[Senate Hearing 111-356]
[From the U.S. Government Publishing Office]
S. Hrg. 111-356
HEALTHY HOWARD: IMPROVING CARE THROUGH INNOVATION
=======================================================================
FIELD HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
ON
EXAMINING HEALTHCARE IN HOWARD COUNTY, MD, FOCUSING ON IMPROVING CARE
THROUGH INNOVATION
__________
FEBRUARY 17, 2009 (COLUMBIA, MD)
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
senate
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut MICHAEL B. ENZI, Wyoming
TOM HARKIN, Iowa JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico RICHARD BURR, North Carolina
PATTY MURRAY, Washington JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island JOHN McCAIN, Arizona
BERNARD SANDERS (I), Vermont ORRIN G. HATCH, Utah
SHERROD BROWN, Ohio LISA MURKOWSKI, Alaska
ROBERT P. CASEY, JR., Pennsylvania TOM COBURN, M.D., Oklahoma
KAY R. HAGAN, North Carolina PAT ROBERTS, Kansas
JEFF MERKLEY, Oregon
J. Michael Myers, Staff Director and Chief Counsel
Frank Macchiarola, Republican Staff Director and Chief Counsel
(ii)
?
C O N T E N T S
__________
STATEMENTS
TUESDAY, FEBRUARY 17, 2009
Page
Mikulski, Hon. Barbara A., a U.S. Senator from the State of
Maryland, opening statement.................................... 1
Sarbanes, Hon. John, a U.S. Representative from the State of
Maryland, opening statement.................................... 2
Ulman, Ken, Howard County Executive, Howard County Government,
Ellicott City, MD.............................................. 3
Prepared statement........................................... 6
Beilenson, Peter, M.D., MPH, Howard County Health Officer, Howard
County Health Department, Ellicott City, MD.................... 7
Prepared statement........................................... 9
Page, Claudia, Director, One-e-App, Oakland, CA.................. 10
Prepared statement........................................... 12
Wensil, Van Lynn, Resident, Hanover, MD.......................... 16
Tucci-Farley, Frances, Resident, Ellicott City, MD............... 18
Prepared statement........................................... 21
(iii)
HEALTHY HOWARD: IMPROVING CARE THROUGH INNOVATION
----------
TUESDAY, FEBRUARY 17, 2009
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The committee met, pursuant to notice, at 11:45 a.m. in
Howard County Community College, Business Training Center
Gateway Building, Room 5, 6751 Columbia Gateway Drive,
Columbia, MD, Hon. Barbara Mikulski, presiding.
Present: Senator Mikulski.
Opening Statement of Senator Mikulski
Senator Mikulski. Good morning, everybody. This is an
official hearing of the Health, Education, Labor, and Pensions
Committee, which I now officially call to order.
As part of our responsibility for doing health reform for
the United States of America, Senator Kennedy's committee,
which is the Health, Education, Labor, and Pensions Committee,
of which I am a member, has established three working groups,
one on coverage, one on prevention, and I chair the working
group on quality. But, at the end of the day, all three of
those issues are artificial silos for purposes of investigation
about what our policy should be.
Part of my approach to combining all of these is to ask,
``How can we deal with the issues of the uninsured in our
country, or the underinsured? ''--where, even if you have
insurance, sometimes it's so little or so Spartan, it doesn't
meet compelling needs of the family. At the same time it's not
only about access, but it's also about, How do we improve the
health of both individuals and also families and How do we have
the greatest impact?
Today, what I'm kicking off, for me, is my innovation tour.
I want to travel the State of Maryland to see what are the best
ideas that we can take back to Washington. Like our President,
I am an old-fashioned, grassroots community organizer. We
believe that the best ideas and the best direction comes from
the people and also comes from those who are most impacted.
I chose Howard County to kick this off because of the bold
vision of our county executive, Ken Ulman, and his very able
and intrepid, unflinching and unflagging health commissioner,
Dr. Peter Beilenson.
In October a year ago, both Mr. Ulman and Dr. Beilenson
shared with us the Howard County dream, which was to make sure
that everyone in Howard County who did not have adequate
healthcare would have it. That's pretty bold. They've embarked
upon, really, this bold initiative. We wanted to come here
today to hear more about it. About lessons they learned from it
that we can take back to Washington so that, when we're talking
about our issues, we really make sure that what we do makes a
difference.
Too often in Washington, the topic is on macroeconomics.
They talk about the big picture, and they forget the little
people. They forget the people who have to implement the
program, the people who have to pay for the program, and the
people who should benefit from the program. I'm a macaroni-and-
cheese economist. I believe----
[Laughter.]
Senator Mikulski [continuing]. That you start with the
basics, well made, as long as it has a salad.
[Laughter.]
But, really more the grassroots approach. So, this is why
we're here today, to listen and to learn.
Invited to join me is Congressman John Sarbanes, a mentor
and a member of the Energy and Commerce Committee, who brings,
one, a great deal of background, himself--before he was a
congressman--as a lawyer, heading up the health practice at one
of our most distinguished law firms. But, on the Energy and
Commerce Committee, it will have major responsibility for the
national legislation, and we're going to be part of your
Maryland team. I'm going to ask him to say a few words before
we turn it over.
I want to thank Mr. Ulman for his initiative and for being
bold enough to do it, and the people of Howard County who are
willing to support this. This is no small undertaking.
Dr. Beilenson, who, along with his own great ideas,
harvested the great ideas of many people, and now we're testing
them out, whether the ideas really work for people.
We want to thank Ms. Page, who's come here to tell us how
to smooth the path of eligibility often challenged.
But, most of all, at the end of the day, we want to hear
from the people. Why did you come to this program? Did it help
you? And if you could sit down to talk with Members of
Congress, what would you tell us about what we needed to keep?
What's your must-do list and what you would work on improving?
So, that's why we're here, and we're really eager to listen
to everybody.
But, I'd like to turn, for a few opening comments, to my
colleague John Sarbanes.
STATEMENT OF HON. JOHN SARBANES, U.S. REPRESENTATIVE FOR
MARYLAND'S 3D DISTRICT, TOWSON, MD
Mr. Sarbanes. I appreciate it, Senator. It's a treat to be
here. This is exactly where we should be: in the field,
listening to the real-life experiences of people that are
trying to tackle this problem of healthcare reform across the
country.
I am thrilled that Senator Mikulski has been given this
portfolio on healthcare quality by Senator Kennedy. As she
indicated, that has a broad reach; and it should, because
that's the underpinning of the healthcare system that works.
Quality is what makes the difference. And quality is what's
being pioneered here by the Healthy Howard Initiative.
I want to congratulate County Executive Ulman and
Commissioner Beilenson on their work. I was privileged to be at
the kickoff when we had great hopes for where this might lead
us and the lessons that we could learn from it. We've just
heard, before this meeting, on some of the advances that have
been made. That's part of the hearing today, to understand the
lessons that you all are seeing, and how they can be made
applicable, more broadly.
I think there's a number of principles that many of us have
come to agree on as we move forward with healthcare reform. No.
1, is universal coverage, No. 2, is universal access, and No.
3, is quality. We're going to have to take those principles and
shape them into an approach that allow for real healthcare
reform. And now is the moment. Many think that we should wait,
but the economic security of so many Americans is dependent on
their healthcare situation. So, if we want to address that
situation, we have to keep moving on healthcare reform.
Hearings like this are a wonderful way for us to gather up
information. So, Senator, thank you for convening it today.
Senator Mikulski. Now we're going to turn to our witnesses.
And the reason I said this is an official hearing is that we
actually have the resources of the committee to take an
official record and testimony. You're now going to go, quite
frankly, into the history books. What you say here today will
be incorporated in all of the information and testimony we're
taking as we're fashioning our health reform initiative.
I'm going to ask each and every one of you to introduce
yourselves as you do testify. But, I'm going to turn it over to
Ken, who's already writing quite a history for Howard County.
Mr. Ulman.
STATEMENT BY KEN ULMAN, HOWARD COUNTY EXECUTIVE, HOWARD COUNTY
GOVERNMENT, ELLICOTT CITY, MD
Mr. Ulman. Well, thank you, Senator. It's truly a great
honor for me to start your healthcare innovation tour in Howard
County, and I really appreciate your leadership on these
issues. It's been great to meet with you every few months over
the last couple of years as we've hatched this idea, and I just
can't thank you enough for your leadership and support of all
the things we're doing in Howard County. I echo those
sentiments for Congressman Sarbanes; it's been a wonderful
partnership, and I thank you for your leadership on these
issues, as well.
You know, this is truly an exciting time for healthcare
innovation in our country. I was glad to see the recent
stimulus package include dollars for healthcare, especially
health IT infrastructure and research. And again, the citizens
of Howard County appreciate your strong leadership and
partnership in these efforts.
We believe, here in Howard County, that healthcare is both
a right and a responsibility. And toward that end, last year we
announced the Healthy Howard Access Plan, becoming one of only
two jurisdictions in the Nation with a plan to provide
affordable access to healthcare and comprehensive wellness,
prevention, and health coaching for all uninsured individuals,
and the only to do it without any mandates on businesses.
I believe that most businesses who do not offer health
insurance to their employees want to, but simply can't afford
the ever-escalating cost of healthcare. We must remember that,
of the approximately 20,000 of our neighbors here in Howard
County who do not have health insurance--of course, we've
whittled down that number since--85 percent are from working
families, people just like the Ellicott City woman who sent me
the following e-mail after we announced our plans for Healthy
Howard. It read,
``Mr. Ulman, You've made my day today, watching
Channel 13 news this morning before work. I am 45 years
old and have lived in Howard County the majority of my
life. I have two children and I have raised them in
Howard County from day one. I don't have health
insurance offered to me at my work, and it seems you're
doing something about it. Recently, I had problems and
needed a doctor. I have ruined my credit and can never
buy anything, because I had to go to the emergency
room. Every day, my cell phone rings with bill
collectors from the emergency room visits. Pretty soon,
I guess my pay will be garnished and I'll be at the
food bank trying to feed my kids. Finally, someone is
trying to do something.''
Unfortunately, this woman's story is an all-too-common one.
In a moment, you'll hear from two of our neighbors here in
Howard County who have similar experiences.
Fortunately, through Healthy Howard's partnership, we were
able to help the woman I just referenced enroll in the Kaiser
Bridge Program. This is 2 years' worth of full health insurance
subsidized by Kaiser Permanente, one of our private-sector
partners.
As you well know, our healthcare system is broken; however,
we've begun to put it back together here in Howard County. By
bringing together existing healthcare resources, such as Howard
County General Hospital, Johns Hopkins Hospital, Chase Brexton,
and specialty medical practices across the county, we are
leveraging our existing healthcare community.
Most critical to this effort is our partnership with Howard
County General Hospital. We have a unique partnership which
allows the hospital to provide care to our Healthy Howard
participants, free of charge. I'm glad to see the recent
attention placed on our system for uncompensated care. And I'd
like to just briefly discuss this area.
Actually, you know what? I'm probably going to skip over
some of this and just----
Senator Mikulski. No, that's OK. We want to hear----
Mr. Ulman. OK.
Senator Mikulski [continuing]. Everything you've got to
say.
Mr. Ulman. When--just to recap----
Senator Mikulski. Believe me, we're--compared to what we
hear every day----
[Laughter.]
Senator Mikulski [continuing]. Your speech is pretty short,
so you're doing fine.
Mr. Ulman. Well, good. I was glad that there was a recent
series in the Sun about this topic of uncompensated care, and
some initiatives.
Just to recap, when an uninsured person goes to a hospital
and cannot afford to pay, the hospital spends time and effort
trying to collect, and then, after not collecting, refers the
matter to a collection agency and typically ruins the patient's
credit. Then, in many cases, the patient files for personal
bankruptcy, as medical bills are the single-biggest cause of
personal bankruptcy in this country.
After all that, the hospital then writes it off to what's
called uncompensated care, but the truth is, it's not
uncompensated care; the hospital is compensated by the rest of
us. Maryland is the only State in the United States with an
all-payor hospital system, meaning that every hospital is
required to treat every patient who comes through their doors,
no matter whether they have insurance or not. The State sets
the rate that the hospital can charge for every procedure a
little bit higher, and that extra premium is set aside in a
fund so the hospital can cover the cost of care for the
uninsured patient who cannot pay. Every Maryland family with
health insurance pays approximately $1,070 per year in this
hidden healthcare tax.
We believe that, through our Healthy Howard Access Plan, we
can, and are, driving down this cost by getting folks the care
they need, when they need it, by providing access to primary
and preventative care, specialist care, prescription drugs, as
well as personalized health coaching. Every Access Plan member
is matched with a health coach to help them formulate a Health
Action Plan and take steps toward achieving their health goals.
This will lead, and is leading, to improved quality of life and
decreasing the risk of future disease development.
