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House GOP Doctors Caucus

Floor Speech

Location: Washington, DC


Mr. ROE of Tennessee. Dr. Gingrey, thank you, and it's good to see you moving your arm well and recovering from your surgery so well.

I think the question that comes up, and Dr. Gingrey and other Members and I have discussed this, when I got here--and I've been here 4 years, and Dr. Gingrey came a couple terms before I did--we did this for a reason because we wanted to impact the health care system in our country. The problem with the health care system in our country was that costs were exploding.

If you look, as he pointed out, the Affordable Care Act has been anything but affordable. It's suggested that by 2016 the average family of four, when you have to buy an essential benefits package--which the government will determine what that is--will cost a family of four $20,000. That's unbelievable when you think that the per capita income in my district is $33,000. So I think we're at a point or we're going to be at a point where no one can afford it.

Well, what Dr. Gingrey is mentioning in the SGR,

sustainable growth rate, what is that? What does that mean, and why should I care if I'm a senior? And Dr. Gingrey and I both have Medicare as our primary source of insurance. Well, Medicare started back in 1965, a great program for seniors who did not have access to care. It met a great need there and has met a great need since then. It started as a $3 billion program. The estimates were from the government estimators that in 25 years this program would be a $12 billion program--we don't do millions here, billions--and the real number in 1990, Madam Speaker, was $110 billion instead of $12 billion. They missed it almost 10 times.

So there have been various schemes throughout this time in which to control the cost, always by reducing the payments to providers. And who are providers? Well, those are the folks who take care of us when we go to the doctor's office--nurse practitioners, it may be a chiropractor, it could be a podiatrist, and it can be your hospital. So when you say providers, those are the folks and institutions that care for us when we're ill.

So in 1997, the Ways and Means Committee brought together something called the Budget Control Act. This is a very complex formula based on how you're going to pay doctors--their zip code, where they live, the cost of an office, the humidity in the air--I know it's an incredibly complicated scheme to pay doctors. The idea is this: We have this much money to spend in Medicare, and so we've put a formula together to only spend this much money. If we spend less than that money, that will go as a savings. If we spend more than that much money, then we will cut the doctors and the providers that amount of money to make that line balance.


Mr. ROE of Tennessee. Well, the particular slide that Dr. Gingrey has down there is very telling. Basically what it says is that each year that we've recalculated what our physicians will be paid, we haven't met those metrics, which means that we have to cut.

Well, what has Congress done? Well, Congress has realized that what we're talking about is not payments to doctors; what we're talking about is access to care for patients. What happens is if you go back to 2003--I think it was 2003--when there was a 5 percent cut in Medicare payments, we realized at that point right there that if you continue to do that, that access would be lost.

So let's fast forward to 2013, what we're just facing. Doctors were facing a 26.5 percent cut, the providers were.

Mr. GINGREY of Georgia. Dr. Roe, that would be right here.

Mr. ROE of Tennessee. That's correct, that number right there. That was avoided by a 1-year so-called ``doc fix.''

What has happened over the last 15 or so, 16 now, years is that the Ways and Means Committee line--now law--says we have to spend this much money, but we've actually spent this much. That is a deficit in spending that we've got to make up somewhere in our budget or add it to the budget deficit.

Now, I go back to when I was in practice just 5 years ago now in Johnson City, Tennessee. Dr. Gingrey, I don't know about you, but I was having a harder and harder time finding primary care access for my patients that I had operated on, or maybe someone who had been my patient for 30 years--if she was 40 years old when I started taking care of her, in 30 years she's 70 years old and needed a primary care doctor. That was getting harder and harder and harder to do.

Now, when you look at today's young medical students, we're having a much harder time convincing these young people to go into primary care. What is primary care? Well, it's pediatrics. If you want someone to take care of your baby, it's family medicine. It's also internal medicine and also OB/GYN. I certainly served as a primary care doctor, as Dr. Gingrey did for his patients, for many, many years. That would be the only doctor that they would see. But that's getting harder for our patients to do. And Dr. Gingrey, that's my primary concern--access for seniors to their doctors.


