we start with what we are trying to do on health care reform on this. but we want to talk about tonight some of the very important work we want to do as we really meet the president's goals. he's laid out to us the goals for health care reform and they are really three hold. they are to make sure that we contain costs. the fact that our businesses have said to us that the high cost of health coverage, providing health benefits for their employees, is -- has gone up almost double digits every year. what that means is that we have doubled the number of -- the cost of health care benefits to our companies in the last 10 years. . that's unsustainable for businesses, whether they're small businesses trying to be economically competitive in their community or large businesses functions -- functioning in the global marketplace and are competing with countries where health

care is not an employer's responsibility and costs are more controlled. we know it's an economic competitive issue, no question about that. we also know it is an issue for government, that i serve on the budget committee, the cost we talk about this, for medicare is unsustainable, if we don't do a better job of containing costs and improving quality and improving outcomes for our seniors, we're going to talk more about this this evening. it's also a huge problem for our families. hear all the time from our constituents about family who was a break in coverage and find themselves faced with buying a family ol policy with a preexisting condition and the cost of that pa policy if they find one is too high for them to afford. in the philadelphia area, a decent family policy costs from $12,000 to $15,000 a year. a family earning even $50,000 a

year, after paying their mortgage and paying their expenses and maybe trying to save something for the children to go to college and it's -- taxes locally and state -- don't have those kinds of dollars left for them to find $12,000 to buy a decent policy. they are completely shut out. which is a very significant problem when they want to go for health coverage. we know cost is absolutely a major issue for our businesses, families, and government. what can we do about it? how can we ensure we'll contain costs and improve quality and extend coverage to the 47 million or 48 million americans who do not have ongoing health insurance coverage. the fact is we can do numbers of things. we have been working hard on this to make sure we create the kind of market reforms that will enable people to buy meaningful coverage that's -- that is -- which is affordable

for them and will have the kind of coverage that matters. we know we need to make changes in the delivery system. that's what we're hoping to focus on tonight. what i mean by that for all of us who go to see doctors and nurses and spend time at all in the doctor's office for ourselveses or our loved ones, our numbers bear this out, we go to more specialists, we have fragmented care. what we don't have is access to a primary care provider who knows us, who follows us, works with us when we get a serious disease, helps us know what it is that we need to be doing, helps us comply with recommendations, and really also helps us know whether we need to see specialists. so whether you're fairly healthy or have a major health care crisis or a chronic ds we know you we can get better quality care and improve health

status for all of us, each of us, but also contain costs. i'm happy to give you some of the numbers that we have in terms of some of the primary care shortages. we often talk about primary care physicians but we also have a shortage of nurses, nurse practitioners, and physicians assistants and so many providers that are there for us but there's not enough of them the council on physician and nurse supply says the u.s. may lack as many as 200,000 needed physicians by 2020. here we are saying that we want you to see a primary care physician or nurse practitioner, look at the massachusetts experience where they worked very hard and effectively to extend coverage to the uninsured, what they found is people were still going to the emergency room because there simply were not enough primary care providers or clinics or community health centers for them to go to. let me go on with other

numbers, if i may. they estimate there could be a shortage of 800,000 nurses by 2020. 46,000 of those fi zigs need to be primary care providers. the number of uninsured rose but the number of medical school graduate -- the number -- there was a 30% growth in population and the number of physicians were the same. what's so interesting about that, we've heard, we have enough physicians but it's not in the right place. we've gotten that wrong. there are not enough primary care physicians or other practitioners. more interestingly, we may want to say that the number of medical students choosing primary care is steadily declining. even amongst those specializing in internal medicine, i'll say that in 1985, half of all internal medicine residents

