SPEAKERS CONTENTS INSERTS
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43–840 CC
1998
H.R. 15, THE ''MEDICARE PREVENTIVE BENEFIT IMPROVEMENT ACT OF 1997''
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON WAYS AND MEANS
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTH CONGRESS
FIRST SESSION
MARCH 13, 1997
Serial 105–13
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Printed for the use of the Committee on Ways and Means
COMMITTEE ON WAYS AND MEANS
BILL ARCHER, Texas, Chairman
PHILIP M. CRANE, Illinois
BILL THOMAS, California
E. CLAY SHAW, Jr., Florida
NANCY L. JOHNSON, Connecticut
JIM BUNNING, Kentucky
AMO HOUGHTON, New York
WALLY HERGER, California
JIM McCRERY, Louisiana
DAVE CAMP, Michigan
JIM RAMSTAD, Minnesota
JIM NUSSLE, Iowa
SAM JOHNSON, Texas
JENNIFER DUNN, Washington
MAC COLLINS, Georgia
ROB PORTMAN, Ohio
PHILIP S. ENGLISH, Pennsylvania
JOHN ENSIGN, Nevada
JON CHRISTENSEN, Nebraska
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WES WATKINS, Oklahoma
J.D. HAYWORTH, Arizona
JERRY WELLER, Illinois
KENNY HULSHOF, Missouri
CHARLES B. RANGEL, New York
FORTNEY PETE STARK, California
ROBERT T. MATSUI, California
BARBARA B. KENNELLY, Connecticut
WILLIAM J. COYNE, Pennsylvania
SANDER M. LEVIN, Michigan
BENJAMIN L. CARDIN, Maryland
JIM McDERMOTT, Washington
GERALD D. KLECZKA, Wisconsin
JOHN LEWIS, Georgia
RICHARD E. NEAL, Massachusetts
MICHAEL R. McNULTY, New York
WILLIAM J. JEFFERSON, Louisiana
JOHN S. TANNER, Tennessee
XAVIER BECERRA, California
KAREN L. THURMAN, Florida
A.L. Singleton, Chief of Staff
Janice Mays, Minority Chief Counsel
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Subcommittee on Health
BILL THOMAS, California, Chairman
NANCY L. JOHNSON, Connecticut
JIM McCRERY, Louisiana
JOHN ENSIGN, Nevada
JON CHRISTENSEN, Nebraska
PHILIP M. CRANE, Illinois
AMO HOUGHTON, New York
SAM JOHNSON, Texas
FORTNEY PETE STARK, California
BENJAMIN L. CARDIN, Maryland
GERALD D. KLECZKA, Wisconsin
JOHN LEWIS, Georgia
XAVIER BECERRA, California
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Ways and Means are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined. The electronic version of the hearing record does not include materials which were not submitted in an electronic format. These materials are kept on file in the official Committee records.
C O N T E N T S
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Text of H.R. 15
Advisory of March 6, 1997, announcing the hearing
WITNESSES
American College of Gastroenterology, Marvin M. Schuster, M.D
American Diabetes Association:
Philip E. Cryer, M.D
Gordon Jump
American Gastroenterological Association, Bernard Levin, M.D
American Urological Association, William R. Turner, Jr., M.D
Cryer, Philip E., M.D., American Diabetes Association
Frame, Paul S., M.D., University of Rochester School of Medicine and Dentistry, Tri-County Family Medicine, and U.S. Preventive Services Task Force
Furse, Hon. Elizabeth, a Representative in Congress from the State of Oregon
Gingrich, Hon. Newt, Speaker of the House, and a Representative in Congress from the State of Georgia
Jump, Gordon, American Diabetes Association
Levin, Bernard, M.D., M.D. Anderson Cancer Center, and American Gastroenterological Association
McGinnis, J. Michael, M.D., Partnership for Prevention
M.D. Anderson Cancer Center, Bernard Levin, M.D
Nethercutt, Hon. George R., Jr., a Representative in Congress from the State of Washington
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Partnership for Prevention, J. Michael McGinnis, M.D
Sabatini, Nelson J., University of Maryland Medical Systems
Schuster, Marvin M., M.D., American College of Gastroenterology
Sisisky, Hon. Norman, a Representative in Congress from the State of Virginia
Tri-County Family Medicine, Paul S. Frame, M.D
Turner, William R., Jr., M.D., American Urological Association, and Medical University of South Carolina
U.S. Preventive Services Task Force, Paul S. Frame, M.D
SUBMISSIONS FOR THE RECORD
American Academy of Family Physicians, statement
American Association of Clinical Endocrinologists, Jacksonville, FL, statement
American College of Radiology, Reston, VA, statement
American Foundation for Urologic Disease, Inc., Baltimore, MD,
Betty Gallo, statement
American Heart Association, statement
Colby, Jay, M.D., and Ashley Davidoff, M.D., University of Massachusetts
Medical Center, Winchester, PA, statement
Gallo, Betty, American Foundation for Urologic Disease, Inc., Baltimore, MD, statement
Gelfand, David, M.D., Wake Forest University, Winston-Salem, NC, statement
Hahnemann University Hospital, Philadelphia, PA, Seth N. Glick, M.D., statement
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Hastings, Hon. Alcee, a Representative in Congress from the State of Florida, statement and attachment
Johnson, Houston, Jr., M.D., Sylvania, OH, statement
McSteen, Martha, National Committee To Preserve Social Security and Medicare, statement
Montz, Fredrick J., M.D., UCLA School of Medicine, Los Angeles, CA, statement
NAACP, Washington, DC, Branch, Rev. Morris L. Shearin, letter
National Committee To Preserve Social Security and Medicare, Martha McSteen, statement
Shays, Hon. Christopher, a Representative in Congress from the State of Connecticut, statement
Shearin, Rev. Morris L., NAACP, Washington, DC, Branch, letter
Wilder, Hon. L. Douglas, Virginia Commonwealth University, statement
INSERT OFFSET FOLIOS 20 TO 39 HERE
[The official Committee record contains additional material here.]
H.R. 15, THE ''MEDICARE PREVENTIVE BENEFIT IMPROVEMENT ACT OF 1997''
THURSDAY, MARCH 13, 1997
House of Representatives,
Committee on Ways and Means,
Subcommittee on Health,
Washington, DC.
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The Subcommittee met, pursuant to notice, at 9:37 a.m., in room 1100, Longworth House Office Building, Hon. William M. Thomas (Chairman of the Subcommittee) presiding.
[The advisory announcing the hearing follows:]
ADVISORY
FROM THE COMMITTEE ON WAYS AND MEANS
SUBCOMMITTEE ON HEALTH
CONTACT: (202) 225–3943
FOR IMMEDIATE RELEASE
March 6, 1997
No. HL–6
Thomas Announces Hearing on H.R. 15,
the ''Medicare Preventive Benefit Improvement
Act of 1997''
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Congressman Bill Thomas (R–CA), Chairman, Subcommittee on Health of the Committee on Ways and Means, today announced that the Subcommittee will hold a hearing on H.R. 15, the ''Medicare Preventive Benefit Improvement Act of 1997.'' The hearing will take place on Thursday, March 13, 1997, in the main committee hearing room, 1100 Longworth House Office Building, beginning at 9:30 a.m.
In view of the limited time available to hear witnesses, oral testimony at this hearing will be limited to invited witnesses only. However, any individual or organization not scheduled for an oral appearance may submit a written statement for consideration by the Committee and for inclusion in the printed record of the hearing.
BACKGROUND:
Medicare currently covers only a limited number of preventive benefits and services. For women 65 and over, Medicare covers screening mammographies once every two years. For Medicare beneficiaries who are disabled, Medicare covers one baseline mammography screening for women age 35–39, 1 mammography screening every 2 years for women age 40-50, and annual screenings for women age 50–64 and for women age 40–50 who are at high risk for breast cancer. Medicare also covers screening pap smears once every three years, and more often—at the discretion of the Secretary of Health and Human Services (HHS)—for women who are at a high risk of developing cervical cancer. Medicare also authorizes coverage for a limited number of drugs and vaccines provided on an outpatient basis.
The bipartisan Medicare Preventive Benefit Improvement Act of 1997, was introduced on January 7, 1997, by Subcommittee Chairman Thomas, Reps. Bilirakis (R–FL), and Cardin (D–MD). The legislation would provide Medicare coverage for: (1) annual mammography screening for all women age 65 and older, whether or not they are at high risk for developing breast cancer; (2) annual pap smears and pelvic examinations for women at high risk of developing cervical cancer; (3) colorectal cancer screening; (4) annual prostate cancer screening; and (5) new diabetes benefits, including outpatient self-management training services and blood-testing strips. The bill also would waive the Part B deductible for mammography screening and pap smear coverage. President Clinton's fiscal year 1998 budget contains a similar proposal to improve Medicare coverage for preventive benefits.
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In announcing the hearing, Chairman Thomas stated: ''While the private sector has generally recognized the value of coverage for preventive benefits, Medicare has continued for over thirty years with a 1965 set of sickness benefits. Medicare beneficiaries ought to have coverage that will help them better manage their medical needs and health. This hearing will examine H.R. 15, which should help the beneficiaries help themselves and stay healthier.''
FOCUS OF THE HEARING:
The hearing will focus on the provisions of the Medicare Preventive Benefit Improvement Act to determine how the new preventive benefits that would be authorized by the legislation may contribute to improved health status and outcomes for Medicare beneficiaries.
DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:
Any person or organization wishing to submit a written statement for the printed record of the hearing should submit at least six (6) copies of their statement and a 3.5-inch diskette in WordPerfect or ASCII format, with their address and date of hearing noted, by the close of business, Thursday, March 27, 1997, to A.L. Singleton, Chief of Staff, Committee on Ways and Means, U.S. House of Representatives, 1102 Longworth House Office Building, Washington, D.C. 20515. If those filing written statements wish to have their statements distributed to the press and interested public at the hearing, they may deliver 200 additional copies for this purpose to the Subcommittee on Health office, room 1136 Longworth House Office Building, at least one hour before the hearing begins.
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FORMATTING REQUIREMENTS:
Each statement presented for printing to the Committee by a witness, any written statement or exhibit submitted for the printed record or any written comments in response to a request for written comments must conform to the guidelines listed below. Any statement or exhibit not in compliance with these guidelines will not be printed, but will be maintained in the Committee files for review and use by the Committee.
1. All statements and any accompanying exhibits for printing must be typed in single space on legal-size paper and may not exceed a total of 10 pages including attachments. At the same time written statements are submitted to the Committee, witnesses are now requested to submit their statements on a 3.5-inch diskette in WordPerfect or ASCII format.
