it is essentially window dressing. >> that is one man's opinion. we think it is far more than window dressing. >> compared to the cost of the ruling government in healthcare in america. >> i understand that but these are serious matters. that is why there are 170 amendments. >> it doesn't matter if there are 1,000 amendment, the point is you are not addressing the essential important elements of healthcare reform in america so let's not tell the american people we are. >> john, that is your opinion. our opinion is getting this right. everyone is entitled to their own opinion. the facts i hear that we are getting that done and we will present that when they have the matter to put before the committee. we don't have that yet. i wish we did today, but we don't. we will try to complete those and in the middle of do we tried to have numbers to give to people. >> i noticed a tough job mr. chairman and i appreciate the many hours you and the staff that put on in the labor on this

issue, but we really are missing the essential elements of healthcare reform in american and i don't know how we can possibly tell americans we are, unless we are giving a complete package of healthcare reform. >> i don't disagree with the john. getting it right in have the numbers that work, having achieved the goals of accessibility, reducing costs and quality healthcare is a complicated task. we would have done it 60 years ago and ever administration and every congress has tried to for more than half a century and haven't been able to come up with exactly the answer but we are determined to try this time to see if we can come together to draft something that does those three goals we all in grayson share. there different ideas on how you do that obviously. which are some of them already in lobbies the the cost, the coverage issues, those are critical issues that need to be addressed and getting it right so we are comfortable with it and certain. i don't disagree with you on that it all end of lease the

getting there is important. mike, any opening comments? >> i am ready to get started. >> barbara, the want to make any opening comments? howie thank you for your good work and your staff also. >> thank you and mr. chairman i know our staff has worked for the weekend. i think the time now is to come to closure on the equality section. we are prepared to deal with the amendments that are out there, offer suggestions for compromise and a new direction with some others. so, i believe the amendment that created the most provocative all, a prolonged conversations was on comparative effectiveness, and i believe mr. chairman there is a pending amendment on robert coburn.

is that correct? >> it could be. is that where we left that, mike? i think it was yours. tom, i think he rode down something. >> i did and i would like for us to consider that if we might under unanimous consent. i understand the concerns. if we are going to do this work. i personally have some question about the area but we are going to do that work. that is inevitable. >> reserving the right to object. reserving the right to object. i am not going to object, but i just want to say, we can't be doing amendments on the back of the envelopes. and i appreciate the fact that we could move this over the weekend. i am going to be clear on what is our parliamentary situation with you are offering this as a substitute for roberts or you are the mendon roberts. >> i am offering a substitute for roberts.

>> now i am very clear about that and we will be ready to discuss it. i withdraw it in the reservations i have and the gentleman may proceed. >> the concerns were raised that if we do this work, with several billion dollar effort, that in fact, we couldn't use the work product to inform and educate and benefit from the work product that it is developed. and the concerns that were raised raised essentially that under the language that we had written, that it might for habit this task force and this agency from actually getting that information out. that is not our intention at all. our intention is that we don't use it to limit or marginalize care, and i won't use the word rationed because that seems to

be offensive and i understand wages offensive. but, in fact, we don't want to use it. so what this amendment simply says is that we strike a section that was all the controversy last week and we say are prohibited by using payment, coverture treatment decisions. nothing in this section shall be construed as preventing the center from disseminating reports or recommendations to healthcare providers. so, the one argument that was truly raised about our previous language is addressed here i believe fully, and would not limit in any way, shape or form the dissemination of that information. if in fact we are not going to use this to limit care, then what we will be using it for is to improve care. to increase quality, to bring people up and make them aware of the standards if they are not there. make them aware of best

practices, make them aware of the alternatives that might be more effective, and so i believe this is a good compromise to this discussion. it allows us to get the information out, but it the same time mashers the american people that we will, in fact, not use it to limit the availability of healthcare resources. >> senator mikulski. >> mr. chairman i want to comment and then i know senator whitehouse also wants to. first of all, i just want to assure the gentleman from oklahoma, who comes to this table with a great deal of clinical experience, and has always had his patience first. so, i appreciate him and i appreciate all physicians. when i looked at the issue of comparative effectiveness, there were going to be two things that