chose primary care. now, only 20% do. i was at a press conference this morning with congresswoman kathy castor and congressman john sarbanes and a young woman who just graduated from osteopathic school she talked about the statistics and she said that most medical school graduates graduate with almost $200,000 in debt. their first job is a resident, still training, is usually paid at $40,000. how do you train for another three or four years, pay $200,000, that's medical school, you may have debt from college as well. it's a major issue going forward to make sure we have more primary care physicians. older americans also are seeking primary care services twice as often as other age groups. as the aging population we know the baby boomers are come, we talk about them in terms of social security, but the fact

is we know as we are aging and needing more health services, it is in-- it is very, very important for us to have access to primary care providers. let me also talk about the fact that one of the reasons we need primary care providers, all of us, but particularly those with chronic conditions, we think about needing health care when we get sick, an episodic experience where we need to go to the hospital, might end up in the emergency room, but for many people, they have chronic conditions. and they need to have an ongoing relationship with health care providers. so that they can get the kind of care they need, get the kind of advice, get the right prescriptions and be able to work with their medical practitioners to be able to comply with that advice and be able to make sure that they are healthy. the number out there is 50% of americans who get health care comply with recommended health care they're told to comply

with. so obviously we need some work here. this is not only the responsibility of those who pay for health services and those provided but for patients as well. let me say on chronic conditions, some of these numbers may surprise us. but the five most costly chronic conditions are cardiovascular disease, cancer, diabetes, asthma, and mental health disorders. over 133 million americans suffer from at least one of these chronic diseases. over 75% of all medicare expenditures can be attributed to patients with five or more chronic conditions. just 10 years ago, these beneficiaries counted for only 50% of the medicare costs. so something's wrong. we have to fix this problem. we have to make sure that people can hopefully prevent some of these chronic diseases we might want to do that in a

number of ways. i know there's discussion about wellness programs for prevention, we've seen some very good models, some larger employers and insurance companies are working harder to incentivize people to eat right, exercise, prevent some of these conditions from worsening. but clearly we have a long way to go and we have much work to do to make sure we help folks with chronic diseases be able to be healthier to get better to not have the disease get any worse and of course in that process, it'll save them money and it'll save all of us the high cost of taking care of patients. any of us who ever visited a renal dialysis cent every know if we can do more to make sure that somebody who, for example, is early diagnosis of diabetic, follows the prescribed treatment, does try to eat right, exercise, really take care of themselves and gets good, consistent health care,

and can prevent themselves from becoming more seriously ill and of course going into any kind of renal failure and needing renal dialysis would save them much problem and save us all a lot of the cost involved. just a few more numbers, i think they're telling. chronic conditions cost american businesses nearly $1 trillion each year in lost productivity. we don't think about the 234ur78 of dollars lost as workers take time off for serious illnesses. about $125 billion of this is due to lost work days. the balance is due to diminished capacity while they're at work. it's not only the cost of insurance and benefits but there's also a cost when their own workers are not being able to really work at the full scale of their potential and their capacity. so we node that we can do more. economic conditions, health

benefits, really taking serious action to make sure that we have enough primary care providers and do a much better job of coordinating care for those with chronic diseases, we'll really have a dramatic impact on americans and the cost to all of us. that's what we're going to do. we heard some others talking about the need to do medical research. we believe strongly in that. we've made very, very good commitment to doing that by putting more money into that by putting $10 million more into n.i.h. in the recovery and reinvestment act. we do want to see better treatment and cures. that takes dollars for medical research and a commitment to the science of biomedical research and some new products and devices. it also takes prevention and it also takes better coordination of care. we -- patients with chronic diseases need access to primary care providers.