Our goal is that a significant number of participants will
never need to set foot in the hospital emergency room, not only
saving us all money, but freeing up the resources of the
hospital for true emergencies. Of course, our program is still
quite young, but we're well on our way. We opened enrollment
last October. Today, we have 109 individuals enrolled in the
Healthy Howard Access Plan, and another 143 in the process of
enrolling. And through the Health-e-Link Web-based system,
which you'll hear more about in a moment, we've connected over
1,200 individuals with other State, Federal, and private
healthcare programs for which they did not realize they were
eligible. Through this enrollment effort and prior efforts to
identify uninsured individuals in Howard County, such as a
letter from the comptroller's office which went out last year,
approximately 2,500 individuals who were uninsured just a few
months ago now have access to affordable healthcare. This means
that over 10 percent of the uninsured in Howard County now have
coverage.
Today, you will hear personal testimony from two Howard
County residents. Both came to open enrollment in October,
thinking they were eligible for Healthy Howard, both were
connected to healthcare through the Health-e-Link system, one
is now a member of the Healthy Howard Access Plan, one is
enrolled in Medical Assistance for Families, an expansion of
the State's Medicaid Program. In addition, you will hear more
about Health-e-Link from Claudia Page, the director of the
Center to Promote Healthcare Access, and then from our county's
health officer, Dr. Beilenson, who you've aptly described a few
moments ago.
I thank you sincerely for your interest in Howard County's
progress and for your tireless advocacy on healthcare issues at
the Federal level. And again, I thank you for your leadership
and for starting your tour here in Howard County.
[The prepared statement of Mr. Ulman follows:]
Prepared Statement of Ken Ulman
Good morning. Senator Mikulski, Congressman Sarbanes, and to all of
you, thank you for being here. It is an honor, Senator, to have you
hold this hearing in Howard County and an honor to be able to speak to
you today about Howard County's efforts to increase access to
affordable health care.
Last year, we announced the Healthy Howard Access Plan, becoming
one of only two jurisdictions in the Nation with a plan to provide
affordable access to health care for all uninsured individuals, and the
only to do it without any mandates on businesses.
I believe that most businesses who do not offer health insurance to
their employees want to but simply cannot afford the ever-escalating
cost of health care. We must remember that of the approximately 20,000
of our neighbors here in Howard County who do not have health
insurance, 85 percent are from working families--people just like the
Ellicott City woman who sent me the following e-mail after we announced
our plans for Healthy Howard.
Mr. Ulman: You have made my day today watching Channel 13
news this morning before work. I am 45 years old and have lived
in Howard County the majority of my life. I have two children
and I have raised them in Howard County from day one. I don't
have health insurance offered to me at my work and it seems you
are doing something about it. Recently I had problems and
needed a doctor. I have ruined my credit and can never buy
anything because I had to go to the emergency room. Everyday my
cell phone rings with bill collectors from the emergency room
visits. Pretty soon I guess my pay will be garnished and I'll
be at the food bank trying to feed my kids--finally someone is
trying to do something.
Unfortunately, this woman's story is an all too common one.
Fortunately, however, through Healthy Howard's partnership, we were
able to help her enroll in the Kaiser Bridge Program. This is 2 years
worth of full health insurance subsidized by Kaiser Permanente.
As you well know, our health care system is broken.
When an uninsured person goes to a hospital and cannot afford to
pay, the hospital spends time and effort trying to collect, and then
after not collecting, refers the matter to a collection agency, and
ruins the patient's credit. Then, in many cases, the patient files for
personal bankruptcy, as medical bills are the single biggest cause of
personal bankruptcy in this country.
After all that, the hospital then writes it off as what's called
``uncompensated care,'' but the truth is it is not uncompensated care,
the hospital is compensated--by the rest of us.
Maryland is the only State in the United States with an all-payer
hospital system, meaning that every hospital is required to treat every
patient who comes through their doors no matter whether they have
insurance or not. The State sets the rate the hospital can charge for
every procedure a little bit higher and that extra premium is set aside
in a fund so the hospital can cover the cost of care for the uninsured
patient who cannot pay. Every Maryland family with health insurance
pays approximately $1,070 per year in this hidden health care tax.
We believe that through our Healthy Howard Access Plan we can drive
down this cost by getting folks the care they need when they need it,
by providing access to primary and preventive care, specialist care,
prescription drugs, as well as personalized health coaching. Every
Access Plan member is matched with a Health Coach to help them
formulate a Health Action Plan and take steps toward achieving their
health goals. This will lead to improved quality of life and will
decrease the risk of future disease development.
Our goal is that a significant number of participants will never
need to set foot in the hospital emergency room, not only saving all of
us money, but freeing up the resources of the hospital for true
emergencies. Of course, our program is still quite young, but we are
well on our way.
We opened enrollment last October. Today we have 109 individuals
enrolled in the Healthy Howard Access Plan and another 143 in the
process of enrolling; and through the Health-e-Link web-based system,
we have connected approximately 1,100 individuals with other State and
Federal health care programs for which they did not realize they were
eligible.
Today you will hear personal testimony from two Howard County
residents. Both came to open enrollment in October thinking they were
eligible for Healthy Howard. Both were connected to health care through
the Health-e-Link system. One is now a member of the Healthy Howard
Access Plan. One is enrolled in Medical Assistance for Families, an
expansion of the State's Medicaid program. In addition, you will hear
more about Health-e-Link from Claudia Page the Director of the Center
to Promote Health Care Access and then from our County's Health
Officer, Dr. Peter Beilenson.
I thank you sincerely for your interest in Howard County's progress
and for your tireless advocacy on health care issues at the Federal
level.
Senator Mikulski. Well, thanks, Mr. Ulman. What we're going
to do is listen to the testimony of everyone and then open it
to questions, and actually maybe even more of a roundtable with
questions, where everyone can jump in.
We now would like to turn to Dr. Peter Beilenson, our
Howard County health officer. A former Baltimore City health
commissioner and a leading voice in public health initiatives.
STATEMENT OF PETER BEILENSON, M.D., MPH, HOWARD COUNTY HEALTH
OFFICER, HOWARD COUNTY HEALTH DEPARTMENT, ELLICOTT CITY, MD
Dr. Beilenson. Thank you very much, Senator and
Congressman, County Executive. It's a pleasure to be here
today.
I just wanted to reiterate some of what the county
executive was saying. We have started our program now. There
are about 250 people either fully enrolled, or on significant
approach to being enrolled in our program, that are eligible to
be enrolled, which is on target for our goal of about 2,000
people, by the end of this year, being in Healthy Howard.
Healthy Howard is a combination of a range of services, but
focusing most intently on primary-care access and health and
wellness care. The county executive mentioned the different
components, but what I wanted to focus on here, particularly,
is the health coaching and the case management--medical case
management and pharmaceutical case management--at Chase Brexton
by a care coordinator, and then everybody has a personal health
coach. We don't know of any other program in the country that
has all the components that we've put together: primary care,
prescription drug, hospital specialist, and personalized health
coaching. The health coaching happens face-to-face, not a phone
call, as is often done by insurance companies managing chronic-
disease folks, where someone--a nurse will call you from
Nashua, NH, here in Baltimore or Columbia, to see if you have
taken your diabetic medications. Here, our health coaches will
go to meet folks face-to-face, help them, in concert with their
primary care physician, to develop a Health Action Plan, which
will help to keep them as well as possible.
Tai Sophia Institute, which I know the Senator is
particularly interested in, won a grant from the Horizon
Foundation, and they are training our health coaches in
innovative medicine and wellness and ways in which to motivate
patients, as well. That's one large aspect of what we're doing.
Our first patients have been seen, starting in early
January. We've now had dozens seen. They're seeing their
primary care docs, and our first patients are now meeting with
their health coach to come up with their Health Action Plan.
Our evaluation of this is particularly important. Hopkins,
UMBC, University of Maryland Schools of Public Health, will be
doing the evaluation that will be looking at health status
improvements, from enrollment to going on in the program. And
also, very importantly, the cost effectiveness. Are we averting
unnecessary hospitalization and emergency room visits?
In response to what the Congressman was asking a little bit
earlier, What did we learn that's replicable or applicable in
other parts of the country? No. 1, clearly, as the county
executive was mentioning earlier, through our efforts, through
the comptroller being able to reach out to eligible parents of
kids with CHIP, to get their children enrolled in CHIP, we sent
out 20,000 letters or so, at a cost of several thousand
dollars--only several thousand dollars--and got 1,200 hits in
the first 2 to 3 weeks. That, combined with our enrollment
efforts for Healthy Howard, were, as the county executive
mentioned, able to reduce, in a very, very short period of
time, by over 10 percent, the number of uninsured people living
in Howard County. We think that this highlights the issue that
has been shown, through many studies, that about 25 or 30
percent of all people who are uninsured in this country
actually are eligible for existing programs, but either don't
know it or haven't applied. In a relatively short timeframe and
relatively insignificant resources, we will be able to knock
down the number of insured from 50 million in this country,
with the economic recession right now, to probably into the low
30 millions. Not solving the problem, but clearly making a
significant dent.
Do you want me to stop or should I keep going? I have
another 30 seconds.
Senator Mikulski. Yes, you keep going.
Dr. Beilenson. OK.
The other----
Senator Mikulski. We're used to long-winded environments.
[Laughter.]
Dr. Beilenson. We're actually--we're pretty----
Senator Mikulski. So, no, you're pretty crisp.
Dr. Beilenson. And we speak fast.
Senator Mikulski. First of all, we have our colleagues,
that can be chatty. The Senate is the original chat room.
[Laughter.]
And then, sometimes we get these experts that----
Dr. Beilenson. Well, we'll be brief.
Senator Mikulski [continuing]. Give us their whole Nobel
Prize statements.
Dr. Beilenson. So, that's certainly one lesson that we've
learned, and it's actually--the replication has started, of
this comptroller letter. The State now does it, through State
legislation, and several States have called me, actually, to
ask how we went about doing this.
The second thing that's applicable or replicable is this
program, in itself, we don't want to see 3,500 iterations of
different counties doing these programs. However, putting
together a network, like we have done here in Howard County, is
certainly doable, in some form or fashion, in many counties,
even many urban and rural areas. And so, the lessons that we
learned, that we'll be showing from our evaluation that Johns
Hopkins and others are doing, I think will inform whether and
how much of what we're doing is replicable. But, we're looking
forward to those results, and we'll have some of them in the
next several months.
[The prepared statement of Dr. Beilenson follows:]
Prepared Statement of Peter Beilenson, M.D., MPH
Despite numerous attempts at the Federal level to increase health
coverage over the past 75 years, the number of uninsured Americans has
continued to grow--with that number now likely approaching 50 million.
The State of Maryland has made some progress in expanding health
coverage to certain vulnerable populations over the past few years, but
the number of uninsured Marylanders still numbers over 700,000. We
believe that it is unconscionable that in the wealthiest, most
technologically advanced country in the world approximately one in
every six of our citizens does not have health coverage. So, rather
than waiting for other levels of government to act, Howard County
developed its own program, Healthy Howard, with input, involvement and
funding from many sources, and a real chance for success.
No other county in America has embarked on an effort to provide
comprehensive, affordable health care and wellness services for all its
citizens. Because employer-based health insurance is shrinking, and
individual policies are prohibitively expensive for many, thousands of
citizens in our county have no way to see a doctor for the sinus
infection that has festered and fatigued them for months; they can't
get the medicine that would cure it; and they can't avoid infecting
others. They have no family doctor to tell them to lose weight and
exercise more to deal with their high blood pressure--or their diabetes
goes untreated. They have no preventive health care or health screening
to help them to avoid expensive and potentially tragic conditions.
So, starting in early October, we began enrolling the first of
2,200 Howard County residents in the first year of the Healthy Howard
Access Plan that will provide them up to six visits a year with a
primary care physician and access to a wide range of specialists. They
will get many prescription drugs free and others at a steep discount.
Our local hospital, Howard County General, is not charging our patients
for hospital stays or for truly urgent emergency room visits. And, very
importantly, every program participant will have a personal health
coach to help devise and implement a personalized health action plan--
common sense activities and services that will help our participants to
live as healthy a life as possible.
Because we believe that health care is both a right and a
responsibility, everyone will have to pay modestly to be a member of
Healthy Howard (either $50 or $85 per person per month, dependent on
income, with a discount for a spouse or domestic partner), and must be
substantively compliant with their health action plan to keep full
involvement in the plan. Who will be included? The vast majority will
be working folks or members of working families, since most uninsured
Americans are working class individuals who cannot afford to buy
insurance if it is not provided at their workplace. Anyone between the
ages of 19 and 64 (younger are eligible for the Children's Health
Insurance Program; older for Medicare) with an income below 300 percent
of the poverty level (approximately $64,000 per year for a family of
four) is eligible for Healthy Howard, if they are Howard County
residents and have not been insured for the past 6 months. In response
to the economic downturn and the significant increase in layoffs, this
6-month restriction is waived for anyone who can demonstrate that they
lost their job.