Mr. ROE of Tennessee. That is correct. And so much so that in California, what they're recommending, I don't know whether they've carried it out or not, but they've recommended expanding the definition of ``primary care'' to a lower-level provider, that would be a nurse or nurse practitioner or PA or this sort of thing, this sort of designation.

I think the other thing, Dr. Gingrey, that we haven't talked about, and we probably should spend some time on, is the age of our practitioners. In our State of Tennessee--where you see that we're not quite as dire in need as Georgia, our friends to the south--the problem with it is that 45 percent of our practicing physicians in the State of Tennessee are over 50 years of age. I'm concerned that with the advent of the Affordable Care Act, the complexity of that, the frustration that I see when I go out and talk to our providers is that I'm afraid that many of them are going to punch the button for the door.

I know in my own practice, where we have now about 100 primary care providers in my program, in my OB/GYN group, in the last several years we've had over 120 years of experience walk out the door and retire. That's not a good thing for the American health care system that just lost access. Quite frankly, the crux of it all is that access. If you do not have access, you will decrease quality, and you will increase cost. That is our concern. Ultimately, the cost will go up if our patients can't get in to see us.


Mr. ROE of Tennessee. I thank you.

And thank you, Mr. Bilirakis, for being here. I appreciate your leadership on the committee, too.

Why should I be concerned about this, and what experience do I have to say that if this is not fixed it will affect access and quality? I've had, I guess I could say, the misfortune in Tennessee of going through health care reform 20 years ago.

What happened? What happened was we had a large group of people in our State who didn't have access to quality, affordable health care. We reformed our Medicaid program and opened it up. We had an open enrollment time where we were going to have these various plans compete against each other. It was very much like the public option I heard discussed during the debates 4 years ago.

What happened? What happened to us was that our costs tripled in 10 years in that plan. It went up three times. And you can already see in the Affordable Care Act, even before it's been fully implemented, the estimates of costs have already doubled. The costs to patients are going up and the costs to businesses are going up. It didn't do what it had to do to really help solve the problem, which is lower the cost, bend the cost curve down. It did not do that.

When we saw those costs go up, what did we do? We started cutting our providers, and we cut our providers and we cut our hospitals and our doctors and our nurse anesthetists and our nurse practitioners and PAs and so forth. Guess what happened? Access got cut off. They stopped seeing those patients.

Now, our practice where we were, we, as an obstetrician as you were, we took everyone, because pregnancy is one of those conditions where you either are or you're not. We felt like if those folks needed care, we kept seeing those critical-care patients like that. But many elective-type things--orthopedics and dermatology and those kinds of things--got cut off, and people would have to drive hours to see a specialist.

So I saw access get denied in that system when the cost of the whole system went up to where no longer the State could afford it. I've seen that happen. That's why patients should be worried.

Dr. Gingrey, you and I know these numbers. We have 10,000 people a day hitting Medicare age. That's 3 1/2 million people this year that are going to be Medicare age. These are new people on the plan with less money. And if we have more people and we're not producing more doctors, do the math. In 10 years, we're going to have 35-plus more people on Medicare, and who is going to care for those people?

Another thing I want to bring up is that we're not just talking about how doctors are paid. We're talking about increasing quality. One of the measures we're going to look at when we look at the new payment formula--right now the way you and I were paid when we were in practice was a patient came in and you got a fee for that visit. That's called fee-for-service medicine. That's going to change. We're going to look at quality outcomes and measures. I'll give you an example about why that's important.

One percent of our Medicare recipients use 20 percent of all Medicare dollars, so we have to look at how we manage the care of those patients better. For instance, with congestive heart failure, when someone leaves the hospital, we know that certain metrics are taking place: weights are taken every day, blood pressure and so on. If you check in with a provider, you can prevent rehospitalizations and save tremendous morbidity, mortality, and cost. It also increases the quality of life that patient has and the quality of care they receive. So doctors are going to be evaluated on the kind of outcomes we have and the quality of care we provide our patients, which we all agree should be done.

