they may not know but they never even get a chance to look. that is my complaint and that is what she wouldn't expect me to say because that is something she wrote lots of letters about when she was living. holcombe i don't get to see the bill? >> mr. chairman? i would like to ask the sponsor of the amendment, my understanding and please correct me if i'm wrong, the intent of this amendment is that people can find out what the cost of, except for emergency medical condition, the estimated price that the provider of services or supplier will charge for the treatment. is there any-- >> ultimately the quality. >> and ultimately the quality. >> ultimately the quality. >> and the rest of the amendment is to shape agencies so that that information can be provided to the patient. ..

>> this is a thick amendment. >> this is the exact opposite of what we're doing here. what we're doing sheer a top down.h a top dowe a top downr e down. a top down.is a top down. what this says is quality parameters throughout the country mean something and we're going to have a quality commission. we're going to have it set or it's going to be available where you can get it. and it's not just going to be who we pick or who somebody else wick picks. we have not one metric, we have no idea whether it's effective. when we measure it independent and ask for a study to stay is this money the metrics that say it is making a difference? we don't have that. we have some small areas but overall for the 16 billion we

spend we don't. and what this amendment is saying not all the wisdom lies in washington and in fact what is right in washington state may be different than what is right in oklahoma given risk factors, environment, climate, everything else but the point is with this amendment -- it is not trying to get quality. it's trying to establish common sense with parameters so you can measure it. have you ever asked yourself why we don't know, why we are not getting kids immunized? we don't know. we just know that we are spending a whole year and we have got these disincentives and that's coming out of washington. >> senator from maryland said this amendment would be canceling a whole bunch of other provisions of the bill.

is that good or bad? >> well in my mind it's a good. that's why we wrote that way. >> why wouldn't what is in the bill sufficiently address what's being addressed? >> it does it the same way we've been doing it. as we create another program we create an agency and another top down bureaucracy and i know that is not a politically correct word at this committee accept when you want to do and earmarking claim that bureaucrats are not doing things right but the point is what we have had doesn't work. it does some but we are throwing billions and we have no metrics. this is saying this is about transparency for the american people. the assumption under the bill we are writing today is there isn't much personal responsibility but there is a lot of government responsibility. and what this amendment does is say you ought to have a little bit of personal responsibility

on your health care and you can find out what things cost, what quality parameters are, you can find the outcomes. this is like a consumer report for health care. that is what this is like. words like accountings, but what is is guidelines and it's not used to ration or limit care. it's to allow personal judgment by individuals to make decisions. i'm going to have another amendment eliminating the and i take back because that's one of the things on the i.t. pete stark agrees the progress rapidly another 35% of the health i.t. because we would tie physicians to their hospitals and have systems integrated but that's another amendment. the whole point is we are looking at it from washington looking out and what i'm trying to do is get us to look at it for now in the country and look

in. >> thank you, mr. chairman. >> senator mikulski. >> let's go to the actual amendment, not what a aspect of it does or may be an interesting idea or whenever. if you go to the front page of the colburn amendment, it says strike subtitle be of title to and insert the following. so he strikes the entire section with a title deed which goes to the patient safety research center, community health teams, trauma system reform and others and eliminates the agency with health research quality so that is what this amendment does. it strikes and inserts essentially an i.t. package. so that's number one. i think that our quality section had a lot of work and it should

stand. second, during the course of the deliberations are held six hearings on quality. six hearings on quality and we wanted them to be bipartisan but hardly any members of the party showed up except the last two. so all this stuff now of information technology and so on is coming brand new. i don't dispute but if you want to be in the game and shot to play and part of the play was to participate at hearings and where there was innovation to also try to suggest if in fact it was innovation. so that's number two. number three on health information technology, great passion of mine as well as i know others on the sides of the aisle because i think it will go to pittard case management, better issues around cost and