Is the plan perfect? Of course not, which is why we have arranged
for a detailed evaluation of Healthy Howard by a team of researchers
from Johns Hopkins, Harvard and the University of Maryland to help us
to improve it as we go. If the plan works, as defined by improved
health status of our participants, costs averted, and decreases in
preventable hospital and emergency room usage, we hope to expand it to
include as many of the 15,000 uninsured residents of the county who
want to join. We obviously need to make the program sustainable and
self-sufficient. It will not be easy, but it is not impossible.
We are aided in our enrollment efforts by the use of an innovative,
web-based electronic application system developed in California, called
Health-e-Link. Although you will hear more about this application from
Claudia Page of One-e-App (the developer of the program), in brief, it
allows for any uninsured individual to go on-line at one of any number
of service-based community organizations and, with the help of a
trained assistor, identify what health program they are eligible for
and then complete the appropriate application. By using this
application on only eight ``eligibility nights'' we held in Columbia in
October, we were able to enroll almost 1,100 uninsured Howard Countians
into health coverage programs. Interestingly, about 750 were eligible
for existing entitlement programs but had not known it. The rest were
enrolled either in Healthy Howard or Kaiser Permanente's donated 2-year
Bridge Program slots. Our experience identifying uninsured but eligible
individuals highlights an important issue that can be addressed at the
Federal level. Estimates are that nationally at least 25 percent of all
uninsured Americans are actually eligible for existing programs. Thus,
if we invested a relatively small amount of resources at better
outreach and more streamlined enrollment processes, the number of
uninsured for whom a new system needs to be devised might well drop
from around 50 million to less than 35 million. By doing so, it might
make systemic health care reform a bit easier to achieve as well.
We hope that our efforts on health care reform in Howard County are
not only beneficial to the uninsured of our county, but will inform the
forthcoming health care reform debate in Washington as well.
Thank you for allowing me to testify.
Senator Mikulski. Well, thank you very much.
Dr. Beilenson. Sure.
Senator Mikulski. And now, we want to turn to Claudia Page,
who's the director of a software company called One-e-App, from
Oakland, CA, but we know it in Howard County, Dr. Beilenson, as
Health-e-Link. From what we understand in our briefings, one of
the most surprising lessons learned was that so many people who
came to the community outreach, who responded to the letter of
invitation, were actually eligible for other existing programs.
When we say there are 47,000 uninsured people in the United
States, and there were so many uninsured in Howard County, what
we found, using some innovative tools around eligibility, that
they were eligible for other programs. And we understand that
your contribution was--technology was a tool in establishing
eligibility. So, why don't you tell us about that.
STATEMENT OF CLAUDIA PAGE, DIRECTOR, ONE-E-APP, OAKLAND, CA
Ms. Page. Great, thank you Senator.
Senator Mikulski. Is that an accurate introduction?
Ms. Page. Absolutely, and with lots of good touchpoints.
So, thank you very much, Senator Mikulski, Representative
Sarbanes, and County Executive Ulman. I'm grateful for the
opportunity to share some insights, both from the work in
Howard County, as well as across the country.
My name is Claudia Page. I am the director of the Center to
Promote Healthcare Access. We're a nonprofit organization that
has developed a system called One-e-App--One Electronic
Application, One-e-App. It is an online screening tool
connecting families and individuals with benefits for which
they're eligible. One-e-App is used in four States, including
Maryland. It's also used in California, Arizona, and Indiana.
It includes a wide range of programs, which is actually
growing, actually, by the week, as families find themselves
more and more in need of a range of programs. So, if you take
all the programs together that are currently in the system,
we've got Medicaid and SCHIP, Food Stamps, TANF, Earned Income
Tax Credit. We've got the WIC program, we've got low-
income auto, low-income energy subsidies--a whole list is
provided in the written testimony that I submitted.
Essentially, it's one channel of many that need to be out there
to help families, an online tool that is either used with or
without assistance.
I'd like to just mention that, in Arizona, their version of
One-e-App is available to the public, who can go on from their
homes or from libraries and apply for programs directly,
without assistance, or they can seek assistance.
As you mentioned, in Howard County the system is called
Health-e-Link. In Howard County, it currently provides
eligibility assistance for Medicaid, Healthy Howard, MCHP--your
SCHIP program--and the Kaiser Bridge Program. It generates
applications, it stores data and documents, it tracks
applications, it allows for the selection of a primary care
provider, dental providers, and it uses kind of a Turbo Tax
approach to helping families connect to the benefits for which
they're eligible. It was implemented in Howard County to
improve the efficiency and generate high-quality applications,
ultimately getting the families and individuals in the right
program, the program for which they're actually eligible.
The current plan is to build out Healthy-e-Link so that it
has the capacity to deliver applications electronically to the
State, so that we're really closing the loop for families
eligible for Medicaid, and hopefully eventually Food Stamps and
MCHP and those programs that are under the State's purview for
final eligibility determination.
I want to use my last couple of seconds to commend the
leadership in Howard County for stepping out boldly, as you
point out, Senator, on both the coverage design front, but also
really taking a look at the way in which families connect to
benefits, and trying to make that process more rational for the
families who, more often than not, find themselves being
referred from one location to another to another, filling out
the same forms, writing the same information again and again
and again. It's an irrational way to do business, both from the
consumer perspective, as well as from an administrative
perspective, because, at some point, all of those paper forms
have to be manually data-entered into a system.
My time is up, by the clock.
Senator Mikulski. No, go ahead. Keep going.
Ms. Page. Well, I'm happy to take--answer any questions and
provide more information----
Senator Mikulski. Because you're kind of the techno-guru.
[Laughter.]
Ms. Page. Well----
Senator Mikulski. You are both a gateway for eligibility
but--and we'll talk more about health IT--information
technology. But, it also is the holder of all the other
information that people might need.
Ms. Page. That's right. I think in Howard County, as we
experienced in San Francisco and, frankly, in most of the
places where One-e-App is being used, there's usually a
motivating event. And in Howard County, it was the advent of a
new healthcare-coverage program for residents. And in that
moment, there was an opportunity to modernize and reform the
systems through which families get connected to benefits. I
think Howard County offers a really important learning
laboratory to both the State and to the Federal Government and
policymakers as they look at both components of that--both of
those important components of healthcare reform: the access
channels, as well as the coverage design channels.
Reforming these systems is not easy. These are systems that
have a long history of siloed systems, siloed administrative
agencies, siloed fiscal streams, funding streams. You know,
untangling those silos is not easy. But, using a tool like One-
e-App and Health-e-Link in Howard County, you can use some
assistance integrator that serves as a data--a smart data-
collection and delivery system, that has a rules engine that
figures out where you need to send the data and the documents
and the signatures, stores the data, so when it's time for a
redetermination or if the family wasn't eligible for that
program, they shouldn't need to go back and start all over
again, getting on the bus and going down and filling out paper
forms.
I think the lessons learned in Howard County and lessons
that the center has been lucky enough to learn, with our
partners in other States and counties, will be valuable at both
the State and the Federal level.
[The prepared statement of Ms. Page follows:]
Prepared Statement of Claudia Page
SUMMARY
The Center to Promote HealthCare Access (The Center) is a non-
profit technology solution provider connecting people to needed public
benefits.
The Center's signature tool is One-e-App, an innovative Web-based
system for connecting families with a range of publicly funded health
and human service programs. One-e-App is used in three other states
(California, Arizona, Indiana) and it provides screening and enrollment
for a range of public benefits programs such as Medicaid, Food Stamps,
TANF, Earned Income Tax Credit, Low-cost energy assistance and more.
One-e-App is used by assistors, eligibility staff and the public
themselves. A complete list of programs is in the written testimony.
In Howard County One-e-App is called ``Health-e-Link'' and it has
been used since the launch of Healthy Howard on October 1, 2008. The
online system screens individuals for potential enrollment in Medicaid,
Healthy Howard, MCHP and Kaiser Bridge and generates applications,
stores data and documents, tracks applications. It uses the Turbo Tax
approach to screening and enrollment by asking only necessary
questions.
Health-e-Link was implemented to improve efficiency, generate high
quality applications, ensure applicants are enrolled in the right
programs and make the process more rational for applicants, who
navigate a complex maze of referrals and handoffs when seeking
coverage. This leads to cost and process inefficiencies for government
and frustration and missed coverage opportunities for applicants.
The County has been successful in its first 5 months of operation
and they deserve huge praise for implementing a new enrollment system
at the same time as an innovative coverage expansion program.
Modernizing enrollment in public benefits is incredibly complex and
disruptive. But it is also necessary and long overdue. Other facets of
State government have evolved to be more efficient and consumer
friendly. Howard County has taken important steps to bring enrollment
innovation to its residents.
The current plan for One-e-App in Maryland is to learn what works
and what does not in Howard and Anne Arundel Counties (next in line to
adopt Health-e-Link) and to work with the State and other counties to
support their use of the on-line application with electronic data
submission capacity. The County is currently working with the State
Department of Mental Health and Hygiene to assess ways to integrate
Health-e-Link with State systems to submit applications electronically.
The Center values its partnership with Howard County and looks
forward to continuing to work with counties and the State to improve
the enrollment process. An increased demand for services and a
worsening and relentless economic crisis create a perfect storm of
opportunity and need to improve efficiency and make the process more
rational for administrators and applicants. Thank you for the
opportunity to provide verbal and written testimony. I am happy to
answer any questions.
______
My name is Claudia Page and I am a co-director at The Center to
Promote HealthCare Access (The Center), a non-profit technology
solution provider improving quality of life by connecting people to
needed public benefits. The Center's signature tool is One-e-App, an
innovative Web-based system for connecting families with a range of
publicly funded health and human service programs.
The Center has been fortunate to partner with Howard County, which
is using the One-e-App software to screen and enroll families in its
pioneering health coverage program, Healthy Howard. Called Health-e-
Link in Maryland, the One-e-App system has been an integral part of the
new coverage program since its launch on October 1, 2008.
I am grateful for the opportunity to provide testimony on
innovations to support improvements in the enrollment process, both for
administrators and individuals in increasing need of services. I will
primarily focus my comments in three areas:
1. Howard County: Making a Difference;
2. Insights on Enrollment Reform: Experiences in Arizona,
California and Indiana; and
3. Next Steps: Building on Progress and Momentum.
I want to preface my comments by acknowledging that systems reform
is hard work and happens through strong commitment and leadership. The
Center is able to carry out its mission-driven work only because of
partners, leaders and innovators like those in Howard County and our
partners in other States and counties.
CONTEXT
If there was ever a time to focus attention on the efficiencies of
the screening and enrollment process for low-income families into
public benefits, now is that time. Hundreds of thousands of Americans
are losing their jobs, their homes and their health care as a result of
severe economic stress at both State and national levels. Economists
predict the recession will continue to erode employer-sponsored health
coverage and weaken the financial stability of families and
individuals.
For county and State governments, this phenomenon means increased
demand for government-sponsored programs such as Medicaid, Food Stamps
and county coverage programs. Governments are facing the largest budget
crisis in recent history and cannot afford to do business as usual
under these circumstances. Technology offers promise in redeploying the
workforce to focus on high-value tasks versus tasks like manually
entering data from paper forms, calling applicants when hand writing
cannot be deciphered, correcting common errors and rescheduling missed
appointments.
For applicants, the process of applying for programs for which they
may be eligible in the current environment means completing multiple
paper forms (supplying much if not all of the same information each
time), traveling to different locations and navigating an incredibly
complex maze of referrals and programs. Ultimately, this results in
missed opportunities for assistance because there is no one place to be
screened for all programs.
The current climate offers a perfect storm of opportunity and
demand to make the process more rational for families and to create a
more efficient and cost-effective process for administrators.
HOWARD COUNTY: MAKING A DIFFERENCE
In launching Healthy Howard, County leaders were visionary about
the new coverage model to extend coverage to otherwise uninsured low-
income residents and the enrollment process for screening, enrolling
and tracking applicants in the program. The new program has captured
local and national attention on both fronts.
Engaging community partners to reach eligible individuals is a
central component of the new program, and the county wanted an easily
deployable tool to streamline and standardize the enrollment process
and to ease the learning curve of the new program rules on community
application assistors. They also wanted to truly close the loop for
applicants by delivering data electronically to back-end systems
wherever possible thereby speeding the process and removing the need
for mailing forms and performing manual data entry.
Healthy Howard launched on time with almost all of these components
in place. The system conducts screening and generates applications for
Medicaid, MCHP, Healthy Howard and the Kaiser Bridge Program. While
there is (always) more work to be done, with this strong start, the
foundation has been laid to make enhancements and to extend the
capabilities of the Health-e-Link system to include more programs,
features and integration to support users and applicants. To this end,
Howard County is currently working with the State Department of Mental
Health and Hygiene to assess ways to integrate Health-e-Link with State
systems to submit applications electronically.
This is the hard work of systems integration and reform. The work
is never done, many IT systems use dated and disparate technology and
there is minimal data sharing between programs. In addition, leadership
at many levels must be committed and sustained, appropriate resources
secured and at the end of the day, progress comes from taking risks.