we need to be able to make sure they get good ongoing chronic disease management. i've introduced legislation, it's house bill 2350, and i have to say it's got enormous support here in the house. 100 co-sponsor, i'm very proud of that and many other looking at it, only introduced it a couple of weeks ago. the idea of that legislation is to make sure that we preserve patient access to primary care and one way to do that is to increase the number of primary care providers by increasing the number of residency programs slots for primary care. we're going to hopefully do that and for more nurse practitioners and more nurses in this country would be very, very helpful. see if a colleague of mine is going to join us, just finish this thought, we also want to -- there's reimbursement for a concept called medical home. this isn't a place, it's a

group of services, a commitment on behalf of the provider, the doctors doctor, nurse practitioner, to be able to provide a medical home so you know you have ongoing care, particularly when you have a chronic disease and we can talk more about that going forward. i did want to thank my colleague for joining me, i see congressman amount mire has joined us, he's also from pennsylvania, the other side of the state. also a community, pittsburgh, which is known for its medical care and medical schools and has a lot of health care providers. i bet and would imagine that congressman altmire has some of the same experiences i do, while we have great quality health care, it is also too often fragmented, too often not accessible, it's too often not affordable for too many of our constituents. so we're here tonight to talk about health care reform and particularly the commitment we're making as we move forward to expand and extend access to

more americans to make it more affordable, that also means a commitment to fixing the delivery system and to primary care. i want to thank congressman altmire for joining us and welcome his comments. mr. altmire: i thank the gentlewoman. it's been a pleasure working with the gentlewoman as part of the new democratic coalition, we're co-chairs of that group. the gentlewoman hit it right on the head that we do have the best health care system anywhere in the world, if you can afford to get in. if you have access, and there are millions of americans that have insurance and they like it and they have access to the system. our medical innovation, our research, our technology far exceeds anything available anywhere else in the world. our quality at the high end exceeds anything available anywhere else. it's why people come from all other the world to the united states to get their transplants to get their heart taken care

of, to get their high end, high tech care because we do it better than anybody else. there's no question about that. the problem is, the costs are skyrocketing with our health care system. every family, every business, every individual in this country is impacted by the cost of health care. and not just with what you're paying directly for your health care costs. what your co-payment, premium, deductible is. but the cost of everything you buy in this country is higher because of health care costs. we use the example of an american-made car. $1,500 of the price of every car made in this country goes to health care costs. the health care corses of the workers who are involved in putting that car together. but it's more than that. it's every level of the supply chain. every segment. if you think about the company that manufacturers the good, the people that ship the good, the people who receive it and stock the shelfs and the people who sell it at every level,

there's a component of cost that is increased because of health care costs of the company involved in that. every level of the supply chain. . every segment of our lives health care is a part of that. what we are trying to grapple with here in this congress over the next few months is how to preserve what works in our current system because we don't want to throw the baby out with the bath water. we don't want to lose the good things about our health care system. but we do want to address the things that don't work. so we think about the fact that we spend $2.5 trillion a year on health care in this country. farrer more than any other country in the world -- far more than any other country in the world. yet in some things we don't get immediatey observinger results we get bottom of the pack results when compared to other countries in life expectancy, infant mortality. we are not middle of the pack, we are in the bottom of the pack. we can do better. we are not getting our money's worth, especially when you

consider the 50 million americans who don't have any health insurance at all. now, when they show upp at the emergency room, they get covered. they get treated. but the bill gets passed to the millions of americans who do have health care coverage. the reason you pay $10 for an aspirin at a hospital is because of the cost shift that takes place. making up for the difference of people who can't afford their health care. and there are tens of millions more who live in fear of losing their coverage. they are one accident, illness, or job loss away from losing everything. and that in the united states of america is unacceptable. so we have very high quality at the high end. but we have very high costs. way more than any other country. we have millions of americans who have coverage and appreciate their coverage and like it, but we have tens of millions more who don't have coverage or are underinsured.