data. some of the elements the senator from oklahoma has mentioned and my effort here when administrative simplification has to be sure it is interoperable and works. one of the things i wanted to of wait and work very hard to do was make sure we don't have a techno katrina. when this money is spent at the end of the day we have a system that does work that promotes the interest of patients, the interest of better acknowledgment of cost, acknowledges civil liberties in the right of privacy, and be able to accomplish those objectives but to deal with the three issues that quite frankly my own maryland medical society said barbara, make sure you were dealing with cost, make sure its center of her ability and lookout for the physicians in terms of obsolescence so we

listened. we listened very hard. so that was on the health of t aspects and on the quality we also listened very hard and tried to do it in a very thorough way. we looked at the basic issues that impact quality. medical errors, simplification, hospital readmission within 30 days and the need to better manage chronic illness. we focused on that and built on the existing structures so mr. chairman i would like to oppose the colburn amendment and if there is no further debate i would like to vote. >> mr. chairman for the purposes of the record i would like to say that i don't think any member on this side of the aisle regardless how many hearings we have attended, we are consulting on the construction of the text of this bill. most of us haven't seen on till we walked in the day before the market. 50% of the bill we haven't seen.

to suggest the number of hearings we went to dictate the level of the input we have in the bill is ludicrous and i would like the record to show i attended some of them. i didn't make all of them, but i was not asked what should be in the base text. the only opportunity that i and others have to affect the language of this bill is to offer amendments that seem to infuriate members. >> i thank the center. >> i'm not infuriated. i'm pretty column. >> let me just say if i can to tom coburn this is a 42 page amendment and as i look at it going through and almost struck me in areas it might instead of striking coal areas as i thumbed through this id tilled the reading, their ideas incorporated which i think at some point would be valuable in the context we are dealing with

to supplement rather the efforts certainly transparency, accountability issues. all loveless i think understand it is going to be very important personal responsibility aspects. you are going to hear from tom harkin shortly as it goes to the issue how do we get people to change lifestyles. you've spoken about this in the past how that may be the critical piece in the long-term implications bringing down costs and improving quality of health in the country so i think there is again one of those moments there is a great sharing of common principles in this bill. things we ought to be built to achieve and to and i can't say with all the details of the amendment but i think some concepts the ones we all embrace and share i think striking the whole section is where it gets an easy because there are very valuable sections senator mikulski has included that are important that go to the heart of what we are trying to

achieve, so i would oppose the amendment but again, as barbara mikulski said there is an appreciation as a medical background and it's important to hear when you had to say. >> mr. chairman if i might, just one point is the process is causes an amendment like this. we are told here's a bill. i would much rather have gone through the bill piecemeal, but part of ours in, part of ours out. i would much rather have done that. we were afforded no time because basically we were not in on the writing of the bill so it is like i said early last week if you want to accomplish it, this is part of the patient choice act. very balanced, just as interested in quality outcome as anybody who's written anything from the other side. but it looks at it in a different way. and it says go to work.

personal responsibility is incentivizing that. we know that from the record. i appreciate the words but the process is what is creating the amendment like this. this amendment isn't a dog. there is more than one way to do a lot of things. our proclivity in washington is to make it washington center. this amendment is about making it patient centered and individual center, not washington centered so i called the question. >> mr. chairman the first two paragraphs, a on the treatment disclosure and we do have that in medicare and on post treatment. how many times have a constituent come to you and said they charged me for this and that but i didn't get that so

you give it to your staff and they do case work and get it worked out. but i don't know that we have that as much in the prior outside of medicare. so i think that has a lot to commend and i'm intrigued by the idea of the post treatment. i'm a little hazy on that how you might estimates that. you might give an estimate but then complications set and a half later on and different things have to be done and your estimate may be way off the mark. but it might have some value. the rest of the amendment i don't see to be frank about it that much value but those to i think to plus i also point out it runs as the u.s. presented if the task force and we will have more to say about that when my title comes upon prevention but i don't see in your substitute anyplace where you would allow