2. Copies of whole documents submitted as exhibit material will not be accepted for printing. Instead, exhibit material should be referenced and quoted or paraphrased. All exhibit material not meeting these specifications will be maintained in the Committee files for review and use by the Committee.
3. A witness appearing at a public hearing, or submitting a statement for the record of a public hearing, or submitting written comments in response to a published request for comments by the Committee, must include on his statement or submission a list of all clients, persons, or organizations on whose behalf the witness appears.
4. A supplemental sheet must accompany each statement listing the name, full address, a telephone number where the witness or the designated representative may be reached and a topical outline or summary of the comments and recommendations in the full statement. This supplemental sheet will not be included in the printed record.
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The above restrictions and limitations apply only to material being submitted for printing. Statements and exhibits or supplementary material submitted solely for distribution to the Members, the press and the public during the course of a public hearing may be submitted in other forms.
Note: All Committee advisories and news releases are available on the World Wide Web at 'HTTP://WWW.HOUSE.GOV/WAYS_MEANS/'.
The Committee seeks to make its facilities accessible to persons with disabilities. If you are in need of special accommodations, please call 202–225–1721 or 202–225–1904 TTD/TTY in advance of the event (four business days notice is requested). Questions with regard to special accommodation needs in general (including availability of Committee materials in alternative formats) may be directed to the Committee as noted above.
—————
Chairman THOMAS. The Subcommittee will come to order. Today's hearing will focus on the bipartisan Medicare Preventive Benefit Improvement Act of 1997, H.R. 15. This legislation was introduced on the first day of the 105th Congress by myself, the Chairman of the Health Subcommittee of the Commerce Committee, Mr. Bilirakis of Florida, and my friend and colleague on the Ways and Means Health Subcommittee, Mr. Cardin of Maryland. H.R. 15 already has more than 70 sponsors, and I am quite sure the cosponsorship will continue to grow.
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While the private sector has recognized the value of coverage for preventive benefits, the benefits available to Medicare beneficiaries enrolled in the fee-for-service program have changed very little since 1965. The primary focus of the Medicare Program has been on healing patients who are already sick. Yet medical science has demonstrated that over the past three decades, much more can be done to prevent or limit the effect of illness and disease in the first place.
Medicare currently provides coverage for only a limited number of preventive services. For example, Medicare covers screening mammographies only once every 2 years for women 65 and over. Because we know the risk of breast cancer continues to rise in women who are in their sixties and seventies, H.R. 15 would provide coverage for annual mammographies for women 65 and over. Because out-of-pocket costs deter older Americans from obtaining screening tests that could save their lives, H.R. 15 would also waive the part B deductible for both Pap smears and annual mammographies.
The Medicare Preventive Benefit Improvement Act also would provide coverage for the first time for prostate cancer and colorectal cancer screening, and would empower diabetes patients to take care of their health care by providing coverage for outpatient self-management training services and for blood-testing strips. It is estimated that nearly 20 percent of Americans over age 65 have diabetes. Almost one-half of those cases now go undiagnosed. Despite the fact that only 9 percent of Medicare beneficiaries are diagnosed with diabetes, $28.6 billion is spent annually to treat these beneficiaries.
Now I and my colleagues believe we can and must do better. With early detection, education, self-monitoring, and proper treatment, we can avoid many of the complications that result from diabetes such as kidney failure, amputation, blindness, nerve damage, heart disease, strokes, and of course, lengthy hospitalizations associated with all of the above.
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H.R. 15 is a first step to provide Medicare beneficiaries with the tools they need to help better control their medical needs.
With that, prior to yielding to the Speaker, I will yield to my colleague, the Ranking Member, the gentleman from California who I understand will then hand off to the gentleman from Maryland.
Mr. STARK. Thank you, Mr. Chairman.
With your permission, I would yield to the coauthor of H.R. 15, our distinguished colleague from Maryland, Mr. Cardin.
Mr. CARDIN. Let me thank Mr. Stark for giving me this opportunity to say a few words about H.R. 15. First, I want to thank Mr. Thomas for holding this hearing, but I really want to congratulate him for his leadership on this preventive health care package. Mr. Thomas, along with Mr. Bilirakis and myself, has filed H.R. 15, and Mr. Thomas has been a real leader in bringing this issue forward. I thank you for it.
It has taken us too long to modernize Medicare to make it deal with wellness as well as sickness. This bill, if enacted, will help keep our seniors healthy, and that will save us money. The preventive health care package deals with medical protocol that is well established and will allow us to have earlier detection of dreaded diseases in our seniors. I hope we will act promptly on this legislation.
We are optimistic this year. Senator Bob Graham has filed a similar bill in the Senate and President Clinton has included a preventive health care package in the budget that he has submitted. I hope this will be the year that we finally enact the preventive health care package.
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I might note that CBO has scored the package as costing money, and that is appropriate under our budget scoring principles, and we understand that. But I think everyone on this Subcommittee also understands that preventive health care will save money. If we detect diseases earlier, the disease is less costly to our society. The bottom line will be to save money for our seniors and for the taxpayers of our country.
I look forward to hearing from the witnesses we have today. If I might, Mr. Chairman, let me just point out that I am very proud that two Marylanders are on the panel today. Mr. Sabatini, who was the former health secretary in Maryland. He has been a distinguished leader in our State on health care issues. And, Dr. Schuster, who has not only been a leader within his own profession but has been extremely helpful to me in my health advisory group. Both he and Dr. Sabatini serve on my advisory committee and help me formulate my views here on Capitol Hill in health care.
I look forward to hearing from all the witnesses, and principally our Speaker first, Mr. Gingrich.
Chairman THOMAS. I thank the gentleman from Maryland, and thank him for his continued support and cooperation in moving this important legislation.
Obviously, the first witness needs no introduction, but I will do it anyway, because frankly, my focused sensitivity on the prevention package, and especially the question of diabetes, is due in large part to discussions that I had with the Speaker. He has been, as he has been in a number of areas, an indepth, outfront participant in putting this package together. We appreciate his support and leadership.
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It is very frustrating when the Republicans have a health care preventive package, the Democrats have a health care preventive package, the President has a health care preventive package, but no health care preventive package moves. That is why we decided to pull this package out and move it. Now it is my pleasure to present to the Subcommittee the Speaker of the House of Representatives, the gentleman from Georgia, Mr. Gingrich.
STATEMENT OF HON. NEWT GINGRICH, SPEAKER OF THE HOUSE, AND A REPRESENTATIVE IN CONGRESS FROM THE STATE OF GEORGIA
Mr. GINGRICH. I thank the Chairman. I want to commend Chairman Thomas and Chairman Bilirakis and Mr. Cardin for taking the initiative on a bipartisan basis to introduce a very, very important bill that I think moves us in exactly the right direction. I first became involved in the issue of diabetes because my mother-in-law, Virginia Ginther, who is in her early eighties, has been diagnosed as diabetic for over 20 years. Because she has been very actively engaged in self-management, and in preventive care, and in monitoring what she needs, she has been able to lead a remarkably full life.
But as I would talk with her over the years, and watch the steps she took, and watched how careful she was, I began to realize there is a dramatic difference in what happens to someone with diabetes if they do take care of themselves and if they do not.
Then in talking with the Center for Disease Control based in Atlanta, one of the great institutions in this country, they indicated they believe with the right kind of preventive care, with the right kind of awareness, the right kind of education, and with testing to make sure people knew as early as possible they had diabetes, because it is their estimate that of the 16 million diabetics in America, 8 million do not know they have diabetes, and they do not learn it until they have had it for 5, or 6, or 7 years, by which point they are beginning to have various manifestations of complications caused by having diabetes.
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The Center for Disease Control estimated that we could keep 80 to 90 percent of the people who go blind from going blind, so they would retain their sight, and that we could save at least one-half of the people who lose their feet through amputation, or who lose their kidneys, or who end up with heart complications. This is a very high percentage of the total cost of Medicare, and a very great human cost in pain and suffering that is clearly unnecessary if we have the right protocols, the right medicine, and the right approach.
I want to associate myself with Mr. Cardin's comment, that it is in fact high time the Health Care Financing Administration moves toward modern wellness and preventive care rather than purely staying mired into what I think is now an obsolete model of medicine where we wait until people need acute care before we take care of them.
I also want to commend Dr. Resa Levetan from DeKalb County who now works here in Washington, whose mother first is the county commission chairman—and I might say a Democrat—who first brought my attention to Dr. Levetan's work. Dr. Levetan is one of the pioneers of finding regimens of care and protocols that dramatically improve health and dramatically lower cost.
Let me point out that 19 percent of the casework in Medicare beneficiaries is diabetic. Let me repeat that: 19 percent of the Medicare population is diabetic. It is the largest single cause of complications among senior citizens. Among American Indians, 1 out of every 3 is diabetic; among black Americans 1 of every 10, and among Hispanic Americans 1 of every 10. It is clearly of great, great concern. Some States have had terrific responses. North Dakota, for example, has a very unique program because the population there is so prone to diabetes.
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Yet, for 96 percent of the health care of our senior citizens, Medicare is the primary responsible manager. So when we look at 19 percent of the Medicare beneficiaries being involved with an illness which is dramatically different if you treat it correctly, and when we look at 96 percent of the health care for those 19 percent coming through a government-managed system, I think we in the Congress have every responsibility to insist on the kind of preventive approach and the wellness approach that H.R. 15 indicates is appropriate.
Let me say two other things about this whole direction. First, this is the tip of an iceberg as we move toward 21st century health care. We are moving into an age of molecular medicine. We are going to learn more about the human body in the next two decades than we have learned in all of previous human history. We badly need methods of professional training and practices, and methods of upgrading protocols so that people who might have learned the medicine of 1960 are not still practicing the medicine of 1960, and reimbursement agencies like the Health Care Financing Administration are not still subsidizing obsolete, and frankly, at times destructive practices.
I think this is a topic I want to commend to this Subcommittee and others to look at. How do we modernize professional behavior, and how do we modernize professional knowledge as the research base grows, I think, remarkably, and as I said, as we enter an age of molecular medicine?
Second, at a practical level here in the Congress that should not be of concern to any diabetic in America, but unfortunately has to be. The CBO, Congressional Budget Office, scoring model is simply wrong. It is archaic. It is antihuman. This bill is going to be scored, I believe, as costing money, which I believe is irrational.
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We have a study in Mr. Cardin's home State of a real-life experience where we can prove that costs went down. There is a study in Los Angeles of a real-life experience where we can prove that costs went down. We can show case after case around this country of experiments where costs have gone down. We are faced with some entrenched staff who say their theory outweighs reality.
