health care reform

i think we use - i can't remember the examples - maybe itwas claritin and allegra. let's say the cer comes out and says one is better than the other. what's going to be the requirement forsomebody who's practicing medicine and allegra doesn't work for their patient but claritin does? the doctor decides with the concurrence of the patient. so, does he have to document that hedidn't follow cer guidelines?

i'm not sure what the rules and regs would be. well, that would be part of what the secretary puts together. that's my whole problem with this is what's the secretary put together? the fact is that i have an amendment, coburn number 9. we really do have a lot of quality problems. we have a lower life expectancy

than other countries. the united states ranks 45th in life expectancy. we have very poor infant mortality rates. and has startlingly high rates in infant mortality, depression, chronic diseases. from city to city, from physician to physician, and hospital to hospital

there are huge differences in the amount of care given and the outcomes of that care. we need to identify the best practicesacross the country learn from the successes, and then duplicate those successes everywhere else. we're in the top 5 of medical expenditures in the world but we're

in the bottom 37th in terms of health outcomes. the who says we rank 37th in the world onhealth care that's behind chile and san salvador. we deserve better than that. when you try to do an internationalcomparison, it is very complicated. i think all too often we tend to be overly simplistic. we look at crude indicators. one finds that americans smoke too much, they drink too much, and they eat too much, especially compared to their northern neighbors. in fact,

and it pains me to say this as a physician, but probably one of the less important things is health care in that overall equation. one of the things in the bill talks about comparative effectiveness studies. information like your age, your diagnosis, gender, and etcetera goes into a national research pool. they collect this data so that when you enteryour information onto the computer system, which doctors have to go to this computer system now, because the government is mandating it, it collects it and then as this plan goes into place the computer is going to kind of pop up and say "do this, do that. you know, we have this data, here's our recommendation." you go with the recommendation it's good. you don't, it's bad.

the fear is that if you don't go with what that little government computer is telling you to do, what if you don't get paid. the other area that some of these bills would put government into is collecting more data on healthcare practices and looking for things that are effective and beginning to develop recommendationsand protocols for what should work. we really don't have a good body of knowledge at this point.

we don't know what works, and for whom it works, and we don't know how much of it you need. so, you have to sort of answer those three questions for a lot of conditions and a lot of treatments,and then you have to keep up with developments and new treatments. so you'retalking about quite a few years of building up a body of knowledge. and then you have to sort ofdemonstrate that it's valid, right? so people have to see that when you make these recommendations that you're not just blowing smoke. what this amendment would require

that the director of the centerfor comparative effectiveness research shall not mandate any national standards of clinical practice or quality health standards. mandate. that doesn't mean they can't study and recommend. that means they won't mandate it. in this legislation and i've given chapter and verse that we domandate clinical practice. (committee members speaking over each other) there is no clear language that says "we prohibit the mandate

of this interfering between a doctor and a patient's decision for their care." - go to page 323.- i want to read you the text. that's a big difference and saying theywill not be used as mandates. - could we come back though to qualityhealth standards?- sure. because i don't know what you object there in establishing a standard on quality health care. because all of a sudden we've now said there is one right way to do this and it's the government's way based on by iconic professors anddoctors of medicine

and it still disregards the patient history, the clinical history, the experience of the physician, and all those combined, which is called theart of medicine. the most important aspect of health care is the doctor-patient relationship. prepare a doctor, sitting down talking to a

patient who needs health care and the one-on-one relationship has gottenlost in today's society. i'm rick baxley, i'm a family practice physician in orlando, florida. the measured outcome system is another barrier between the doctor-patientrelationship. just a simple example: i have a patient who works a second shift

and i hand them a perscription that saysthey need to take a pill three times a day because it's a generic and it doesn'tcost as much as the one time a day medicine. well that's fine, and i do that but i know that the patient is not take it butonce or twice a day no matter how many times i've put on the sheet, on that prescription. because of their lifestyle and the way they work and their time andthat kind of thing, and the kids that they

gotta pick up after their second shiftand all that other stuff that the likelihood of them taking that pillthree times a day is almost zero. but, the pharmacy company says that they're notgoing to pay or the the insurance company says that they're not going to pay the pharmacy for the one pill a day brand. they're going to pay the 3 times a day... they'll pay for the 3 pills a day so whether they get used to not is irrelevant.