Howard County is a tremendous learning laboratory on all fronts for the
State of Maryland and other counties and States contemplating coverage
and systems reform to improve enrollment in public programs.
ONE-E-APP BACKGROUND
One-e-App is currently used in Arizona, California, Indiana and
Maryland by State and county workers and community-based assistors in
hospitals, clinics, schools, health plans and other locations. In
Arizona (and soon in California), One-e-App is also publicly
accessible, which means applicants themselves go online (at home,
libraries, school computer labs, work) to complete and submit
applications.
The One-e-App software was created in 2002 to support enrollment in
a variety of health programs. Over the last several years, the system
has evolved to include a range of government and non-government health
and social services programs. The breadth of programs continues to grow
with unemployment, low income housing, banking programs and others
currently being considered.
The following programs are included in One-e-App, though not all
counties and States have implemented all programs. One-e-App integrates
with other systems and wherever possible, applications, documentation
and signatures are submitted electronically. When electronic delivery
is impossible, pre-populated, error-checked paper applications are
generated and mailed or faxed. In some cases, a referral is generated.
Health programs
Medicaid
S-CHIP
Early Periodic Screening Diagnosis and Treatment (EPSDT)
Express Lane Eligibility (ELE--a School Lunch and Medicaid
linkage)
County Indigent Care and Coverage Expansion Programs (for
adults and children)
Kaiser Permanente Child Health Program
Kaiser Permanente Bridge Program
Medicare Cost Sharing
Facility-based Sliding Fee
School Lunch Medicaid
Family Pact
Cancer Detection (Breast, Cervical and Prostate)
Social Services and other support programs
Food Stamps
TANF (Temporary Aid to Needy Families)
Supplemental Nutrition for Women, Infants and Children
(WIC)
Earned Income Tax Credit (EITC)
Voter Registration
General Assistance
Programs to be implemented in Spring 2009:
CARE (discount electric and natural gas bills through
major CA public utilities)
Low Income Auto Insurance
Child Tax Credit
Voter Registration
The impact of this broad range of programs in the system is
enormous: Imagine a mother bringing her sick child to a clinic and
being screened for health coverage. She is told she has to pay a share
of the cost for her coverage. Now imagine she is also told she may be
eligible for up to $4,700 in earned income tax credit, which could help
her cover her health coverage costs.
INSIGHTS ON ENROLLMENT REFORM: EXPERIENCES IN ARIZONA, CALIFORNIA
AND INDIANA
The following are benefits and insights from other jurisdictions
using the One-e-App software to inform the Maryland and Healthy Howard
experience:
Efficiency gains in time and resources are most
significantly realized through systems integration and electronic data
exchange. In Arizona, One-e-App interfaces with two State systems to
deliver data and signatures and provide document access for Medicaid,
Food Stamps and TANF. In California, One-e-App interfaces with State's
Single Point of Entry to deliver applications for children's Medicaid
and S-CHIP. The system also interfaces with a variety of county
systems, local health plans, patient management systems and other
systems.
Automation reduces errors and speeds time to benefits. An
assessment of Health-e-App (the predecessor to One-e-App in California)
revealed a 40 percent reduction in errors and a 21 percent increase in
eligibility determination time using the online process vs. the paper
process.
Public Access is an increasingly important channel to
reach and engage consumers. In Arizona, for every application received
online, an estimated 20 minutes or more of State staff time are saved.
In addition, to date applicants are showing proficiency in navigating
an online application (fewer than 5 percent of the applicants who
submitted applications have contacted the help desk). Several
California counties will soon use kiosks in emergency rooms and schools
to encourage applicants themselves to participate in the enrollment
process (while still providing in person and other assistance for those
who need it).
Modernizing the enrollment process requires more than
improving the front end of the process, the back end infrastructure
also needs to evolve and change. The State of California is undertaking
a major effort to create a service-oriented IT infrastructure to permit
data sharing across programs and to leverage assets across departments.
The effort has begun by establishing governance and oversight capacity.
The Center looks forward to sharing more information on these and
other benefits and lessons learned and to connecting interested
individuals with contacts in other States to learn more.
NEXT STEPS: BUILDING ON PROGRESS AND MOMENTUM
The current plan for One-e-App in Maryland is to learn what works
and what does not in Howard and Anne Arundel Counties (next in line to
adopt Health-e-Link) and to work with the State and other counties to
support their use of the on-line application with electronic data
submission capacity.
I was struck by a recent quote in the Baltimore Sun in which a
representative from a local nonprofit which assists people trying to
navigate the health care system said: ``People don't always know--even
providers don't always know--which application they should fill out,
which program they should apply for.''
This captures the spirit of the challenge: the complexity and
number of programs (Federal, State and local), the number of forms, the
categorical nature of programs such as Medicaid and Food Stamps, the
siloed nature of systems, oversight agencies, financing streams and
advocates. The main victim in this fragmented system is the applicant.
Modernizing enrollment in public benefits is complex and
disruptive, but it is also necessary and long overdue. Other facets of
State government have evolved to be more efficient and consumer
friendly. Howard County has taken important steps to bring enrollment
innovation to its residents. The Center looks forward to continuing to
support Howard County and others in improving access to benefits
through innovation and reform.
Thank you for this opportunity to testify today. I am happy to
answer any questions you may have.
Senator Mikulski. Well, that's pretty impressive. We're
going to come back to you about how that actually worked. What
you also see, are some of the stumbling blocks. Not only are
there programmatic silos, but the good news about computers is,
we've kept computer security, but it also means it's hard for
computers to talk with--just like----
Ms. Page. That's right.
Senator Mikulski. Computers are like people, it's hard for
them to talk to each other----
[Laughter.]
Senator Mikulski [continuing]. And communicate, cooperate.
Well, now, let's really go to the heart of why all of us
are here and what prompted Ken Ulman and Dr. Beilenson to do
this, which is with people of Howard County.
Howard County, demographically, would seem like it has no
problems, that it is one of the most affluent counties; it is
indeed a beautiful county, it's been well managed, it's been
well planned. There we are. When Mr. Ulman told me, initially,
the number of people who were uninsured, not even underinsured,
in Howard County, it was an eye opener for me, because we
always think of places like Baltimore City, where people are
having a tough time. We'd like to now turn to the families and
get a sense from you--How did you come into this program? What
did this program mean? What did you like about it? What would
you recommend that we would think about either changing or
improving, not only for them, but from us. This is the
laboratory of innovation, and we want to learn from it.
Ms. Wensil, why don't we start with you.
STATEMENT OF VAN LYNN WENSIL, RESIDENT, HANOVER, MD
Ms. Wensil. Thank you for being here. We really appreciate
it.
My story is not atypical. My family has lived in Howard
County for seven generations now, all within about a 2\1/2\
mile radius. I was married for 33 years, and that marriage
ended in divorce. For 18 months, I was covered under the COBRA
plan. Under that plan, I paid, for an individual insurance,
$648 a month. That did not include my children, who were still
umbrellaed under their father.
When that 18 months started to terminate, I started
shopping. I was turned down by every insurance company--Kaiser
Permanente, Blue Cross and Blue Shield--because I had pre-
existing conditions.
I have COPD; specifically, emphysema, early stage. I don't
look forward to a real good outcome on that one. I would
literally wake up panicky that I might lose my house. All it
would take is a really bad case of pneumonia or an accident,
and I could be without my home.
This is such an innovative approach. I just feel like I won
the lottery the day I got the call that I had been accepted
into this program. I have already met with my primary care
physician. I have a referral for blood tests, blood work. This
is the first time in years. It's been over 6\1/2\ years that I
have been without insurance. It's changed my--I feel lighter. I
literally don't feel the weight of worry that I did before.
I am looking forward to meeting with my health coach. There
are things that I want to know. I'm sure there are things that
she wants to know--or he--about me. I just feel so supported. I
feel supported on level of physician-patient, I feel supported
by my county, I feel supported by such a band of people that
really are working to prevent illness, to deal with illness
and--on a personal level rather than waiting until someone is
really ill, really hurt, and having to deal with it in the
emergency room. That is just such a blessing to me.
I thank you all. I appreciate everything you've done. I
thank you for your ears today.
One thing I will say that I loved about the system, and
just meeting with my physician the one time, they have a
program that specifically sends you to where the prescriptions
are cheapest. That was so appreciated. I didn't have to shop
around. And I appreciate that, specifically.
Thank you.
Senator Mikulski. Ms. Wensil, before we go to Ms. Tucci-
Farley, could you step back for 2 seconds and just give a quick
cameo of how you found out about the program? Where did you go
to apply for the program, and what happened when you did apply,
and--take us through those steps.
Ms. Wensil. OK.
Senator Mikulski. Your narrative is quite compelling and
poignant, and if we could get those sequential steps, it would
be helpful for us.
Ms. Wensil. Oh, thank you. I first read about it in the
Howard County Times. Right away, I was like a dog with a bone
and called the county, was given paperwork, saying how this was
going to be used, how I was going to be able to access. I went
to the public library, Howard County Public Library. I took
paperwork with me, verification of salary, birth certificate,
identification of who I was and that I was a legitimate
resident of Howard County. It was a very easy process. There
was actually excitement in the room. It was a very pleasant
place to be. Even though the wait was somewhat long, there was
a cheerfulness, and everybody was rooting everybody else on.
That was a little bit of a surprise to me.
Senator Mikulski. It's not typical if we're applying for a
program.
Ms. Wensil. Absolutely. I got to know several of the people
standing next to me fairly intimately, because we were all----
Senator Mikulski. In it together.
Ms. Wensil [continuing]. In it together, yes. Absolutely.
It was a breeze, as far as paperwork. I don't know what else to
say. It was just very easy, and I was appreciated for accessing
the plan, but I was also appreciative.
Senator Mikulski. You were told you were eligible, then
what happened?
Ms. Wensil. Yes. I was given access to the healthcare
providers, where I called to make my first appointment. Within
the first month, you were to call and schedule your first
primary care visit. We are allowed six primary-care visits a
year. Women are allowed one extra. I met with my wonderful
physician. I got some prescriptions that I hadn't been using or
even compromising myself by lowering the dosage.
Senator Mikulski. To stretch it out?
Ms. Wensil. Absolutely. Absolutely. So, I really
appreciated my four prescriptions, which cost me, unbelievably,
only $28. One prescription used to cost me $96. So, like I
said----
Senator Mikulski. This is pretty stunning.
Ms. Wensil [continuing]. This was my lottery number, and it
is not unappreciated.
Senator Mikulski. Well, thank you, I think that's pretty
telling, and we appreciate the detail.
Ms. Tucci-Farley, now share with us your story.
STATEMENT OF FRANCES TUCCI-FARLEY, RESIDENT, ELLICOTT CITY, MD
Ms. Tucci-Farley. My name is Frances Tucci-Farley, and--you
know, it's funny, I'm sitting here in front of a script, but
this is my life I'm talking about, and I really shouldn't need
it, but I want to make sure that all the credit due is not
skipped over in any way.
Senator Mikulski. Well, I'll tell you what we're going to
do to help you out. The way we say it in Congress is, I ask
unanimous consent that all written testimony be included in the
record. And speak from your mind and your heart.
Ms. Tucci-Farley. OK. I think it'll--well, you use it for
whatever you need to, to make this applicable to everybody that
needs it.
Senator Mikulski. But, you've got to pull up the mike so we
have the record.
Ms. Tucci-Farley. My name is Frances Tucci-Farley. I'm a
single mother. I have two children, one in kindergarten and one
a sophomore in college. I've been a resident of Howard County
for 20 years, and was married for a total of 28 years,
divorced, and since then, have suffered an incident that
impregnated me, and I went through with the pregnancy. With
that decision in mind, I began full-time work as soon as I was
able, and--shortly after the birth--worked at a particular
company for 5 years. In June 2008, with no forewarning, our
company laid me off and I was completely devastated. My oldest
son had health insurance through his college, and my youngest
son had health insurance through his father.
I just have to pause in between, because it's a--there are
some details in there I need to just grapple with.
Senator Mikulski. Well, we understand. There were many
tragedies that hit you, but one of which was, the father of
your son passed away.
Ms. Tucci-Farley. Yes.
Senator Mikulski. And it was sudden and unexpected, and it
had great emotional impact and great----
Ms. Tucci-Farley. Yes. Great reconciliation occurred to
even allow that climate to be so.
Just before I was laid off, I was in a car accident. I was
driving my youngest son to the library, and with no
forewarning, we were impacted in the rear by two vehicles, and
I was injured. It aggravated back surgery that I had, 4 years
ago, which I was completely paralyzed on one side. Since the
accident, I've been experiencing some of those same symptoms;
not to a full degree, but I recognize them. Due to my layoff, I
no longer had health insurance; and so, those symptoms have
gone unchecked for the past 7 months.
In the mix of all that--the accident, the layoff, trying to
land with my feet on the ground--I went to DSS. It's the only
place I knew where to go. I even went there, scratching and
clawing, knowing that there is such an oppressive environment
in there that, if you're at the low point, it's probably the
worst door to walk through, because you feel completely
degraded as a human being. There's a certain resignation on the
other side of the desk that makes you not at all feel welcome
or even hopeful that there might be a positive outcome that
would solve your situation.