so the challenge we have as a congress is how to fix what doesn't work, what's broken, but how to preserve what does work. we have put forward a plan and we are in the very beginning stages, there's a lot of negotiation that's going to go into this both in the house and in the other body, to talk about how we can achieve that goal. but make no mistake as the gentlewoman knows, we are not going to fail. we are going to pass a health care bill this year because the american people have demanded that we do that. and as i said it affects everybody in this country. the cost increases double and triple the rate of inflation every single year are simply unsustainable. we are never going to get ourselves out of the budget crisis that we have. our annual budget deficit and our structural debt that we have over the long term unless as the president says we bend that cost curve on health care. we have to bring costs more into line with the rate of general

inflation. ms. schwartz: would the gentleman yield for a moment. i think when some of our constituents hear some of those words they really want to know, and i think that's one of the things we are really interested in in pursuing here, is they want to know, does that mean i'm going to get less health care? does it mean aim not going to get what i mean? i'm going to go to the emergency room and turn me away? the fact is we are trying to be smarter than that. what we are saying instead is we want to make sure you get the right service when is you need them. i'm sure you hear from constituents who find they go to the emergency room because there simply isn't a doctor in their community. i remember when i was growing up there was a general practitioner down the street. we all went to him. and i bet there is no general practitioner there anymore. for many people i know parts of my own district we have seen some hospital units close. we have seen doctors offices close. it just isn't the way medicine is practiced right now. the truth is through

reimbursement both insurance companies and what we have done under medicare, we have not created any incentive for doctors or nurse practitioners to go and open an office in a small community and to provide those kind of services. instead we have encouraged them to become specialists, to really do the fancy kind of things. while we need them and we want to make sure we have those specialized physicians there and avail -- available for us, if we only focus on that we have really forgotten the simple things. which is how do you really talk to a patient? make sure they understand what they need to do? how do we make sure we have a shared sponet -- responsibility? the patient can say i'm sure can i take a pill for that. and we'll be fine. but that takes a patient-doctor relationship. that's often what's missing is that ongoing relationship with primary care providers. that's both physicians and nurse practitioners.

and that's one of the things we want to address. i'm sure that the gentleman's heard the cost of medical homes. maybe you want to talk about that. the idea of an ongoing relationship, the fact we are interested in this health care reform of creating a new opportunity to reimburse primary care practitioners for that kind of ongoing relationpship with patients so they know what special toist see. help someone sort through the many medications they take. i was going to give you one number my staff gave me earlier which i was struck by. it said that medical beneficiaries with fiver or more chronic conditions see an average of 13 different physicians per year. are prescribed an average of 50 different prescriptions. that's a lot to sort through if you're not an expert. it really is. to think about actually having someone you could talk to and say wait a minute, do i really -- should i still be taking these? shouldn't i? who do i ask about this? sure you have heard some of these stories from your own

constituents and some of your own providers as well. mr. altmire: i have. i thank the gentlewoman. there's a lot to talk about just with this one concept. this one component of health care. part of the issue that we'll i'm sure get into is computerized medical records. having electronic health record you carry with you everywhere so you avoid the situation that you described, the gentlewoman described, that you have as a consumer 50 different medications and when you show up at a provider somewhere that's out of of your hometown, if i go to san diego and put my a.t.m. card in the machine, can i pull up all my financial records, safe and secure, i never think about privacy. if on that same trip i end up in the emergency room, they don't have my medical history. they don't have my family's medical history. they don't have my allergies, prescription drug regiment. they don't have any imaging i have taken. there is no reason health care has to be the only industry in the country that hasn't gone to

an interconnected, interoperable information technology system. that's part of where the gentlewoman is going. but the other part, and this is a great point, is we have to begin to have our reimbursement system structured in a way that we incentivize the quality of care rather than the volume of care. we should not just talk about how often theatient comes to see the doctor and reimburse based solely on that. we should be reimbursed based on what's the appropriate setting for the patient. where would the patient rather be? and where is the patient going to get the highest quality care? and we don't do that right now in our health care system. and if you have a chronic disease, there are some cases, certainly it would be on an individual basis, in conversation with your physician, where it should be determined based on reimbursement, based on money, what setting you are going to achieve that care, get that care, but it should be what's the best outcome likely based on