Now there is something wrong with that, and I think we have a bipartisan obligation to engage this spring in an intellectual debate and bring in as much reality as necessary to get an accurate score, because the truth is, if every citizen who had diabetes knew it early, if every citizen has an appropriate kind of care—and some of it is very simple, such as just checking your feet by using a broomstraw to test it to make sure that your sensations are still right. There are a lot of things that can be done.
That clearly is going to improve the quality of health, lower the cost to the system, and be better for human beings both personally and financially. I think we have to insist that changes in human behavior get dynamically scored because it is accurate and because we can provide the case studies—I am not a theoretician. I am a historian. But if you have enough history stacked up and again, and again, and again it proves the same thing, at some point the theoreticians ought to have to change their theory to fit reality, rather than insist on scoring the theory and denying reality.
So I want to commend again Mr. Thomas, Mr. Bilirakis, and Mr. Cardin. This is an extremely important initiative. It is not everything we want. We are going to be working with Chairman Porter on research because we want to get a cure, not simply be able to improve the treatments. But the first two steps of knowing you have it and knowing how to manage it are very important steps at this stage.
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So I thank you very much for your leadership, and I can assure you that you have my support to schedule a bill at the earliest possible time, and I will do all I can to make sure this bill passes the House with a huge majority.
[The prepared statement follows:]
Statement of Hon. Newt Gingrich, Speaker of the House, and a Representative in Congress from the State of Georgia
Thanks for allowing me to testify today regarding the diabetes provisions of H.R. 15. I appreciate the opportunity to be here and commend Chairman Bill Thomas for the leadership that he and Chairman Mike Bilirakis and Congressman Ben Cardin have shown on this issue, as well as the other components of the prevention package which I know have received wide bipartisan support.
As many of you are aware, I've been outspoken for several years about diabetes. The fact is, my mother-in-law has diabetes and I've watched how she cares for the disease. I know that when people take care of themselves and are educated about the disease, they can dramatically improve their quality of life.
I'm also proud to say that the Centers for Disease Control and Prevention is located in Georgia and I am fortunate enough to frequently have the chance to meet with their experts who inform me about the impact of diabetes and other diseases in human terms. In fact, I met with them three weeks ago and we discussed how the federal government can have an impact on reducing the incidence of diabetes-related illnesses.
I want to share with you just a few fact about diabetes and I'll leave it to the experts to handle the detailed analyses. Diabetes affects 16 million Americans and only half are aware they have the disease. Of the total number of diabetic cases, about half are in Americans over 55 years of age. 19% of the Medicare population is diabetic (American Diabetes Association).
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96% of those over 65 with diabetes get their health care through the federal government, and overall 57% of all diabetics receive health care coverage through government-financed health insurance programs such as Medicare, military coverage, Medicaid, and other public assistance (Diabetes Care, June 1994).
Numerous studies have shown that with aggressive self-management training and education, we can reduce diabetes-related blindness, kidney disease, amputations and hospitalizations. The proper treatment and management of diabetes could reduce diabetes-related blindness by 90%, diabetes-related kidney disease by 50%, and diabetes-related complications and amputations by 50% (Practical Diabetology, December 1995).
But just think about that for a minutes. How many folks who suffer from diabetes don't know to take their shoes off in the doctors' offices so that the doctor will check their feet for diabetes-related foot sores?
So if we can reduce complications by 60%, as a study at the National Institutes of Health demonstrated, we can dramatically increase the quality of life for those living with diabetes.
I think H.R. 15 demonstrates smarter government. I know that everyone doesn't agree that this approach will save money, but there have been studies which have proven that prevention does save money. I understand, for example, that Maryland has a diabetes program in place that's proven that there are up-front savings from prevention. And I've argued for the need for a dynamic accounting method because, quite frankly, our current method for estimating cost isn't practical. We need to apply real cases instead of hypothetical models to determine costs.
Finally, I think diabetes can serve as a model for 21st century medicine. Government has a role in ushering in a new era of health care through upgrading protocols and regulations and helping to ensure that the latest standards for care are practiced in every doctor's office in the country.
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I apologize that my schedule doesn't permit me to stay longer. I look forward to working with you to pass this legislation this year. Thanks again for the opportunity to testify today.
—————
Chairman THOMAS. Thank you very much, Mr. Speaker. With your help and that of the Chairman of this Committee to provide the wherewithal, I see no reason why this bill should not move.
Mr. GINGRICH. Thank you all very much.
Chairman THOMAS. Thank you very much.
Our next witness is Gordon Jump. He is an actor and a diabetic. I do not think he minds following Speaker Gingrich; he has been second banana before. He is normally called a character actor in that regard and he has a long list of television program and movie credits. But I guess, Mr. Jump, you are probably best known in your starring role as the lonely Maytag repairman.
It is a pleasure and an honor to have you before us to share your life, your management, your understanding of diabetes.
Thank you very much.
STATEMENT OF GORDON JUMP, ACTOR, ON BEHALF OF AMERICAN DIABETES ASSOCIATION
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Mr. JUMP. Thank you, Mr. Chairman, and other distinguished Members of your panel. It is a pleasure for me to be able to come into your presence and share with you what I think is a pretty typical profile of the diabetic.
A number of years ago, almost 30, I had an appendix operation and my physician, after being rehabilitated from the operation, asked me to come in, and took some samples. He called me back and said, You are very, very dangerously close to having too much sugar in your system and your body is not handling it properly. That is about all that was said because I, first of all, started to beg off. You are telling me that I am diabetic? He said, Yes; if you are not, you are doggone close to it.
Now that physician was one of the finest physicians that I have ever met. He was a doctor's doctor. But unfortunately, he could not tell me a whole lot about diabetes, and eventually died of the disease himself several years after, and spending 2 1/2 years I think, or at least 2 years on dialysis. But his immune system went bye-bye and it ended up being his demise.
I had contact with other doctors and my physical condition was deteriorating slowly, but I still did not want to admit that I had diabetes. But I eventually had to stop that, and maybe now we could handle it with oral medication. So I found an endocrinologist who gave me the medication I needed to help reduce my blood sugar. After a few years that did not work.
About 3 years ago I had to bite the bullet and get involved with insulin. In the process of doing that I found a doctor that examined me closely, who was an endocrinologist. He explained a little bit of the things that I needed to know about diabetes, but certainly did not explain all I needed to know. I did, however, start using insulin, and fortunately the insulin that is manufactured today is of human chemistry. They produce it in the laboratory. So it is wonderful to have those medications at your disposal because of the great research that is done.
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I started to feel better. The pain in my legs and other areas of my body started to decrease. But my blood sugar levels were not where I thought they should be. I ran across a gentleman at a fundraising event for the City of Hope in California. The gentleman, somehow in our conversation it became evident that he is diabetic. He shared with me the fact that he was no longer using insulin. I said, How do you get into a position like that, and he referred me to a doctor, Dr. Jerry Nadler, at the City of Hope. They took a look at me and said, We think maybe we will be able to help you.
Now that help came really, first of all, through education. They have a tremendous program where they take their patients and tell them all they need to know about diabetes. Then they help them to learn to control the blood sugar. I now, four times a day, put in my record book my blood sugar ratings; before breakfast, before lunch, before dinner, and before bedtime. If I cannot make it every day, that is too bad, but for the most part we get it three or four times a day. It is important to know what that blood sugar is, then you can control it much better.
But control, of course, by the use of little test strips. I put a drop of blood on these test strips; you do that four times a day. But that keeps you and your body physically in line.
We need the education. We need the help in support of our care. A lot of people think you cannot teach old dogs new tricks. I just want you to know that I want to jump through a few more hoops before I roll over and play dead and you can help me do that.
Thank you very much.
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Chairman THOMAS. Thank you very much, Mr. Jump. In looking at your biography I noticed that your mother was Welsh and your father was English.
Mr. JUMP. Yes.
Chairman THOMAS. My father was Welsh and my mother was English, and you obviously display amazing fortitude if you honestly think there is something called English cooking, and you actually prepare it and consume it. So perhaps your fortitude forged in that early cradle has helped you deal with the concerns you now have and your ability to manage.
If you do not mind if the Members could ask you some questions because you showed me a book in which you are recording the data, and you have medication and equipment. Could you just give us a rough idea of the cost of the management? Now my understanding is you have insurance which helps you with that, but do you know the actual cost of the regimen that you go through?
Mr. JUMP. The strips themselves, and if you are using them four times a day on a regular basis, I buy them in quantities of 100, you get 25 days of use out of 100 strips. They run pretty close between $60, I think about $65, maybe as high as $70. I do receive some help because of my insurance program, so I am not as severely disturbed financially as a lot of people might be. But I will tell you, gaining the knowledge and then learning how to do this, you think of poking yourself four times a day to get a blood sample and then shooting yourself twice a day with insulin as being unreasonable. But I want you to know, it sure beats the alternative.
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The more we can do to legitimately help people with the disease, the better off I would think the whole country would be, because there are a lot of very productive people out there whose lives can be or will be shortened because of diabetes.
Chairman THOMAS. I want to thank you for presenting your real story. Oftentimes we deal with programs that involve billions and billions of dollars and you cannot get a handle on it in terms of what it really means from an individual point of view. We appreciate your willingness to come and refocus us on a human scale because that is where it ultimately works.
Any Member on the panel have any questions?
Thank you very much, Mr. Jump, and good luck to you.
Mr. JUMP. Thank you.
Chairman THOMAS. We now have a series of Members who wish to testify on the H.R. 15 preventive package bill. The first Member is our colleague from Virginia, Hon. Norm Sisisky. If you have any written testimony, Norm, obviously it will be made a part of the record without objection, and you can talk to us in any way you see fit.
STATEMENT OF HON. NORMAN SISISKY, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF VIRGINIA
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Mr. SISISKY. I have a real-life story, too, Mr. Chairman, and truth in testimony, I am on Medicare.
Mr. Chairman, and Members of the Subcommittee, I would like to thank you for the opportunity to testify today on the Medicare preventive benefits and H.R. 15, the Medicare Preventive Benefit Improvement Act.
I want to commend you, Mr. Chairman, and Representative Cardin, for your leadership on this legislation, and for making this a bipartisan initiative. At a time when Congress is debating the future of the Medicare Program, we cannot be distracted by partisan differences, and I am glad the Subcommittee is moving forward to improve the Medicare Program. I am before you today to address the provisions in H.R. 15 that establish Medicare coverage for colorectal cancer screening.
I have an intense personal interest in this issue. I was struck with this cancer less than 2 years ago. Thankfully, it was caught in a screening, and I am one of the fortunate ones today.