I think coordinating care, hopefully, with better electronic records--and I could spend an hour talking about that. If we have a coordinated electronic system where, when you order a test at your office or the hospital, we have access to it so that test is not repeated and duplicated, that will make a huge difference in cost.

I just had a duplicated test, myself, done. You may have, too, when you had your procedure. I had a surgical procedure done 2 weeks ago this last Monday, and there was some testing on myself that really didn't have to be done. But because of various rules and regulations and the inability to get that information easily, it was easier to repeat it and pay for it than it was to go find it. I think that happens to 300 million people. Actually, it is 47 million of us who get Medicare now. We need to do that, better coordinate that information with sharing and transparency.


Mr. ROE of Tennessee. I had the misfortune of going from paper to an electronic record. I was in the process, at our practice, of converting. It's a very difficult conversion. I think if you started with just an electronic medical record, it would be much easier than transferring tens of thousands of patient charts to an EMR. But when you start from scratch, it's a little easier.

Certainly I think the electronic ePrescribe, which I like, I didn't have the pharmacist call me and tell--I can't believe he couldn't read my prescription. Anyway, they claimed they couldn't, and this solves that problem.

I think there are some disadvantages to it, but overall, I think it is the wave of the future. I think you are correct.

I'm going to bring up something now about: let's say we go ahead and we do fix the SGR payment that's based on quality and that's based on outcomes and transparency, on hospital re-admissions, and so forth--on all those metrics we've talked about to better serve our patients. There will still be fee-for-service. I'm sure, Dr. Gingrey, you're a rural Georgia Representative as I'm a rural east Tennessee Representative. I have counties that have one doctor, and you can't do an accountable care organization--or all of these things--in a small, rural county. So fee-for-service medicine will still be there for those patients so they can have access in small, rural counties and don't have to drive long distances.

Let's say we do all of this wonderful stuff and that we fix this payment model and that it all looks good. The Affordable Care Act has in it one little thing called the Independent Payment Advisory Board. This Independent Payment Advisory Board trumps what we just did--all of the things that you're going to do in your Energy and Commerce. Also, thank you very much for what you're doing on that. As to all of these cuts that you see right here, let me just give you the data.


Mr. ROE of Tennessee. I think correctly the Congress, in its constitutional authority, has overridden the SGR 15 times since 2002. I think that's the correct data.

What this IPAB does in the Affordable Care Act--it sets the same metric. It has a very complicated formula, which is the same as SGR, and if you have expenditures above those projections, cuts will be made. There is no judicial review, no administrative review, and it takes a 60-vote margin in the Senate to override this. Let me tell you how important this is, what Dr. Gingrey just pointed out.

Whether you agree with the plan or don't agree with the plan, there was a great article in the New England Journal of Medicine, one of our premier medical journals, that was published in June of 2011. I would recommend this for anyone to read as it will take you 30 minutes or less. They went back with the CMS and looked at the last 25 years and said, What if we had IPAB then? What would it do? In 21 of the 25 years, cuts would have occurred to providers--and I know exactly. Because of what I have seen in Tennessee, I know exactly what would happen. What would happen is you cut those providers right there. As you're seeing up there, Dr. Gingrey, I can tell you that, as to the access to care, that entire map of the United States right there would be a bright red because you would not have the providers to take care of those patients.

That is a tremendous concern for me because it is current law. This year, those 15 bureaucrats are supposed to be nominated by the President. What happens if he doesn't nominate those 15 people? One person--that's the HHS Secretary, Secretary Sebelius--makes those decisions and recommendations. I hear it all the time. I go on the talk shows like you do, and they say, Well, in the bill right here, it says that you cannot ration care. That's true. This board can't ration care. What they can do is just not pay the providers. In 2017, I think, or in 2018, the hospitals are included in this. They're not included first, but they will be in 5 short years.


