from gao that it will actually save money. back and look at it again and see in the language should be used. a simple amendment, score them for us, as to whether they are going to save money. if they don't save money they shouldn't go forward until they do net money over the period of ten years. >> senator yñ

amendment even know i'm going to oppose it. i always admired his frugalty he brought to the table and brought things to our attention that we had to pay attention to. but i find his recommendation -- his amendment to be most peculiar and i will tell you why. first of all, there's no doubt, we have to acknowledge the cost of health care and the cost of writing a new prescription for health care. this would only add one more layer to evaluating what cost is. i think the sequences are number one, i have never heard of gao doing a perspective analysis of anything. they've always done a retroanalysis, usually to give us a sense of cost or better and more efficient management reforms.

so gao can't do this because they would know what it is we're doing other than what is actually in title 2. i don't know how they would evaluate it other than giving us scrubbing information that is already in the public domain. so i view this amendment as simply throwing sand in the gears. we do have ongoing conversations with the congressional budget office on the cost of both this title and the cost of the bill. oddly, that's the appropriate place where those conversations should be going on and i believe the committee established a feedback group now between us and the gao in terms of the cost of whatever title. however, let's talk about cost

and what prevention and quality is. there are many things in here when you score the cost -- my father used to say, basrb, sometimes you have to spend money to make money. we have to save money to spend money. i didn't sit here while i was getting a manicure and wrote up five ideas on how to achieve quality. we had extensive hearings in terms of public experts in the area, number two the consensus in that area about what needed to be achieved, number three, estimated costs that it would be based on real life experiences. like the north carolina approach on medical homes. the management, the patient safety implementation, the checklist that was developed that saved michigan $200.

we went and held extensive haegz and went to the public domain on the consensus of ideas to improve quality and got estimates about what it would be. we put a lot of stock into these agencies, gao and cbo and i have a lot of respect for them, but the methodologies at times are dated. let me give you a metaphor, say you wanted to lower the cost of your gasoline expenditure in your family checkbook and went out and bought a hybrid, under cbo's method, that would be counted as a cost. you're counting it as a saving. that's kind of what we're doing here. what we're looking at is how we can achieve savings by improving quality, by improving problems and at the same time, yes, what we make expenditures but in the long run they'll be improving.

i oppose the gao study because it is -- they've never done anything like this before. i believe we should stick with cbo, even where we question these methodology, we have both an organization that advises congress and we have a feed back group where we can be discussing this. i urge that we defeat the gregg amendment. >> mr. chairman if i might briefly respond. >> senator gregg. >> first off, i don't think it's throwing sand in the gears to find out how much the programs will cost. whether they are going to be savers or expenditures. i have no dog in the fight on behalf of gao, i'm willing to modify the amendment and would ask to modify the amendment to wherever it says gao, we'll insert, end or cbo. i would say that we -- what we

do need, however is an umpire, a fair ash ter of whether or not we're getting what we claim we're asking for. this bill is already scored as being a trillion dollar add onto the deficit, the debt, we haven't seen the entire bill. when we finish scoring the entire bill, should we get the language, i'm sure it will be close to close to a $2 trillion in spending. so to spend more to get savings, which was may well have been good advice from your father, i don't think is applying when you're talking trillions of dollars. i think a better metaphor would be the one out of vietnam, where we had to destroy the village to save it. when you put this much debt on the back of america for purposes of improving the health care system and getting savings, you'll never catch your tail. the debt will overwem you. i believe that we should have a

gate keeping that says, okay, this program yes, it's projected -- you're saying it's going to save you money, yes, it will. another program, you say it will save money over the long term. no, it won't. take one example in the workforce section of this bill, there's -- >> wait a minute. we're entitled -- you can do that when you get to workforce. >> i'm taking this as an example. there is a lot of talk about adding a lot more personnel, the dartmouth studies which are the rule of the road around here in the area of quality developing saves, says when you add a lot more personnel, you increase costs. there ought to be an evaluation, we can do the same in the quality area. a lot of issues on the quality side. i don't think that we should go forward on a wish and prayer and anecdotal events. we ought to have an independent evaluation whether the things