Mr. Chairman, there are moments in everyone's life that they will never forget. When my doctor called me in to tell me I had cancer, my life changed forever. Having cancer makes you feel very much alone. It is not easy to talk about. It is not easy to tell your family and friends that you have cancer. As time went by, I realized I was not alone, and I am sure everyone here has a family member or loved one who has had to face cancer.
In Congress, we have lost many of our colleagues to this disease. I will never forget the late nights on the floor in the last Congress, I had the opportunity to spend a lot of time with our dear friend, Bill Emerson. Bill and I served a long time together in Congress and we had never been particularly close. But we developed a very strong bond because we both struggled against cancer. I could always turn to Bill for encouraging words. I would tell him to be a fighter, and to beat this thing, and he would say, You are going to beat it too, Sisisky.
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Thankfully, I was blessed. So far, I've beaten cancer. But Bill Emerson was not so lucky, and we all miss him terribly.
With the support of my family and with the help of friends like Bill Emerson, I made two commitments. First, I made a commitment to myself that I would do everything I could to survive. I spent 52 weeks, working every day, on chemotherapy.
Second, I made a commitment that as a Congressman, I would do everything I could to help people beat this disease. What I learned and what H.R. 15 underscores is that early detection saves lives. Early detection, together with some excellent doctors, saved my life. But I also learned that most Americans are not screened for colorectal cancer, and that is terrible.
With your leadership, Mr. Chairman, the place to start is with Medicare. a national colorectal screening program under Medicare will saves lives, and H.R. 15 takes a bold step into the future. I must say that with all the benefits that H.R. 15 provides, it does fall a step short of providing the best colorectal screening coverage for all Americans. H.R. 15 does not include Medicare coverage of the barium enema test. Now my written testimony calls attention to a recommendation by an impressive list of professional medical societies, and I will not name them here this morning.
These medical professionals report that there is evidence to support the use of the barium enema as a screening procedure for high risk individuals. Further, the Office of Technology Assessment reports the barium test is one of the two most cost-effective tests for screening individuals at an average risk, and the soon to be released report by the Agency for Health Care Policy Research states there is evidence supporting the use of the barium test for anyone who is either average risk or high risk.
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Mr. Chairman, I am not a doctor. I am only a patient. But I urge you to listen to the experts in the field. The barium test has an important role to play in preventing cancer deaths. I have had three of these tests. Now for whatever reason, barium screening is especially important to African-Americans. According to a number of recent studies, many African-Americans are struck by colorectal cancer in the portion of their colon that only a barium test can detect. The mortality rate for African-Americans who get colorectal cancer is 50 percent higher than for all other Americans with colorectal cancer—50 percent higher, Mr. Chairman. That is terrible.
We have an opportunity to address this situation through H.R. 15 to make sure we provide the most comprehensive screening methods available to help all Americans fight this killer. With your permission, I would like to insert a statement by former Governor Wilder at the appropriate time in the record.
Chairman THOMAS. Without objection.
Mr. SISISKY. My time is running out. You told me to spend 5 minutes, and I will try to do this. But what really worries me, you said you would do a test on this for 2 years. Two years, Mr. Chairman, knowing some of our good friends in the bureaucracy, it will probably take longer than that. But how many lives could be saved in those 2 years? Can you imagine being a physician and not being able to recommend a test that you know would help someone just because Medicare will not pay for it, or the patient will not be able to afford it?
I think the barium test should be included in this bill. There are simply too many lives at stake for the barium test to be left out. I have had the barium test three times, as I told you. Believe me when I tell you, there is nothing pleasant about this test. I do not believe there is any doctor anywhere who would prescribe the test for a patient if he or she knew it was absolutely not necessary. But the bill denies or delays Medicare coverage of this test and I just implore you, do not get involved in a fight between medical specialties. This is what I told the American College of Gastroenterology when they came to see me.
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Mr. Chairman, there is a fight between medical specialties—I was not going to bring this up, but it is happening. You will probably hear some of it today. Let us just save lives. Please, I implore you, include the barium enema in H.R. 15.
Thank you very much.
[The prepared statement and attachments follow:]
Statement of Hon. Norman Sisisky, a Representative in Congress from the State of Virginia
Mr. Chairman, I would like to thank you and the Members of the Subcommittee for the opportunity to testify before you today on the issue of Medicare preventative benefits and the bill H.R. 15, the ''Medicare Preventative Benefit Improvement Act of 1997.''
I want to commend you Mr. Chairman, and Representative Cardin, for you leadership on this important legislation, and for making this legislation a bipartisan initiative. It is particularly important that partisan differences and the intense focus on controlling costs in the Medicare program not divert this Committee and the Congress from making needed improvements in the program. Indeed, at a time when there are fewer Medicare dollars available, it is critical that Medicare funds be spent in the most cost-effective manner possible. I think that the committee understands that we can save lives and control costs, and this legislation is an important step in that direction. I look forward to working with you to see the enactment of Medicare preventative benefits in the 105th Congress.
My testimony today addresses the provisions in this legislation that would establish Medicare coverage for colorectal cancer screening. This is an issue which I have an intense personal interest because I was struck with colorectal cancer less than two years ago. I am one of the fortunate ones whose cancer was detected in a routine screening. Many are not so fortunate, but today I am finished with my treatments and I feel great.
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Mr. Chairman, there are moments in everyone's life that they will never forget. One such moment came for me when my doctor called me into his office and told me that I had colorectal cancer. I did not know at the time but I was one of more than 150,000 Americans who would hear that message during the year. What I did know is that I and my family were about to face a challenge unlike any other we had experienced.
As I learned more about the disease of colorectal cancer and my own situation, I made two commitments. First, I committed to myself and my family that I would do whatever I could to beat this disease. No matter what was required—surgery, radiation, chemotherapy, or other procedure or treatment—I was going to fight as hard as I could to be a cancer survivor. I was determined then, and am determined today, that I will not be among the 45,000 Americans who die each year from colorectal cancer.
Second, I committed that, as a Member of Congress, I would do whatever I could to help people beat his disease. As I learned more about this disease, it became apparent that the most significant hope for reducing the number of Americans who get colorectal cancer, and reducing the mortality rate from the disease, is colorectal cancer screening. Because colorectal cancer generally develops over a five to ten year period, a comprehensive screening program beginning at age 50 has the potential to save thousands of lives that would otherwise be lost to this disease.
The place to start a national colorectal screening program is with the Medicare population. If we can establish colorectal cancer screening as an essential test for the Medicare population, there is reason to hope that private insurers, HMOs, and other health care payors will follow our lead and begin to provide coverage for screening individuals between the ages of 50 and 65. Mr. Chairman, I am greatly encouraged by the efforts of you, and Representative Cardin, in producing legislation that would establish a colorectal cancer screening program within Medicare.
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While I appreciate the leadership you have shown on this issue, Mr. Chairman, I must today voice a concern with H.R. 15 as it is currently written. The problem I have is that H.R. 15 fails to cover one of the most cost-effective colorectal cancer screening procedures currently available, the barium enema screening procedure. The barium enema is recommended for colorectal screening by such organizations as the American Cancer Society, the American College of Gastroenterology, the American Gastroenterological Association, the American College of Physicians, the Blue Cross/Blue Shield Association of America, the Academy of Family Physicians, and the American College of Radiology. Further, it was determined by the Office of Technology Assessment that the barium screening was one of the two most cost-effective procedures for screening individuals at average-risk for colorectal cancer, and was found to be the most cost-effective for screening individuals at high-risk for colorectal cancer in a study by Dr. David Eddy. A soon to be released ''evidence report'' by the Agency for Health Care Policy and Research also concluded that there is evidence to support the use of the barium test as a screening procedure for individuals at average and high-risk for colorectal cancer.
The barium enema is particularly important to African Americans who, according to a number of recent studies, are more commonly struck by colorectal cancer in a portion of the colon that is not reached by sigmoidoscopy. It is my understanding that under H.R. 15, sigmoidoscopy is the only procedure covered by Medicare recipients who are at average-risk for colorectal cancer. Mr Chairman, I'm not a doctor. I came to understand many of these issues through my treatment as a patient. As a cancer patient and a Member of Congress, I do not believe that we can tolerate the fact that the mortality rate for African Americans who get colorectal cancer is 50% higher than for all other Americans with colorectal cancer. I believe that H.R. 15 needs to address this situation and establish a colorectal cancer screening program within Medicare that is adequate to detect the disease where it most commonly occurs in African Americans. This way, we can be sure that we are providing the most comprehensive screening package available for every American.
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The former Governor of Virginia, the Honorable Douglas Wilder, recently held a Symposium at Virginia Commonwealth University on ''Race and Health Care As We Approach the 21st Century'' at which there was an extensive discussion of how this country has failed to meet the needs of African Americans. I have enclosed with my testimony a written statement by Governor Wilder, and ask that it be included in the appropriate section of the hearing record.
It is my further understanding of H.R. 15 that the bill includes a provision that directs the Secretary of Health and Human Services to study the barium enema and determine, within two years, whether Medicare coverage should be extended to this procedure as well as those specified in the bill. Mr. Chairman, I do not believe that there is any reason why the barium test should be treated differently than the other tests that are specified in the bill. Mr. Chairman, the barium test has to be included. Believe me, I have had this procedure and there is nothing pleasant about it. If you have had it, you know that there is no doctor, anywhere, who would require a patient to get screened by this procedure if they did not absolutely need to. If the bill excludes Medicare coverage of the barium enema, it will deny patients and their doctors the option on using this procedure. I really think that is wrong.
I am aware that there is at least one medical specialty association which has put forward a number of arguments as to why this procedure should be excluded or delayed under Medicare. Mr. Chairman, I urge you and the Members of the Subcommittee to read the reports I have sited in my testimony and review the overwhelming evidence to the contrary if you have any doubts. I urge you to read in particular the reports which have been published within the past six weeks—including the report that is endorsed by one medical specialty association that has opposed coverage of the barium test. All of these reports and recommendations include the option of using the barium enema to screen for colorectal cancer—H.R. 15 should provide that option as well. We must make sure that this legislation is based on the best medical techniques that exist to protect patients from colorectal cancer and help them fight this killer.
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In conclusion, I would like to leave the Members of the Subcommittee with one thought. It is time for the Medicare program to include coverage of screening for colorectal cancer. I could afford to have these tests done. Many people cannot, especially those who live in lower economic circumstances. A comprehensive colorectal cancer screening program can save tens of thousands of lives, and it can reduce the pain and suffering that comes with this disease. I speak from personal experience on this matter, and I hope we can all work together in the bipartisan spirit with which you developed this legislation to see this program enacted into law.
Thank you again for the opportunity to testify before the Subcommittee. I would be pleased to answer any questions you may have.
