data and work with providers 

to improve performance—the Massachusetts Health Quality Partners and the Wisconsin Collaborative for Healthcare Quality; and finally health system innovations 

in the Netherlands and Denmark. 

Geisinger Health System and Denver Health 

The Geisinger Health System, on whose board I am pleased to serve, is a leader 

in innovation and quality improvement—contributing to its ranking in this year’s 

NCQA State of the Nation’s Health report in the top five health plans in the Nation 

and top three participating in Medicare. In a September 2008 article in the health 

policy journal, Health Affairs, Geisinger CEO Glenn Steele, M.D., chief innovation 

officer, Ron Paulus, M.D., and I summarized how Geisinger achieves continuous innovation in health care.31 Geisinger is an integrated delivery system in northeastern Pennsylvania with clinical leadership that focuses on value creation, measures innovation returns, and is appropriately rewarded in the market both because 

it has its own Medicare Advantage plan and because it is participating in the Medicare physician group practice demonstration for Medicare patients not enrolled in 

plans. Its pilot test of patient-centered medical homes in two primary care group 

practice sites has reduced hospital admissions of Medicare patients by 20 percent. 

Its erythropoietin pharmacist-driven care management model for anemia associated 

with chronic kidney disease resulted in $3,800/patient/year in drug cost savings. It 

has redesigned its care process for coronary artery bypass graft surgery (‘‘CABG’’) 

to provide ‘‘proven care’’ and offered insurers a global fee with a ‘‘warranty.’’ 

Geisinger’s mission, dedicated innovation and quality improvement units, electronic health information system, and alignment of financial incentives through its 

own health plan contribute to its record of innovation. Its innovation experience has 

three implications for national policy: (1) aligning incentives to reward enhanced 

healthcare value creation; (2) recognizing that electronic health records are absolutely necessary, but not sufficient to create sustainable change in care delivery; and 

(3) creating policies that encourage greater organization of care delivery and collaboration among payers and providers to foster propagation of innovation that enhances value. 

Denver Health, a comprehensive and integrated medical system that is Colorado’s 

largest health care safety-net provider, has a national reputation as a high-performance organization. Members of The Commonwealth Fund Commission on a High 

Performance Health System observed Denver Health during a site visit in March 

2006, to assess its operation and determine whether it might serve as a model for 

other public and private health care systems around the country.32 The Commission 

concluded that Denver Health is indeed a ‘‘learning laboratory.’’ It has succeeded 

at providing coordinated care to the community, promoting a culture of continuous 

quality improvement, adopting new technology and incorporating it into everyday 

32 

33 J.C. Cantor, C. Schoen, D. Belloff, S.K.H. How, and D. McCarthy, Aiming Higher: Results 

from a State Scorecard on Health System Performance, (New York: The Commonwealth Fund, 

June 2007). 

practice, taking risks and making mid-course corrections, and providing leadership 

and support to its staff. 

Since 2003, Denver Health has transformed itself and created a culture of deliberate improvement. As a result, the organization adopted specific new processes and 

tools. For example, it systematically applied the principles of ‘‘lean manufacturing’’ 

based on Toyota’s approach to streamlining its operations and eliminating waste. 

Denver Health has also focused on building its infrastructure for high performance 

in two important areas: information technology (IT) and workforce. The organization’s investment in health-oriented IT, which has totaled $275 million since 1997, 

has enabled the establishment of a centralized data warehouse that integrates both 

clinical and financial data and allows for standardized reporting. A single imaged 

electronic-record format is used across the entire system so that a patient’s information can be retrieved in ‘‘real time’’ by any of his or her providers. To ensure that 

it has a capable workforce, Denver Health has restructured its hiring practices to 

recruit and retain the ‘‘right people.’’ 

While there are many factors contributing to the overall high quality of care that 

Denver Health provides to its patients, the Commission highlighted several: 

• Denver Health is an integrated system, endowed with appropriate tools including an electronic information system and infrastructure to provide coordinated care 

to the community. 

• It has its own Medicaid-managed care plan, and State officials have been supportive of policies that permit it to use surpluses from its plan to provide care to 

a large uninsured and indigent patient population. 

• Denver Health promotes a culture of improvement, peopled by dedicated staff. 

The decisions are data-driven and feedback loops allow for continuous quality improvement. Innovation at Denver Health has strong support at the top. 

Geisinger Health System and Denver Health differ in major respects: one is a 

nonprofit integrated delivery system in a rural area with a disproportionate concentration of elderly Medicare patients; the other is a public integrated delivery system in a large metropolitan area with a disproportionate concentration of lowincome uninsured and Medicaid patients. But both receive at least a portion of their 

revenues on a ‘‘bundled’’ capitated rate per person enrolled and their public/nonprofit, mission-driven organization leads them to dedicate surpluses gained from 

eliminating waste and preventing avoidable complications to improving care. They 

both have invested extensively in health information systems. They have dedicated 

innovation and quality improvement units that lead the organizations in continuous 

innovation and improvement. They are led by clinician leaders with a commitment 

to excellence in patient care, while maintaining fiscal stability of the organization. 

Iowa and Vermont 

In June 2007 the Commonwealth Fund Commission on a High Performance 

Health System released a State scorecard on health system performance.33 This was 

followed in May 2008 with a child health State scorecard on health system performance. There was wide variation across States on health outcomes, quality, access, 

equity, and cost. Iowa ranked first on performance of its health system for children 

and second on the overall State scorecard. Vermont was second on the children’s 

health scorecard and fourth on the overall scorecard. 

Many factors help explain why these States stand out. Both have high rates of 

health insurance coverage as a result of State Medicaid and SCHIP policies. They 

rank highly on children and adults cared for in patient-centered medical homes. 

Both have medical schools with an emphasis on training primary care physicians. 

And both have a long history of collaboration to promote quality. Both have public 

health departments that are strongly linked to their communities and that have a 

mission to serve communities. In both States, public health partners well with Medicaid and with the private sector, especially in terms of outreach to pregnant women 

and young children. 

Iowa has a longstanding commitment to children. In the past decade, the State 

paid particular attention to the needs of its youngest residents, from birth to age 

5. After piloting a variety of early childhood preventive programs in the early 1990s 

to identify and serve at-risk children and families, the Iowa Legislature established 

a statewide initiative to fund designated ‘‘local empowerment areas’’ across the 

State to create local partnerships among clinicians, parents, child care representatives, and educators focused on preventive services. The University of Iowa and a 

33 

34 Iowa Healthcare Collaborative, 2008 Annual Report, (Des Moines: Iowa Healthcare Collaborative, 2008). 35M.W. Friedberg, D.G. Safran, K.L. Coltin, et al., ‘‘Readiness for the Patient-Centered Medical Home: Structural Capabilities of Massachusetts Primary Care Practices,’’ Journal of General Internal Medicine, published online December 3, 2008. 36http://www.mhqp.org. 

substantial portion of practices in the State have all voluntarily adopted the same 

EMR system, which is streamlining referral processes. 

The Iowa Healthcare Collaborative (IHC) has also been a key means through 

which the State’s healthcare community has come together to improve quality, patient safety, and the value of health care.34 By focusing on transparency and accountability, sharing performance information and best practices among both health 

care providers and the general public, the IHC has driven important progress in 

clinical improvement and empowered patients and families across the State. The 

collaborative has actively facilitated gains in efficiency by distributing the tools and 

principles of the Toyota Production System, better known as ‘‘Lean,’’ on its Website. 

The group also serves as the Iowa field office, or ‘‘node,’’ for IHI’s 5 million lives 

campaign to reduce incidents of medical harm. Further quality improvement efforts 

include medical home initiatives, establishment of a community advisory council, reduction of healthcare-associated infections, and support of rapid response teams. 

The Vermont legislature, in collaboration with public health, Medicaid and the 

private sector developed a blueprint for health care in Vermont. It builds on the 

Wagner chronic care model, using measurement and direct support to practices. 

They have bought into the medical home idea using NCQA criteria. The State is 

trying to use payment reform to drive quality, and is encouraging adoption of EMR 

and supporting outreach to help practices implement changes in their micro-processes (appointments, handling messages, tracking laboratory results, creating registries). Also, Medicaid and the health plans have agreed on common measures of 

quality, which helps the practices focus on a few things, rather than responding to 

multiple different expectations. 

Vermont also has long placed a high priority on children. In 1989, the State enacted the Dr. Dynasaur program, which expanded health insurance coverage to children up to age 17 in families earning less than 225 percent of the Federal poverty 

level, as well as pregnant women in families earning less than 200 percent of poverty. 

In 2006, Vermont expanded SCHIP income eligibility levels for children in families with incomes up to 300 percent of the Federal poverty level. Vermont is also 

home to the Vermont Child Health Improvement Project (VCHIP), a regional partnership of professional society chapters; the Department of Public Health; the 

State’s Medicaid agency; the University of Vermont’s Department of Pediatrics faculty; the Banking, Insurance, Securities and Health Care Administration; and three 

Vermont-managed care organizations. These public and private partners use measurement-based efforts and a systems approach to improve the quality of children’s 

health care. VCHIP shares lessons learned and other findings with public health 

agencies and policymakers to inform decisionmaking, enhance services, and target 

resources. Disease management programs are also being introduced into public insurance plans. 

Massachusetts Health Quality Partners and Wisconsin Collaborative for Healthcare 

Quality 

Commonwealth Fund-sponsored work shows that open sharing of quality performance data through public reporting can be effective as an impetus to quality improvement. Massachusetts Health Quality Partners has been a leader in collecting 

and disseminating quality data on hospitals and physician groups, and educating 

providers and patients to use that information to facilitate quality improvement activities.35 Formed in 1995, Massachusetts Health Quality Partners (MHQP) pioneered the collection and public release of data on patient experiences with hospital 

care. In the mid-2000s it collected information from the State’s five largest private 

health plans on the quality of care provided by 150 medical groups on 15 measures 

of clinical quality developed by the National Committee on Quality Assurance (the 

Health Plan Employer Data and Information Set, or HEDIS). The coalition then 

posted this data in 2006 on its Website to encourage consumers to search for highquality providers and guide physicians looking to improve their performance.36 It 

followed with data on patient experiences with physician care at the medical group 

level. 