for the preventive services task force. >> we have a whole section on prevention and the choice act as well. >> well maybe you have something coming up -- >> mr. chairman, thank you. i appreciate senator coburn's efforts and interest in power in patient. he's always my knowing him a decade and a half interested in that and i support his efforts but i don't think though this is a washington centered versus patient centered discussion senator mikulski and the amendment is only patient senter if you will. i've been in treat watching the process with senator mikulski starting with the check list which has been around a couple of years now to her work on the discharge plan and that information can about because of this age or q effort to work with hospitals and so i see to learn from hospitals and pass

those ideas are around and develop them with one hospital and some sense competing with another and sharing information i think that this whole section much of which senator coburn wants to repeal this section helps in the mechanism of getting hospitals to share information getting hospitals to work with one another. i spend a lot of time as i think every member of this committee does talking to local hospitals and that's the administrators to be sure but also the nurses and doctors and the patient is occupational therapists and all and we really do learn from each other and i think this legislation greases the wheels to do that and this section will help us do that better so i oppose the amendment. >> mr. chairman i don't know whether this can be done in the kennedy or not but since we've got some encouragement on section 211 is it possible to divide the amendment? >> we might but i think rather than trying to do this at this

moment i suggest there be some effort to do that if tom coburn is willing but other than that we ought to vote on this and this is a long process. >> mr. chairman i just want to make a comment because it sounds to me like not many people have read this. this is about the effectiveness, efficiency and quality services. that is the commission is about. the outcome of health care services and procedures, clinical practice, primary-care practice, oriented practice oriented research practice oriented that means patience with real disease, personal health care technologies, facilities and equipment, health care cost productivity and market, health promotion and disease promotion, epidemiology and medical liability. and you know, so i want to characterize that accurately. this does everything you want to do in your quality section does

it for less cost with a whole lot less red tape with a whole lot more acceptance in the provider community. >> thank you and what i would suggest is that can be a discussion that can be revisited but at this point we want to move along and try to parcel out and break it out so i'm going to presume the recorded vote and the clerk will call the roll. [roll call] [roll call]

[roll call] [roll call] [roll call] [roll call] >> [inaudible] murkowski is no and mikulski is

yes. i voted no and the recent vote is aye. can i told you this goes back to when her dad was your. we get each other's mail, we get each other's e-mail. when her dad was here i was invited so much to the reagan white house. [laughter] thanking me and wanting to share their appreciation i just want us to be careful. >> the amendment is open for -- bill is open for further amendment. >> colburn amendment number 12. >> colburn amendment number 12, please. [inaudible] >> let me explain to you i look at health care i.t. and there's no question we we need it and

it's quite a help. the bill wasn't allowed on till 2011. why is that? there's no interoperable standard that's completed. we all want interoperable standard. if you want to save lives and cut costs to mauro you will vote for this amendment. let me explain why. under the into a kickback a hospital in a big city is prohibited from using their computer software giving that to the providers would it be radiologists or family practitioners or surgeons or obstetricians their purchasing power especially groups of hospitals and chains of costa was tremendous. they have the latest of their. if tomorrow there is no antikickback on just this

section where they could share their software with all the doctors that practice after hospital you would automatically bring 50% of the hospital physician practice in this country up to the latest level of interoperable. you also would make them interoperable with their hospital and with another because they would be using the same system. so, instead of waiting two years and i think it is going to be 2012 until it's finished but let's assume and set of waiting two more years we could tamar a 150% of the physicians in this country connect them all together within interoperable standard of whatever they are using today. the second point is when they're becomes a true interoperable standard all these health care facilities doing electronic medical records and

sophisticated i.t. are going to have to buy a fix, a patch to become interoperable. what this amendment says is the hospital can buy insurance so all of a sudden wheat now house the hospitals dispensing to their practitioners at a faster level and bringing upgrades so we encourage that and on just a little personal note to the practice of used to belong to our quote today is $480,000 it's not interoperable. and when we ask the question about when the standards come in two years what will it cost to make us buy the patch? what will the cost be? another $350,000. such decisions all across the country are not body and health i.t. because they are waiting for the standards because they know if they wait until the