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Dear Chairman Thomas:
The following statement and information is a supplement to my testimony before the Ways and Means Health Subcommittee hearing on the Medicare Preventive Benefits Improvement Act, H.R. 15, on March 13, 1997. I am providing this information to the committee as reference material for my testimony, and to provide details on the specifics of my oral testimony.
I am submitting for the committee's consideration a number of recent colorectal cancer screening recommendations which include the barium enema. Included with my statement is a copy of the recently released colorectal cancer (CRC) screening recommendations of the American Gastroenterology Association (AGA), which include the barium enema, and were endorsed by the American College of Gastroenterology. These published recommendations, along with recommendations by the American College of Physicians, the Blue Cross/Blue Shield Association of America, the Academy of Family Physicians, and the American College of Radiology, support the use of the barium enema for colorectal cancer screening, contradicting the ACG's position on the use of the barium enema.
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I am also submitting for the committee's consideration a key study that was published in the American College of Gastroenterology's own peer reviewed journal in May 1995. That article, published by Dr. Ozick, et. al., in fact, confirms an earlier study that presented medical evidence on the increased occurrence of colorectal cancer in the right (proximal) colon of African Americans. It concludes, as do other studies, that ''Current screening recommendations may not be effective enough for preventing colon cancer in this population [African Americans].''
I hope that these documents will help illuminate my oral testimony before the Health Subcommittee. I believe that these recommendations and the information they contain strongly support the inclusion of the barium enema in CRC screening legislation. It is my belief that with the ACG's endorsement of the barium enema contained in the AGA's colorectal cancer screening issue, the medical community has reached a consensus and unanimously agreed to include the barium enema in colorectal cancer screening legislation. I would urge the Members of the Health Subcommittee to review the screening recommendations I have attached which support the inclusion of the barium enema in CRC screening programs.
[The study is being retained in the Committee's files.]
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Statement of Hon. L. Douglas Wilder, Distinguished Professor, Virginia Commonwealth University, Center for Public Policy
Mr. Chairman, I am pleased to submit this statement on a subject of great interest to me: improving Medicare's preventive benefits, especially screening for colorectal and prostate cancers, two of the most deadly cancers. Colorectal cancer will claim more than 50,000 and prostate cancer more than 42,000 Americans in 1997. As the Congress considers H.R. 15 and other measures to provide preventive benefits under Medicare, it is vitally important that we consider the differences in how these and other cancers manifest themselves in African Americans, and ensure that this population has access to appropriate screening.
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This subject is particularly timely. In January, in conjunction with Virginia Commonwealth University, I held a Symposium entitled ''Race and Health Care as We Approach the 21st Century,'' which focused not only on the unique challenges African Americans face in health care, but also on the obstacles this population faces in gaining access to adequate screening for certain kinds of cancer. Among the distinguished participants was the past president of the American Cancer Society who participated in a discussion about the particular needs of African Americans with regard to some of the screenings included in your legislation.
Mr. Chairman, you are probably unaware that African Americans are struck with certain cancers more frequently—and differently—than other Americans, yet no genetic or hereditary reasons have been identified which account for this. The challenge is particularly acute for prostate and colorectal cancers, where the statistics are astonishing. African American males have the highest incidence of prostate cancer in the world—66 percent higher than white men, with a mortality rate more than two times higher. Access to adequate screening can dramatically improve these statistics. As you may know, if detected while localized, the 5-year survival rate for prostate cancer is 99 percent.
For colorectal cancer, the mortality rate among African Americans continues to rise, even as the American Cancer Society reports declines in colorectal cancer among other segments of the population. African Americans who get colorectal cancer are 50 percent more likely to die of the disease than others in this country. In addition, the disease affects African Americans differently than it affects white Americans: the National Cancer Institute's Black/White Cancer Survival Study found that African Americans have a greater tendency to get colorectal cancer in the right colon—the portion not reached by sigmoidoscopy—than other Americans, explaining, at least in part, this higher mortality rate from the disease. These data illustrate the special importance of regular prostate and colorectal cancer screening for African Americans to detect these cancers at the earliest stages and, to the extent possible, correct the disparity in the incidence of the disease.
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If enacted, H.R. 15 would take an important step in providing adequate screening for all Americans, including African Americans. However, I am deeply disturbed by one aspect of your bill, which is inadequate for screening African Americans. Because colon cancer manifests itself more frequently in the right colon of African Americans, it is vitally important that the entire colon be screened for the disease to ensure early detection of the disease. Indeed, it is important that all Americans have the option of screening the entire colon because as many as 50% of colon cancers occur in the right colon. Flexible sigmoidoscopy therefore may be inadequate for a broader segment of the population.
H.R. 15's approach for those at average risk would provide screening only with flexible sigmoidoscopy, which screens only the left colon. Indeed, the bill provides a total colon exam for average risk individuals only if the Secretary of Health and Human Services (''HHS'') certifies the barium enema—a common procedure used today for colon cancer screening—is appropriate. The bill directs the Secretary of HHS to complete this review within two years from enactment, which means that—at best—this approach delays reimbursement for barium enema for at least that amount of time. More realistically, this approach probably delays coverage for many years, as HHS usually misses even statutorily-mandated guidelines. In the meantime, hundreds and perhaps thousands of African Americans—and quite possibly members of other racial and ethnic groups—will die due to inadequate screening for colorectal cancer. Even those who are screened will be denied reimbursement for the appropriate procedure.
President Clinton and key Members of the U.S. Congress, both Republican and Democratic, have adopted an approach that provides appropriate choices for patients in the Medicare population, including the African American population and other Medicare recipients, who prefer a comprehensive screening option. My good friend Congressman Norm Sisisky, of Virginia, himself a colorectal cancer survivor, has taken a leading role in advocating regular preventive screening and has indicated that his ''mission in the 105th Congress [is] to enact Medicare coverage for colorectal cancer screening.'' Congressman Sisisky has supported the excellent work of Congressman Alcee Hastings, of Florida, Congresswoman Louise Slaughter, of New York, and Senator John Breaux, of Louisiana, who in the 104th Congress introduced legislation in the House and Senate to provide Medicare coverage for colorectal cancer screening and who are likely to do so again in the 105th Congress. Their approach has also been supported by a number of members of the Congressional Black Caucus, including the distinguished Ranking Member of the Ways and Means Committee, Rep. Charles Rangel (D–NY), who know and understand the special needs of the African American population and are personally committed to providing appropriate screening options to accommodate those needs. I urgently ask that you reconsider your position and agree to substitute their approach to colorectal cancer screening.
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I recognize that legislation alone will not be enough to convince Americans, including African Americans, to undergo preventive screening. A broad public education campaign is needed to foster serious discussion about the benefits of these screening procedures for all Americans. I will do all I can to ensure that part of this campaign will be providing African Americans throughout the United States and in your Congressional District with information about the special impact of these cancers on our population, and on our special screening needs. I am pleased that the American Gastroenterology Association recently published recommendations for regular colorectal cancer screening, which recommended procedures appropriate for the African American population. I understand the American Cancer Society will also be issuing similar recommendations for preventive colorectal cancer screening.
It is vitally important that preventive screening be covered by Medicare and that all Americans—including African Americans—have access to affordable, appropriate screening procedures. I commend the Chairman for his leadership and, with the changes I have urgently recommended, urge enactment of this important legislation. Now is the time to act. The lives of tens of thousands of elderly Americans could be saved and their quality of life improved if the Congress and President Clinton have the courage to meet the people's challenge to work together for the common good.
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Chairman THOMAS. Thank you very much, Norman. As you know, it is included in the broader sense, but it requires a review by the Secretary. There is no question the area of preventive medicine is continuing to emerge, both in terms of technology and in diagnostic capability. The reason we decided to move in a bipartisan basis was to remove the preventive area from the larger macropolitics of Medicare, and we are certainly open, and one of the reasons I wanted to hold a hearing was to get the latest evidence available.
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You will find there is also some controversy in the area of the prostate screening procedure. Our goal is to make sure the available options are: One, good science, and as comprehensive as possible. It is entirely possible that as this preventive bill makes its way through the legislative process, we are going to be able to expand the opportunities for early detection through the most recently available medical information. I know and understand the gentleman's position. He feels it deeply, and we appreciate his willingness to share with us his concerns.
Any additional questions?
Mr. CARDIN. If I may, Mr. Chairman, underscore the point that we want to make sure all medically reasonable tests are available, and I very much appreciate your testimony.
Chairman THOMAS. Thank you very much.
Mr. SISISKY. Thank you very much.
Chairman THOMAS. Next I would ask our colleague from Washington, Hon. George Nethercutt. If you have any written testimony, it will be made a part of the record without objection, and you can talk to us in any way you see fit. Joining him is another Northwest colleague, Hon. Elizabeth Furse, a Member of Congress from Oregon.
Thank you both for being here.
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STATEMENT OF HON. GEORGE R. NETHERCUTT, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF WASHINGTON
Mr. NETHERCUTT. Thank you, Chairman, Mr. Cardin, and Members of the Subcommittee. I am pleased to testify before you today in support of H.R. 15, specifically section 6 as it relates to the disease of diabetes. The diabetes benefits improvement section of H.R. 15 is very important to diabetics all over the Nation.
Last Congress, Elizabeth Furse and I were involved in submitting legislation that really is part of your bill that would provide Medicare coverage for blood test strips and diabetes education. I cannot understate to this Subcommittee the importance of that kind of support for Medicare patients.
I have a personal story because my wife and I have a young daughter who is 16 now who is diabetic, who was diagnosed when she was age 6. I can tell you from personal experience that control of this disease is directly related to education. It is related to diligence in taking care of your system, what you eat, when you eat it, how you test, and having the resources available to provide blood test strips in order to test your blood glucose levels. It is quite literally, the noncure cure. If you take care of your blood sugars as a diabetic, you can live a long life.
In the Medicare population, which is disproportionately affected by type II diabetes, we find many people either do not know they have the disease, or by the time they discover it, it is too late and they are suffering complications, which Medicare pays for: The cost of blindness, amputations, and heart and kidney failure. You have heard this, I believe, already in this panel.
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But the point is, it cannot be emphasized too much, that by getting on the front end of diabetes, efforts to cure and prevent and control this disease, we are going to be financially way ahead. As a society, we are going to benefit tremendously, and the 16 million diabetics who have this disease will thank all of us for a job well done. It is just good public policy. It makes great sense to do it.
I want to say two quick things in the few seconds that I have left. Elizabeth and I have started the Congressional Diabetes Caucus. It now has 51 members, both Democrats and Republicans, recognizing that this disease is indiscriminate. It affects Democrats, Republicans, whites, blacks, Native Americans, you name it, old, young, everybody. There is no safety here because of your particular stripe.