i, as we looked at it from experience of other countries and even from learned groups and foundations here. one was the shelp not shackled a physician, and interject government into the practicing room. that a physician brings experience, brings scientific training, brings dedication, and assumes risk and liability in that room. so, we made sure that what we had in our legislation would in no way interfere with who is in charge in that room when that doctors talking to the patient. the second argument that this raised was stifling innovation, and what we were also told there is, if you follow the obama language in the stimulus package

about we must not be construed, you will accomplish that purpose. i disagree with the center's recommendation up there. it is very rigid, it is very stringent. haygood absolutely have a draconian impact on the practice of care, because it could even prohibit them from being able to use any government entity. if there is in fact information that arises that gives better information about tools and methodologies that have been used, they would say at the va, be prohibited from using it. what will not object to the coburn substitute. i think, and stick with the original language that i had in my bill. i had come or are built. i had offered a different language.

that was rejected so i think the time now is to vote yes or no. >> senators, thank you. i would like to join senator mikulski in opposing this. i understand where senator coburn is coming from, and i appreciate his desire not to have an interference in the doctor/patient relationship. none of us want that but i think the effect of this language will be to totally unhinge payment from performance and to do so in ways that could have far-reaching effects throughout the rest of the system as we try to improve quality. to use a hypothetical example to illustrate my point, let's say was clearly proven that if he could get somebody to prevents-- presents with a respiratory infection under the right antibiotic within three hours, that the course of treatment was much improved for that individual, that the cost went down for the hospital and for the system and everything was better if he could do that.

so, cms says okay we are going to do a 5% belfiore timbers sent vaunty, an additional reward payment for every hospital able to get people on the right antibiotic at the right time within those three hours of their presenting. that seems like the kind of thing we want to encourage the health care reimbursement system to do, assuming that the evidence truly supports it. i think that that qualifies as the payment decision by a government entity that would be forbidden and even more this early cms could make this very decision unless and until this organization wrote it up. if telenational organizations decided this was the smart thing to do, then it could go ahead and do it but as soon as they organization rhoda, now suddenly can't do it any longer. so, it has i think the problem of overreaching and overbred said and risk damaging a lot of what we are trying to achieve, so i don't think it is an improvement over the present

language, although i understand the senator's concerns. franqui what it creates is enough discipline free-for-all for physician reimbursement. >> yes sir. first of all the language must be construed as exactly what is in the 1965 medicare bill. and nobody at this table can deny that medicare is rationing care as we speak. they are. and that is the language that allows them to do it. we have the same language. the second point and senator whitehouse boss argument, forgets that medicine is personal. what is the right antibiotic for me? let's zilaitis a faurot going to alone which is great for pneumonia. we talk about a respiratory infection. they are absolutely contraindicated most of the time

and elderly patients because they cause mental confusion. but there's no question they are the best medicine when it comes to treating a large number respiratory infections. they are oral, the work like a nike antibiotic yep they are oral. but we are going to take out that personal knowledge and we are going to say we are going to do it. i am can founded. unless you are really wanting this agency to control pfaff-- cost to the limiting of care, there's nothing wrong with our language. and the vote against it says you want to reserve that. you want to reserve it just in case we may need to have the heavy hand of government come down and tell you you can't give a virtual colonoscopy or when you can use epigenetic org u.s nuba jenne, gwen and oncologist can do this and-- what you are talking about is practicing medicine. well, kealy there except our

language or say our language doesn't have anything to do with it or you want to practice medicine. sally there we would prohibit the federal government from practicing medicine or we are going to crete this maisel where they can like medicare is today with the same language. and so, i think the vote is going to speak for itself. were reserving the right for this board to dictate to the american providers what they will and won't do. understand he denied that the fact is that is what is going to happen because that is what is happening today. that is what is happening with medicaid programs today. they tell them what they can in cantu, so if we want the government to make those decisions, to ignore the art of medicine, to ignore the personal nature of medicine then we 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 something on a chart that says, here's the best way, but what about the individual patient? could we save money? yeah. we have the sade note-- sin dems? no. we have the same kind of confidence? lori reed-- lead the world and cares? it is a big issue and i understand we are not going to win this vote, but the political ramifications is coming you are going in a direction that most americans don't want you to go. >> senator, thank you very much. we would like a recorded vote on this. the clerk will call the roll.