Mr. ROE of Tennessee. That is correct, Dr. Gingrey.

Unless you are very deeply buried into this--meaning, if you're a Medicare recipient out there today--you don't see this. I go home, and I see my physician friends and talk to my friends who are on Medicare. They don't know this has happened or that it could potentially happen to them, but it can and it will, and it is the law right now unless we change the law.

I would strongly encourage my colleagues on both sides of the aisle--and we have bipartisan support for the appeal of the IPAB--to put that constitutional authority back in the hands of the people who are directly responsible and responsive to the American people--us, the Representatives. Let us make those changes and, the Senate, the same thing.


Mr. ROE of Tennessee. That's correct.

I had the privilege of being in the chambers when a good part of this health care debate was going on in front of the Supreme Court. It was the first time I'd ever been there. Fascinating. I'd totally misread it.

As you pointed out, it was the first time in American history that the Supreme Court said that you had to purchase a good or service--even if it's good for you, that you had to purchase it. We've never forced anybody into commerce before like this. As an individual, I think you have a right to make good decisions and bad decisions. I agree with you. I think a good decision is, if you can afford health insurance coverage, you should purchase it. I think there is no question. I have for my family my entire life, and I would recommend it strongly and encourage people to protect themselves in that way.

But does the government have the right to do it?

This Court said 5-4 that they did. The Court also said that they did not have the right to force States into expanding their Medicaid if they did not want to, and the IPAB specifically was not brought up.

I believe it will be challenged and should be. No one has standing yet because it hasn't gone into effect. In other words, they haven't issued any rulings--or the Secretary hasn't--to say that I've been harmed by that ruling so that, therefore, now I have standing in the Court and that I can bring a case.


Mr. ROE of Tennessee. Actually, the IPAB board of 15 bureaucrats will make $165,000 a year with a 6-year term, and they can be appointed twice to that term. And it's something, and what bothers me about it is, no, it says in the bill you can't ration care, but we are the elected representatives. We should be able to go back home, as Congressman Bilirakis said, we should be able to go back home and face our constituents, and they're going to say: Dr. Roe, we have a situation where I can't go see my doctor. I can't go in and see them because they aren't accepting patients, and they aren't accepting patients because of this particular board that's cut their reimbursements enough to where they can't afford to see patients.

Now, another couple of things I want to talk about in the Affordable Care Act, not just SGR formula effects, but there is a tax out there in the Affordable Care Act that hasn't been very well discussed, and that tax is on individual insurance accounts. For instance, there are companies out there that are self-insured, and they're going to get a bill for each person that has insurance. Let's say a family of four or five, they'll get a bill for four or five people, and one company in particular, this will add--and they have no reinsurance. They cover everything. They're totally self-insured, but this basically is a tax that will go into a fund to indemnify insurance companies so that they won't have a loss of more than $60,000 a year, and this is billions of dollars when you stretch it across the country.

And these insurance companies are going to not have the loss to encourage them to accept patients on the exchange. That's as wrong as it gets to take a company that is doing everything right, they're going ahead and providing the health insurance coverage for their employees, and to penalize them for that.

So there are many, many issues in the Affordable Care Act we could talk about, but I want to basically finish my comments on the sustainable growth rate by saying in the past, since 2001, just so that our viewers out there will understand this, since 2001, your Medicare doctor at home has gotten an average increase in his or her payments when you come see them of 0.29 percent per year, 0.29 percent per year. When you look at all that graph that Dr. Gingrey has down there and you do all the math, that's how much of an increase. It's a very minimal increase. It hasn't even come near to covering the cost of inflation.

So again, Dr. Gingrey, I want to conclude by saying that the major concern I have, and I saw it in my practice, is the cost of care, and, number two, access to care. I'm concerned as our patients age and our population ages--and look, a good thing is happening in America: almost every 10 years we live, we're adding 3 years to our life expectancy. In 1908, the life expectancy in America was 48 years old, 47-48. In 1922 when my mother was born--and she's still living, I might add. She's living alone, by herself, doing great. She has Medicare. And I'm going to tell my mother now that later today I'm going to call her prescription in. She notified me today that she needed some medicine called in, and so I will do that for her today. I look at her and I think about her need for access to care, and if it's cut off, what does she do.