the setting that you get? if home and community-based care is the best setting, we shouldn't provide a financial disincentive to get it there. if that's the most appropriate cost-effective setting and most importantly that's where the patient wants to be and that's where their family wants the patient to be, then by all mens we should incentivize that setting. ms. schwartz: the gentleman would yield. i appreciate very much your raising the issue of health information technology. you are absolutely right. the health industry has been so slow to really been involved in -- to really use the computer, to use information technology in a way that so many other industries have. and i think as any of us know who started out in our professionals careers not using computers, we sort of are a little slow to be anxious to do it. we were nervous about that. i remember someone who worked for me a number years ago who resisted completely.

don't be silly, i know what i'm doing. i take notes. i do fine. we finally told her she had to use a computer. and i remember just a few months later the computer system went down and she was like, oh, my goodness, how can i function? imagine health care which has been so paper driven and so labor intensive. the idea that physicians would have at their fingertip even within their own city, even within their own medical practice sometimes, talking with a medical practitioner who said, sometimes i don't know a patient who had been in my office seeing another doctor the day before. because the notes weren't transcribed yet, i didn't know what happened. or three days ago. or a patient of mine who i was visiting, and they said they now have the primary care physician has the ability to see the hospital records while their patient is in the hospital. they don't have to wait three weeks for the specialist who saw them in the hospital to write them a summary, have it

dictated, and mail it to the primary care physician three weeks later or four weeks later. turns out those three or four weeks are incredibly important after discharge for the patient to be following again advice of the physician. it's a very uncertain time. to be able to have contact with your primary care physician during that time and for the primary care physician to know firsthand what happened to you because of an electronic medical record is extremely important to helping them be able to provide the right care for you. and preventing the readmission which is a huge cost for all of us. we have talked a lot about that in terms of infections. there are a lot of reasons why people get readmitted to the hospital. if we can prevent that by the right kind of home care, right kind of of attention from our primary care physician, that's not going to only help that person be healthier but get the care they want. one other mention on the eleckic

-- electronic medical records, there are clinical protocols. we like to think every physician knows what to do with us. by and large they are pretty good. if you have to do all -- do five things for somebody when they come into you because they have some particular health condition and you tend to do four of those five most of the time, you're probably pretty good. but it turns out if you do all five every time, your patients are going to be better off for it. so maybe we don't -- we are not used to the fact the doctor might actually look that up on the electronic medical record and have to check it off. turns out it makes a big difference. you did remember to remind them to stop smoking and you did remember to tell a parent to put a child in a seat belt. all those things many seem so directly connected to what you are seeing them for, but make sure that they get the care they need. remind them about a mammogram. it's time.

a many woman who hasn't had a mammogram for three or four years. maybe it's time. not to mention obviously making sure they are taking the right medications. electronic medical records which you wrote the new dems championed we have a president who championed it as well. we put in a $19 billion in the recovery and reinvestment act to help really push forward in a much more ambitious way the use of electronic medical records in our physicians offices and in our hospitals and have them be secure, private, and interoperable is absolutely key. if you want to comment on that or other issues related to primary care and other things we can do in the delivery system that will help us be able to contain costs and get better at care. mr. altmire: i wanted to comment, following up on the gentlewoman's remarks about quality of care, medical errors. there are a hundred thousand people every year that lose their lives due to a preventable

medical error. 100,000 people. and needless to say each one of those individuals there's a tragic component to their personal story. their families, certainly their own loss of of life. but there's also a burden to the health care system of medical errors because there are hundreds of thousands more that because of preventable medical errors are injured and their treatment costs more and each one of those individuals more importantly has suffered a severe medical setback, their families are impacted by that, their lives may never be the same. but in the aggregate when we talk about cost reduction, something as simple as preventing infection as the gentlewoman talked about, as preventing medical errors through the use of information technology, these are things that are going to save billions of dollars for our health care system in the aggregate and more importantly they are going