The Wisconsin Collaborative for Healthcare Quality (WCHQ), founded in 2003, involves physician groups, hospitals, health plans, employers, and labor organizations 

34 

37 A.L. Greer, Embracing Accountability: Physician Leadership, Public Reporting, and Teamwork in the Wisconsin Collaborative for Healthcare Quality, (New York: The Commonwealth 

Fund, June 2008). 38http://wchq.org/Reporting/. 39 C. Schoen, R. Osborn, S.K.H. How, M.M. Doty, and J. Peugh, ‘‘In Chronic Condition: Experiences of Patients with Complex Health Care Needs, in Eight Countries, 2008,’’ Health Affairs, 

January/February 2009; 28(1): w1–w16. 40 I. Johansen, ‘‘What Makes a High Performance Health Care System and How Do We Get 

There? Denmark,’’ Presentation to the Commonwealth Fund International Symposium, November 3, 2006. 

that want to enhance transparency and promote quality in the health care system.37

WCHQ publicly reports comparative information on its member physician practices, 

hospitals, and health plans through an interactive Web-based tool.38 The WCHQ 

has earned credibility among health care providers because the measures are reported in ways that allow member groups to identify variation by physician practice 

and target areas for improvement. WCHQ also developed and unveiled a quadrant 

analysis to demonstrate the relationship between quality outcomes and risk-adjusted charges. This innovative approach to quantifying the value each member hospital provides when caring for patients with specific conditions was developed in response to the business community’s desire for a more sophisticated measure of a 

hospital’s efficiency. 

Netherlands and Denmark 

A Commonwealth Fund survey of chronically ill adults in eight countries found 

that the Netherlands consistently outperformed other countries, while the United 

States typically fared worst.39 The Dutch had the highest satisfaction with their 

health system, the best access to needed care, the longest relationship with a regular doctor, the easiest time getting a same-day appointment with their doctor, the 

least difficulty getting care on nights and weekends, the best care coordination and 

least duplicate tests or missing records, and the lowest reported rates of medical errors—while the United States fared worst on all these measures. 

The Netherlands has historically had a strong primary care system that requires 

primary care referrals for specialized care. They have an organized system of offhours care. Over 90 percent of primary care physicians have electronic medical 

records. Peer physicians visit and audit each others’ practices every 3 years. They 

have an advanced system of public reporting of quality. 

Denmark also places great emphasis on patient-centered primary care, which is 

highly accessible and has an outstanding information system that assists primary 

care physicians in coordinating care. Denmark, like most European countries, has 

a universal health insurance system with no patient cost-sharing for physician or 

hospital services. Every Dane selects a primary care physician who receives a 

monthly payment per patient for serving as the patient’s medical home, in addition 

to fees for services provided. Incomes of primary care physicians are slightly higher 

than those of specialists, who are salaried and employed by hospitals. Patients can 

easily obtain care on the same day if they are sick or need medical attention, and 

an organized ‘‘off-hours service’’ provides telephone consultations (for which they are 

paid a fee) and clinic services on nights and weekends. The patient’s own primary 

care physician receives an e-mail the next day with a record of the off-hours consultation. 

All primary care physicians (except a few near retirement) are required to have 

an electronic medical record system, and 98 percent do. Danish physicians are now 

paid about $8 for e-mail consultations with patients, a service that is growing rapidly. The easy accessibility of physician advice by phone or e-mail, and electronic 

systems for prescriptions and refills cuts down markedly on both physician time and 

patient time. Primary care physicians save an estimated 50 minutes a day from information systems that simplify their tasks, a return that easily justifies their investment in a practice information technology system.40

Primary care physicians prescribe electronically and information systems provide 

information at the point of prescribing on the lowest cost drug available in a given 

class. Patients pay the difference if physicians prescribe a more expensive drug. 

Drug prices are updated automatically every 2 weeks in physician and pharmacy 

electronic information systems. 

In many ways what the Netherlands and Denmark have done is not remarkable— 

they emphasize primary care and patients are enrolled with a physician and typically maintain that relationship over a long period of time. Primary care physicians 

are paid well, they have reasonable working hours since they are supported by offhours systems of care on nights and weekends, and they have information systems 

that make it possible for them to provide highly coordinated care. They are comVerDate Nov 24 2008 13:47 Dec 03, 2010 Jkt 035165 PO 00000 Frm 00038 Fmt 6633 Sfmt 6621 S:\DOCS\47121.TXT DENISE
35 

mitted to providing the best quality care for the resources available. Yet, they spend 

less than half per capita what the United States spends. The United States has 

made other choices—a payment system that rewards highly specialized care and 

procedures, financial barriers that deter patients from seeking care or filling prescriptions written by their physicians to manage their conditions, no organized system of care on nights and weekends other than emergency rooms, lack of investment 

in health information technology, and inadequate commitment to transparency and 

quality improvement. 

IV. POLICY SOLUTIONS

Health care reform is a unique opportunity to transform the U.S. health care system. The Commonwealth Fund Commission on a High Performance Health System 

has identified five strategies for improving access, quality, and efficiency: 

• Provide affordable health coverage for all. The most important factor determining the ability to obtain health care is adequate health insurance coverage. The 

uninsured are much less likely to obtain preventive care. They are much less likely 

to fill prescriptions and to have their chronic conditions controlled, with the consequence that opportunities are missed to save lives and prevent disability. In Commonwealth Fund international surveys, the United States stands out for reported 

difficulties obtaining needed care. It is time that all Americans receive the security 

of health care coverage enjoyed by citizens of every other major industrialized country. Providing everyone—regardless of age or employment status—with affordable 

insurance options, including a comprehensive package of benefits, will enhance access to care. This, in turn, will help reduce disparities in care, increase the proportion of people receiving appropriate primary care to prevent illness, and improve the 

care and health of millions of Americans living with chronic conditions. • Reform provider payment. Our open-ended fee-for-service payment system must 

be overhauled to reduce wasteful and ineffective care and to spur innovations that 

can save lives and increase the value of our health care dollars. We need to revamp 

our system for paying health care providers—reform that will reward high-quality 

care and prudent stewardship of resources, move toward shared provider accountability for the total care of patients, and correct the imbalance in payment whereby 

specialty care is rewarded more than primary or preventive care. • Organize our care delivery systems. We need to reorganize the delivery of care, 

moving from our current fragmented system to one where physicians and other care 

providers are rewarded for banding together into integrated or virtual organizations 

capable of delivering 21st-century health care. Patients need to have easy access to 

appropriate care and treatment information, and providers need to be responsive to 

the needs of all their patients. Providers must also collaborate in delivering highquality, high-value care, and they should receive the support needed for continuous 

improvement. Community health centers—a major source of care in many lowincome communities—should be assisted in meeting the standards of patient-centered medical homes. 

• Invest in a modern health system. The United States lags behind other countries 

in the adoption of health information technology and a system of health information 

exchange. In such a system, patient information would be available to all providers 

at the point of care, as well as to patients themselves through electronic health 

record systems, helping to ensure that care is well coordinated. Early investment 

in the infrastructure of a high performance health system—including information 

technology, research on comparative effectiveness of drugs, devices, and procedures, 

data on provider performance on quality and affordability, and a workforce that ensures a team approach to care—is an essential building block. 

• Ensure strong national leadership. None of the above will be possible if government does not take the lead. The Federal Government—the Nation’s largest purchaser of health care services—has tremendous leverage to effect changes in coverage, care delivery, and payment. National leadership can encourage the collaboration and coordination among private-sector leaders and government officials that are 

necessary to set and achieve national goals for a high performance health system. 

It can also help set priorities and targets for improvement, create a system for monitoring and reporting on performance 

INFORMATION TECHNOLOGY

Congress has already begun to make important investments in the infrastructure 

required to improve quality and efficiency in consideration of the economic stimulus 

package. While some have questioned whether information technology will generate 

significant health system savings, The Commonwealth Fund report, Bending the 

Curve, put the aggregate systemwide savings of promoting health information techVerDate Nov 24 2008 13:47 Dec 03, 2010 Jkt 035165 PO 00000 Frm 00039 Fmt 6633 Sfmt 6621 S:\DOCS\47121.TXT DENISE
36 

41 C. Schoen, S. Guterman, A. Shih, J. Lau, S. Kasimow, A. Gauthier, and K. Davis, Bending 

the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending, (New 

York: The Commonwealth Fund, December 2007). 42 R. Amarasingham, ‘‘Clinical Information Technologies,’’ Ibid. 43 A.C. Beal, M.M. Doty, S.E. Hernandez, K.K. Shea, and K. Davis, Closing the Divide: How 

Medical Homes Promote Equity in Health Care: Results From The Commonwealth Fund 2006 

Health Care Quality Survey, (New York: The Commonwealth Fund, June 2007). 

nology at $88 billion over 10 years.41 The authors estimated that the cost reductions 

would result from a lower rate of medical errors, more efficient use of diagnostic 

testing, more effective drug utilization, and decreased provider costs, among other 

improvements. Additional savings would likely flow from better care coordination 

among multiple providers—and improved chronic care management—that would 

lead to a decrease in provider utilization and better health outcomes. Financial benefits accrue to all payers, with investments in health IT estimated to result in substantial cumulative net savings to all levels of government and households over 10 

years and cumulative savings to private insurers after 11 years. 

A recent Commonwealth Fund-sponsored study of health IT in Texas hospitals led 

by Ruben Amarasingham of the University of Texas Southwestern Medical Center 

has shown that hospitals with more advanced information technology capacity have 

fewer complications and decreased mortality rates.42 Amarasingham and his colleagues’ findings importantly show that utilizing IT to automate test results, order 

entry, and decision support was not only associated with better quality but also 

lower average adjusted costs for hospital admissions and lower mean hospital costs 

for a variety of clinical conditions, including heart failure and coronary artery bypass grafting. Computerized decision support was particularly effective at generating savings. Higher degrees of decision support automation was associated with 

lower average adjusted costs of $538 for all conditions. If these reductions were realized among the 37 million hospital admissions in the United States in 2005, hospitals across the country would stand to save almost $20 billion a year. 