I waited in that line--I actually waited in six different
lines, it took a total of 6 hours while I was there. I was in a
short line at the very beginning, and then sat, with each
individual case worker for one interview, one application,
another interview, another application, and it was just like a
progressive dinner; I was, for 6 hours, passed from one
caseworker to the next, and finally went out, only wanting
health insurance.
I was told it would be about a 30-day wait, and so, in July
I began calling to find out the status. Between July and
October, I received no response. I did receive, however, one
letter in August that stated that they were unable to process
my application, due to, and I quote, ``an agency delay has
occurred beyond our control.'' I called to find out what that
might mean. I left messages. Each of those voice messages said,
``If you don't hear from us within 48 hours, call my superior
and he will return''--and then I went all the way up the ranks.
Months went by, with no response.
I remember hearing, back in June, about Healthy Howard. In
the interim, I happened to catch, on NPR, an interview with Dr.
Beilenson, and learned more about Healthy Howard, and counted
the days--literally checked off the days between July and
October, when I could stand in that line and finally get
coverage for myself.
Coincidentally, the tragic death of my son's father
occurred. And again, though it was a dire circumstance under
which my son was conceived, there was great reconciliation, and
a phenomenal cooperation was the result, by that time, of
arduous efforts to make things work. And by that time, my son
had bonded greatly to his father. He provided health insurance,
he was paying child support, and he was cooperating, on almost
a daily basis, with his homework, just launching him into
kindergarten and making sure that he was stable and had a new
foundation, a new beginning. And that's the point that we were
at.
On Yom Kippur, October 9, we were actually going to go on a
day trip. We had some serious conversations to resolve and some
plans for my son's future that we were going to start founding.
Went to his house, no answer, couldn't get in, and, in the
interim, I witnessed an auto accident, so I stopped, because I
was called to be a witness for that, the officer needed
testimony, and I asked him, ``Please, there's a friend I have
that lives around the corner, is it possible, when you're
through processing this, can you please take me to his house,
and can you go inside and check? '' And at the time, it was
completely unexpected, but just something instinctively said it
was very wrong. They went inside and said, ``He's gone.''
Senator Mikulski. Wow.
Ms. Tucci-Farley. So, my son, sitting in the back of the
car, said, ``Mom, is Daddy OK? '' And I said, ``You know,
remember when Jesus said he was going to prepare a place? '' I
said, ``Well, Daddy's place was ready, and the angels came and
took Daddy.''
I drove in circles that day, already prescheduled to go to
Healthy Howard that evening. I went from playground to
playground, not knowing how to speak the reality to my son,
because he was still not getting it.
It wasn't until I was standing in the line, again driving
to the library with my son; this time, not an accident, but
another series of blind-sided events. When I was standing in
the line, there were lots of people in the room. Like you said,
the atmosphere was extraordinary--it was profound. It was
positive. People were hopeful. People that didn't speak
English, people that were Chinese, people that were Asian,
people that were African-American; every color of the palette
was there. While we were waiting, it wasn't an arduous wait, it
was OK to be there. Everybody was understanding. They were
even--like you said, some comraderies forming. You could hear
the conversations around the room. An oriental woman came over
and showed him this little shaky dog that you'd want to take
your coat off for, and made him cheerful again. I finally got
to the front of the line, tried to withhold my stoic
disposition and begin the process of handing over my paperwork.
And before I could get out of me needing to stay composed and
contain myself, the process was over. I had handed my
paperwork, they copied them, they handed them back, they
smiled, and, of course, the woman said, ``And so, you'll be
needing healthcare for yourself? '' It was that moment that it
dawned on me, ``No, I need it for my son.'' At that moment, I
realized that his health coverage was going to be terminated
because his father's employment was no longer a viable source.
So, of course, the woman very discreetly, called over a
senior representative from Howard County Health Department, and
she provided me resources for grief counseling, summer camp for
my son, and just beaucoup resources and numbers in which she
went over and above the call of duty, and even called me the
next day to see how my progress was going. She called me the
next week to see if there were any other resources she could
provide. It was just over and above the call of duty. I was
told, ``Make an appointment.'' Make the appointment, you'll
receive a call, ``We'll evaluate your application and tell you
what you're eligible for.''
In that very short--I believe it was less than 10 days--
whereas, with DSS this was going on 7 months--they had an
answer, they said I was approved. Yet, because my case was
initiated through DSS, it was pending, and they could not
process me, because DSS would not release my case, even though
I only wanted health insurance.
Through some ingenuity of the director, or one of the
directors, I believe, at Howard County Health Department, she
finally figured out a way to have my case released from DSS,
and which they did so; and, in 3 days, she solved what DSS was
unable to solve, because of their backlog, lobbies, and system,
in 7 months. So, I was able to be given a card for health
insurance, just medications--because my son's medications had
been suspended in the lapse--was able to resume medications,
even before getting my cards, and now we're in the process of
waiting for our official cards so that we can continue and I
can get care--neurological care for some of the damage that's
occurred from the accident, and hopefully get feeling back in
my limbs without having to go through surgery again.
One of the things I'd like to see changed is for there to
be some sort of partnership or release for the Howard County
Health Department and the Health-e-Link system to be able to
handle the overflow of caseload that DSS is stymied by. I think
it would be a fantastic improvement in the system overall for
the country, especially if Healthy Howard is a model program
for other States to emulate.
I ended up being eligible for medical assistance, my son
ended up being eligible for MCHP after all; it wasn't going to
be a premium-based health coverage, like I initially thought.
That was a fantastic piece of news. It was a very smooth
transition, and one seamless action of processing my documents;
phone call when it was promised, came as delivered, came over
and above the call of duty, was completely, completely
regenerative, to the state that we were in.
Though these ordeals throughout the past months have been
extremely exhausting--losing my job, being in the auto
accident, suffering a death in the family, having to be at the
top of your game with unemployment and following that criteria,
in light of everything else, is a completely consuming
undertaking. Now I'm able to focus back on getting re-employed.
I want to get out of the system as quickly as possible; I'm
used to being on the other end of giving, not the receiving
end. It is a bit of a cross to be on this end. Anyway, I just
wanted to ask if there was a way to possibly use my example to
illustrate how easily Health-e-Link can facilitate delivery of
care so that they can move on to the next person and the next
person and the next person.
Senator Mikulski. Well, you've already done that.
Thank you. Is there anything else you want to add? Or you
want to think a little bit and then come back--we'll come back
to you.
Ms. Tucci-Farley. Yes, I need to sit a little bit.
[The prepared statement of Ms. Tucci-Farley follows:]
Prepared Statement of Frances Tucci-Farley
Senator Mikulski and committee members, my name is Frances Tucci-
Farley and I am a resident of Howard County, MD. Thank you for the
opportunity to share my story with you about what I've gone through to
get health care for me and my son.
All of this started back in early June when I was in a car accident
and injured. Shortly after the accident, I was laid off from my job. I
went to the Department of Social Services here in the county to apply
for health care for myself. Thankfully, my son (he just turned six
earlier this month), had health insurance through his father.
Between June and October, I tried several times to check on my
application at Social Services and was unable to get an answer from
anyone. The only feedback I received about my application was a letter
stating, and I quote, ``an agency delay has occurred beyond our
control.''
Then came October 9. My entire world changed in an instant on this
day. There was a tragic loss. The father of my son passed away from a
heart attack. It was a sudden, unexpected, and devastating loss. I was
devastated. My son was devastated.
His death had a significant emotional and financial impact. In
addition, I was concerned about health care for my son because his
health benefits through his father were terminated upon his father's
death. Now it was me and my son who needed health care. So, on October
9, the very same day my son lost his father, I headed to the East
Columbia Library. I had heard about Healthy Howard and that the Health
Department was having open enrollment for health care at that branch.
There were a lot of people at the library who needed health care. I
waited my turn and was seen by someone from the Health Department. They
collected my documents and signed me up for a phone appointment to
figure out what program we were eligible for. When I told the Health
Department people about my situation, they immediately set me up with
one of their staff who helped connect me to several community
resources. They were able to tell me about grief counseling options,
even a camp for children who have lost a parent that I can sign up my
son for this summer.
Compared to what I had been through at Social Services, this seemed
too easy. I went to the library thinking I was just applying for
Healthy Howard, but when they worked on my case I was told that I was
eligible for Medical Assistance. And my son was eligible for the
Maryland Children's Health Program or MCHP.
I thought everything was set and then we had another major set
back. The Health Department called to say that since I had applied at
Social Services first and my case was still pending there, the Health
Department wasn't allowed to work on it. Social Services had done
nothing for me since June but the Health Department wasn't allowed to
work on my case and get us approved for health care. This makes
absolutely no sense and must be changed. If the system at Social
Services is so overwhelmed and they had a way to take one more person
out of their lobby by allowing another agency to work on my case, why
wouldn't they want to take advantage of that? I wasn't applying for
other services, we just needed health care. Thankfully, the supervisor
at the Health Department was able to figure out a way to get my case
released and both my son and I were approved for health care. We were
even able to get a temporary card for my son so he could get his
medications. He had been without his meds for 5 days.
I have been going through a lot over these past few months. I was
injured in an accident, I lost my job and I am now faced with raising a
child on my own. The Health Department and this new process they have
to enroll people--the Health-e-Link system--really made it easy. To me,
it also made applying for health care a humane and professional
process. It is hard enough as it is to ask for help and it gets really
frustrating and upsetting when you don't know what you qualify for and
you can't seem to get anyone to answer your questions or give you an
update on your case. I wasn't asking to be treated differently from
anyone else. I did all the right stuff--I went to Social Services, I
filled out the application, I gathered up all of my important
documents. I just needed someone to work on my case and see if I was
eligible for health care. Then, all of a sudden, I needed help for my
son as well. There was this overwhelming sense of despair and
helplessness when I first applied for health care at Social Services.
It was an entirely different feeling when I got to the library on
October 9. With the Health Department and that Health-e-Link system, I
got feedback immediately--they told me what we were likely to be
eligible for and then explained what would happen next with the
application.
Even in the best of situations, it is hard work having a pulse.
Health care is not a luxury item. It is something I need for myself and
for my son. There must be an easier way to get people access to health
care. It looks like the Health Department may have a solution with
Health-e-Link.
Thank you for the opportunity to share my story with you today.
Senator Mikulski. First of all, thank you. Thank you, Ms.
Wensil. These were hard stories to live. They're harder stories
to relive. And they're much harder to relive them in public.
So, we thank you, first of all, for your courage.
Ms. Tucci-Farley. Thank you.
Senator Mikulski. We thank you for your courage in being
willing to share this in public. I think we've all been touched
by it, and, of course, that means we have to be, ourselves,
moved to action. So, while you kind of regroup a minute, we're
going to turn to these folks, and then we'll come back to you.
Ms. Tucci-Farley. Thank you for the opportunity to share.
Senator Mikulski. Thank you.
What I'd like to do is ask a couple of questions, turn it
over to Congressman Sarbanes, and we'll do that for, maybe, a
couple of rounds, until about 1 o'clock.
I'd like to kick this off with the county executive, who
really undertook a pretty bold experiment and had to marshal a
tremendous amount of community support. I would like to ask him
what he felt would be elements of the program that could be
implemented nationally, and what, if any, pitfalls that you saw
in doing that, and perhaps Dr. Beilenson can respond to those
two questions.
Mr. Ulman. Sure. Thank you, Senator.
Let me also just say, thank you for the testimony and the
wonderful stories. I also commend your courage in telling those
stories here. You asked what you could do, and the Senator
said, ``You've already done it.'' I'd echo that. I mean, we can
think about policy and talk about policy, but, it's incredibly
important for people to know your stories; and so, thank you
for that. Certainly inspirational, and keeps us going in
fighting harder for this effort. You've put wind behind our
efforts to keep this going.
Because we've heard a little criticism. People like to
criticize when someone takes on a new effort. We knew this was
going to be hard work. There is no question about it. I think
the lessons--and I'll ask Dr. Beilenson--the lessons that I
think we've learned are that there's a lot of people who are
eligible for existing programs. We knew that, as Dr. Beilenson
said. But, to see how many people there are like you who got
into something that your son was eligible for, that you were
eligible for, that, for a variety of reasons, your experience
with DSS, you just weren't getting. I mean, this is something
that the Senator, her leadership at the national level has
provided funding for, has provided opportunities for, and it's
just not getting to you. That's been a huge lesson for us, and
it's buffeted, sort of, our belief that there are folks who are
eligible for existing programs. And to me, that's one of the
most exciting pieces.
The other is that this network that we've been able to pull
together is functioning. We just started, but, when I hear the
story about how inexpensive your prescriptions are--we've
talked about this pharmacy benefits coordinator who's going to
tell you that Walgreens has it for $4, but Giant now has it for
free, because they have free antibiotics. We can talk about
that, but to hear you saying that four prescriptions is costing
you $28, when one was costing you $96, I just had a huge smile,
internally and externally, to hear you say that, because we've
been trying out, ``OK, what's our budget for pharmaceuticals.