will save money. honestly if they don't save money, we're in deep trouble. we're running up trillions of dollars of debt. and the debt as senator conrad says it the threat. i just would ask we support this amendment obviously. >> if i can, just to express a point on that. whether it's the gao or the cbo or -- these are not policy making bodies and we are. we can debate about whether or not an investment in some aspect of quality is a good decision or not a good decision. i would be reluctant to set the precedent of giving an outside organization to have the ability to cancel the program because they've conclude that's it might have a cost associated with it. that's really our function as a body here as well as a finance committee to make those determinations. it's been a general conclusion

over the last number of months as we've had a number of hearings and working groups that we clearly are going to bend the curve down, it is going to be in the area of prevention and quality, not quantity as has dominated the health care, how much people are in a doctor's office, in a hospital that determine the sick care system. we're all interested in keeping people out of those offices, out of those hospitals, true prevention and improvement of quality. we rank 37th in the world in terms of quality of health care according to organizations that evaluate these kinds of issues. title 2 of our bill includes the following, includes research and provisions of research and provide patient with medication management and reduce hospital readmissions, facilitate shared decision-making and conduct health outcomes, researches,

integrate patient study training in clinical education and improve the health of women. stream line transactions, those are ideas that have been submitted to us and these are areas that could vastly improve quality. there will be some cost associated with it. if the criteria is exclusively, whether they decide then to strike them from the bill. we basically relegated ourself to nothing more than the proposals of the bill and to determine whether or not they include it or not. that in my experience is never something we've done before, given the outside organization the ability to preclude something. we need to assess. i would like to know what costs are, that a legitimate inquiry and essential inquiry. to defer the power to terminate goes way beyond what anyone would want to set as a

precedent. >> i don't think his amendment deals with terminating. it preincludes i am plimtation which means we don't get to start it. we're not stopping a program already in effect, it's allowing us to set the policy. but we're not the accountants and the ones that put together the numbers and that's why he's putting cbo in it as well. they are the one that's can tell us what -- kind of what the numbers are -- >> but they have. >> they haven't, because we're rushing head long into the bill without having the numbers and we need those numbers to make good evaluations, we need to have them after we do that if not before. that will give us better numbers to go on. there have to be some limits to what we're spending and when they exceed all programs that you mepntioned there over the

ten-year period would result in savings, and that's what we're hoping for. so it seems like a logical provision to me when we don't have the cost to begin with. >> could i just enter a fact into the conversation as we listen. title 2, first of all, when cbo gave us the preliminary scoring, and we saw the trillion plus, that was uncovered. they looked at title 2 and said there was no cost to my title. so cbo has already spoken on title 2. what they raise as a flashing light, yellow light was the coverage. so you're going ask cbo to do the same thing that they did a view of. >> but that, as senator knows, a little bit at the margins are of the implications of what they said because they said there was

no direct spending in title 2. it is an authorizing events which create discretionary spending potential. because we pursue that, we should know whether or not it's going to return the savings that are represented it well. you're not going to be able to know that unless you have cbo or gao look and give us a score on whether that's going to occur. it is a bit off the mark to say they didn't score it as costing anything because it was an authorizing event. as we know authorizing events lead to appropriations -- >> senator bingaman. i was going to comment. i think the amendment assumes that the ga omt or cbo can know more than they actually claim to be able to know. we have this letter that doug endorsed, the director wrote to senator conrad on the 16th of

june a few days ago and he talks about -- says policy options that could produce budget tri savings in the long run. a number of specific reforms show great promise for reducing federal spending on health care overtime without harming people's health. then he goes on to say, however, experts do not know exactly how best to structure those reforms to achieve that goal. they will need to learn through experimentation. some of what we have in here is going to inform our judgment about what works and what doesn't in reducing health care costs and reducing the budget deficit. for us to say until -- saying until the experts can tell us that it will, we will not proceed means we will never do the experimentation that's

needed to inform the judgment of experts in these areas.@@$%gi )) have -- are very much in expectation in changes which we're not certain will occur. and i hope they do and i very much hope that we see the improvements in quality and reduction in cost that we're working for here but i think there's a lot of experimentation in this. >> i don't want to close off debate, but i would like to move along, if we can.