Modern health care also requires replacing antiquated paper-based medical 

records with systems that take advantage of modern health information technology. 

Medicare can do its share by joining with private payers in contributing funds to 

help those who cannot afford to purchase such technology on their own—especially 

safety-net clinics and hospitals serving uninsured and low-income patients. It can 

also create incentives for the adoption of information systems meeting approved 

standards, and help establish ‘‘health information networks’’ that allow patients and 

the health professionals that care for them to have all relevant medical information 

available at their fingertips. While such a change requires upfront investment, it 

would begin to pay dividends in the future. 

PRIMARY CARE

If the United States is serious about closing the quality chasm, it will need to 

build a strong primary care system. This will require fundamental provider payment 

reform, encouraging all patients to enroll with a patient-centered medical home that 

is accessible and accountable for patient outcomes, and supporting those physician 

practices with information technology and technical assistance in care process design to improve quality and reliability of care. 

One important place to start is to ensure that all the Nation’s community health 

centers meet the standards of a patient-centered medical home, and have the information tools and technical assistance necessary to reach benchmark levels of quality. Work by staff at the Commonwealth Fund has found that racial/ethnic disparities in access to needed care can be eliminated if patients are enrolled in such systems of care.43

COMPARATIVE EFFECTIVENESS

Medicare, Medicaid, and private insurers can also ensure that the care they cover 

is based on the best and latest research findings on effectiveness. Insurers should 

cover all medications, devices, and procedures that have been scientifically shown 

to improve patient outcomes and quality of life. But insurers also should be prudent 

purchasers, paying no more for a device or treatment than they would for another 

that is equally effective. The Bending the Curve report estimates that a center on 

medical effectiveness and health care decisionmaking could save $368 billion over 

10 years, if insurance benefit design and payment were tied to evidence on costeffectiveness. 

37 

HEALTH GOALS AND TARGETS FOR IMPROVEMENT

The Federal Government can also raise the bar for health system performance 

and help providers get the tools they need to reach the highest attainable levels of 

performance. This should start with setting explicit goals and priorities for improvement—including a focus on the most prevalent chronic conditions, which account for 

a large majority of health care costs. 

For example, Medicare could join with private insurers and other payers to develop a database that lets providers and the public know how they are doing relative to what is possible. Having reliable comparative data, adjusted for differences 

in patient characteristics, is the first step along the path to improvement. Such a 

database should provide timely feedback on how each and every provider—whether 

health system, hospital, physician, or long-term care facility—is doing on quality 

and health outcome metrics that are tied to achievable benchmarks. The Commonwealth Fund is helping to support such a tool through its WhyNotTheBest.org 

Website with data and tools to improve hospital clinical quality and patients’ experiences. 

In sum, experience shows that policies to alleviate the quality chasm and improve 

the performance of our health care system must be multifaceted and mutually reinforcing. Work by the Commonwealth Fund demonstrates that it is not only possible—but critical—to employ strategies that simultaneously improve quality, reduce 

costs, and increase access for all Americans. 

Armed with the knowledge that the status quo is no longer acceptable, we have 

entered a new era ripe with opportunity to close the quality chasm and improve the 

health and well-being of American families. Working together we can change 

course—and move the U.S. health system on a path to high performance. 


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Senator MIKULSKI. Wow, all that in 5 minutes. 

Ms. Davenport-Ennis. 


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66 

STATEMENT OF NANCY DAVENPORT-ENNIS, CEO, NATIONAL 

PATIENT ADVOCATE FOUNDATION, WASHINGTON, DC 

Ms. DAVENPORT-ENNIS. Thank you, Madam Chairwoman, for the 

opportunity to be with you today. Thank you, members of the 

panel. 

I am Nancy Davenport-Ennis, and I am the founder of the National Patient Advocate Foundation, which is a policy organization 

whose mission is to try to remove and work with legislators and 

regulators to inform and improve healthcare access in America. 

Our heart lives in Patient Advocate Foundation, founded at the 

same time, that provides direct patient services to patients in each 

of the 50 States in the United States. 

My testimony is grounded in more than 12 years of documentation across more than 350,000 closed patient cases, reporting the 

concrete gaps and failures in our current healthcare delivery systems. 

I would like to share that my testimony today will focus on how 

the use of three specific tools, we feel, could help to improve the 

level of quality care that patients receive in our healthcare system 

and lead to improved outcomes and better coordinated care for patients. 

They are health information technology, widespread use and 

adoption of medical guidelines across all disease areas, and comparative effectiveness research. 

In the area of health information technology, it is known to reduce medical errors and to improve patient safety. However, only 

25 percent of healthcare providers in the United States today, as 

reported in a study released in January, are currently using health 

information technology. In other countries, such as the United 

Kingdom and Australia, adoption is at about 75 percent. 

In 2006, one-third of patients reported a medical, medication, or 

laboratory error during the previous 2 years. These errors resulted 

in the unnecessary deaths of nearly 100,000 patients annually, as 

reported by the Commonwealth Fund. 

NPAF does support health IT funding in the stimulus and believes that it should be available to all providers regardless of practice size. We are pleased that today we do have, through the Certification Commission for Healthcare Information, 55 electronic 

health records that have been certified. 

There is no better example of how health information technology 

can benefit patients than a story of a 13-year-old patient whose 

parents reached out to us. The child had terrific headaches and uncontrollable vomiting. When she went to her primary care physician, after X-rays and several tests, they could not determine what 

the problem was with the child. 

They electronically transmitted her records to a specialist in a 

nearby city, where there was a research center. And within hours, 

the records were reviewed, and the child was scheduled to be there 

the next morning. The child was diagnosed with Chiari syndrome. 

We also feel that medical guidelines afford some degree of consistency in care that can be delivered routinely and uniformly. 

Within the cancer community, guidelines are fairly routine. The 

guidelines are developed by panels of experts, and these guidelines 

provide us some system to know that when a treating physician, 

67 

1 Boosting Cancer Trial Participation. National Cancer Institute, February 2006. 

perhaps in a smaller community, is deciding what is the best 

course of care, the guideline can give them recommendation. 

We would also like to say that guidelines provide a process 

through which these treatments have been well vetted. We feel 

that medical guidelines are based upon clinical trials’ research. A 

story of a 45-year-old patient who came to us with a disease that 

had been diagnosed as incurable. We enrolled her in a clinical trial 

at the National Institutes of Health. Today, Mary Schwartz is disease free 31⁄2 years after being told that she had approximately 6 

years to live. 

This clinical trial information also, we feel, is what is going to 

drive the comparative effectiveness research in the United States 

of America. We strongly support comparative effectiveness research 

and would ask that the panel join us in supporting clinical focus 

in that area. 

We are pleased to take additional questions. 

Thank you, Madam Chairperson and members of the panel. 

[The prepared statement of Ms. Davenport-Ennis follows:] 

PREPARED STATEMENT OF NANCY DAVENPORT-ENNIS

SUMMARY

National Patient Advocate Foundation believes our healthcare system should 

incent quality and promote transparency to encourage patients to be better purchasers of health care. The use of health information technology, medical guidelines, 

clinical trials, and comparative effectiveness research are tools that should be utilized to help improve the level of quality care Americans receive in our health care 

system. 

Quality healthcare coverage leads to improved outcomes and better coordinated 

care for patients. One tool that has proven valuable to patients and providers is 

health information technology. In the United States, the Veterans Administration 

(VA) leads in complete adoption of health information technology (HIT); however, 

only 10–30 percent of U.S. primary care providers utilize electronic medical records. 

The IOM report, Crossing the Quality Chasm, explains that re-designing the 

health care delivery system will require many changes. One of which, applying evidence to health care delivery, can be partially addressed with adoption of proven 

medical guidelines such as those developed by the National Comprehensive Cancer 

Network (NCCN). 

Clinical research has improved the treatment of various diseases and has helped 

doctors make well-informed decisions about what particular therapy is best for their 

patients. In cancer, clinical trial research has vastly improved survival rates for 

many cancers and led to improved cancer care. However, according to the National 

Cancer Institute, less than 5 percent of adults diagnosed with cancer annually enroll in a clinical trial.1 Broader enrollment in cancer clinical trials will enable researchers to discover new and better ways to treat and prevent cancer leading to 

higher quality cancer care for patients. 

National Patient Advocate Foundation supports comparative effectiveness research to determine the comparative clinical effectiveness of various treatment options for those with chronic and debilitating diseases. However, it is our belief that 

using comparative effectiveness research findings to limit access, deny treatment or 

reimbursement will not benefit patients or our healthcare system as a whole. Onesize-fits-all will not help us achieve a high quality healthcare system since we know 

that patients can have very different reactions to certain medications or therapies. 

National Patient Advocate Foundation supports the IOM report’s premise that 

‘‘narrowing the quality chasm will make it possible to bring the benefits of medical 

science and technology to all Americans in every community, and this in turn will 

mean less pain and suffering, less disability, greater longevity, and a more productive workforce.’’ 

68 

1 R Atkinson, D Castro & S Ezell. The Digital Road to Recovery: A Stimulus Plan to Create 

Jobs, Boost Productivity and Revitalize America. The Information Technology & Innovation 

Foundation, January 2009. 2Why Not the Best? Results from the National Scorecard on U.S. Health System Performance. 

The Commonwealth Fund Commission on a High Performance Health System, July 2008. 3The Commonwealth Fund Commission on a High Performance Health System, Why Not the 

Best? Results from a National Scorecard on U.S. Health System Performance. The Commonwealth Fund, September 2006. 4 J Corrigan, L Kohn, M Donaldson, eds. To Err is Human: Building a Safer Health System. 

Committee on Quality of Health Care in America, Institute of Medicine, The National Academies Press, 1999. 5 J Corrigan, L Kohn, M Donaldson, eds. To Err is Human: Building a Safer Health System. 

Committee on Quality of Health Care in America, Institute of Medicine, The National Academies Press, 1999. 