[roll call] >> no by proxy. @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ ãu [roll call] [roll call] the bode is ten ayes, 13 days. >> it was a good discussion tom and i thank you. this will be ed think and

ongoing discussion about how best we do it and i thank you for your thoughts and ideas. the bill is open for a further amendment for title to. >> i have coburn amendment number ten. >> coburn amendment number ten. do we have copies of that, tom? >> we should have. they have been here all week, so i don't know if you have them in front of you today or not. >> i think we do, don't we? >> should i defer until we get them passed around? we could do that. >> thanks. go ahead tom. >> what this amendment does is strike title ii, subtitled b with healthcare transparency provisions and investments in cutting edge technology. this the amendment would promote healthcare provider transparency as well as make medicare and

medicaid patient in cutter data available. this amendment would make substantial improvements in health information technology by utilizing the same technology that atm's and debit cards have used as an effective tool to protect personal information while providing more efficient access to important information. to promote competition and fair pricing for patients, providers will be required to provide a cost estimate for non-emergency treatments for coke after the treatment provider, must furnish an itemized list for charges for such treatment at the time of billing. to encourage more research and accountability for public programs, the secretary of health and human services is required to make available to the public including tran internet web site data on claims and patient encounters under medicare and medicaid. this is all privacy protected. to cut them bureaucratic red tape and administrative waste is the amendment utilizes cutting

edge technology to promote efficiency. every doctor's office including mine has shelves and shelves of color-coded folders, containing valuable in private medical information. everytime you visit your doctor, a nurse must record that come up paul lit, records same information as far as recurrence to your history, your present condition, your complaint, family history, which is similar to the last time you came to the doctor. not only that, once it is bank completed it can take months to get paid for whatever that visit was. instead of money thing for treatment dollars it caught up in the quagmire that exists under outdated medical information system and i think everybody this table wants is to see i.t. successful and healthcare. it is easy when you walk into a hospital or a physicians or any providers office to see why one out of $3 does not go to help

anybody get well or prevent them from getting sick. what this act this is propose adopting the same model used by the financial-services industry and promoting the use of automatic, automated teller machines. individuals get a card, on that card is their health information. they carry it with them. it gets updated every time you encounter the healthcare system. but they carry it. it is their health i.t. carper go rabid then as keeping all the health i.t. cars, we will have the record of this retreat and an updated file on i.t. but they will carry their own card. they also have the option of doing it through local health or some other mechanism that we don't know will come to market now, but what it does come instead of putting this large burden in the middle of the healthcare center, it creates in uses technology with which to utilize things that are already proven out there. and so we enabled that.

if used correctly the patient's savings on this could be billions and billions of dollars every year. it would also give us better and more timely information. one of the biggest problems we have as physicians to care for multiple patient's to see multiple doctors is getting the information from the other doctor. it will be right there in your card. the legislation would provide a charter for treating member owned, independent health record bank accounts that are operated in a cooperative institution for the medical information wedded here to strict privacy guidelines yet be computerized and readily available when needed. and you can see it, it is a large section from the patient's choice act which encompasses this and it is a 38 page amendment. >> senator mikulski. >> mr. chairman, i strongly oppose the coburn amendment.

the consequences of the coburn amendment is it strikes the entire practically, the entire quality initiatives. i say to my colleagues, if they would turn their binder that describes the bill, go to page for the index, he will get a better sense of it. let's say what the coburn amendment does is strike solve the health system quality improvements with the exception of creating a health infrastructure. first of all, if you look good the coburn and amendment, page 14, it strikes the agency of health research, the agency withheld research quality. that has been an agency that has stood the test of time, under both republican and democratic presidents, where we have focused quality research. it totally eliminates that. then, it eliminates our entire

quality section on healthcare delivery system research, our grants to community health to support a medical home model for goldstrike grants to implement medical management services and the treatment of chronic disease. eight eliminates this section senator murray did on trauma centers. it eliminates reducing the reporting on hospital readmissions. it eliminates shared decision-making, a recommendation that all professional medical associations support better informed decision. it strikes the center for health the outcomes research. it eliminates the codification of what we do in a women's health programs and it strikes the demonstration program to integrate quality improvement and patient's safety and clinical education. if you want to get rid of the patient's safety research center, community mental health teams, a reform of trauma

