Thomas Coburn

Mr. COBURN

Mr. COBURN. Mr. Chairman, this bill in no way limits the ability of the doctor to care for a woman whose life is at risk with a late-term pregnancy. Having been involved in obstetrical care, delivering over 3,000 children, caring for women with complicated pregnancies, anencephaly, neural tube defects, hydrocephaly and all the major complications associated with that, this procedure is an unneeded, gruesome attack on life. May God forgive this Nation for what we allow in terms of procedures to be performed on our unborn children.

Mr. COBURN

Mr. COBURN. I thank the gentleman from Florida [Mr. Canady] for yielding to me, Madam Speaker. Madam Speaker, I want to thank the gentleman for his efforts. On behalf of my profession as a physician, I am extremely disgusted that such a procedure would ever come about. As I thought about this procedure tonight and the discussions that we would have about it, I thought it would be very important for us to try to get a mental picture of it. As a practicing obstetrician delivering babies, I delivered two babies this weekend, to think that at times we inadvertently have to deliver babies at 24 and 25 weeks, if we think about it, those of us who know what that is like, of holding a small infant, an infant somewhat larger than this model, somewhat larger than this model in our hands and see it struggle for life, and know that in institutions throughout this country that we see efforts, great strides being made to save those infants, and now infants at 23\1/2\ weeks have made it to living, fully functional, capable adults, and healthy children; to know that we hold in our hands a child that, through this method, would no longer be viable. The difference is that we will spend untold hundreds of thousands of dollars when this accidentally falls in our lap to save this child, and then we allow a procedure such as this. I think one of the important points that needs to be made about this procedure, this procedure does not have anything to do with women. It has to do with the convenience of a doctor. For us to lose sight of that point will be a tragedy. If we want to terminate a pregnancy at 20 to 24 weeks, there are many ways to do it. We do not have to do it this way. This way has been developed so that it is easy for the physician, it is easy for the operator to complete the task and collect their fee of terminating the life. I think it must not be lost sight of, as this was developed as a technology to make it efficient to kill babies. Finally, I wanted to just comment on a Dear Colleague letter that I got today, which so misstates this bill that it somewhat disappoints me in our Chamber that we would try to confuse situations away from the truth. This comes from one of our colleagues in California. It talks about how some of his constituents would not be allowed, because they had a trisomy 13 baby, a baby that had three 13 chromosomes, that their child, they would never have been able to abort their child should they have wanted to, if this procedure is banned. Of course, as the gentleman knows, that is not the case. If in fact there is a medical indication for this procedure it can be performed, although nobody can think of a medical indication now, not the 12 doctors that are on the advisory panel, the scientific panel for the AMA, not anybody else out there can think of a medical reason why we should use this procedure. I also wanted to share with you also, one of my patients, his name is Kelsey Goss, Kelsey is 47 years old. Kelsey has Down syndrome. Kelsey has lived a wonderful life. The last 20 years or so has not been great in terms of the stroke that he had, but he has been a joy to his mother, a joy to his father until he died. To say that he was not valued, to say that he, because he had [[Page H 11429]] three chromosomes in the wrong place, did not contribute to our society to me speaks at the very issue that we tend to want to cover up in our society. I want to thank the gentleman again for bringing this forward. As a physician who has performed abortions to save the life of a mother, I can think of no other reason why we should ever participate in any type of effort to terminate a life that is so helpless, so innocent, and this cannot be allowed to happen anymore. I will just tell you that I will fight hard to see that this is banned, I will fight hard to make sure that we expose those that continue to do it afterwards, to make sure that it is not carried out, because in fact when we hold that little 22-week baby, we know it can feel, it is gasping for air, it has pain fibers, it knows and senses the very precarious situation that it is in.