PREPARED STATEMENT OF NANCY DAVENPORT-ENNIS

Good morning. Thank you, Mr. Chairman and members of the committee, for the 

opportunity to testify before you. My name is Nancy Davenport-Ennis, and I am the 

Founder of the National Patient Advocate Foundation and the Patient Advocate 

Foundation. National Patient Advocate Foundation is a policy organization based in 

Washington, DC that is dedicated to providing the patient’s voice in order to improve access to health care at the Federal and State levels. Patient Advocate Foundation is a direct patient services organization which provides case management 

services to patients throughout the country seeking information and assistance for 

access to care issues resulting from a diagnosis of a chronic, debilitating or lifethreatening disease. My testimony is grounded in more than 12 years of documentation across 300,000 closed patient cases reporting the concrete gaps and failures in 

our current healthcare delivery and financing systems. 

When the Institute of Medicine published their report, ‘‘Crossing the Quality 

Chasm: A New Health System for the 21st Century,’’ back in March 2001, the hope 

was that doctors, elected officials and patients would demand that we fix our payment policies which have been reimbursing for unnecessary and ineffective care, 

adopt electronic medical records to help coordinate care in our complex healthcare 

system, and provide doctors with independent clinical research to help guide them 

when prescribing a treatment protocol. Unfortunately, almost 8 years have passed 

and progress is moving very slowly. In health information technology, only 10–30 

percent of primary care providers utilize electronic medical records (EMRs). In other 

countries, such as the United Kingdom and Australia, adoption is around 75 percent.1 In terms of treatment guidelines, while we have very specific and notable 

guidelines in cancer, that is not the case for many other chronic diseases in the 

country where we still lack good scientific and evidence-based research to guide 

many clinical diagnoses. There are gaps in the utilization of treatment guidelines 

and in the availability of guidelines for specific patient and/or disease populations, 

such as the pediatric population. These gaps impact all healthcare stakeholders, including the patients I am here to represent. 

Even though the United States spends 16 percent of GDP on healthcare, which 

is more than any other industrialized country, there is significant evidence that the 

quality of medical care trails other developed nations. The United States continues 

to fall behind other industrialized countries when comparing various dimensions of 

health system performance including: healthy lives, quality, access, efficiency, and 

equity. In The Commonwealth Fund’s National Scorecard on U.S. Health System 

Performance, the United States achieved an overall score of 65 out of 100. Compared to 19 countries, the United States now ranks last on a measure of mortality 

amenable to medical care. However, the report did show that hospitals are showing 

‘‘measureable improvement on basic treatment guidelines for which data are collected and reported nationally on Federal Websites.’’2

Our system often reimburses for services independent of quality measurements. 

Currently, many providers lack incentive to promote and prescribe preventive care 

for their patients. Addressing these systemic reimbursement issues could greatly 

improve the quality of medical care patients receive. NPAF recommends we undertake reimbursement reform and include direct processes to incent providers to provide quality care. 

In 2006, a study by The Commonwealth Fund found that one-third of patients reported a medical, medication or laboratory error during the previous 2 years.3 These 

errors result in the unnecessary deaths of nearly 100,000 patients annually.4 In addition to the deaths that medical errors impose, the total financial cost of preventable adverse events, including lost income, lost household functioning, disability, 

etc., are estimated to be $35 billion a year.5

69 

The Agency for Healthcare Research and Quality (AHRQ) estimates that treating 

the Nation’s 10 most expensive medical conditions cost nearly $500 billion in 2005. 

The conditions beginning with the least expensive include: normal childbirth, back 

problems, osteoarthritis and other joint diseases, diabetes (type 1 & 2), hypertension, asthma and chronic obstructive pulmonary disease (COPD), mental disorders including depression, cancer, trauma disorders, and heart disease. Many of 

them—including cancer, heart disease and diabetes—are common, chronic conditions that may be reduced and in some instances prevented. Promoting and rewarding high-quality health care will help reduce unnecessary healthcare spending as we 

move away from acute, episodic care needs and towards disease prevention and 

management. 

Transforming our healthcare system into a system that incents high-quality 

healthcare services is a long-term initiative, but there are steps we can take now 

to improve the care patients receive throughout the country. In the last 2 years, the 

World Health Organization’s (WHO) Safe Surgery Saves Lives program implemented a 19-item surgical safety checklist in eight countries to improve patient care 

and reduce complications and death associated with surgery. Similar to the checklist 

a pilot runs through before takeoff, surgeons and nurses participating in the study 

completed a series of basic safety checks before and after each operation. The study 

found that the checklist cut surgical deaths and complications by a third. Study authors say that work is already underway to develop additional checklists for maternity and childbirth, heart disease, pneumonia, HIV and mental health. This WHO 

study illustrates that something as simple as a checklist can improve quality and 

safety in our healthcare system in ways that will be of enormous benefit to patients. 

Study authors assert that few U.S. hospitals currently use these surgical safety 

checklists. While various hospitals and physicians have developed checklists, utilization needs to be more widespread in our health care system. 

National Patient Advocate Foundation believes our healthcare system should 

incent quality and promote transparency to encourage patients to be better purchasers of health care. The use of quality measures, comparative effectiveness research, medical guidelines and evidence-based medicine are tools that should be utilized to help improve the level of quality care patients receive in our healthcare system. 

Quality healthcare coverage leads to improved outcomes and better coordinated 

care for patients. One tool that has proven valuable to patients and providers is 

health information technology. In the United States, the Veterans Administration 

(VA) leads in complete adoption of health information technology (HIT). In addition, 

institutions such as the Cleveland Clinic have universally adopted HIT. The American Health Information Community, a federally chartered advisory committee, officially certified HIT systems and developed interoperability standards so that with 

financial support, such as the funding included in the economic stimulus, providers 

can adopt and use HIT thus reducing medical errors. 

The parents of a 13-year-old patient sought the assistance of Patient Advocate 

Foundation after their daughter began experiencing severe headaches that caused 

extreme pain and vomiting. Even after her pediatrician ordered X-rays and other 

tests, no diagnosis was reached. The family remained concerned, however, and after 

being provided a disc which contained all of the tests performed as well as radiology 

reports, the parents made an appointment with a pediatric neurologist. The neurologist and a pediatric radiologist, who specialize in neurological disorders, were able 

to review thoroughly the patient’s electronic medical records and all of the tests included on the disc and to diagnose the girl with Chiari Malformation, an abnormality in the lower part of the brain. The appointment with the specialists had been 

scheduled in very short order due to the immediate availability of the patient’s 

health record in an electronic format. This example illustrates how health information technology allows instant access to medical records resulting in improved patient care. 

The National Comprehensive Cancer Network (NCCN) is dedicated to improving 

the quality and effectiveness of care provided to cancer patients. Through the leadership and expertise of clinical professionals at their member institutions, NCCN 

develops clinical practice guidelines appropriate for use by patients, clinicians, and 

other healthcare decisionmakers. NCCN guidelines are considered ‘‘the gold standard’’ because they are developed by medical professionals adhering to strict standards on conflicts of interest. Our healthcare system should support and adhere to 

medical guidelines that are independently developed by skilled medical professionals 

and free from conflicts of interest. When assisting patients, case managers at Patient Advocate Foundation frequently cite medical guidelines when successfully appealing to insurance companies that have denied a particular treatment protocol. 

70 

6Patient Data Analysis Report. Patient Advocate Foundation, February 2008. 

7 University of Michigan Comprehensive Cancer Center, November 2006. 

8 Boosting Cancer Trial Participation. National Cancer Institute, February 2006. 

NCCN guidelines are practical, up to date, easily accessible online at no charge, 

and relevant to a physicians’ practice. These guidelines are developed by panels of 

unpaid, multidisciplinary experts including surgeons, nurses, patient representatives, radiation therapists, hematologists and clinical oncologists, who to date, have 

developed over 100 guidelines for therapeutic interventions covering 98 percent of 

all cancers. The guidelines specify best practices from a point of screening and diagnosis, through development of treatment plans, including all protocols selected, as 

well as maintenance and follow-up recommendations. NCCN guidelines also provide 

specific information concerning supportive care needed for patients to tolerate and 

respond favorably to therapeutic interventions. The American Society of Clinical Oncology (ASCO) has also developed guidelines specific to cancer that are focused on 

technology assessments, which evaluate the appropriate use of specific therapeutic 

interventions. 

Other disease areas, including cardiology, also develop and utilize national guidelines. Guidelines are a tool routinely used in the field of cancer by treating physicians, patients, nurses, social workers and insurers. In addition, PAF case mangers 

use guidelines frequently when assisting patients with pre-authorizations or when 

negotiating appeals. Finally, the Centers for Medicare and Medicaid Services (CMS) 

uses NCCN guidelines to make coverage determinations about the use of off-label 

drugs and biologics in cancer care as well as in technology assessments. 

Patient Advocate Foundation predominantly assists patients with healthcare access issues, but many patients also have underlying issues with the quality of care 

they are receiving. Approximately 78 percent of patients contacting Patient Advocate Foundation in 2007 had a cancer diagnosis.6 After a serious diagnosis like cancer, many patients wish to seek a second opinion, but insurance companies are increasingly refusing to cover this important service. Research conducted by the University of Michigan Comprehensive Cancer Center found that more than half of 

breast cancer patients who sought second opinions received a change in their recommended treatment plan.7 For some patients, a change in diagnosis and/or treatment results in less-invasive and higher-quality care. 

Clinical research has improved the treatment of various diseases and has helped 

doctors make well-informed decisions about what particular therapy is best for their 

patients. In cancer, clinical trial research has vastly improved survival rates for 

many cancers and led to improved cancer care. However, according to the National 

Cancer Institute, less than 5 percent of adults diagnosed annually with cancer enroll in a clinical trial.8 Broader enrollment in cancer clinical trials will enable researchers to discover new and better ways to treat and prevent cancer leading to 

higher-quality cancer care for patients. Unfortunately, access to clinical trials is decreasing here in the United States because many companies are moving their clinical trials abroad where it is not only less expensive, but where accrual rates are 

improved thus allowing trials to close earlier. While this may seem like a positive 

development because it may lower the cost of drug development and reduce the clinical time to accrual completion, our Nation must address disparities in outcomes 

from one population group to another. These very disparities may be extrapolated 

to the whole U.S. population who may ultimately engage in the treatment protocols 

resulting from the trial. NPAF encourages the Federal agencies to work collaboratively with manufacturers to address regulatory barriers that may contribute to 

the exodus in recent years of these clinical trials. 