We know they're out there, we know that there are benefits out
there that we're just not leveraging.'' And so, to hear that is
tremendously exciting for us.
I think the one pitfall, if you will, is how hard it is to
find people. People are busy. We've got to first----
Senator Mikulski. How hard to find people to do what--to
participate in the program or to be providers?
Mr. Ulman. Participate. You read the paper, and you heard a
radio interview, and you heard about us, and you checked us off
on your list. Well, there are thousands of people like you who
still don't know that we exist. That's the toughest lesson for
us. How do we reach that next group of people that are working
two jobs and are busy? Because we know this is working and so,
we want as many people--we want to hear this story for the
thousands of people who don't have healthcare.
Senator Mikulski. Well, this takes me, then, to Ms. Page
and Dr. Beilenson. This goes to eligibility and certification,
as well as case management. So, I'm going to put my social-work
hat on. Going back to my days as a social worker, and also
talking to people who are on the other side of the desk, that
Ms. Wensil and Ms. Tucci-Farley found so, at times, harsh or
even despondent, and contributing to the despair, is that the
workers themselves are so burdened by books and books of regs,
schoolmarmish requirements, at times even where Congress, in
its desire to save money, has even created harsh punitive types
of questions and so on.
Now, what they just talked about here was, in itself,
almost revolutionary, that, when they talk about walking into
this room, and the energy, the vitality, the hospitality; they
didn't feel like the process was either humiliating or harsh
and punitive. Also, the people administering it, themselves,
weren't so worn down and burned out, where they themselves
needed help to help you. You know, we often, at times, forget
that the helper needs help to be of help.
So, my question, then, goes to you, Ms. Page. You've got
something pretty revolutionary going on here in this--the
Center for----
Ms. Page. The Center to Promote Healthcare Access.
Senator Mikulski. Could you tell us about this? Is this a
proprietary tool, could you tell us about that? How do you do
what you do? And how did this come here to create an
environment that worked for everybody, from those who were
signing up for the program, but for also those who were--
because if you administer a demeaning program, you yourself
feel demeaned in administering it. So, could you help us out,
here?
Ms. Page. Sure. You know, it's interesting that One-e-App
actually got its start in California, where the creation was
funded, in part, by two foundations, two conversion
foundations, the California Healthcare Foundation and the
California Endowment, who provided funds to help create the
system----
Senator Mikulski. Like an IPO?
Ms. Page. Kind of. Exactly. And after that----
Senator Mikulski. Or venture----
Ms. Page. Well, it's----
Senator Mikulski. Let me put it this way, if you're a
social entrepreneur, this was the venture capital.
Ms. Page. That's right. And after some period of years,
realized that it wasn't the day-to-day work of foundations to
continue to manage and oversee, and even though they weren't
the technology developers, they still had their hands kind of
deep in the work and decided that it was worthwhile to create a
nonprofit organization to focus, not just on the technology
piece, but also on the advocacy and education piece of this
reform work. And they actually provided seed funding to create
the Center to Promote Healthcare Access.
One of the other things that happened in that transaction
was, the intellectual property to One-e-App is actually still
owned by those two foundations, who provide to the Center a no-
cost license to then sublicense it at no cost to other
jurisdictions who are going to use it for this important work.
So, any new jurisdiction, county, State, who's using One-e-App
takes as its starting point a core system that then is
configured and customized to work with the local programs and
business processes.
Senator Mikulski. So that a South Dakota and a North
Dakota, with a very different population size and demographic
than, certainly, California, which is almost like a nation-
state, in just size and language and so on--so, this is not a
one-size-fits-all technology.
Ms. Page. It's a starting point, but not a one-size-fits-
all, primarily because the rules--I mean, Medicaid looks
different in every State. Medical looks different in every
California county, even though it's generally the same; the
business processes and some of the rules are different. You can
generalize some of them, but we have found that the more
accurate the screening is at that moment in time where you're
with the family and you're able to collect as much information
as you can, the greater the benefit to the family. You're doing
a more accurate screen and actually sending their data to the
program. One-e-App also is the final determinant for a handful
of programs, but for Medicaid, we aren't the system that makes
that final determination; States and counties make that
decision. But, we're sending the information there with a
greater likelihood that it will be approved.
Senator Mikulski. Well, Ms. Page, we could spend a lot of
time just talking with you, and I think what we'd like is to
see more of a report, or like an annual report, or something,
and we'll come back to you.
Ms. Page. Great. Thank you.
Senator Mikulski. But, before I turn to Congressman
Sarbanes, technology is a tool. Very often, among my
colleagues, there is a belief that technology is the silver
bullet, it will solve everything, and so on. But, technology is
only as good as the people that use it. You need the tool, but
then you need the people and you need the culture. Technology
doesn't create the culture.
How did you do this, Dr. Beilenson? This is so unlike
anything I have heard, in 30 years of working as a social
worker, about the so-called intake process, and even in another
life, when I tried to change that culture myself. How did you
accomplish that?
Dr. Beilenson. Well, we have great people, and that's truly
their mission, not that it's----
Senator Mikulski. But, great people need a great culture
and a great organization.
Dr. Beilenson. Well, I think that, the county executive
certainly fostered a culture of innovation for the county. And
when we first met--I don't know, it was a couple--well, it was
actually the campaign--a couple of years ago, when we were
talking about this--me moving into this position, the fact that
he made it very clear that he wanted public health to be one of
his top priorities as a county executive, obviously sold me on
this. As you well know, it's extremely unusual for--
particularly for a suburban county executive, to make public
health a top priority.
Senator Mikulski. No, we acknowledge that, but let's go to
the room now. Let's go to the application.
Dr. Beilenson. These folks, both the architects and the
enrollment people, are just incredibly dedicated, and they just
buy into it as a mission. Part of our mission statement is
making sure that we provide access to healthcare and wellness
for the county. I mean, it's really as simple as that. And
we've put together a great team. John knows several of them,
from other lives, and they've just been dedicated. But, that
being said, I don't want to neglect, because I'm sure they'll
point out, that eventually they probably would get burned out.
You cannot see 1,100 people in 8 days and keep processing and
processing.
So, one point to make that I think has been lost in the
tremendous job that you all have done in expanding--in
recertifying CHIP and expanding CHIP--is, that all goes to
services. But, that you've got to do two things. You've got to
do outreach, because you've got to somehow bring people in. Ms.
Wensil and Ms. Tucci-Farley heard about this in certain ways,
but there's got to be a lot more outreach to get people into
existing programs.
And second, someone's got to do the enrollment to--and part
of DSS's problem is, as you said, they're overburdened, and so,
somehow some of this funding--and it's a small amount that's
necessary--needs to go to enrollment, to people who would
actually do the enrollment process, whether it's our type of
process or DSS's, because otherwise people are going to still
get burned out.
Senator Mikulski. Are you saying the money for the
technology or the money for more workers or----
Dr. Beilenson. Yes, to all three, although the relative
expenditure, compared to the healthcare costs, are small. But,
not to forget that those are three important components.
Senator Mikulski. John. Congressman Sarbanes. Thank you.
Mr. Sarbanes. Thank you, Senator.
Thanks for the testimony. It's very, very powerful. I have
so many questions and so little time, so----
[Laughter.]
Mr. Sarbanes [continuing]. I'm just going to try and jump
around, here.
I think, in part, what you've done is, you made it possible
for care to be delivered in all the ways people wish it were
delivered, and are frustrated, day in and day out, that it's
not delivered. So, you're allowing folks to bring the best
approach to healthcare into this model. And there's a lot of
pent-up frustration about that, not just here in Howard County,
but obviously across the country, which is why you're getting
this call now for healthcare reform.
On the issue of IT, I'm glad we got to that point, because,
we just--in the stimulus bill, there's $20 billion now that's
going to try to boost the health IT infrastructure across the
country. Much of that is in the form of incentives to try to
get providers to step up into something that they're a little
bit reluctant to do because of the expense associated with it.
But, you're pointing out that there's other places where you
can direct resources and attention when it comes to information
technology, particularly when it comes to processing that
you're doing. So, that's making a huge difference.
I want to congratulate you on this aspect of connecting
people to their eligibility, that already exists--they just
don't know it--because, we just sent, again, a huge influx of
funds to support CHIP, to support FMAT, you know, Medicaid
program, across the country. We want to know that the people
who are eligible for that are getting the access that they're
entitled to, and that's exactly what you're about. So, I
congratulate you on that. And also on the State having picked
up, through the comptroller's office, this obligation. That
already shows that you're bearing fruit more widely than just
Howard County, because that model is being used.
Ms. Wensil, your testimony struck me as having the theme
that--I mean, you talked about this idea of, sort of, winning
the lottery. Of course, healthcare in America shouldn't be
analogous to winning the lottery. I want to make sure that
people have access, as a matter of course. But, what struck me
was just how excited you were to access the plan. I think I
heard in that the reality that people want to look after
themselves, they want to have healthcare, they want to be
healthy. That suggests that if the system can step forward and
make that possible, that there will be an equal investment on
the part of individuals and families to do their part. I know
that's part of the design, obviously, of these Health Action
Plans and so forth. So, I'm interested, interested to have you
talk to that just a little bit more, this concept that people
really do want to look after themselves. They want to be fit,
they want to be healthy, and they're willing to participate if
there's a system that's going to join them as a real partner.
Ms. Wensil. Oh, absolutely. I know both of us have cared
for our children, with the best of intention, sometimes at the
loss of our health or--so, to feel like, again, I have access
to that, to basic medication that I wasn't taking or was self-
manipulating, that's a big deal for me. I feel better when I
take my medication. I want to feel better. I want to get to the
point where I can walk more. But, with COPD, I couldn't. And
without medication, I couldn't. So, yes, I'm feeling better
immediately, but also, I'm not depressed about life and my
circumstance. I feel, ``OK, I've got somebody backing me on
this. I've got support,'' which I haven't had for so long. And
that's a big deal. When you feel like--and maybe that was part
of the ambience in that room, is that we felt--we felt like,
OK, somebody's looking at our issues. You know, we're just
little people, sometimes with big issues, but we felt like, OK,
somebody's paying attention that this is a real issue in our
lives, that we may not get things taken care of.
I broke my finger; I fixed it myself, I strapped it up
myself. And thus, I have a very crooked finger. But, I wasn't
going to go to the health--I mean, to the emergency room for
just a small finger. I thought, well, I pretty much will garner
arthritis pretty badly because of it. But, those are decisions
that everyday people are making: Do I take care of this now?
The problem with this method is that we're not taking care
of basic health, we're not taking care of routine health. We're
waiting until something really goes wrong, and then we'll end
up in the emergency room, for thousands and thousands and
thousands of dollars more. Whereas, that mammogram would have
been worth it, that, bloodwork--it's the routine issues that we
have ignored, being in this circumstance.
Mr. Sarbanes. Thank you. I've got----
Ms. Wensil. You're welcome. Thank you.
Mr. Sarbanes [continuing]. A question for Ms. Tucci-Farley,
but why don't we--you can go----
Senator Mikulski. Go ahead. Go ahead.
Mr. Sarbanes. OK. Well, what I heard from your testimony,
which was very, very compelling, obviously, and heart-
wrenching--and again, I want to thank you for the courage to be
here, and you, Ms. Wensil, to tell your personal stories. But,
the theme that came through to me from your testimony was that
the last--life throws enough curves at you; the worst time to
have to be worrying about your healthcare coverage and whether
that's going to be there for you is when you're dealing with
other crises in your life. And, of course, that's the situation
that so many people face. They have this thing that's hanging
over them, which is this anxiety about whether they can get the
care they need. And then, when life throws another thing at
them, the combination of those two things can be, just enough
to put them over the edge.
You had a great quote. I guess it was DSS that said to you,
``An agency delay has occurred beyond our control,'' which is,
I think, a good slogan for the healthcare system in this
country. You know, something has occurred beyond our control
which is preventing millions and millions of people from
getting access to the healthcare that they deserve. I thought
maybe you could just speak for a couple more moments to this
question of what it would mean--because you've obviously been
in the situation where you didn't have the healthcare coverage
available to you, and yet, you were trying to field all these
other things that were coming at you, and what kind of a
difference it would have made in your life, and a difference I
assume it's making now, to know that that part of your life is
under control, that you don't have to get up in the morning
with that anxiety; and so, you're in a better position to
handle the other things that are coming at you.
Ms. Tucci-Farley. There's one instance that comes to mind
immediately. In the line of work that I do, it may require that
I do some heavy lifting, as well, along with it. I am an
exhibit designer by trade, and----
Senator Mikulski. A what designer? I'm sorry.
Ms. Tucci-Farley. An exhibit designer. I've got some work
in the U.S. Capitol. Put that on record, huh?
[Laughter.]