Mr. COBURN

Mr. COBURN. I think the first thing we do is realize we have a problem, and [[Page H 10482]] every Federal Government agency that has testified before the House Committee on Commerce admitted that we had significant problems. Anywhere from 5 to 15 percent was common, with most saying 10 to 11 percent. We have to ask ourself the question why have we not been able to attack the fraud and abuse that is there. I mean why for the last 15 years have we allowed 10 percent of the dollars for Medicare to go to fraud? I mean it is inexcusable. It is also inexcusable for us to now when we start to change it for the Attorney General's office and the Inspector General's office to say, ``Oh, wait, wait, don't change it,'' because obviously we have not put into effect what we need to put into effect to correct the problem. Our goal is to eliminate fraud and abuse. The way we do that is to make sure we change the expectation of those who are defrauding and abusing; that we, in fact, will catch them. If we change that expectation, then we will limit greatly the amount of people, and number of people, who attempt to defraud. That requires two main things: First, you have to clarify the rules; and second, you have to have an aggressive fraud and abuse program. I think this program that is in this bill is a very aggressive program.

Mr. COBURN. Mr. Speaker, first of all, I want to thank the gentleman for the criminal provisions put in there. I also would add that we doubled the money penalties, we put mandatory sanctions on providers so they could [[Page H 10483]] not continue to participate in the Medicare system, and we are trying to straighten out the computer problem as well. I just want to say, as a practicing physician, although physicians will, in fact, get less money than what they would have, which is a cut, or a slowdown in growth, as we hear from the other side, that to act irresponsibly and not save this program is wrong. This bill has lots of things that I do not agree with in it in terms of detail, but the underlying bill is a good bill, to do what the American people want done; that is, control the growth and make sure a quality health care program for our seniors that has choice and is affordable is there. I think this bill does it. I can say to all providers, not just doctors, but hospitals and others, that we will have to work harder to be more efficient, to do the right thing, to be careful and to work in a constructive manner to change the system, to make it more efficient, but we can do it. We owe it to our children and our grandchildren to make sure we do that.

Mr. COBURN. That is correct.

Mr. COBURN. No, they have not. I think the important thing, everybody that has a credit card, whether it is a BankAmericard or Visa card, when they use that today their bank knows it tonight. If they use it in Japan, they know it tonight. If they use it in South America, they know it tonight. Our Medicare computer system, we do not know it and we will never know it if it is between two different divisions. It will never be tracked together, so in fact, we have in the past, through this bureaucracy, not even kept up the pace with 1970's computer knowledge and placement. We have spent the last 9 years trying to get a tracking system that will not be available for 3 or 4 more years.

Mr. COBURN. They benefit in that if the savings, I believe, are above $1,000, they share in the savings. They also benefit because they put on notice providers that are not honorable, that they are going to be caught, and it will not take long for the people who are presently abusing this system to recognize that we are going to have 36 million people out there helping us help them do the right thing.

Mr. COBURN. The program is designed to allow the senior to, first, be involved, to encourage them to report it, and also to benefit, if in fact they benefit----

Mr. COBURN. That is right, and do that in a unified package that we would know up front what their costs are, know what to expect, and know that they had quality and service.

Mr. COBURN. I think we might just talk about fraud and abuse for a minute.

Mr. COBURN. That is true.

Mr. COBURN. I was going to discuss another one of the options, Medicare-plus, and that is the opportunity. Heretofore physicians as groups have not been allowed to get together and offer their services as a group in hopes to lowering the costs and attracting more patients, and one of the options under the Medicare Preservation Act is to allow us in conjunction with inpatient hospital facilities and outpatient hospital facilities to offer a provider services network program where we go and offer our services for a fee which would be paid through the Medicare program where we can vastly expand the benefits and also lower the costs. Doctors for years were saying, ``Let use compete, let us go in. We'll show you that we can deliver the service.'' And now it is time for the doctors to show that in fact they do that, and I believe that they will. It will allow you to keep your doctor and still go into a Medicare-plus, if that is fact is what you want to do.