senator mikulski. >> chairman, if senator bingaman and senator gregg, the statements we made, we're comfortable we're at the point where we will see cost savings. he anticipated there would be savings from the wellness provision, prevention proigs, what are we afraid of? if we think it will demonstrate savings, what is the harm in affirming in a. i think as senator gregg has mentioned, this is not something that we're going to float out here for a few months or a year. we're going to be putting in place a system, systems that will be with us for perhaps decades. and i think it is important that we have some understanding as to the cost. if we believe that we've structured this in such a way that we will see the costs, why

are we afraid of whether it's a gao or a cbo score? >> the reason is as you read the amendment it precludes implementation of any program. so any program. there may be programs within here, you're eliminating something that -- >> like immunization. >> they may actually reduce costs but any program with an increase in cost, which we can't know until you try them out, that's the part of this that worries me. i'm not afraid of find gs out what things cost, the gao or some other group would have the right, power of collectively the congress, even though we thought something had value, the gao says it costs too much, it is gone. that's exceeding way beyond -- >> that's a precedent i would be uneasy about implementing. >> i would be happy to name the program that's would be subject

to this requirement within titles 2, 3 and 4 and negotiate which ones with the chairman are applicable to this requirement. >> well, i don't know if we can do that this moment here. why don't we just -- if there's no further debate we'll call this question. all those in favor say aye. >> those opposed? >> no. >> the clerk will call the roll. >> senator dodd. >> no. >> no by proxy. >> senator mikulski. >> snow. >> senator bingasman. >> no senator brown. >> no, senator casey? >> no. >> senator hagen? >> no by proxy. >> senator enzi. >> aye.

>> senator gregg. >> aye. >> senator bird. >> aye by proxy. >> senator mccain. >> aye by proxy. >> senator coburn? >> aye by proxy. >> 13 nos and ten yays. >> 13-10 was the vote. the subject is open to further amendment. i think senator hatch has number 8. we adopted an amendment before you arrived. we adopted a hatch amendment while you weren't here? >> no, that's a blessing. we're on number eight.

>> am i on -- >> you're up, sir. >> we included your chiropractor immunity -- >> that means a lot. that means a lot. i'll call amendment number 8 on comparative ektiveness research. the purpose of the amendment, to summarize -- >> which number is this? >> number eight. number eight. >> staff will please distribute the amendment if it hasn't been already. >> okay. >> go ahead, orrin. >> thank you, mr. chairman. the purpose is to prohibt the use of comparative effectiveness research by providing the standard of care in state and federal courts. now, what i'm concerned about, i believe patients and providers should better understand their care and be confident of its

efficacy but never lose sight of the fact or of the basic understanding that medicine is simply not an exact science. we're all different beings and we sometimes need different therapies, some drugs work for some people, some work for others, some don't work for some people as well. there's a varability that affects their treatment outcomes and only within the confines of the physician/patient relationship should treatment decisions be made. we must preserve and protect that physician/patient relationship. what might work for one person or even many patients does not mean it will work for every patient. allows physicians to practice medicine without the fear of frivolous lawsuits and add more medicine through frivolous

liability lawsuits. in my earlier life, much earlier life, i did some medical liability defense work, defending doctors and hospitals and nurses and health care providers, et cetera. and once they came up with the doctrine of informed consent, rather than the standard of practice in the community, every case went to the jury. with the language in this bill, every case will not only go to the jury but they'll have good -- they'll have an easier time making a case to the jury in certain cases. i don't want to interfere with the physician/patient relationship. i think we got to allow physicians to practice medicine without the fear of frivolous lawsuits. in my experience with medical malpractice lawsuits, a high percentage of frivolous, they are brought because the personal injury lawyers can make money