There are times when I might be designing a particular
space, and I have to go into that space and figure out some of
the logistics. That requires lifting and so on, so forth. When
I'm on interviews, that's one of the questions. Right now, I
don't have feeling in my left arm, and I don't have feeling
down half of my spine, and when I even sit at the keyboard, my
hands go numb. I'm a little bit disingenuous in promising all
these great things that I can do, when I'm sitting in an
interview, trying to get a job, because the light in my
refrigerator is brighter than the front porch light; meaning
that there's nothing left in my refrigerator. It's a matter of
survival for me to get a job. And when I'm sitting at an
interview, and an interviewer detects that there's any kind of
tentativeness in your answer, the job market is so saturated,
you're immediately disqualified. I can't do that. I almost am
not sure, unless I get medical care soon, if this is going to
steer me back into having surgery again. And being a sole
parent, with my son--other son away at college, what do I do if
I need surgery again? Who takes care of me? I don't have family
in the State that's available to do that. And so, that
basically rides in the back of my thinking all the time. You
know, if something happens to me, there is no other parent now.
If something happens to me, there's no--it's like doing Cirque
de Soleil without the net. Knowing that you have healthcare is
an extraordinary, extraordinary element of having peace of
mind. There is just----
Mr. Sarbanes. And confidence as you go out into the world.
Senator Mikulski. Which, in and of itself is healthcare.
Ms. Tucci-Farley. Yes, part of the stress is, I think, at
times--when I'm fighting to not get sick, I'm fighting my own
decline in well-being overall.
Senator Mikulski. Dr. Beilenson, did you want to add
something?
Dr. Beilenson. Yes, I just wanted to add one thing. When
you were talking about the health IT, what Claudia was implying
was that we have this great engine, sort of a search engine,
Turbo Tax engine, that will help you fill out what you need to
fill out to get enrolled. But, it doesn't connect to the State
of Maryland. DSS's system is even worse. And so, if some of the
health IT money could be used, not just for physicians, but for
the States to do these things, the value added for that and the
cost-effectiveness would be vastly greater. You could get tens
to hundreds of thousands of people enrolled very quickly if you
had the ability to connect. For example, if we went through
Health-e-Link, and Peter Beilenson was eligible for MA
expansion, Medicaid expansion, it would literally--with the
appropriate technology improvements, I'd be enrolled. I'd get
my Medicaid card. That does not happen now. They collect all
the information, send it to the State, and we hope it gets in.
Senator Mikulski. So, what you're saying is, the State
system is both dated and it is not interoperable.
Dr. Beilenson. Absolutely. And some of the IT money would
be great to go there.
Senator Mikulski. I want to go on, then, for the final
round--because it is 1 o'clock and we're scheduled to end--I
want to focus on this case-management health-coach issue, and
then John--Congressman Sarbanes--and then kind of a summing-up.
We've now covered what--the compelling human need--it was
like to apply, the way you facilitated that and created a
culture of hospitality. So, you've now seen your primary care
doc, and you've got your medicines at the best price, and
you're on your way. Well, in our sick system--because we don't
have a healthcare system, we have it oriented to sickness--so,
the person then sees primary. Each one of these women have
things that will require specialized care, and off they go. And
no--there is no kind of continuity of who follows them, as
human beings and as families--because each has children, here--
and then there's this famous thing that you hear, no matter
what doctor you see, that says ``diet and exercise,'' and they
give you a little piece of paper, usually given to you by
somebody overweight themselves----
[Laughter.]
Senator Mikulski [continuing]. And no help whatsoever. So,
if you had a heart attack or you have serious pulmonary
compromise, what kind of exercise--you could be terrified
starting to do the wrong thing.
Now, under the genius of the Howard County system, what
happens--No. 1, you have a healthcare system, not a sick care
system--and what happens to help people be able to follow--do
they have a health plan? How do they follow it? And how is it
really one that motivates people rather than just simply,
again, school-
marmish compliance from a call center?
Dr. Beilenson. Well, the only actual innovative part of our
five-part program is that it--besides the fact that it ties
everything together--is the personalized health coaching. We
don't know of another system that has all the different
components plus the health coach. And the health coaches are
specialized in motivation----
Senator Mikulski. Why don't you describe, though, from the
stand--I'm a case example, and we've heard that; that's why I
wanted to hear this--so, follow with me now, not a laundry list
of abstractions----
Dr. Beilenson. Right.
Senator Mikulski [continuing]. Follow with me how this
works and what happens to a person.
Dr. Beilenson. OK. I'll use an actual person, but won't use
their name, obviously.
Senator Mikulski. Correct.
Dr. Beilenson. We've had several dozen people come in for
their initial primary-care visit. You go to the primary care,
and, as you were saying, we have a primary-care home, which is
Chase Brexton, who coordinates all healthcare. People are not
just getting sent to the specialists or to the hospital and not
connecting back with their health home. So, they have that.
Then, once they've seen the individual, the individual gets
assigned a health coach. We have different types of folks as
health coaches. One of our more creative types is a personal
trainer.
Senator Mikulski. Well, why don't you give us a
description, then, of the categories of people you have as a
health coach.
Dr. Beilenson. We have personal trainer, health educator.
We either have or are having a social worker. I may have
actually misstated that we have one.
Senator Mikulski. I think you ought to.
Dr. Beilenson. I agree. My wife's a social worker, too,
went to the University of Maryland, just like you.
[Laughter.]
No, were at Catholic University, right?
Senator Mikulski. No, I was--Maryland.
Dr. Beilenson. Maryland. So, she was just like you. And
then, nurse. So, we have--and depending on what your issues
are, you'll have a specific health coach who works in concert
with the others, so there's the team approach to it.
Let's just say, Patient X is seeing their primary care doc,
they're diabetic, they have a wound that needs care. They would
work with their health coach on what types of things they'll
need to do to better control their diabetes, whether it's see
their primary care doc on a certain regular basis to get their
sugar checked and to get their wound checked, to improve their
nutrition and exercise. We have community resources that are
brought to bear, whether it's walking programs, yoga programs,
nutrition classes that they be assigned to. The care
coordinator at Chase Brexton, who actually would coordinate the
referral to the wound center at Howard County General Hospital,
which will, of course, be done pro bono. And then, all of that
is connected back, and the health coach makes sure that all
those things were done, and the care coordinator makes sure
that the care has been coordinated, as well.
Obviously, if any prescriptions are needed, as Ms. Wensil
was saying, those are dealt with in a value-based formulary, as
well.
Senator Mikulski. Well, Dr. Beilenson--because then I want
to listen to our two other witnesses here, their families--what
is the difference between the health coach and something you're
calling the care coordinator or are they one and the same?
Dr. Beilenson. They are not one and the same. The health
coach is more of the motivational, wellness, keeping people
healthy, getting them motivated to do the things that will keep
them healthy, following them regularly, meeting with them face-
to-face. And that's--I'm not sure if you actually have yours
yet or----
Ms. Wensil. I don't. I haven't met with mine.
Dr. Beilenson. She'll be getting hers shortly.
Senator Mikulski. So, what's the care coordinator?
Dr. Beilenson. The care coordinator literally coordinates--
sits at Chase Brexton. You come out of the primary care doc's
office with a prescription for diabetic medication and a
referral to an orthopaedist. That care coordinator makes those
medical referrals and signs you up for the pharmacy assistance
program, or whatever the cheapest pharmaceutical program is, to
get you those medications as inexpensively as possible.
Senator Mikulski. What does the care coordinator do? Do
they watch everybody's progress? Do they host team meetings,
where they just, then, kind of--and that's no small matter,
telling you where to get the cheapest prescription. As we said,
it was a make-or-break bit of information.
Dr. Beilenson. The care coordinator manages the
individual's clinical care. The health coach takes care of the
holistic person. So, it's much more that a health coach is sort
of managing and motivating the individual's health and wellness
plan.
Senator Mikulski. But, I'm still back to this care
coordinator----
Dr. Beilenson. Yes.
Senator Mikulski [continuing]. And who's in charge of the
patient? If this, in fact, is their--so, we know it's the
doctor.
Dr. Beilenson. Yes.
Senator Mikulski. We've heard that. But, doctors don't
follow patients. They really don't. They follow you when you
come back for your routine visit, but not from that visit to--
let's take your diabetic. OK, so if you've got a wound that
doesn't heal, that's one whole thing. But, you're going to have
to do a whole variety of other things.
Dr. Beilenson. Correct. Well, understanding that it is
solely a tool, we do have an electronic clinical record that
keeps track of all these things. So, they can be queried by the
physician, by the care coordinator, and by the health coach to
make sure that things are being done in an appropriate fashion.
And it's a team approach to looking at this. Our health coaches
meet with our--and I don't know if he's here, but he--some of
our staff is here. Liddy's probably here, our executive
director. They meet in a team, to go over each patient to make
sure that the appropriate things are being taken care of. The
care coordinator is much on location, and, as you said, has a
difficult job, but is not so responsible as are the health
coaches for making sure that everything that needs to be done
is done.
Senator Mikulski. Do you see my question?
Dr. Beilenson. I do.
Senator Mikulski. You've got a lot of people, which is
excellent, and you've got a lot of moving parts, which is
excellent, and you've also looked at the behavioral
encouragement, which is really so fresh and innovative--it's
very fresh and innovative--but, the current healthcare system,
first of all, doesn't pay for case management, it doesn't pay
for even the most dated-of-thinking case management. And the
case management is--your primary care doctor says, ``This is
what you need to do, this is the specialist you need to see,
and this is that famous diet-and-exercise kind of thing,'' of
which nobody takes any responsibility to followup. So, maybe
you come back to your primary care doc, maybe your A1C now is
at 10 or more, heading to the danger zone.
Dr. Beilenson. Right.
Senator Mikulski. Have you done the diet? No. Have you done
the exercise? No. Did you see the specialist? ``No, the line
was busy.'' So, who----
Dr. Beilenson. The idea is, the health coach----
Senator Mikulski. The health coach. That's their job?
Dr. Beilenson. Correct. Because they can query everything
and see if it's not done----
Senator Mikulski. And who----
Dr. Beilenson [continuing]. In a vacuum, however. I mean,
they may need to talk to the care coordinator. Can we find the
person a specialist visit at a time that's more appropriate for
them, or whatever?
Senator Mikulski. OK.
Dr. Beilenson. But, the evaluation will also show how well
we're doing on all this, so that's why we're very pleased that
we have this large-scale evaluation that's ongoing.
Senator Mikulski. Well, we're going to come back.
So, you haven't met with yours, yet.
Ms. Wensil. No, I have not. I have not met with the health
coach yet. I have----
Senator Mikulski. But, you've embarked upon--and, again, I
don't want to pry, here--but, you've embarked upon,
essentially, what was the medical sequencing of what you needed
to do to even get you ready for that next step of the health
coaching.
Ms. Wensil. Right.
Senator Mikulski. Is that correct?
Ms. Wensil. Right. One of the things that the physician
fills out on your first visit is basically an outline of your
health and what you are capable of doing, all the way from
strenuous cardiovascular to yoga and relaxation techniques. So,
when you ask, ``Who's responsible? '' it's an interesting
question for me----
Senator Mikulski. Well, the first one is you.
Ms. Wensil. Right. And that's the way I feel. I feel like,
OK, I've finally been given the power back to take some of that
responsibility. It's not that I didn't have the
responsibility----
Senator Mikulski. No, I understand.
Ms. Wensil. You understand that.
Senator Mikulski. But, there could be a 45-year-old guy,
with the acute wound that doesn't heal, who has just been
divorced, his job is teeter-tottering, he's depressed as the
dickens, he doesn't want to cook for himself, he's sitting
there, watching TV, eating potato chips or drinking Coca Cola
or beer--his blood sugar is going sky high, and he's going into
a deep depression. That's a little bit different than how
you're going to take responsibility for yourself, because you
need somebody to help take responsibility, to help you even get
to that point.
Ms. Wensil. That's true.
Senator Mikulski. So, you see----
Ms. Wensil. That's true.
Senator Mikulski. I really do sound like a social worker,
don't I?
[Laughter.]
But, Ms. Tucci-Farley, you kind of had almost that. You
know, as you now signed up for your program, and you ran into
all kinds of bureaucracy, obviously you are a woman of
incredible spunk--both of you are. I mean, not only the
personal courage, but, you have a lot of spunk, in terms of the
activities of daily living. Now, where are you in this process,
have you had a health coach?
Ms. Tucci-Farley. Not yet.
Senator Mikulski. Or you're not there yet.
Ms. Tucci-Farley. I have not yet declared a confirmed
provider. Some of the names that I was given as participants
within the medical assistance program are no longer
participating, so I have a card that has a doctor's name on it
that I never selected and don't know who they are.
Senator Mikulski. OK.
Ms. Tucci-Farley. So, that's one of the things that perhaps
needs to be looked at, too, is updating the system.
Senator Mikulski. I think that's an excellent suggestion.
Ms. Tucci-Farley. I received a phone call this morning,
from a representative of the Health Department, giving me
several more names of referrals.