Mr. COBURN. Thank you. I would like to make one point so that seniors know a provision of this bill is that, if you would decide you wanted to go into an HMO and did not like it for the first 2 years, you can get out any time you want. So what we have also done is increased----

Mr. COBURN. I would be happy to. First of all, I think we need to correct what we heard a minute ago, that there [[Page H 10480]] was a $20,000 deductible. That is not even allowed under this plan. So it is not going to be one of the options, and the information stated was incorrect. A medical savings account is an account like I presently have as a physician. I have a deductible, and I pay a premium each year for that deductible. It is a high dollar deductible. It is $10,000 for my entire family. I am fortunate enough to be able to have that kind of deductible. I am responsible for the bills in between it. Under the Medicare Program, we will have deductibles, high deductible medical savings account available, which the Government will place into that account, the average payment for that area to purchase a high deductible policy; and what is left over can be used for medical care for that person for that period of time.

Mr. COBURN. Mr. Speaker, one of the advantages that I have had in dealing with Medicare is I am a practicing physician. I continue to practice on the weekends. I know Medicare both from a patient perspective and as well as a provider perspective. It is unique to be able to understand; it is very, very complicated. That is one of the reasons our seniors are so concerned, not only because of the rhetoric but because it is very difficult to understand. As we have changed Medicare, we really are going to give four very simple options.

Mr. COBURN. There is 9 percent already in a managed care option who are very satisfied.

Mr. COBURN. I just wanted to add, 7 years ago the part B premium was about $26. And it is $46 and 10 now. It is going to rise. It is going to rise a small amount each year for the next 7 years. But it is still going to stay at 31.5 percent of the total cost for the part B program. I think it is important for people to realize that the rate of rise is not going to be significantly different than what the rate of rise has been in the past.

Mr. COBURN. If the gentleman would yield, I think one other critical point, is it morally right to allow Medicare to grow faster than what it should, to be more inefficient than what we can make it? It is morally wrong to do that, and we should do everything in our power to make this an efficient system that delivers affordable quality health care with choice for our seniors. We can do that. But we have to do that by being honest with what the problem is, being honest with what the numbers are, and then carrying that honesty out and say, yeah, we made the hard votes to do the right thing. To do anything else, we would be shirking our responsibility.

Mr. COBURN. I heard a wonderful example on how to explain this. I have three grown daughters. But I did have teenage daughters. If I gave one of them $20 a week allowance and we come to negotiate again the next year and she wants $40 a week and I say I will give you $25, then she comes to tell me that I have given her a cut? No, I have given her a $5 increase. When you put it in the terms, it is what it would be versus what it should be. I want to go back to the real point of why we are doing what we need to do. We are not getting value for our dollars in Medicare today. If we are going to assume a 10.5-percent growth, then we are going to assume that we are going to continue to not get value for our dollars. So we have to ask the question, do we have an obligation to the seniors that are on Medicare today, to those of us that are working, paying for Medicare through our payroll deductions and to the children that are going to have to pay for it in the future to get the best value for every dollar that we spend? If you look at this plan, that is an attempt to move in that direction. We are giving an allowance. It is going up. It is not going up as much as it has in the past in terms of inflation.

Mr. COBURN

Mr. COBURN. Mr. Chairman, many of the people of this country sent new representatives to this Congress, representatives that have a basis of experience. As a practicing physician who continues to care for Medicare patients and Medicaid patients, whose practice was made of a majority of Medicaid and Medicare patients, I have truthfully and honestly looked at this bill. This bill is going to save Medicare. It is not perfect, but it does the things that we need to do to preserve this program. To do otherwise, to put a band-aid on it, is wrong. I want to share with the Members for a moment what happened and what we have done by changing some of the system. Not long ago, in the late 1980s, a program called the Clinical Laboratory Improvement Act was introduced. The effect of the act is that you can have a pregnancy test at home using technology today that the Federal Government says your doctor is not capable of using unless approved by the Government. As a result of that, what we see is that 30 percent of the doctors, and mainly in rural America, are still testing, 54 percent of the doctors stopped some form of testing because of this law. Seven percent dropped tests for other reasons, and 9 percent of the rural doctors in this country quit testing completely. The fact is we had a well-intentioned plan. There were problems with pap smears in this country, but there were not that kind of problems. Now what we do is we have patients paying two and three times for the same testing, waiting 2 and 3 days to get the same results back. CLIA was well-intended. It has now been changed. We will have quality because we are going to trust our caregivers to give us quality.