off of defense costs, generally between 50 and 200,000. i think they may be higher today. what insurance company is not going to bow out of the case with whatever the defense costs are and leads to a multiplisty of suits that really will go to the jury but should be found by the jury to be frivolous in nature. this would add to that in my opinion and add to it in very serious ways. without any safeguards in place, the safety and health care delivered to patients would be in serious jeopardy. patients are different. doctors approach patients differently. your own physician knows what your pluses and minuses are or at least has a better indication than one size fits all safety standard that might be put out from washington here. now, in addition, our president has pledged to the american people he will not sign a bill

that does not contain health care costs. well, both sides of the aisle now, one of primary reasons for the staggering rise in the could have of health care is due to frivolous lawsuits against physicians and against hospitals and nurses and health care providers and so many others. and a lot of them are brought to get the defense costs because you can make a darn good living. off of these suits. because they are generally brought on a contingency basis and the attorneys get 25 and 40% in con ting ent fees. i can't blame the attorneys for bringing these kind of lawsuits. since we don't write the laws to resolve these type of problems. and if we go the way that we're talking about with comparative effectiveness, setting the standards for everybody in the country and for every individual regardless of what that

individual's individual needs are, i think we're just opening up the door for a multi -- plethora of frivolous lawsuits. i think you have to put safeguards in place to mitigate these litigations and of course, you know, i'm very strong supporter when you have a true medical liability of resolving those problems having worked in the past i've seen the wrong eye taken off, wrong leg taken off. wrong kidney. there ought to be tremendous settlements for those and they were settled and those type of cases should be taken care of and others where there is a serious negligence on the part of the physician or the health care provider. but all too often we're providing a means to drive up unnecessary defensive costs. we all want defensive medicine,

everyone would like to have doctors rule out a lot of things and by necessity will be some defensive medici but it goes wa beyond that. doctors, give caution to whether somebody comes in with a minor problem, you can't afford to just give them one pharmaceutical and tell them it might help them get through it. you've got to make sure to rule out every possible problem that might possibly arrive. i use commonly the argument that if somebody comes if with a common cold, you can't say take two aspirin and in seven days you'll feel better or don't do anything, in seven days you'll feel better. 50 bucks. >> no, they come in, you can't -- the doctor can't take the chance of the slight possibility that there might be something more involved. you're going to get respiratory

exams and in some cases we know mris and cat scans are overused. sometimes they are used because the doctors are paying for them and have them in the facilities and want to make money off of them. i'm not trying to paint the medical provision as being wrong here or being evil, but it does happen. we all know it. and all i can say is that we're with this language in the bill, if we don't correct it, you're going to open the door to even more medical liability, frivolous lawsuits than ever before, when in fact when you do have a good case, you still can bring it. i would be the first to stand up for people to be able to bring that case. i think it's a reasonable approach. last but not least, if we don't change it the way i would like to have it changed. we'll have rationing established right here in washington, d.c. and it's going to be by the comparative effectiveness of the people. some people want that.

some people think that's the only way to get health care costs under control. i believe we ought to give the best health care we can to everybody nor should we ration care or ignore the fact that different physicians have different specialties and sometimes because patients are different each of us is a different entity in this world and we have different problems and different genetics and we have different makeups and different blood in a lot of ways. and they keep going and on with the differences. sometimes what works for one doesn't work with another. i see that in the pharmaceutical world all the time. i'm very concerned when we do these type of a bill, we do it in a way that doesn't increase cost and make it even worse than what we have now. i think that language will make it worse. this would correct the language in a small way but nevertheless an important way. >> thank you, senator.

let me turn to senator -- i believe the only member of our side of the judiciary committee, i know senator hatch as well. >> let's be clear, senator hatch's amendment number 8 would prohibit the use of research conclusions and recommendations out of the center for help outcomes search and evaluation as evidence in any civil action involving medical negligence or misconduct. this amendment seeks to set rules of evidence for every court in every state in every state in federal court across the country. that is certainly not something we should be doing in health care reform. the admissibility of evidence in a particular case should be decided by the court based on well established principles of law. so, that's not one. number two, this legislation, in other words, the