So we have a bipartisan Congressional Diabetes Caucus which I would request to have that be made a part of the record if the Subcommittee so approves.
Also next Wednesday, March 19, we will have a diabetes screening day on Capitol Hill. Elizabeth and I and the other Members of the Congressional Diabetes Caucus will be doing blood testing, and we will be screening ourselves and encouraging staff and families, and everybody in this room and in the Capitol to come and have their blood tested and screened to see if you have diabetes and you do not know it.
So I urge this panel to adopt this bill, report it promptly, get it to the floor, and let us pass it. Not only because it affects diabetes, but because it affects many other serious diseases that need this kind of attention.
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So I thank you for the opportunity to testify, Chairman, and I do have a statement I would ask be made part of the record along with the list of diabetes caucus members.
I would be happy to answer questions you may have.
[The prepared statement and attachment follow:]
Statement of Hon. George R. Nethercutt, Jr., a Representative in Congress from the State of Washington
Mr. Chairman and members of the Subcommittee, I am pleased to testify before you today in strong support of H.R. 15, the Medicare Preventive Benefit Improvement Act, and specifically in support of section six of the bill, the diabetes benefits improvement section.
In the last session of Congress I sponsored legislation, H.R. 4264, that would accomplish the results of the diabetes portion of H.R. 15. This legislation has been reintroduced in the 105th Congress by my colleague from Oregon and me as H.R. 58. The provisions of H.R. 58 and of your legislation would improve the Medicare program by providing coverage for diabetes education self-management and blood testing strips for diabetics. The importance of these measures cannot be understated.
I know from personal experience, as the father of a daughter with diabetes who was diagnosed at the young age of six, that self-management education and access to blood testing strips are crucial to controlling the costly complications of the disease. In addition, in my former position as President of the Spokane Chapter of the Juvenile Diabetes Foundation, I came in contact with hundreds of diabetics who benefitted, in terms of better health and lower costs, by learning from professionals how best to control their disease and avoid complications.
Diabetes is a very individualized disease. Each diabetic, and there are over 16 million in the United States, must learn how their own body reacts to food, exercise and insulin, and adjust accordingly. Managing diabetes requires the constant monitoring of blood glucose levels. Both insulin dependent (type I) and non-insulin dependent (type II) diabetics must vigilantly check their blood glucose levels to avoid the debilitating and costly consequences that will result from poor management. Checking one's blood glucose requires the knowledge of when to check the blood and having the blood testing strips to conduct the tests.
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The statistics associated with diabetes are staggering. It is estimated that 90 percent of diabetes-related blindness is preventable, 50 percent of kidney disease requiring dialysis is preventable, 50 percent of diabetic-related amputations are preventable and 50 percent of diabetic-related hospitalizations are preventable. Through its reimbursement system, Medicare tragically does not encourage proper management. I strongly believe that this results in higher long-term costs. Last month, I toured the Diabetes Institute at the National Institutes of Health (NIH). The researchers at NIH expressed their frustration to me that the most simple health management techniques that they pioneer to reduce serious and costly complications are not being taught to the Medicare population.
As you know, a high percentage of the Medicare population has diabetes. Many more have the disease but will not discover it until their symptoms progress to more serious health problems. Finally, Mr. Chairman and members of the Subcommittee, you should know that there is strong support within the House for addressing the complications of diabetes. I formed the Congressional Diabetes Caucus with Representative Furse during the last session and we now have 50 members of the House who have committed to raising the awareness level of the disease, addressing its complications and working to find a cure. I ask that a list of the Caucus members be made a part of the record.
Mr. Chairman and members of the Subcommittee, I sincerely commend you for including diabetes preventive care benefits in H.R. 15. Thank you for providing me with the opportunity to testify before you in support of the bill.
INSERT OFFSET FOLIO 1 HERE
[The official Committee record contains additional material here.]
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Mrs. JOHNSON [presiding]. Thank you. Your statement will be made a part of the record.
Would you like to comment, Ms. Furse.
STATEMENT OF HON. ELIZABETH FURSE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF OREGON
Ms. FURSE. Yes, thank you so much. I will be very brief. Like Mr. Nethercutt, I also have a daughter who has diabetes. I really want to thank the Chairman, Mr. Thomas, and Mr. Bilirakis, for including provisions in H.R. 15 that will improve Medicare coverage.
Mr. Nethercutt and I have introduced a bill, H.R. 58, that would give Medicare coverage for self-management training and strips. That is a very highly supported bill. We have over 210 cosponsors. It would do what your language would do.
I want to point out something I just recently learned. A company, which is a very large pharmacy, provides self-management training for their patients. What they found is that they have an average saving of $215 per person, per patient, once they provide this training, a staggering 42-percent reduction in emergency room visits. Diabetes is a very interesting disease in that the patient can manage the disease on a daily basis. So by providing this kind of coverage, you will be in fact providing tremendous savings to the health care system.
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There are 16 million Americans with diabetes, and I imagine there is not a person in this room who does not know of someone who has diabetes.
Thank you, and I want to applaud you for your provisions on H.R. 15, and I ask that you continue to work on making these changes a reality. They will save money. But even more important, they will very much improve the lives of people with diabetes, which is a disease which leads to amputations, blindness, heart disease, all sorts of things that could be prevented with good training and good management.
So I want to thank you, Madam Chairman, and would be happy to answer questions.
[The prepared statement follows:]
Statement of Hon. Elizabeth Furse, a Representative in Congress from the State of Oregon
Mr. Chairman, members of the Subcommittee, thank you for giving me the opportunity to testify today. I want to thank Mr. Thomas, as well as my colleague on the Commerce Committee, Mr. Bilirakis, for including provisions to improve Medicare coverage for people with diabetes in H.R. 15. I also want to thank my colleague from the Pacific Northwest, Mr. Nethercutt, who co-founded the Congressional Diabetes Caucus with me. Together, as parents of children with diabetes, we are working to prove that there is no place for partisanship in tackling this devastating disease.
Earlier this year, Mr. Nethercutt and I introduced H.R. 58 to make two important changes in Medicare for people with diabetes: improved coverage of self-management training and blood testing strips. H.R. 58 rectifies two critical gaps in Medicare coverage which result in thousands more emergency room visits, increased hospitalizations, and cases of blindness, amputation and stroke. I am pleased to report that as of today H.R. 58 has over 195 cosponsors—including 18 bipartisan members of the full Ways and Means Committee—making it one of the most widely support bills of this young 105th Congress.
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Among all diseases, diabetes is the only one that is managed on a daily basis by the patient. If a person with diabetes lacks the education and/or the proper supplies to manage their disease, they'll do a poor job. When people do a poor job of managing their disease they end up in the hospital, go blind, suffer heart attacks and strokes. Medicare won't pay for adequate coverage of self-management training and the necessary tools to manage diabetes, but it will pay for all the avoidable, preventable, costly complications of this disease. It is a Medicare policy which Speaker Gingrich calls ''maximizing illness, cost, and suffering.'' (To Renew America)
There are numerous studies which clearly demonstrate how improving coverage of diabetes education and supplies saves money. I recently learned about a major pharmacy which provides self-management training for their patients. After they initiated this program, they experienced a 12% reduction in hospitalizations and a staggering 42% reduction in emergency room visits. In addition, outpatient visits, doctor office visits, and other medical expenses all plummeted. They saved an average of $215 per patient. These figures are not projections; they are real results being achieved in the private sector. The Medicare program needs to follow their lead.
Mr. Chairman, I am certain everyone in this room knows at least one of the 16 million Americans who has diabetes. Among all preventive benefits, improving Medicare coverage for people with diabetes will make a dramatic difference. I applaud your provisions in H.R. 15 which improve coverage of self-management training and blood-testing strips, and ask all my colleagues to support this important legislation. I look forward to working with you to make these changes a reality.
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Mrs. JOHNSON. I thank you both for your testimony, and I appreciate your putting the experience of that pharmacist group on the record. Last year when we asked CBO to score this, we got a savings. This year they say it is going to cost $2.5 billion. It is genuinely weird how we evaluate the costs of preventive health, and particularly in an area like this where there are just so many, many people affected and where, it does seem to me that intelligent management of the disease is clearly going to save costs; maybe not the first year, but overall.
So we will continue to work with you and with the diabetes association on the cost estimate to see if we can overcome that small barrier. But I appreciate the leadership you have both provided in bringing this issue before the Congress over the last several years, and we do hope to get definitive action this year.
Mr. McCrery, would you like to inquire?
Mr. MCCRERY. No.
Mrs. JOHNSON. Mr. Christensen.
Mr. CHRISTENSEN. Thank you, Madam Chairman. I want to thank you also for your leadership. My grandmother had diabetes. My grandfather had diabetes. My 6-year-old nephew has diabetes type I. I am probably in line, so I am going to be there next Wednesday for the screening and would love for you to put me on your caucus, and be involved as much as I can be.
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Ms. FURSE. Thank you.
Mr. CHRISTENSEN. I also guess I would like to solicit your help in maybe formulating a letter, and see if we cannot change the process around here in terms of the way we do scoring with CBO. At least on issues where we can agree. Let us forget about the way they score capital gains for this one.
But for an issue that is so black and white as diabetes and saving money, a dollar saved now can save us thousands later, I would think that there is a way we can reformulate the way CBO does their archaic, and as the Speaker said, inhumane way of scoring. I guess I would ask for advice and solicit your help in putting some pressure in the right places on CBO so that we do not have this kind of a scoring lapse when it comes to such an important issue as diabetes.
But I am looking forward to working with you on it, and I just applaud your leadership, both of you.
Thank you.
Mr. NETHERCUTT. Congressman, let me respond quickly. We are working on a letter, and a meeting, and an opportunity to sit down with CBO and say, Let us be sure we understand what you are thinking about and why, and then make as persuasive an argument as we can to bring some reason to the way they look at this particular bill and hopefully turn the result positive.
Ms. FURSE. We have in the private sector an example. It is a huge pharmacy. They have hundreds and hundreds and thousands of patients. So we can bring that very—they show these tremendous savings just by doing what our bill would do.
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So thank you, Mr. Christensen, we would love to have you on our caucus.
Thank you.
Mr. CHRISTENSEN. Thank you.
Mrs. JOHNSON. I thank you for your willingness to work with CBO but—and I speak only for myself now. I do not speak for the Chairman or any other Member of the Subcommittee. But the staff was just telling me that last year when we came so close to at least getting home testing, the administration opposed it. It would have had a small impact on part B premiums. We have here before us now the opportunity to make Medicare a far more preventive oriented program by dealing with some of the testing needs that are just terribly important that our colleague, Mr. Sisisky, pointed to, and that women have pointed to with annual mammograms and so on and so forth, and certainly in the area of diabetes.