standards get here they won't have an additional 300,000 or 400,000 or 200 individual practice may be 50 or $60,000 worth of expenses. and i actually had this conversation with congressman stark. he doesn't object because he think it will help with patience. it certainly will reconnect and all the advantages of electronic medical record on the advantage of information from the hospital to every doctor taken care of that patient is solved because we take away a roadblock that allows hospitals to share the software today. and that is all this amendment is trying to do is to get a little bit of exception to the stark and psychic back and say hospitals, you can share your software with physicians practicing at your hospital. if you're not practicing their, you don't get but if you are you can share which means they will get automatic upgrades and continue to talk to one another. so i think it's a matter of

efficiency and quality and it will get i.t. working faster and it will get the i.t. communicating faster while we wait on the interoperable standard. with that i rest my case. >> mr. chairman i naturally very sympathetic to the policy goals that have been articulated by senator coburn and in fact i have repeatedly said one of my great passions in this house on a tea is to make sure that it's interoperable and not obsolescence before it begins. also, it is a wonderful combination of senator colburn and pete stark which shows we can all work together. where i am as i've been notified by the judiciary committee that

they feel that our voting on this is outside of the scope of the health committee and belongs in the judiciary committee. what i have here is a letter from senator kohl asking the antitrust subcommittee be consulted on any proposals with the health care reform that create the antitrust exemptions or alter the applications of the antitrust law so they want the colburn amendment referred to them and not dealt with in this committee and we have looked at the colburn amendment and congressman stark and feel there are good elements to it. who wants kickbacks? the fact if we could facilitate health of i.t. that in and of itself would be a goal line in the situation where i have this

letter from senator kohl addressed to senator kennedy, enzi, bachus and senator grassley. so, i would recommend we not vote on the colburn amendment but referred to the judiciary committee. and with admonition, with the admonition that we really are supportive of the policy roles outlined in the committee. >> mr. chairman, my comment would be if we come through that legislation all the provisions outside of the scope of the committee i think it would be a lot smaller than it is so i suggest we then go through the bill, find those provisions outside the scope of the committee and eliminate them as soon as possible.

>> senator mccain, there's only one committee without bumping against and that is the finance committee. >> there are numerous provisions outside the scope of the committee and i would be glad to identify them to the chairman. >> i don't want to get into that. the fact is they view this as judiciary. what is the thinking of you and senator enzi on this? >> mr. chairman, i am not familiar with our work committee doing for referring. i know there can be point of order is raised on the floor in a normal circumstance but it's my understanding this bill will not go through a normal circumstance. it has to be merged with the finance committee bill, and it's my understanding that on the process on that they are not going to take one bill or the other for fear it would look like they were favoring one kennedy over the other committee but there would be the merging of the bill and then there is i think will 44 that allows it to come to the floor and this might be an even bigger reason for not

taking one bill or the other. there are no points of order against that no matter what committees are infringed or bothered with i think we ought to go ahead and solve and they would have an opportunity on the floor to make any comments to try to make any changes the same as anybody else but it's really something critical to this piece of the bill, and i would even be willing to do the medical liability. [laughter] which public has more jurisdiction of the committee but this 1i see as being kind of intricate to be able to do the halls of i.t. peace. >> and health information technology is the very foundation to what we want to do on quality. senator coburn and i are absolutely on agreement. perhaps a middle ground would be

just to take the amendment and also simultaneously refer to the judiciary if they have some big objection they want to will hearings they can let us know but i feel we all agree when the principles, policy goals quite frankly just might review there are no policy objections so mr. chairman, what do you think of that recommendation? >> this is one of the areas i think again i don't see any debate what we are trying to achieve. when we touch on the committee jurisdiction what we are trying to do is not for a new policy so john is correct there's a lot of places in this bill we are touching but it's more technical in nature conforming rather than new policy initiatives and i don't -- this is an antitrust area of jurisdiction and so i