so, there's a lot of nuances that the government and the insurance companieshave not figured out yet. and i don't think they're going to becauseof the economics of the medicine. they are thinking more of the economics than they are the art and science of medicine. this is a very important section of this bill. very important. medicine is personal. medicine is individual. it doesn't fit in a box.

no, but it does fit practicing guidelines and you, yourself has said that. - that national academy of clinicians...- senator, can i finish my point? please, go ahead. guidelines are important but they're just that. they're guidelines. and if, in fact, you pass this bill out of here with this

you're going to raise the cost of medicine. because now what we're gonna do - here's the guideline that you need to follow and sort it out, andimplement it. the people who will implement this willbe bureaucrats and the first rule of bureaucrat isnever do what is best when you can do what is safe for your own job. and that will be the logo under which they operate and administer whatever comes up out of

cer. well, when the law passes the group that passes it may exist for only a moment in time. it's a group of people who probably willnever assemble again exactly the same way. so, who is really able to tell you whatthe bill meant? well, the committees who really wrote it make an effort at it. they write a report and they say, "this is what we mean, this is where we're trying to go, this is the way you should think about interpreting this." and, it's not the law, but it's an instruction to the bureaucracy.

so, the bill goes over to thebureaucracy, to the agency that is responsible for administering thatprogram, and then the report would go to them. and they're pretty much on the hook to file that report to the extent that they can. and then where they have questions they can call up the staff of the committee saying, "what did you guys mean here?" they can also call up friends they have in the hospital industry and say, "you know we're thinking about writing up some regulations here but we're not sure this would work. what do you think of this?" another thing that people don't understand about the bureaucracy is that the same person has probably been working on that same issue for a

long time and they're really experts now. sometimes they have their own ideasand so there's something called bureaucratic drift, which is when the bureaucrat sometimesmoves closer to what congress wants and moves further away from what the president wants or if the bureaucrat favors what the president is wanting. they might move closer to the president. and so, the political scientists have developed a term called the zone of indifference. and that is, the bureaucrat can get awaywith writing the rules in a way that

takes lose interpretation of the law and as long as they don't do it too brashly, if they do it too much, one side or the other - the president or the congress - is going to notice and drive them around. you want to pay close attention to yoursubcommittee because that subcommittee very likely also controls your authorizing legislation.

and so if you make them mad, they can do subtle things like take away your staff or they can make a recommendation to the appropriations committee thatyour budget get cut or that function be cut. the other place that the bureaucrat gets in a lot of trouble is if it's a highly salient issue. in the case of effectiveness standards in heath care, that's going to be a salient issue. every doc, every medical specialty group is going to be watching that like a hawk because it's going to limit the behavior of the physician. it's going to potentially reduce their income. and so, the zone of indifference get very

narrow when the issue is salient. so they write these regulations and publish them, and then they have to overseethe process of them being implemented. and then, of course, the people who do the implementing make their own interpretations about what the regulations should be. the concerns were raised that if we dothis work with this several billion dollar effort that in fact we couldn't use the workproduct

to inform and educate and benefit from the work product that is developed. and the concerns that were raised were raised essentially under the language that we had written that it might prohibit this task force and this agency from actually getting that information out and that's not our intention at all. so,what this amendment simply says,

we strike a section that we was all thecontroversy last week and then we say are prohibited from being used by anygovernment entity for payment coverage or treatment decisions. nothing in thesection shall be construed as preventing the center for disseminatingreports and recommendations to health care providers. so, the one argument that was trulyraised about our previous language is addressed here, i believe fully, and would not limit in any way, shape, or form thedissemination of that information.