systems, and essentially be able to improve our system and also eliminate the agency on health and research quality, than that is the coburn amendment. by next we builds and improves on the existing structure. by efforts are the result of not me, but many of around this table and again we have consulted with professional societies, learned organizations, foundations and schools of public health that had been working and analyzing this for years on how to improve quality. the senators amendment does go to ways to deal with health information technology, but it is things like healthtrust and so on. it is weaker, it is tepid and it is really just a way of getting rid of the quality section. so i would urge the defeat of the coburn amendment, if in fact

you support one, the quality initiatives that we have undertaken and try to do in a bipartisan basis. and, substitute it with something we have never heard of or discussed that relates to the information technology. >> mr. chairman? >> senator. >> mr. chairman, i speak in favor of the coburn amendment and i don't believe the threshold is whether we have tried something or not. the question is how creatively can get in solving the healthcare problem. i actually negative building on existing program because everybody has walked in here in sedar current healthcare system is in shambles, the structurally unsound, that it is unsustainable. i think what dr. coburn is focused on his words that we all have selectively used, transparency, accountability, and he treats the health care services commission. it does do away with the hq r

cube-- ahrq but it is transformed and i thought that was in the spirit with which we were engaging in a debate on healthcare reform, that we needed to look at things and change them so that they worked in the 21st century. senator coburn's focus on technology on the ability to get real data in the hands of patients, the customers of healthcare. a hsc's purpose is to enhance the quality, the appropriateness and effectiveness of the healthcare services. through the publication of quality and price information. now, we may have a disagreement as to whether we are doing away with work that somebody has already worked on, but make a judgment based upon whether this information is valuable to the healthcare system of the 21st century. it if it is an effort to enhance

quality, enhance the display appropriateness and the effectiveness of healthcare services, which is the utilization aspect, i am not sure why we would not before. the chairman himself understands what fasb is, and this is a group who plays a role similar to the financial accounting standards board in establishing accounting principles. it is going to be a commission set to try to determine what the quality standards are, what the appropriateness standards are, what the effectiveness standards are. we can throw a lot of the amendments out because somebody has already worked on something and we have built on a system that we all have agreed need significant changes. , we have mr. chairman a lack of uniform standards. and today you can't compare apples and apples.

until we get a matrix in place that allows us to make that determination, i am not sure how we will ever gauge whether any language is successful. we have got to make data on pricing and effectiveness of healthcare services widely available for code is absolutely crucial to the success of an effective healthcare marketplace. without that, then we are only relying on the federal government to run it, but also tell us whether it is good for not. at the end of the day, i believe it is important that patients, customers, actually be the ones that determine the quality, the effectiveness and more importantly the cost. >> thank you senator. >> mr. chairman as somebody who cares very much about the development of our health information infrastructure, i have noted over the years that a

considerable amount of consensus has gone into developing the basic ground rules and under president obama a very energetic process is underway to which he has committed as you know, $20 billion expenditures to develop our health information structure. there may very well be a role in that process for an idea like a health records trust that electronically gathers all of our health information. but that is a very robust effort that is going on right now and i don't think it is appropriate for this committee to sideline that effort by dropping this amendment into the middle of that pot. i trust the obama administration to work with the secretary and a whole bunch of very good people at barken national quality foundation and the national quality assurance and other people putting together a good program and i don't think we should sort-- short circuit. there's a lot going on that would trump, and i think it would trumpet without adequate justification.

>> mr. chairman? on a little different no, i want to particularly draw attention to the first three pages of this amendment because my mom would expect me to do it. my mother was a, went through a lot of hospitalization at the end of for life in one of the things she always complained about was that she never got to see the bill. the bill goes to medicare. they can put anything on that they want. the patient does not know what they got it or not in one of the things this is insisting on is that the patients be given an estimate beforehand and then a bill afterwards, and i think it is a great idea. i am sure there are a lot of things-- at to hospitals doing more packaging pricing. you get the charge for the kleenex and the bedpan and that's sort of thing and that kind of comes with the room anyway. but, they don't know what the medion