Patient Advocate Foundation assisted a 45-year-old woman diagnosed with an adrenal tumor who was unable to locate treatment for her rare cancer. After accumulating nearly $10,000 in unpaid medical bills for out-of-network care, she was told 

she had 6 months to live and she should go home and prepare herself and her family. Immediately after contacting PAF, the patient’s case manager began investigating clinical trials. PAF was successful in enrolling the patient in a clinical trial 

at the National Institutes of Health (NIH); the trial was successful, and the patient 

is cancer free today, 3 years after enrollment in the clinical trial. Unfortunately, 

many patients are unaware that clinical trials may be a good treatment option for 

them and seek less effective and/or lower-quality care as a result. 

Patients seeking the assistance of Patient Advocate Foundation describe many 

reasons for not enrolling in clinical trials including: high costs and/or lack of insurance coverage; trial location; age restrictions; fear that the trial will reduce their 

quality of life; and fear they may receive a placebo. Patient Advocate Foundation 

assisted a 30-year-old man diagnosed with stage IV olfactory neuroblastoma, a pediatric disease that is only seen in 1 percent of adults, who had difficulty enrolling 

71 

in an appropriate clinical trial. The PAF case manager facilitated an agreement 

with the sponsors of a pediatric clinical trial at Duke University so that the clinical 

trial could be administered at the University of Alabama at Birmingham Hospital 

where the patient was located. Enrollment in this clinical trial ensured the greatest 

opportunity for control of disease for the longest period of time. 

In 2005, cancer expenditures cost patients, insurers and the government $69 billion making it one of the top 10 most expensive diseases. Clinical trials are critical 

in fighting cancer and improving the quality of care that cancer patients receive. 

We must strengthen our efforts to enroll patients in clinical trials if we wish to understand and effectively treat some of the most costly diseases. 

The IOM report, Crossing the Quality Chasm, explains that re-designing the 

healthcare delivery system will require many changes. One of which, applying evidence to healthcare delivery, can be partially addressed with adoption of proven 

medical guidelines. 

National Patient Advocate Foundation supports comparative effectiveness research to determine the comparative clinical effectiveness of various treatment options for patients with chronic and debilitating diseases. However, it is our belief 

that using comparative effectiveness research findings to limit access, or deny treatment or reimbursement will not benefit patients or our healthcare system as a 

whole. A one-size-fits-all approach will not help us achieve a high-quality healthcare 

system since we know that patients can have very different reactions to certain 

medications or therapies. Moreover, denying access to some of the newer and/or 

more expensive treatments will only move us further away from personalized medicine which should be our ultimate goal. As we continue to learn more about genetics 

and gene profiles, science will enable us to further tailor medical care to an individual’s needs which will benefit patients and payers by eliminating ineffective and 

sometimes costly treatments. Comparative effectiveness research should be used as 

a tool for doctors and patients to determine the best course of action for individual 

patients. Similar to clinical trials, comparative effectiveness research and medical 

guidelines must be sensitive to different patient populations since we know that ethnic populations react differently to medical treatments, as do patients with multiple 

co-morbidities. 

In addition, National Patient Advocate Foundation strongly advocates that all relevant stakeholders, including patient and consumer groups, representatives from 

the public and private sectors, such as government, physicians and other healthcare 

providers, medical specialists, insurers, and manufacturers of drugs and medical devices, should be involved in every step of the process, from setting the research 

agenda, and developing study methodology, to the translation and dissemination of 

findings. 

National Patient Advocate Foundation strongly supports the goal stated in the 

IOM report: 

‘‘Narrowing the quality chasm will make it possible to bring the benefits of 

medical science and technology to all Americans in every community, and this 

in turn will mean less pain and suffering, less disability, greater longevity, and 

a more productive workforce.’’ 

Senator MIKULSKI. Well, those were excellent examples, and each 

one with such specific recommendations. 

I am going to go to a broad-based question that perhaps all could 

jump in on. Just a brief comment, and then get to my question, because it goes to case management. 

My background is that of a social worker. I was a foster care 

worker, and I was a child abuse and child neglect worker. The key 

to helping a family was ongoing, intrepid, and unrelenting case 

management. 

Here goes my question. Dr. Beale, you talked about behavioral 

medicine, and often that is synonymous for mental or emotional illness or challenges. Also the biggest thing, in no matter what is diagnosed, is compliance with what you are asking the patient or the 

family to change, even if it is the treatment of cancer and so on. 

No. 1, how do you motivate people to comply? How do you stand 

sentry in a free society without being a ‘‘health nanny? ’’ Because 

we don’t want health nannies or health nags, we want compliance. 

72 

Also with our practitioners, no matter how dedicated and dutydriven, given the demands of time, they will see a patient, and they 

will pass them on, and nobody keeps track. 

Dr. Cassel, I am going to open with you to share your thoughts 

on the much talked about medical home. Tell me what you think 

that means, and do you agree that compliance and follow-through 

is a significant part of that? And should we have a human being, 

or can we do it with HIT, which is being talked about all the time? 

Can we have a techno-case manager? Do we need a human being 

as a case manager? And is a primary care physician really able to 

be a case manager? 

Dr. CASSEL. Thank you, Madam Chair. 

Those are excellent questions, and I think the one-sentence answer is that the techno-case manager won’t do it alone. You need 

to have human beings enabled by technology, and then the reach 

can be much farther. 

I completely agree with you about the importance of compliance, 

although I personally prefer other terms that suggest that it really 

is a partnership between the clinicians and the patient. There actually is research that shows that if there is a better relationship between the doctor and the patient, the patient is much more likely 

to comply with the recommendations of the treatment. 

Sometimes it is just a matter of not really understanding, not 

really having somebody who can answer your questions, not really 

being able to juggle the requirements of the treatment with all of 

the other requirements of your life. 

What the case manager helps you to do is to understand that 

interface between the patient and family and their life and what 

the doctor thinks they should do. And the doctor—you are absolutely right. A primary care physician in a one- or two-person practice is not going to be able to be a medical home with just the addition of an electronic medical record. 

That is why the emphasis on the team. You have got to have people who can actually have that interaction, proactive interaction, 

with the patient to be able to make that phone call, and ask, ‘‘How 

are you doing? Do you have any questions? ’’ Respond to their 

needs. Understand what their situation is in the community. 

You probably know better than anyone, a social worker is the 

best person to really do that. A social worker and a nurse and a 

primary care physician together would be my idea of the minimum 

for what would really constitute a medical home. 

If they then have the technology to connect to all of the other 

specialists and maybe even do e-mail with the patient and other 

kinds of communications with the pharmacy, then that is a truly 

empowered medical home. 

Senator MIKULSKI. Well, Dr. Cassel, do you think that is realistic? The whole discussion will be to expand the concept of primary care. 

Dr. CASSEL. Right. 

Senator MIKULSKI. If we look at the Massachusetts model—and 

others could comment on it—do you think it is a realistic expectation that a primary care operation, the physician’s office, would 

have exactly what you said? 

73 

First of all, social workers are usually not even included in the 

discussion. 

Dr. CASSEL. Right. 

Senator MIKULSKI. They are included because, quite frankly, I 

am here. 

[Laughter.] 

Dr. CASSEL. Well, you are talking to a geriatrician. So the social 

worker is our best friend. 

Senator MIKULSKI. And we would be a hell of a team. 

Dr. CASSEL. Right. But let me answer your question, because I 

think that the large physician practices—and Karen Davis will tell 

you this. The Commonwealth Fund Commission has really looked 

into this. That is why there are great advantages to the scale of 

a large, integrated system of care. 

The real challenge for the medical home will be how can you get 

small practices who aren’t used to practicing in that setting to have 

some kind of virtual team coming together even in rural areas to 

offer those kinds of services to their patients? 

I believe it can be done. But I don’t think that doctors alone can 

do it. 

Senator MIKULSKI. Well, my time is up. Dr. Davis, do you think 

you could fill us in there? 

Dr. DAVIS. There are some practical models. In North Carolina, 

Community Care of North Carolina is a network. The State is divided into 15 regions. The Medicaid program funds the network, 

which are social workers and nurses to work with the physician 

practices in that region to do exactly what you have said about case 

management. 

At the Geisinger Health System in Pennsylvania, they are large 

enough that their health plan pays the salaries of nurses who are 

embedded in physicians’ practices and responsible for working with 

Medicare patients who are high risk, have complex problems. 

But the key, as Dr. Cassel said, is trust in the physician, a good 

relationship, and then adding to that these extra services that can 

work with patients who have very difficult problems to handle. 

Senator MIKULSKI. Not extra, integrated? They are not extra 

services. They have to be integrated services. 

Dr. DAVIS. Right. Integrated services. 

Senator MIKULSKI. They have to be viewed as an essential part 

of primary care, not ‘‘isn’t it swell if we could afford it? ’’ 

Well, my time is up. Let me turn to Senator Dodd, and hopefully, 

we will have time for another round. That was just the kind of exchange I had hoped for. 

Senator DODD. Yes, that is great. Madam Chairman, thank you 

very much again. 

Thank you to our panel of witnesses. You are just excellent witnesses and are providing a tremendously valuable service. 

Obviously, the challenge in many ways to our healthcare system 

is how we promote quality, achieve value, and ensure the system 

is equitable. In many ways, those three elements will have a lot to 

do with bending that curve on cost, even though I think all of us 

recognize there are going to be some up-front costs we will have to 

make. 

74 

If we promote the ideas of quality, value, and equitability, I 

think you have a chance of really moving in that direction. 

I just want to mention, Madam Chairman, I have started last 

week a series of town hall meetings in my own State on healthcare, 

inviting the people of my State to come and talk about what they 

anticipate and what they would hope would be achieved with 

healthcare reform. 