Mr. COBURN

Mr. COBURN. Mr. Speaker, as Congress begins its consideration of reforming Medicare, I want to bring to the attention of my colleagues, perhaps the most important component of the Medicare reform debate. What must we do to ensure the quality of care that Medicare patients will receive after changes are made to the program? While all of us in Congress are deeply concerned about the solvency of the Medicare trust fund, we must be equally concerned that the changes made to this program do not adversely affect the availability of health care to the elderly. As a practicing physician, I have spoken with my patients; and as a Member of Congress, I also have heard from thousands of my constituents. Their message is a clear one. Any Medicare reform proposal must guarantee patient choice and access quality. It must not result in a decline in the quality of care Medicare patients now receive. For the last several months, I have been working closely with the patient access to Specialty Care Coalition, a group of 115 patient, senior citizen, physician, and nonphysician organizations, dedicated to the principle that patients must be able to access the providers of their own choice. This week, I introduced H.R. 2350, the Patient Choice and Access Act, a bill to provide protection to beneficiaries enrolled in the Medicare Program. Throughout the process of crafting a Medicare reform bill, I have been urging the House leadership to include my patient protection provisions. The cornerstone of the current Medicare law is choice of health care provider. Presently, there is a belief that the Federal Government can save money by enrolling seniors into managed care deliver systems. And I agree how such changes can produce dramatic Federal savings, I am not opposed to the concept of managed care or a gatekeeper model. Instead, I want to make sure that quality of care for seniors is preserved, should most of the elderly population be moved into managed care. In addition, I have deep concerns about how these proposed changes in Medicare may affect my rural constituents. Today, many major changes are taking place in the way people purchase health insurance and receive medical care. The pressures to reduce health spending continues to be intense, and health plans and providers have become more aggressive in their cost containment activities. While many health plans have developed a number of effective techniques to achieve economy and maintain quality of care, others have not always achieved that balance. Since Medicare is a federally funded program, we should make sure that these tax dollars are returned to Medicare enrollees in the form of appropriate patient care. After changes are made to Medicare, many existing and new products will be offered to the Medicare population. Our most vulnerable population will be flung into a fiercely competitive marketplace, where access to appropriated medical services may take a back seat. I believe that in this rapidly changing environment, Medicare patients must be given basic rights and effective protection against the potential that these new markets may inappropriately restrict access to medically necessary health care services. My legislative proposal addresses these concerns, and it puts the patient first, not the doctor, not the insurance company, but the patient. My bill is designed to improve and enhance health care to our country's senior citizens. It will not add to the cost of the Medicare Program. Under my legislation, all patients will have the option to seek the out-of-network treatment they desire no matter what health care plan they select. True freedom of choice for patients can only be achieved by making out-of-network medically necessary treatment and services available for all health care plans. Real health care security is the freedom for patients to choose their own primary and specialty care provider, and then to continue to access these same caregivers. All patients should have the option, at an additional copayment known in advance, to seek the out-of-network treatment they desire. This point-of-service feature should be built into every health care plan, and not just offered as an option at the time of enrollment. Patinets, especially seniors, are acting with less than perfect information about their health status at the time of enrollment. In reality, patients are unable to assess their health care needs, until they actually get sick or need specialty care. Consequently, the broadest possible patient protection is to build choice of health care provider into every health care plan. The most effective check against abuses in this changing marketplace is the patient's power to go outside the network established by the health plan and obtain medical services. Health plans that provide good service to their enrollees will not be troubled by this requirement. Only health plans that fail to meet the