if, in fact we're not going to use thisto limit care then, what we will be using this for is toimprove care. i disagree with the senator'srecommendation. it is very rigid. it is very stringent. it could absolutely have draconian impact on the practice of care because if you're going to be prohibiting them

from being able to use by what it says "anygovernment entity." if there is, in fact, information thatarises that gives better information about tools andmethodologies that are being used they would, say at the va, be prohibited from using it. senator whitehouse:i'd like to join senator murkowski in opposing this.

i understand where senator coburn iscoming from and i appreciate his desire not to have an interference in the doctor-patientrelationship, none of us want that, but i think the affected of this language will be to totally unhinge payment from performance and to do so in ways that could have farreaching affects throughout the rest of the system as we try toimprove quality.

let's just say that it was clearlyproven that if you could get somebody whopresents at the emergency room with a respiratory infection on to the right antibiotics within three hours that the course of treatment was muchimproved for that individual that the costs went down forthe hospital and for the system and everything was better, if you could dothat. so, cms says, okay well what we're going to do it, we're going to do a 5% percent bounty or 10% percent bounty, anadditional reward payment for every hospitals that's able to get people on theright antibiotic, at the right

time, within those three hours of theirpresenting. that seems like a kind of thing we wantto encourage the healthcare reimbursement system to do, assuming thatthe evidence truly supports it. so obviously it has to be simply a research enterprise initially, and then a dissemination effort, and you have, you have to find ways to get it into thehands of physicians who are busy and

lots of demands on their time. they have to be, what you're offering has to be relevant totheir particular practice and their setting. and so, you overcome all those problems first and then you say, i think, at some point you say, if you follow this,

these recommendations, follow them80% of the time or 75% of the time or something like that then we will not only pay you, but we will pay you a bonus. if you want the bonus, then you've got tofollow these recommendations. and if you don't want to follow the recommendations, you don't have to butyou won't get the bonus. and then at some point you say if you didn't follow the recommendations and you had a bad outcome we're sure as heck not going to pay for you to fix the outcome

and we may not even pay for you to do that same procedure again. we're just not going to pay for it. but this is years in the future. of course, it's those years in the future that the physicians are worried about. at some point the a recommendation will become mandatory and they might not be right for yourpatient. and physicians tend to feel that their patients are unique.

as somebody who deals with data, nothing is unique. it's all just a distribution, some people are in it and some people aren't. i've never bought the argument thateach patient is unique. senator whitehouse's argument forgets that medicine is personal. what is the right antibiotic, for me? let's say it's a fluoroquinolone, which is great for pneumonias.

we talked about a respiratory infection. fluoroquinolones are absolutelycontraindicated most the time in elderly patients because they cause mental confusion. but, there's no question they're the bestmedicine when it comes to treating a large number of respiratory infections.they're oral, they work like an iv antibiotic. but yet they're oral.

but we're gonna take out that personal knowledge and we're going to say we're going to do it. so, if we want the government to makethose decisions to ignore the art of medicine to ignore the personal nature ofmedicine, that will defeat this amendment. but, if we really want to

benefit from this agency and get the information out there and then allow the physicians using their gray hair, using their training, using their experience,and also most importantly using the knowledge of the individual patient. not what's something that on a chart that says here's the best way tocookbook this,

but what about the individual patient? could we save money? yeah. could we have the same kinds of outcomes? no. will we have the same kind of confidence? no. will we lead the world in cures? no. so, you know, it's a big issue and i understand we're not going to winthis vote but the political ramification is thatyou're going in a direction that most

americans don't want you to go. senator, thank you very much. i presume we'd like a recorded vote on this issue. - yes, yes. - okay then we will call the role on the coburn amendment number 9. (names being called in the background) the bill is open to further amendments. senator coburn. senator coburn:i have coburn amendment number 10.