As all of us know on this side of the panel, you never know when 

you hold a town meeting what is going to happen. Seven hundred 

people showed up at 8:30 a.m. on a Friday to come out and talk. 

We thought maybe 100 people might show up to come and talk 

about it. 

The issues they raised are ones you have been talking about here 

today—the need for improved patient incentives for primary care. 

We need to recruit and retain primary care providers. A good deal 

about eliminating duplicative, unnecessary testing, these various 

items that people raise all the time. 

Obviously, expansion of health information technology, and 

again, the numbers from the Commonwealth Fund or others, we 

have all used them. I used them last Monday. It is a staggering 

number. Every time I say it, I can’t believe I am accurate. That 

98,000 people lose their lives every year in this country because of 

medical errors, it is just a stunning number. When you think we 

are in the 21st century and this is going on in the United States, 

it is really hard to believe. 

I was pleased to see—and I know that Senator Mikulski and others had a lot to do with this. I know Senator Kennedy did as well. 

The $23 billion investment in health IT that is in this stimulus 

package that is moving its way through here. 

While people complain about various aspects, when we hear 

about sod on the Mall and so forth, I wish they would talk as much 

about putting resources, in the health IT area. It would make a 

huge difference. 

I have a number of questions, but let me focus on two quickly, 

if I can. In Connecticut, we have the Help Me Grow program. I 

know, Ms. Davis, you are very familiar with this, and I want to 

mention it because it has been a tremendous success. 

This is a statewide program in Connecticut since 2002. It is a 

comprehensive, statewide coordinated system of early identification 

and referral for children at risk for developmental or behavioral 

problems. We are now serving about 4,000 at-risk children in Connecticut per year as the care coordinator so that these children access and receive healthcare services, including preventive 

screenings and treatments. 

A fellow by the name of Dr. Paul Dworkin, who I know you 

know, and the Connecticut Children’s Health Medical Center, 

among many others, are doing some tremendous work. In fact, 

Commonwealth Fund has recently given them a grant to help replicate the Help Me Grow model in five States across the country 

because of their success. Polk County, IA, Orange County, CA, already have programs that are up and running. 

Dr. Dworkin and his colleagues’ program is really a model, 

Madam Chairman, for changing our current healthcare delivery 

system for children, which is what we have been working on this 

75 

week and the votes we will be cast in a few minutes on the CHIP 

program and are indicative of our interest in the subject matter. 

In doing so, they have identified two critical gaps in the current 

system. First, they found that care coordination is critical. It is the 

critical missing element to the current care model for children. And 

second, they have cited a need to establish and promote a mid-level 

assessment capacity for screening at-risk children and intervening 

quickly where necessary. 

I wonder, Karen, since this is something you are so familiar with, 

that you might comment on these observations and provide your 

recommendations on how to implement them in the context of 

healthcare reform? 

Dr. DAVIS. Yes, the Help Me Grow program is a very important 

model. That also picks up on Senator Mikulski’s point that any pediatrician, any parent can call this toll-free number and make sure 

that that child gets the services that that child needs. 

It is a way of not putting all of the burden on the pediatrician 

to know everything that is available in the community, but to make 

it very easy to make that linkage and then have absolute certainty 

that they will follow up and connect that child or that parent with 

the necessary service. It is an excellent model. 

Senator DODD. Yes. I wanted to jump quickly because the longterm services and supports, Dr. Cassel, they are a particular interest of Senator Kennedy’s. It is an interest, I know, of Senator Mikulski’s and mine as well. There is some debate as to whether or 

not—as we talk about universal healthcare reform—whether or not 

long-term services are going to be a part of that. That is an ongoing 

debate around here as to whether or not it should be. 

I am an advocate of it. I think it is critical if we are going to 

have universal care that we provide long-term care and services 

and support. I just wonder—— 

Senator MIKULSKI. Can I ask you what you mean by ‘‘long-term 

services? ’’ 

Senator DODD. Well, providing the kind of living conditions 

where people don’t need much necessarily, but need some. You 

have a graduated care process as their health conditions deteriorate, but they don’t have to wait until they absolutely reach the 

point where there is very little options for them. They can have 

longer lives. 

Senator MIKULSKI. You mean the continuum, all the way from 

independent living—— 

Senator DODD. Yes. Right. 

Senator MIKULSKI [continuing]. Supportive at-home health services. 

Senator DODD. Absolutely. Choices, where people have choices, 

they can make as well. We have an aging population. The great 

news is people are living longer, but they want the quality of life 

to be there as well. 

I can’t imagine us having a universal healthcare reform package 

and not including a long-term support and services for people. 

Senator MIKULSKI. Absolutely. 

Senator DODD. I wonder if you might just, in the context of our 

discussion here today, comment on that as well, since I know you 

have done so much work in this area. 

76 

Dr. CASSEL. Well, thank you, Senator Dodd. I appreciate that. 

I have often thought it was kind of a blind spot in our health policy world that people didn’t want to include long-term care in these 

discussions. Yet, I think it is also a place where we can get tremendous advances in affordability by coordinating acute and long-term 

care services. 

There is a place where there is both huge redundancies and also 

huge gaps in care, huge opportunities for errors to occur when the 

long-term care providers aren’t talking to the acute care providers, 

and vice versa. There is huge amounts of data on that. 

There is both outcome reasons, but also financial reasons to 

bring them together. One is Medicare. One is Medicaid. They don’t 

connect financially so you have the silo problem that Senator Mikulski mentioned earlier. 

In fact, I believe, if you look at models from other countries, 

which the Commonwealth Fund has done, that you can get real efficiencies as well as better quality of care if you actually take it on 

as a part of the care and try to figure out a way to do that. 

Senator DODD. Yes. You know, one point, and my time is up. 

Someone made, I thought, a very wise suggestion. And that is to 

begin, in Medicare, providing screening and prevention to people at 

the age of 55. I know there is talk about moving the enrollment age 

down to 55, but I don’t know how much support there might be for 

that. 

But certainly to begin to provide prevention to people at age 55 

rather than waiting until they are 65 so that you begin, you can 

start treating people in anticipation, before something becomes an 

acute chronic illness. Having the ability to intervene at an earlier 

time and save an awful lot. 

If you are not impressed by the ethical question, certainly the financial motivations ought to be there to promote that idea. 

Senator MIKULSKI. Senator Dodd, there are a couple of issues 

here. One is the management of chronic illness. And that could 

begin at any age. 

For example, the autistic child would have, even through early 

adulthood, these kinds of living arrangements, graduated living arrangements for independence. But then there are other kinds of 

challenges, such as the management of diabetes. And all those illnesses that have the underpinnings of inflammation, which can 

cause even Alzheimer’s, etc. 

One is the management of chronic illness, and then the other, 

though, is when you are getting older and you do go from independent living to supportive services at home to the need for assisted living to perhaps a more substantial in-residence thing. 

Those are two separate things, but they need to be viewed as the 

continuum. You are onto something. 

One of the things I would like to suggest, as we then move on 

to our colleagues, we are coming up on the 20th anniversary of legislation you and Senator Kennedy helped George Mitchell and I do, 

which was the anti-spousal impoverishment legislation. 

Do you remember the old Reagan rules of spend down—or I 

should say David Stockton rules—so you only had $3,000 left in 

your bank account before you could get Medicaid. We changed 

77 

those laws so that you could keep more of an asset, as well as your 

family home or your family farm. 

It was meant to be a down payment. It is now the 20th anniversary coming up, and nothing new has happened. 

As we look through this, I would like to join with you and our 

colleagues on both sides of the aisle to say it is nice to have the 

20th anniversary, but what is the new thinking that can really look 

at not only the issues around financial assets, but what are we 

going to do with people with the need for long-term care? 

It shouldn’t be at home or nursing home as your only two 

choices. We have got a lot of work to do and a lot of Senators who 

want to ask questions. 

Senator DODD. Well, we can submit some questions. 

Senator MIKULSKI. Absolutely. Please. Your full statements will 

be included the record. 

We are going to go according to seniority. Senator Casey and 

then Hagan and Merkley. 

Senator CASEY. Chairwoman Mikulski, thank you for calling this 

hearing and for your leadership on the whole host of issues we are 

talking about today. 

I am going to be very brief. I have to be in the chair in the Senate. The place doesn’t operate unless someone is in the chair. I will 

probably be below 5 minutes. 

It is difficult to choose here because we have great questions for 

a wonderful panel. Dr. Cassel, if you will pardon me, I know you 

have roots in Philly, but the Geisinger plan was mentioned over 

here. I have got to ask a quick question about that. Then I will run 

out the door. 

To Karen Davis, I wanted to ask you about Geisinger in terms 

of their health IT system. Dr. Steele will be glad that I mentioned 

it, but I am serious about the importance of it. 

How do you see that model and the methodology—the way they 

set it up, the way it has been implemented and effective, I think, 

very effective—how do you see that playing out on a national scale? 

That is part A. Part B is the challenge on balancing that kind of 

technology with privacy. 

Dr. DAVIS. Well, thank you very much. I should say that I am 

on the board of the Geisinger Health System, a nonprofit system. 

I obviously think it is a terrific model, and the IT, which they 

have had for over 10 years, facilitates quality improvement. But 

the fact that they have a dedicated innovation and quality improvement unit makes all the difference. 

Again, it is not up to the individual physician to figure out how 

to have systems that make sure every diabetic gets appropriate 

care, that makes them provide perfect care for coronary bypass surgery. They really re-engineer their care processes and build it in. 

So the question you raise is about how do we do this on the national basis? I think, first of all, we need to provide incentives for 

integrated delivery systems to flourish and give bonuses, as Dr. 

Teisberg has said, for performance on health outcomes and results. 

Second, I think many of the smaller practices are going to need 

financial help with IT adoption. That is why what you are doing 

in the stimulus bill is very important. 

78 

But the third point is I think they are going to need technical 

assistance. A big system like Geisinger, with 750 physicians, they 

have an organization that helps them adopt these changes that let 

them provide better care. We are going to need either to change the 

way we fund the quality improvement organizations in Medicare 

and charge them with this task or to fund models like they have 

in North Carolina of an infrastructure of support. 