Senator Mikulski. This is my last followup and then I'll go
to John Sarbanes.
So, I've given you this 45-year-old guy who comes in to the
doctor and the doctor says, ``You've got to get blood work? ''
And the plan has been an excellent plan, and he sat there and
said, ``Aha.''
Dr. Beilenson. The health coach.
Senator Mikulski. And what would the health coach do?
Dr. Beilenson. Well, again, you would know if the person
got lab work, because it's electronic records. You would know
if the person went to nutrition classes, because they're
connecting, as well. The one thing we're having a little
problem on accountability with is the exercise program, because
let's say the exercise program is 3 days a week, a hour a day,
at Centennial Park, walking. Well, it's going to be hard to
check that. You know, in the wintertime it's easier to check,
because they've gone to yoga class, et cetera, et cetera.
Senator Mikulski. Got it. Go ahead.
Dr. Beilenson. It's all in an electronic medical record. It
is done in concert with the others, however. It is done in
concert with the primary care doc. So, the health coach is the
one that's predominantly responsible, but----
Senator Mikulski. So, then what would the health coach do?
They know that he didn't do it.
Dr. Beilenson. As the county executive said at the very
beginning--this is based on rights, like healthcare is a right,
but also responsibility. As part of the sign-up process, if you
are not substantively complying with your program, your
behavioral action plan, your Health Action Plan, you actually
go on probation and could eventually lose most of the services.
So there is a stick.
Senator Mikulski. So, that's the stick. But, let me ask you
this. And now we're really running over on time. The health
coach sees this--and this happens every day in just about every
case that we could go to for a variety of things, in every
setting, from being followed at some of the most prestigious
institutions, to poor rural areas. Would the health coach
essentially call George and say, ``George, gee, what's going
on? '' and essentially do personal outreach to engage the
person and actually ask them why, and see if they could come
by, or could they drop by and have a conversational
relationship to identify this?
Dr. Beilenson. Yes. That's exactly correct. And when it's--
--
Senator Mikulski. Because the health coach brings great
individual expertise, from nutrition to, being a nurse, but it
is the relationship that makes or breaks the health coach. Am I
right?
Dr. Beilenson. You're 100-percent correct.
Senator Mikulski. Isn't it based on, not only formalized
credentials, but a relationship?
Dr. Beilenson. Absolutely. That's why we're so pleased.
Kate Hetherington's here, as I'm sure you know, from Howard
Community College; they're going to be doing some training of
our health coaches. Bob Duggan's here, from Tai Sophia; they
are, as well. But, we specifically hire people who have
demonstrated great rapport with folks, because it is completely
the relationship.
Senator Mikulski. So, then would they call this person?
Dr. Beilenson. They would not only call them, they would
arrange a meeting with them, face-to-face. They might go to
their home to see what the issues are going on there. They
might meet them at the mall, because that's near where the
place that person works, at the auto store or whatever. That's
the whole point of the program. That's why we're most hopeful
that this is different than other programs, and will show
better outcomes, because we have----
Senator Mikulski. Well, it sure is different. Then, let's
say they found--again, it's the 45-year-old guy on the verge
of--so, then the health coach would say, ``Well, OK, my job is
really--I'm very good at exercise. What you need is a couple of
other things.''
Dr. Beilenson. Yes.
Senator Mikulski. ``And let me see how I could help you get
connected.''
Dr. Beilenson. Yes.
Senator Mikulski. So, they'd come back to the care
coordinator or----
Dr. Beilenson. Well, we also have a community--I don't mean
to throw too many wrenches in the thing, but----
Senator Mikulski. No, but, you see, you have a lot of
people, but I want to know who they come back to.
Dr. Beilenson. The health coach. The health coach is the
center of their care universe who will make referrals, as need
be, but will followup. If they need a program, a nutrition
program, they'll call their community resource coordinator, who
will find such a thing. The person--and getting back to your
point about meeting people where they are, that's the whole
key. So, here's a great example----
Senator Mikulski. That's a social-work phrase, too,
``meeting people where they are.''
Dr. Beilenson. Yes, my wife has explained that to me.
[Laughter.]
I would never have thought of this, but if you go on
Comcast--we all get Comcast, living in the city.
Senator Mikulski. Kind of.
Dr. Beilenson. I didn't know you could do this, but----
Senator Mikulski. Kind of.
[Laughter.]
Dr. Beilenson [continuing]. But, on the----
Senator Mikulski. It's like eligibility----
[Laughter.]
Dr. Beilenson. No, I actually get Comcast. You know----
Senator Mikulski. I----
Dr. Beilenson. I know. But, if you go to ``On Demand,'' and
you go through the ``On Demand'' things, there's actually a
fitness program. Let's say you can't initially get out; you
don't have a car, you can't get to Centennial Park. You just go
on, and for 3 days a week, you do the 25 or 30 minutes of
what's on TV--like Tae Bo, that kind of stuff. I would never
have thought of this, but our personal trainer did--so that you
meet people where they are. They may not be able to get out
yet. And that's the whole point of the wellness program.
Senator Mikulski. Well, which would be true of Ms. Wensil
and Ms. Tucci-Farley. They're not going to go out and go for
the burn, ooh-ah, ooh-ah------
[Laughter.]
Senator Mikulski [continuing]. Because of breathing
problems, and then the other, neurological manifestations.
Well, I think I've got a good picture. Again, we could take
each one of these areas, but there's two pretty innovative
ideas here. One, the way you enroll people and the culture of
hospitality is pretty significant. And then, once you enroll,
you don't feel like you're on your own, that you're not a
medical record being passed along, et cetera, et cetera. This
is pretty innovative.
Congressman Sarbanes, you want to go for the last round,
and then we're going to wrap it up.
Mr. Sarbanes. Thank you, Senator. I don't have any more
questions, because I know we're running short on time. I just
had some closing observations.
First of all, thank you, again, to the panel, for being
here. Terrific testimony. Congratulations, to County Executive
Ulman and to Health Officer Beilenson, for their work on this.
One thing that occurred to me as I listened to the
testimony, first of all, you didn't have to do this. You really
did not have to do it. Nobody would have noticed if you didn't
do it, but you decided to do it anyway. That's the first point.
The second point is, the logistics of what you took on, I'm
sure, made you think, every other day, ``Let's forget about
this, it's too hard.'' Now, once you launched it publicly, you
couldn't go back, but I know, leading up to that public launch,
you must have, many times, thought to yourself, ``It's just
trying to break through the system in so many ways is just too
hard,'' and many others probably that--the terrain is littered
with people who probably set off with all the best intentions
and then abandoned them. So, I just congratulate you for
pushing through.
If all you'd accomplished was to spot this phenomenon that
many people who are eligible for benefits are not getting them,
and connected those to them--if that's all you had
accomplished, it would have been a terrific success. You really
ought to chalk that one up. But, obviously you want to go
further, you want to explore what the best design is of
providing care.
This notion of focusing on prevention--I'm glad we had this
hearing right in the wake, Senator, of the stimulus bill,
because there are so many things that are in that bill that
align with the testimony that we've had today. There's a
billion dollars going to wellness and prevention, there's a
billion dollars going to looking at good outcomes and
researching the effectiveness of different treatments,
alternative treatments. And then, of course, there's the
resources going to support Medicaid and SCHIP and all the rest
of it. So, these are things that we have to focus on if we're
going to fix the system in a positive way.
And then, the last, I guess, observation I had was that,
managed care has been a term that's been thrown around for many
years, and in the commercial arena, managed care has not scored
well, in my view and in the view of many. You're talking about
a different kind of managed care, which I think is working. And
when you look at connecting people to eligibility, that's about
thinking of managed care on the front end, managing the
opportunities for people to get access. It's sort of like the
public version of managed care. And it, I think, really informs
what we need to do, going forward, in designing a healthcare
system that works across the country.
Your testimony today has just been invaluable to us. We've
got it all recorded. We've taken notes. And you can bet that we
will plow this into the discussions on how to reform the
system, going forward.
Thanks again, Senator, for letting me participate in the
hearing.
Senator Mikulski. Thank you, Congressman Sarbanes.
Well, I'd like to, too, give a few concluding observations.
One, we want to thank all who participated in our hearing.
We also want to thank all who make the Howard County Health
Initiative such a success.
Really, I think I said, this hearing's a matter of public
record and goes into the history books of what we're embarking
upon. But, I really think, echoing Congressman Sarbanes's
words, to you, County Executive Ulman, and to you, Dr.
Beilenson, this is pretty bold, and you were willing, not only
to undertake an enormous undertaking, which is trying to deal
with the uninsured or the underinsured, primarily with the
uninsured, but also to bring bold ideas in changing a whole
healthcare system that's focused on insurance and payments and
how do you get into it and how do you get out of it and what do
you get out of it, to really focusing on patient-centered
healthcare, from the minute you walk in the door to the minute
you have to keep going to other doors to be healthy. So, we
want to thank you for that.
Observations that you've made, and we've picked up, is,
first of all, the whole concept of uncompensated care is a
myth, that care is compensated, but it is compensated by
essentially a hidden health tax on everyone who pays to
subsidize where ERs become the primary care physician. When we
then look at cost-saving, which must be part of any equation or
calculus in doing what we're doing, that cost-saving, first of
all, if we look at the concrete nature of it, this should be,
presuming it all works as we've heard, lower or eliminate the
use of ERs for primary care. That's a big deal. If we could go
to any one of our institutions, not only those--like a Hopkins
or a Maryland, but a Holy Cross, Mercy, St. Agnes--their rising
uncompensated or people doing this, particularly in these tough
times, is emerging.
Second is the whole concept of prevention. And the way we
heard it today was a couple of kinds of prevention. One,
recidivism, that if you are treated in an acute-care facility
for that open wound or failing to come in because you can't
catch your breath, that whatever treatment you get, because you
go into something, it should reduce returning to acute care for
a chronic condition.
Third, the management of chronic illness and, again,
prevention. If you have a diabetic propensity, you might not be
able to beat those genes, but you can delay the consequences.
My definition of prevention is, not only, like, let's make sure
we don't get malaria, and vaccinations and so on, but it's also
the prevention of a chronic situation, deteriorating to
debilitating. Again, going to that diabetic, if we can do the
right intervention, see, then that person doesn't progress to
kidney dialysis or the melancholy nature of an amputation. So,
if we can intervene there and keep them on a regiment where
they might be insulin-dependent their whole life, but that's
the only thing they'd be dependent on. That would be it.
And then, also, the better use of physicians. Instead of
the physician saying, ``Let me sort out those drugs. Are you
really doing a diet? Well, let me tell you about broccoli''--
nobody's going to have that time, and we've got to hear about
broccoli and eating vegetables and all of those things. So,
within our healthcare team, we make highest and best use of
what people are best at doing. Therefore, lower the stress on
that.
Also, what you're saying is, there's the technology issue.
Technology is a tool, but, by and large, the most important
thing is that, once enrolled in a humane, efficient, and
probably more error reduced program you're going to have a
better outcome. We haven't even talked about the followup, both
with the physician and other modalities of actual healthcare
and the health coach. When people talk about a primary-care
home, they usually mean a doc, and we're hearing continuously
about how health IT's going to solve everything. But, it's not
a techno-case manager. Even those calls, which are prompters,
like, ``Have you taken your heart medicine today, or your
insulin? ''--that's only a prompter, that's not a motivator.
This is what quality is all about. It's a culture of patient-
centered care. It's providing a continuum of care. It's using a
variety of trained people. And at the end of the day, people
are better off and our society is better off.
We thank you for what you've done. I also want to announce
that there are two more important issues. One, the committee
will be examining our workforce issues, because, whether it's
the Massachusetts model or the Howard County model, there's
going to be more stresses, first of all, on physicians and the
need for primary care, more on people who already are in
healthcare, but there is a workforce shortage in nursing. And
you're doing very creative things in Howard County Community
College, and our School of Nursing at Maryland is doing the
same.
The other is a concept that I will be holding a hearing on
next week; it's called Integrative Healthcare. I note in the
audience is Bob Duggan, from Tai Sophia, who will be
testifying. Integrative Healthcare is what we're talking about
here. At the same time next week, there will be an Institute of
Medicine Summit on Integrative Medicine. That's not necessarily
integrative healthcare, but it is a good step, because, at the
end of the day, it has to be about people, not about insurance,
not about technology, not about trying to shoehorn yourself in.
Next week we will be holding a week-long focus on
integrative--IOM will do medicine; the Kennedy committee, under
my direction, will be doing integrative healthcare. Stay tuned
to C-SPAN. And, most of all, know that our President has told
the Congress that he wants to be sure that, by the end of this
year, we have made a major step towards healthcare reform.
We hope to have a complete bill done by then, but, if not,
we will have the elements, and it will be done before the 111th
Congress concludes.
Before the Congress concludes, we'll have it done, but
today, this concludes the hearing on quality in healthcare in
Howard County.
Thank you.
[Whereupon, at 1:25 p.m., the hearing was adjourned.]