needs of their subscribers will be affected. Making out-of-network treatment and services available for enrollees in all health care plans provides a very good quality assurance check. It ensures that all health care plans provide seniors with the health care they need and deserve. If a Medicare enrollee is not satisfied with care, he or she could pursue other treatment for a reasonable, but not cost-prohibitive price. Today, the fastest growing health insurance product is a managed care plan with the availability of out-of-network coverage. Patients have been demanding this freedom to choose, and the marketplace has responded. Requiring this type of plan for any senior is not intrusive, but rather advances a developing trend. Building a point-of-service feature into all health plans under Medicare will not affect any health plan's ability to be aggressive in their cost-containment activities, nor will it limit their efforts to encourage providers and patients to use health care resources wisely. It will simply put pressure on health plans to keep the patient's welfare uppermost on their agenda, ahead of dividends and the bottom line. [[Page H 9647]] The managed care industry has consistently claimed that a point-of- service feature in all health plans would greatly increase the cost of doing business. This assertion is simply not true. The point-of-service feature is not costly. According to a cost-impact study released this year by the actuarial firm of Milliman and Robertson, Inc., at the request of the Patient Access to Specialty Care Coalition, a point-of- service feature built into all managed care plans would place no financial burden on these plans. Moreover, in testimony before the Congress this year, the Congressional Budget Office stated that requiring a point-of-service feature would not add to the Federal Government's cost of the Medicare Program. Instead, the cost is covered by patients, who expect to bear some additional expense for this point-of-service feature. This cost, however, is not great, and it is a simple actuarial calculation to determine a reasonable copayment. My legislation calls for the managed care plan to share with its potential enrollees the cost schedule for going out of network. My legislation contains additional provisions to ensure that patients receive the full range of health care services to which they are entitled. It assures access to specialty care, and provides Medicare patients with an enrollee information checklist so they can have adequate and important information to compare the quality of all health care plans offered to seniors. Also, it includes several Medicare patient rights provisions, and a streamlined rapid appeals process within a health care plan, when there has been a denial of care. Finally, my bill places a ban on provider financial incentive schemes which result in the withholding of care or a denial of a referral. My legislation does not include any provider protection and is not an any-willing-provider bill. Any-willing-provider provisions deal with the contractual relationships between health plans and providers of medical services. The focus of my bill is on patient choice and the health care rights of Medicare enrollees. Mr. Speaker, H.R. 2350, the Patient Choice and Access Act of 1995, offers Medicare enrollees real choice and real patient protection. It will give the Medicare patient effective protection against the potential for restricting access to medically necessary health care services. Finally, it will provide a quality assurance check on all health care plans to make sure that they are providing the full range of health care services to their enrollees. I urge my colleagues in the Congress to cosponsor this bill, and to join with me in my efforts to include these provisions in a Medicare reform proposal. Only if this patient component is included in Medicare reform legislation can we be able to say that we have worked to achieve quality health care and Medicare enrollees protection, and preserved patient freedom of choice in selecting health care providers.

Mr. COBURN

Mr. COBURN. I yield to the gentleman from Indiana.

Mr. COBURN. I would like to interject one thing. It is not moral to take away somebody's comfort about their security. And there is no intention anywhere in any of the plans to do anything other than to make sure every senior citizen in this country has quality affordable health care.

Mr. COBURN. They can go to a provider-based network to do that. So the options that are, in fact, not available now, are going to be available that they have not had before. They not only will have choice of options, but choice of doctors.

Mr. COBURN. It would be a blessing for hundreds and hundreds of people in my district to have that option. It is not available to them now. We need to listen to the seniors of this country. They have a lot of experience to share with us.