I think it is not enough to have the IT. That makes a lot of good 

things happen, but you need more than that. 

Senator CASEY. Thank you very much. 

Senator MIKULSKI. I am going to turn to the Senator from North 

Carolina. We have been hearing so much about it. 

Senator Hagan. 

Senator HAGAN. Thank you, Madam Chairman. I also thank you 

for my offer to move up in seniority, but I was kind of worried 

somebody else might come in. I had so many papers. I decided just 

to stay right here. 

This is an excellent panel, and actually Dr. Allen Dobson was 

here last week specifically talking about the community care centers in North Carolina. My question relates, too, to the health information technology. 

I know that in the reports I have read, we know that that is 

probably a very, very important tool, and I understand that the 

Veterans Administration is using that quite a bit now. I was budget chairman in North Carolina for a number of years, so I am very 

familiar with the community care centers. 

One of the things that we also talked about quite a bit was actually having physicians with a palm-held device that, as they are 

prescribing medication, they can find out what other medications 

the patient is currently taking, what the contraindications are. It 

would reduce, No. 1, fraud, but also any medical errors that might 

take place. 

As sort of a roundabout question—and I guess this is directed to 

Ms. Davis—can you tell us anything about what the VA is doing 

in relation to this? And then if there is any very cost-effective 

model such as hand-held devices, that would help in implementation that wouldn’t cost a whole lot of money immediately? To start 

getting special small practices and the individual silos actually onboard at an earlier point in time. 

I think we have got to be moving toward health information technology across the United States in order to be sure that the quality 

of care can be handled in an appropriate fashion. 

Dr. DAVIS. Well, I am sure Dr. Cassel can also comment on the 

electronic prescribing. It certainly is a very powerful and low-cost 

approach to eliminating medical errors, eliminating the handwriting problems. 

Decision support—suggesting to the physician a different medication that because a patient has an allergy or because maybe there 

is something at a lower cost. That is a system they have in Denmark, where the doctor is told, when they prescribe electronically, 

there is a lower cost drug that is equally effective. 

But on the VA, first of all, the records do show that their health 

outcomes, quality indicators are above the rest of the United 

79 

States. They have just done an extraordinary job over the last 10, 

15 years. 

One simple example, they are doing home monitoring of patients 

with chronic conditions. The person at home enters information 

every morning in a pad by the phone. If they don’t do it, the phone 

rings, and they get asked that information. 

Then nurses, again, are monitoring that information, and red 

lights go off if the patient is out of control or getting into a yellow 

danger zone. 

So, yes, there are a lot of applications that really can improve 

care. I think there are others here who may be familiar with it. 

Ms. DAVENPORT-ENNIS. Senator Hagan, I would like to also answer your question, if I may, having served on AHIC 1.0 for the 

last 3 years and working in this particular area. 

In the VA, I think we know there are two major advantages. Not 

only do they have electronic health records domestically and internationally where we have troops, and they do use the hand-held 

devices. Literally, if a patient is injured today in Iraq, we know 

within moments the medical record while our people are standing 

with him to evacuate him. 

In the United States, we have also moved the VA population to 

the use of personal health records. By doing that, the very example 

that we were citing with the home health monitoring, through the 

PHRs now the patients are getting prompts of appointments that 

they need to follow. Medications—if they are having any types of 

side effects or adverse events these are immediately recorded. And 

there is immediate intervention. 

When we look at the VA model, certainly I think all of us in the 

country feel it is the most complete and ideal model. I think we 

have a significant step to get from there to taking the remaining 

75 percent of providers to get them into some form of utilization, 

and dollars will certainly help us do that through the stimulus. 

Thank you for your consideration of that when it comes to the 

Senate. 

Senator MIKULSKI. Senator Hagan, do you have a follow-up question? 

Senator HAGAN. Do we have time? 

Senator MIKULSKI. If you have a short question. 

Senator HAGAN. Well, it was concerning the nursing shortage. I 

think that at least in North Carolina, it is certainly an issue that 

we have grappled with for quite a while, and one of the issues has 

to do with the qualification of the nursing instructors to be sure 

that they have either the master’s or the Ph.D. 

Many people can earn more money than at that level, and it is 

just sort of a compounding problem. I know that money, obviously, 

will help some of it. We know, too, that nurses are very responsible 

for a lot of this care. But do you have any other ideas or suggestions on that? 

Dr. TEISBERG. It is a great question. In all of the follow-up work 

that we have done in the 2 years since ‘‘Redefining Healthcare’’ 

published, we have worked with groups implementing the idea of 

how to do integrated multidisciplinary practice, which includes, of 

course, nurses and social workers and others. 

80 

One of the things we have found is there is tremendous leverage 

on the pressures on nurses and doctors when you actually put together team care around patient needs rather than simply structuring things by medical specialty. 

When Ms. Davis tells you that we need organization and delivery 

done differently, she is absolutely right. If you organize a team 

around the patient needs, then you have these other roles. I call 

them a ‘‘compagnie autour,’’ which is what they get called internationally. 

But it can be a nurse. It can be a social worker. It can be a family member. It can be a community member. You end up with additional members of the team who provide a lot of those coordination 

services that today fall on nurses but don’t necessarily require a 

nursing degree. 

As we move to truly patient-centered care, truly coordinated care 

around multidisciplinary teams, we have other options, and they 

provide leverage. So instead of forecasting forward shortages with 

a ruler, we create a different set of possibilities. 

Senator HAGAN. Thank you. 

Senator MIKULSKI. Senator Hagan, in the economic stimulus 

package, along with a beginning investment in health IT, there are 

also additional resources to deal with the nursing shortage, again 

making the down payment in anticipation of the changes that we 

hope to achieve over the next couple of years in the area. 

None of this is throwing money at anything. The health IT is not 

only to get some of the investments going, but the language to ensure interoperability so we don’t have a techno boondoggle. 

In the area of nursing shortage, all the work shows that we don’t 

have a shortage of talent, and we don’t have a shortage of people 

who want to go into nursing. We have a shortage of people who 

teach the people who want to go into nursing. We make some investments in that area at our wonderful university-level 4-year programs and also at the community college level for our 2-year nursing graduates that, again, could perform many of these vital functions. 

We would like to visit with you even on the vote to discuss it. 

So we invite you in dealing with this. 

Now we are going to turn to our new Senator from Oregon, Senator Merkley. 

Senator MERKLEY. Thank you very much, Madam Chair. 

Thank you for your presentations. Many of you have dealt in 

some aspect with ‘‘results-based’’ healthcare, and there is a pilot 

project in Oregon that is set up like this. 

They provide a quarterly report, and the clinic receives bonuses 

based on three tiers. The first tier is really for participating in the 

pilot, sending the data, compiling the data, helps compensate them 

for their cost. 

The second is for improvement in access and in—you all can help 

me with this term—but H-E-D-I-S? HEDIS? HEDIS benchmarks, 

reaching those benchmarks for progress. The percent of the population that receives preventive care. For example, are diabetics getting their blood sugar level testing, etc? 

A third is for benchmarks such as avoiding emergency room visits, hospital visits, and so forth. 

81 

I am not sure if any of you are familiar with this model or if it 

is very similar to ones you are familiar with. Is this a type of strategy that is worth experimenting in and that makes some sense? 

Dr. DAVIS. I would like to learn more about it. I think the third 

tier is pretty unique. I would like to learn more about that. 

In California, the Integrated Healthcare Association has the first 

two tiers. All the major health plans reward medical groups for reporting data, adopting information technology. They give bonuses 

for doing the preventive care like the Pap smears. 

I haven’t heard of an initiative that really rewards avoiding ambulatory-sensitive hospitalizations, reduces re-admissions by reducing complications, or is sufficiently accessible 24–7 that people 

don’t have to go to the emergency room. 

I think that is very, very interesting. I would like to follow up 

with that. 

Senator MERKLEY. Thank you. I would be delighted to follow up 

with you and learn more about how that compares to other experiments around the country. 

Any other thoughts or comments on that? 

Ms. DAVENPORT-ENNIS. I think the comment that I would like to 

make to you, Senator Merkley, is that from the patient perspective, 

if that model, indeed, can be successful, it means that mom and 

dad and children can get care in the community and with their primary care physician. 

When that happens, we see there is usually greater compliance 

to care and less cost involved. We hope that model can work. 

Senator MERKLEY. Thank you. 

Dr. TEISBERG. Yes, I would add that as you are looking to measure quality to drive results-based care that you want to make sure 

that you are measuring results. In Minnesota, when they measured 

processes such as did the patient get their blood sugar measured, 

they got very good process compliance. Then when they checked to 

see whether the outcomes for patients had actually improved, they 

discovered that the outcomes were not what they were hoping for. 

When they started measuring the results—was the HbA1c, the 

blood sugar level, below the threshold? Once they were measuring 

the result, the percentage of patients who actually achieved the result more than doubled in the first couple of years of reporting. 

Measuring processes alone may not get the results that you want 

because you actually want to get the health results so that you do 

avoid the complications. You want to set up a situation where they 

are not just getting to the doctor, but they are actually not needing 

amputation, not going blind, not having heart attacks. You want to 

get clinically meaningful outcomes. 

Senator MERKLEY. Thank you. 

To that point, there is a former governor of Oregon, and this governor, Governor Kitzhaber, heads a group called the Archimedes 

Movement. This is about evidence-based practice, but also about 

finding ways to pay for, if you will, the course of treatment as opposed to the set of procedures. Does that fit with what you are saying? 

Dr. TEISBERG. Yes, absolutely. What we have talked about is creating payment for the cycle of care rather than for the pieces, that 

there are just tremendous efficiencies in coordinating care. This is 

82 

the essence of why care needs to be reorganized into integrated 

practice units around the common sets of medical circumstances 

that patients face. 

Senator MERKLEY. Can you help us get a clear vision of how one 

actually does that on a practical level? A patient comes in who 

has—maybe you can give us an example of a problem, and how the 

difference between how you would pay for the procedures and pay 

for this cycle of care? 