Mr. ROE of Tennessee. Dr. Gingrey, I think one of the things I know you did and I know one of the things that I did was to come here to this body, this great body, to work on the repair of our health care system and improve on it.

One of the major pieces of our health care system is our Medicare system. I cannot tell you the patients I have seen in my career that have benefited, whose lives have been helped and saved by the Medicare system and by the doctors and nurses and hospitals and other providers who've cared for them. You have, too. I've operated on them, and I've seen them get cardiac care, renal, whatever it may be, that has improved the quality, improved and lengthened the quality of their life, not just to live longer, but to live better.

My goodness, look at the number of patients that we see of our orthopedic friends that we have that are mobile, that are active who've had joint replacements and so forth. Look, if you're 80 years old, 75 or 80 years old, you understand that your life is not going to be that much longer, but you also want the quality of that life to be the absolute best it can be. And it cannot be if you can't get your knee fixed if you're in pain, or your hip fixed if you're in pain. One of the things that I think our side of the aisle is committed to, I believe the other side, we may have differences of opinion, but one of the things I want to do is to be sure that we shore up and save this great system of Medicare.

I had a meeting today just after lunch about the Medicare part D program that was passed by the Republicans at some political risk for them. That's been a plan that has actually come in under-budget. It came in under-budget because seniors are able to go shop and purchase exactly what they want that meets their needs. That is exactly what we want to do in the Medicare system.

And when our budget is published next week, we are going to look at a system where we help fix and save and sustain Medicare, as you pointed out, not only for your mother, who's 95, and my mother who is 90, but for my two grandchildren who are 7 and 9. They also deserve the same great system, and we're going to have to change it; but I think we can make it better. I really believe it can be more responsive. You see what patients do when they get Medicare Advantage. You saw what they did. There was a little confusion, I admit, when Medicare part D first came out. There is no confusion now. People shop for the best value that meets their needs, and that's exactly what we should do.

Let me give you an example, Dr. Gingrey. I turned 65 a very short time ago. What happened to me when I turned 65? Nothing. I got one day older. Except what happened was I had a plan now that had an alphabet soup--A, B, C, D.

The day before I had a health care plan. Why, when you turn 65 years of age, don't you have a health care plan? And in that health care plan I can pick out I don't need fertility coverage at age 65, thank you very much. And I think that's the kind of thing--allow seniors to be able to pick what meets their needs and meets their family's needs at that particular point in their life; not just one-size-fits-all, but what they need.

And seniors have done that. They do it with everything else in their life. There's no reason it should change when you hit 65. You should pick out what plan--just like you and I can do up here with the Federal Employees Health Benefits plan. There's no reason that a senior shouldn't have exactly the same plan. It will be cheaper. It will be a better plan for them, and that's one of the things I think we're going to be discussing in the next several months when the Republican budget is published.


Mr. ROE of Tennessee. I have just one quick statement, Dr. Gingrey. And when you brought this up in 2003--and I want to thank you, because I can remember sitting at my desk in my office in 2003 working, and I could take this pen right here, and in about a minute or a minute and a half, I could write two or three prescriptions that might take up a patient's entire monthly income. That was the decision patients were having to have.

And Republicans stepped up to the plate, made a very difficult decision. Like you said, maybe we should have some criticism for not having offsets. But seniors out there today don't have to make that decision about whether I break this pill in half or whether I don't take it today or whether I buy food.

And you ran across that in your practice. I mean, I would look in our area, many widows that I would see would have a $600, $700 a month Social Security check and maybe a $100 or $200 a month pension. And you write three prescriptions, and the first thing they say is, Dr. Roe, it's gone. And you could easily do that. So I want to thank you for your vote.


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