I, for one, think a few cents on the part B premium, especially when it just went down from 31 to 25 percent of program costs, would be worth it. But I think we need to begin to talk to seniors about that and see whether they think it would be worth it. Because it is foolish for us to not have a more modern benefit package in Medicare. More and more, Medicare is interpreting the old law very narrowly. So it no longer covers some things that it covered 6 months ago, and 8 months ago, and 9 months ago, at least in my part of the country, because they are trying to save money through a very rigid interpretation of the law.
So it is time to really address this issue of better preventive services under Medicare, even if it does have some impact on the cost of the program, and that that has to be shared by people paying their part B premium because, of course, we do pay the premium of low-income seniors, and many people who receive part B benefits are retired on very comfortable incomes. So we really have to be more honest with the American public and with the retirees about the importance of these benefits as well as their cost. So I think there is no group that I have ever found that is more realistic about, you do not get something for nothing than, frankly, my retirees.
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So I would like your help in taking this one directly.
Mr. CHRISTENSEN. Would you yield?
Mrs. JOHNSON. I would be happy to yield.
Mr. CHRISTENSEN. Madam Chairwoman, you have raised a good point. In light of the fact that after what we went through this past year in the elections, it would be great if we could get the leadership of both parties and the outside interest groups to take a hands-off approach on this one if we were to do something so forward, and such a good area of diabetes to say, This is not going to be made a political issue. If it raises a few cents in this Medicare part B premium to do such a thing, we are not going to use it as a political weapon and say that you raised Medicare part B costs.
If we could get some kind of agreement from the outside groups, such as AARP, and the leadership on both sides to say, This is for the good of the country, it is good for the citizenry, and we are not going to politicize this issue, I think we would be so far ahead as a country, as a nation, and as a people. I would like to seek your help in that area, Ms. Furse.
Ms. FURSE. Yes.
Mrs. JOHNSON. I would go a step beyond. I would challenge AARP—and I hope they are here. I would challenge the Committee To Preserve Social Security, and I hope they are here. I would challenge the Senior Citizens Council, and I hope they are here—to come out to your members to support expansion of the Medicare law to cover some prevention, and to take responsibility for being part of the payors of that system, as they currently are.
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So this is a time for more honest dialog in America. If the senior groups cannot be honest with their members about the importance of prevention, then frankly, do not come here and complain about the quality of the Medicare benefit package.
Mr. NETHERCUTT. That is right. I hope they are listening. They are the direct beneficiaries. The truth is, the senior population will directly benefit. So it is in their best interest to support it, in my judgment.
Mrs. JOHNSON. Thank you very much.
Our next witness is Christopher Shays. He is not here, so we will call the first panel, Dr. Paul Frame, Dr. Michael McGinnis, and Nelson Sabatini. We will start with Dr. Frame, who is the clinical associate professor, Department of Family Medicine, University of Rochester School of Medicine and Dentistry, and rural family physician with Tri-County Family Medicine Center, on behalf of the U.S. Preventive Services Task Force; followed by Dr. Michael McGinnis, scholar-in-residence, National Academy of Sciences, on behalf of the Partnership for Prevention; and then followed by Nelson Sabatini, vice president for Integrated Delivery Systems Operations, University of Maryland Medical Systems, Baltimore, Maryland.
Gentlemen, welcome.
Dr. Frame.
STATEMENT OF PAUL S. FRAME, M.D., CLINICAL ASSOCIATE PROFESSOR, DEPARTMENT OF FAMILY MEDICINE, UNIVERSITY OF ROCHESTER SCHOOL OF MEDICINE AND DENTISTRY, ROCHESTER, NEW YORK; AND RURAL FAMILY PHYSICIAN WITH TRI-COUNTY FAMILY MEDICINE, COCHTON, NEW YORK; ON BEHALF OF U.S. PREVENTIVE SERVICES TASK FORCE
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Dr. FRAME. Good morning. As was mentioned, my name is Paul Frame. I have been a rural family physician in upstate New York for the past 23 years and am a faculty member at the University of Rochester School of Medicine and Dentistry. I am here today representing the U.S. Preventive Services Task Force, and I am delighted to have the opportunity to testify on behalf of H.R. 15 in support of the importance of preventive services for older Americans.
The U.S. Preventive Services Task Force is an independent, federally supported expert advisory panel that was first convened in 1984 to develop recommendations for preventive services based on a rigorous evaluation of the scientific evidence. The mission of the task force was to state the scientific evidence, or lack of evidence, supporting specific preventive interventions, rather than to make policy decisions.
Also, unlike many expert panels, the task force was largely composed of generalists rather than specialists. The work of the task force through its first report issued in 1989 and its second report released this past year in 1996 has been a critical force in convincing clinicians, health care purchasers, policymakers, and the public of the importance of clinical preventive services as a routine part of medical care. Currently, the task force is a part of the Agency for Health Care Policy and Research.
The recommendations contained in the 1996 task force report, which is this book, ''The Guide to Clinical Preventive Services,'' support most, but not all, of the proposed changes incorporated in H.R. 15. First, the task force now recommends colorectal cancer screening in men and women over age 50. We strongly support the inclusion of annual fecal occult blood testing and periodic sigmoidoscopy as covered benefits under Medicare. There is good evidence we can prevent deaths from colorectal cancer with early detection.
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Second, we support coverage of periodic mammography for women over age 50. However, because mammography trials that screened women annually compared to mammography trials which screened women every 2 to 3 years got roughly equal benefits, the task force made a recommendation that mammography screening be done every 1 to 2 years. It is not known whether annual mammography is better than screening every 2 years.
Third, the task force recommends Pap smear screening for cervical cancer at least every 3 years for all women who have been sexually active and have a cervix. It is not possible to determine scientifically an upper age after which screening can be discontinued. But many experts recommend that women over age 65 who have had multiple previous negative smears no longer need screening. Medicare coverage of Pap smears, however, is important because some older women have not had adequate previous screening.
We were, however, confused by language in H.R. 15 about ''screening pelvic examinations'' because we are unaware of any evidence that the pelvic examination has proven to be a good screening test for ovarian cancer or for other diseases in asymptomatic women.
Fourth, the task force did not find sufficient evidence to determine whether screening by prostate specific antigen reduces mortality from prostate cancer. PSA screening will detect large numbers of prostate cancers, some of which would never otherwise have been clinically apparent. Thus, the incidence of prostate cancer has risen dramatically in recent years. However, it is not known whether this increased detection and aggressive treatment leads to increased survival.
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It is known that treatment by radical prostatectomy or radiation is expensive and causes significant morbidity. Several studies in the United States and abroad are currently in progress to answer this most important question of whether screening and early detection of prostate cancer reduces mortality. The Preventive Services Task Force does not currently endorse routine PSA screening.
The task force realizes there may be differences between what services are recommended for the general population and what services should be covered by insurance. We feel that services should not be recommended by policymaking bodies unless there is solid evidence of benefit.
However, in some circumstances, especially when there is controversy among the medical community, it is reasonable to provide coverage for a service so that the patient and their physician can jointly decide on an informed course of action, even in the absence of definitive scientific evidence. Medicare coverage is a way to ensure that this choice does not depend on one's ability to pay out-of-pocket expenses.
The task force strongly supports incorporation of preventive services into the routine medical care of older people. Expanded Medicare coverage of services that are of proven benefit is essential if we wish doctors and other providers to deliver these vital services and older Americans to receive them.
Thank you very much. I would be happy to answer any questions.
[The prepared statement follows:]
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Statement of Paul S. Frame, M.D., Member, U.S. Preventive Services Task Force, Clinical Associate Professor, Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York; and Rural Family Physician With Tri-County Family Medicine, Cochton, New York
I am delighted to testify on HR 15 today, and to speak about the importance of preventive services for older Americans. I am a family physician in practice in upstate New York and a faculty member at the University of Rochester, but I am here today representing the U.S. Preventive Services Task Force (USPSTF), of which I have been a member since 1990.
The USPSTF is an independent, federally supported expert panel first convened in 1984 to develop recommendations for preventive services based on a rigorous evaluation of the scientific evidence. The work of the Task Force, through its first report in 1989 and its second report released in late 1995, has been a critical force in convincing clinicians, health care purchasers, policy makers, and the public of the importance of clinical preventive services as a part of primary health care. Task Force recommendations have been adopted by various professional societies and health plans, and its Guide to Clinical Preventive Services is used widely by clinicians, medical educators, and policy makers.
The second USPSTF, on which I served, consisted of 10 experts representing family medicine, internal medicine, pediatrics, obstetrics and gynecology, and preventive medicine. Our report, Guide to Clinical Preventive Services, 2nd edition, evaluated more than 6,000 studies of more than 200 different services, including immunizations, screening tests, counseling, and chemoprophylaxis against certain diseases. The Task Force recommended only those services for which there was scientific evidence of significant clinical benefits to patients. Fortunately, medical studies have now demonstrated that many preventive services delivered in the primary care setting can save lives, prevent illness, and improve the quality of life for individuals. The Task Force strongly endorsed the value of preventive services for older Americans, who are at higher risk of heart disease, stroke, cancer, pneumonia, and many other illnesses for which we now have effective preventive interventions.
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It is essential that Medicare coverage be extended to those preventive services proven to be effective. Inadequate reimbursement remains an important barrier to the effective delivery of preventive services in primary care populations. Even modest out-of-pocket costs can deter older Americans, especially those most in need, from obtaining immunizations and screening tests that are very important to their health. Although some preventive services may save money, it is unreasonable to expect preventive care to always pay for itself, any more than we expect medical treatments to pay for themselves. The purpose of preventive care, like that of medical care in general, is to prolong life and improve the quality of life. Even when preventive care requires additional expenditures, it often gives better value for the health care dollar than many treatment services that are routinely delivered.
Among the most important changes in the recent USPSTF report was a new recommendation for colorectal cancer screening in men and women over age 50. This reflected important new studies that had been published after 1989. Results from other international studies, published within the last six months, have further strengthened the evidence that regular screening can reduce deaths from colorectal cancer. The Task Force strongly supports the inclusion of annual fecal occult blood testing and/or periodic sigmoidoscopy as a covered benefit under Medicare.