Dr. TEISBERG. Yes, think about a patient with diabetes. A patient 

with diabetes would often—Type 2 diabetes would often also have 

hypertension, also have vascular problems. From my perspective, if 

I were a patient with diabetes—thank goodness I am not. If I were, 

that would be one medical condition, not three or four. We need to 

think about it from a patient perspective. 

Then we can—our DRGs right now are too narrow. We think 

about these in pieces. 

Senator MERKLEY. And DRG is? For us outside the profession. 

Dr. TEISBERG. I am sorry. That is the payment structure that is 

used in hospitals, and then we have a payment structure used for 

outpatient, RBRVS. 

They are set up in these narrow buckets that you are talking 

about, and what we need to do is allow for teams to be paid for 

wider episodes of care. It would be common in other services, other 

businesses to do it that way. If we set up payment around the cycle 

of care, around the episode, rather than around the individual procedures or interventions, then we can do it. 

One of the reasons for measuring results by teams rather than 

by individuals is to pull people together that way. My written testimony talks about restructuring payment. I didn’t talk about that 

orally because it is short. 

Senator MERKLEY. I appreciate very much your input. Thank 

you. 

Senator MIKULSKI. Well, we are just concluded about 3:10 p.m., 

and I know the votes will be beginning shortly. This has been a 

very, very informative panel. 

Before I conclude, I want to go back to Dr. Robinson-Beale and 

her startling statistic of the number of people on antidepressants. 

Doctor, could you repeat that number? I think it was between 9 

percent and 17 percent? 

Dr. ROBINSON-BEALE. Nine percent and seventeen percent. 

Again, I am basing that not only on the work that we have done 

at United, but also in other venues where I have been, where it 

seems to be consistent. That is what is alarming. 

Where you have 9 percent to 17 percent of the medical population—that is the population that is seeking medical care, so there 

is a claim out there—that are on antidepressant medications. 

Even if you assume, and we have done a little bit of study on 

that, that maybe 20 percent are on those mediations needlessly, 

that is still a staggering number of individuals who are being treated for forms of depression and anxiety in the primary care arena. 

Senator DODD. Barbara, can I just—why is that? Why is there 

such a disparity in that number? I would understand 9 to 17 is a 

rather large gap. 

83 

Dr. ROBINSON-BEALE. It depends upon, one, the type of practice 

that you are looking at, also the type of individuals. We see a big 

difference in terms of access to behavioral healthcare depending 

upon whether the person is blue collar, white collar, whether or not 

they are living in certain parts of the country. 

In New York and in California, where it is stylish to seek a mental health therapist because it is just a nice thing to have, you have 

higher incidence of people accessing care. Those variations are not 

uncommon. I think the staggering thing is that it is much higher 

than any other chronic medical illness that you have out there in 

terms of the prevalence. 

Senator MIKULSKI. Are you saying that there are more people on 

antidepressants than, say, insulin or insulin-resistant drugs, going 

back as we used diabetes as an excellent example of a chronic condition? 

Dr. ROBINSON-BEALE. What I am saying is that when we look at 

those numbers, I am saying that in your diabetic population, 40 

percent to 42 percent of those individuals will have depression. We 

are finding more and more there is a close—— 

Senator MIKULSKI. No, no, no. Here is my question. 

Dr. ROBINSON-BEALE. OK. 

Senator MIKULSKI. Do they have depression, or have they been 

given antidepressive medication? I don’t consider those to be the 

same thing. 

Dr. ROBINSON-BEALE. Sure, and let me answer it this way. The 

dispensing of an antidepressant medication is linked to many times 

a physician who feels that they see someone who has some symptoms of depression. It doesn’t mean that they necessarily have 

major depressive disorder, which is one of the DSM-IV diagnoses, 

but it is very clear that they have depressive symptomatology. 

We have found that even treating mild or moderate depression 

that you will get a tremendous improvement in that individual’s 

compliance with—for diabetes, there was a lot of work done on that 

in terms of medication adherence, in terms of their diabetic medication, also compliance in terms of following through on their medical regimes. 

It doesn’t change their habits as it relates to exercise, unfortunately, or maybe diet compliance. But it does have a great deal to 

do with their compliance as it relates to medical regimes. 

Senator MIKULSKI. Well, that is also what Dr. Teisberg has been 

talking about, which is to measure the outcome. So for a diabetic, 

you can measure whether you are taking your blood sugar every 

day. 

One of the keys to chronic management, Dr. Cassel would say, 

is aggressive testing. It is a tried and true technique. You might 

have started, when you found this out, at an A1c of 8.5. That is 

a little scary. That is up over 200 points. 

Everybody works hard. You might get your A1c down to 7.5. 

Under the ADA guidelines, you want to be 7.0 or down to 6.5 or 

6.0. Is that right? 

Dr. CASSEL. Not always. 

Senator MIKULSKI. Not always. OK, but I want to go to this 

point, which goes to the team approach. One of the things, and 

again, just in reading, my general reading in some of this testiVerDate Nov 24 2008 13:47 Dec 03, 2010 Jkt 035165 PO 00000 Frm 00087 Fmt 6633 Sfmt 6601 S:\DOCS\47121.TXT DENISE
84 

mony and others today, there are certain issues where depression 

sometimes appears when people find out they either have a problem or the circumstances in their life that are triggering other traditionally medically diagnosed issues are causing great either anxiety or depression. 

That then takes the team approach in terms of the appropriate 

medication, but without getting to the underlying symptom. A 

woman could come in and have terrible symptoms of depression, 

but it could be that she is a victim of wife beating and abuse. What 

she needs is a shelter and a way out along with the temporary 

bridge to bring her over. 

There is talk of people, as you know in the geriatric population, 

the issue of depression versus Alzheimer’s. Many patients who are 

diagnosed with Alzheimer’s get depressed because they have Alzheimer’s, which is a natural reaction. So they need a lot of help. 

The point, with her statistic and your case management, would 

go to this more comprehensive approach. We can’t expect a primary 

care physician to do it all and to do it all by him or herself. They 

need to be using other specialists and other people to work with 

other aspects of the patients overall condition. 

When we are talking about reforming healthcare, we have got to 

really get a new paradigm, not only a new insurance mechanism. 

Isn’t that really what you are saying? And because of new breakthroughs in metrics, we can actually measure outcomes, measure 

results as well as process. We don’t have to make it either/or. 

At the same time, success, meaning the improved quality and, in 

case of chronic illness, really preventing the deterioration into a far 

more serious problem. The diabetic who is vibrant and in compliance is a lot better off than the one who isn’t, because noncompliance is going to lead to kidney dialysis, amputation, and retina disintegration. 

I think what our colleagues need to think about, and I think this 

is what the challenge of quality is, is how do we bring new thinking and not only new ways of financing? 

Dr. Teisberg, and then we are going to wrap it up. The vote has 

just begun. 

Dr. TEISBERG. Thank you. 

It is a critical insight that you are identifying that we need to 

have a new way of organizing healthcare, a new way of thinking 

about the structure of delivery. If you think about it, what can the 

Senate do, what can the Congress do to enable that and to spur 

that to happen? 

If we measure results by teams, you have to be on one. You can’t 

organize everyone into teams, but you can require the measurement of the results so that people have to be part of it. They have 

to be part of coordinated care. 

It is your most powerful lever to achieve change in the structure, 

and I would encourage you to use it. You have people ready to go 

with it. If you say we are going to measure results by coordinated 

teams, people will find their way to them. 

Senator MIKULSKI. Go ahead, Dr. Robinson-Beale. I am listening. 

Dr. ROBINSON-BEALE. I would also like to say, as part of the 

team, to make sure that behavioral health is considered and not 

forgotten. The de facto system for treating behavioral health now 

85 

is the primary care arena. Without their having the tools to do so 

and being able to detect and being able to diagnose and do it objectively—and there are tools out there—I think we will have a very 

difficult problem. 

Unless those measures that are out there that are comprehensive 

measures so you are not just measuring, with the diabetic, the hemoglobin A1c, but you are also measuring the screening rate for 

depression, without those kind of comprehensive approaches, I 

think we will still miss the ball. 

Dr. TEISBERG. Yes, you will need multiple measures, and if you 

have multidisciplinary teams, you will get them. When you put 

multidisciplinary teams together, they suggest a more comprehensive set of measures. That is what they want to live with. 

Senator MIKULSKI. That is good. 

Ms. DAVENPORT-ENNIS. I would like to say, Madam Chair, as a 

closing statement that if we look within the cancer community, the 

use of multidisciplinary teams is routine in the treatment of cancer 

patients, and I think there are lessons that can be learned from 

that model as you move forward. 

Senator MIKULSKI. Well, the Institute of—I am sorry. Dr. Cassel, 

did you want to say something? 

Dr. CASSEL. I just wanted to add to Elizabeth’s point about measures, that the measures alone can’t do it. That you have got to have 

the skills among the providers who know how to work together. 

It is medical knowledge and clinical nursing knowledge and social work knowledge. It is also teamwork and management skills, 

which we don’t teach enough of, and I think that needs to be a big 

part of the new model that you are talking about. 

Dr. TEISBERG. Yes, if you measure—— 

Senator MIKULSKI. Well, Thank you. 

Dr. TEISBERG [continuing]. Results, the team has to achieve it together. 

Senator MIKULSKI. Thank you, Dr. Cassel. 

We are going to adjourn this committee until February 5, when 

we are going to be holding another hearing on quality. This hearing 

will be on the best practices. In other words, actual case examples 

on the best practices. 

Later on during the month, we will be holding a hearing on integrative healthcare. We also note that when we turn to the Institute 

of Medicine during the last week in February, we will be holding 

a 3-day summit on integrative medicine, which I believe is what everyone at this table is talking about. 

You need integrative medicine to help create the kinds of teams 

we are talking about, but you need integrative healthcare because 

it is really the new paradigm. 

Well, with that, we are going to go and actually vote on expanding healthcare for children. This committee is in recess until February 5th at the hearing on best practices. 

86 

Thank you very much for coming, being so patient and willing to 

shoehorn in so much content in such a short amount of time. 

Thank you so much. 

[Whereupon, at 3:19 p.m., the hearing was adjourned.] 

Æ