The Task Force also strongly supports the benefits of periodic mammography in women over age 50. Continued screening is important for older women, since the risk of breast cancer continues to rise in women during their 60s and 70s. Important gaps in our scientific knowledge remain, however, including the optimal frequency of screening in older women. Because mammography trials that screened women every two years have achieved benefits equal to those in which women were screened more frequently, the Task Force recommended mammography every 1–2 years and did not conclude that annual mammography is necessarily superior to screening every two years. Although it is reasonable to assume that more frequent screening may pick up some tumors earlier, we do not know for certain whether it will save more lives. More frequent screening will entail additional inconvenience and risks to women, including false-positive mammogram results and additional biopsies. Because the optimal screening strategy is not known, reimbursement for annual mammography would allow women and their clinicians the freedom to choose the screening program that seems most appropriate for them.
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The Task Force recommends Pap smear screening for cervical cancer at least every three years for all women who have been sexually active and have a cervix. It is not possible to determine scientifically an upper age after which screening can be discontinued, but many experts recommend that women over age 65 who have had multiple previously negative smears no longer need screening. Medicare coverage of Pap smears is still important, however, because some women have not had previous screening and thus are at risk for cervical cancer.
HR 15 provides for coverage for ''screening pelvic examinations'' in addition to Pap smears. This is confusing, as there is no evidence that the pelvic examination apart from the Pap smear is a good screening test—for ovarian cancer, for example. It would be helpful to have clarification of the intent of this part of the legislation.
Although screening with prostate-specific antigen (PSA) can increase the detection of early prostate cancers, the Task Force did not find sufficient evidence to recommend that all older men be routinely screened for prostate cancer. The benefits of screening and the optimal treatment of early prostate cancer remain uncertain. At the same time, the potential harms of screening may be significant, including frequent false-positive results and the likelihood that some tumors detected by screening would not have caused symptoms during a man's lifetime. These are the same conclusion reached by the American College of Physicians, the Office of Technology Assessment, and the Canadian Task Force on the Periodic Health Exam, among others. A large trial being conducted by the National Cancer Institute and at least 10 trials in Canada and Europe are currently underway to determine the benefits and risks of screening for prostate cancer with PSA, but the results from these trials will not be available for 10 or more years. Because of this, it is understandable that many men have chosen to undergo screening based on the ability of the PSA test to detect cancer, even though conclusive evidence is lacking that it will reduce their risk of dying of prostate cancer. Medicare coverage of routine screening is one way to ensure that this choice will not depend on whether older men can afford the out-of-pocket costs of screening.
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The USPSTF recommended only those services for which there was good evidence of benefit. It did not consider costs or cost-effectiveness in making its recommendations. Nonetheless, these issues are appropriate concerns for policy makers. As you deliberate on this bill, I urge you to consider that the resources required to cover services of potential but unproven benefit—such as PSA testing—might have a greater impact on health if devoted to measures for which scientific evidence was stronger and better established—such as smoking-cessation or efforts to improve immunization of the elderly against influenza and pneumonia.
In conclusion, the U.S. Preventive Services Task Force strongly supports the incorporation of preventive services into routine medical care as a way of improving the health status of older Americans. Expanded Medicare coverage of preventive services that are of proven benefit is essential if we wish doctors and other providers to deliver these vital services and older Americans to receive them.
Thank you very much. I would be happy to respond to any questions that you have.
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Mrs. JOHNSON. Thank you, Dr. Frame.
Dr. McGinnis.
STATEMENT OF J. MICHAEL MCGINNIS, M.D., SCHOLAR-IN-RESIDENCE, NATIONAL ACADEMY OF SCIENCES; ON BEHALF OF PARTNERSHIP FOR PREVENTION
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Dr. MCGINNIS. Thank you, Madam Chairwoman. As you mentioned, I am Michael McGinnis, scholar-in-residence, National Academy of Sciences, and a member of the Partnership for Prevention board of directors. Partnership for Prevention is a national nonprofit educational and policy research organization whose diverse members share an interest in finding effective ways to make prevention an integral part of national health policy. I should mention that my testimony is also endorsed by the American College of Preventive Medicine, of which I am a fellow.
Madam Chairwoman, we commend you and the Chairman, Representative Cardin, and other Members of the Subcommittee for your leadership in sponsoring this important bill. The essence of my testimony can be summarized in just three points.
First, many of the infirmities of old age occur far earlier and more frequently than they should.
Second, in the field of medicine, prevention has led the way in insisting that its interventions be supported by the evidence; a standard of vital importance when time is scarce and resources are dear.
And third, if I, as an aging person, were limited to just one preventive intervention that could make the greatest difference in both the quality and length of my life, that intervention would be a program of physical activity.
Having said that, let me now mention there are specific provisions currently in H.R. 15 that receive our strongest endorsement. Namely, coverage of colorectal cancer screening tests, including sigmoidoscopy and fecal occult blood tests, coverage for clinical breast examinations, and coverage for diabetes management. We also wholeheartedly endorse the waiver of deductibles for mammograms, Pap tests, and protections against balance billing for colorectal cancer screening tests.
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While H.R. 15 significantly expands Medicare's coverage of needed preventive services, there are several areas in which we believe the bill could better reflect the exigencies of both the science and the economy.
Our first recommendation is that Medicare cover those preventive services recommended by the U.S. Preventive Services Task Force and alluded to by Dr. Frame including, and perhaps I should say especially, the counseling services identified. Further, Congress should authorize the Secretary of Health and Human Services to modify Medicare's coverage of preventive services in order to respond to advances in science and new evidence of effectiveness.
Perhaps the most important practical implication is that rather than cover services whose benefits are still not proven, such as PSA screening for prostate cancer, Medicare should cover preventive counseling services, which we know will improve health. Such services would include counseling on matters like smoking cessation, diet and exercise, injury prevention, and dental health.
In the same spirit of a focus on effectiveness, we strongly encourage the Subcommittee to ensure that the useful information provided by the U.S. Preventive Services Task Force Guide to Clinical Preventive Services is available and updated in the future. The task force, developed by the Office of Disease Prevention and Health Promotion and now housed at AHCPR, provides an invaluable reference for clinicians and policymakers alike.
Our second recommendation is that Congress and the administration reduce barriers to the use of preventive services. Many studies have found that participants in cost-sharing insurance arrangements are the least likely to use care of any type. H.R. 15 removes a number of these financial barriers by waiving deductibles for mammography and Pap tests, and by eliminating balance billing for colorectal cancer screening tests.
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There has been much attention to the matter of mammography for women ages 40 to 50. But the real attention should go to the fact that among women over 50 for whom there is no doubt that mammography saves lives, only half receive the services currently. Partnership strongly encourages the Subcommittee to remove all financial barriers to Medicare's provision of preventive services.
Finally, Partnership recommends that Medicare utilize those tools proven to be effective to empower beneficiaries to be more engaged in decisions about health behavior and health services, sometimes referred to by the term ''demand management.'' The fact is that a number of self-management supporting information tools look to be effective in improving health and reducing the cost of care. We feel this area deserves a closer look by Congress and HCFA, and urge demonstration projects.
In conclusion, Madam Chairwoman, H.R. 15 is important to our Nation's preventive strategy because it would make the fact that people can be healthy well into older life not just a matter of science, but a matter of policy. In these days we all seek better ways to increase return on investment. In health financing, H.R. 15 can do much to offer that better way.
Thank you for your leadership and for the opportunity to be with you today.
[The prepared statement and attachments follow:]
Statement of J. Michael McGinnis, M.D., Scholar-in-Residence, National Academy of Sciences; on Behalf of Partnership for Prevention
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Mr. Chairman and members of the Subcommittee, I am Michael McGinnis, Scholar-In-Residence at the National Academy of Sciences and member of the Partnership for Prevention Board of Directors, on whose behalf I appear today. Partnership for Prevention is a national nonprofit educational and policy research organization whose diverse members share an interest in finding effective ways in which prevention can be made an integral part of national health policy and practice. (Appendix A lists the members of Partnership for Prevention.) The Subcommittee should also know that my testimony today has been endorsed by the American College of Preventive Medicine, where I am also a fellow.
I am pleased to have this opportunity to testify before you today in support of the Medicare Preventive Benefit Improvement Act (H.R. 15). Although Medicare's lack of coverage for preventive services has been debated in years past, it has been quite some time since this issue has received such scrutiny by the Ways and Means Committee. Partnership is encouraged by the opportunity that this reinvigorated discussion represents and commends Chairman Thomas, Representative Cardin, and other members of the Subcommittee on Health who have cosponsored this bill for their leadership.
My testimony today is guided by three general recommendations, advanced by Partnership for Prevention, that address Medicare's coverage of preventive services:
• Medicare should cover those preventive services recommended by the U.S. Preventive Services Task Force.
• Congress and the Administration should reduce barriers to the use of all preventive services.
• Medicare should utilize those tools proven effective to empower Medicare beneficiaries to make informed decisions about their own health, to adopt healthy behaviors, and to make appropriate use of medical care.
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Partnership believes that H.R. 15 takes an important step toward meeting these objectives. While we have constructive suggestions for improvement, we support both the general approach and content of this legislation.
Partnership for Prevention
Partnership for Prevention was founded in 1990 to provide private-sector leadership in achieving the Healthy People 2000 national health objectives. The mission of the organization is to increase the priority for prevention among policy-makers, federal and state agencies, corporations and other nonprofit organizations. In making our case, we adhere to the highest standards of scientific evidence. While there are many organizations and associations active in the field of health promotion and disease prevention, Partnership for Prevention coordinates and focuses the efforts of existing groups in order to achieve significant changes in national health policies with an emphasis on prevention.
Members of Partnership represent some of the leading organizations in business and industry, professional and trade associations, universities and academic health centers, civic organizations, nonprofit disease groups and state health departments.
Partnership also endeavors to be a resource for Members of Congress and their staff by providing educational resources, such as our ''Prevention Primer,'' and our recent Medicare forum. This forum, at which you, Mr. Chairman, Congressman Cardin, and Chairman Bilirakis spoke, provided more than 200 attendees with information about the importance of prevention for seniors. Currently, we are working to assist in the development of a new Congressional coalition, comprising Members of Congress with an interest in prevention issues, in order to supplement our efforts to provide both legislators and staff with educational, scientific information about prevention.
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The Prevention Context for H.R. 15
H.R. 15 represents a significant advance toward the goal of providing seniors with access to needed preventive services. Clinical preventive services, such as mammography, colorectal cancer screening tests, and immunizations, are a key part of a broad strategy to prevent disease and promote healthy lifestyles for older Americans. However, clinical prevention is not the only element of a comprehensive approach to health promotion and disease prevention. Many of prevention's most promising opportunities are often overlooked because prevention is so narrowly defined in the eye of the public. Prevention is a much broader concept than a regular checkup or regular screening. A safe water supply, regular exercise, and seat-belt laws are all part of prevention. So are strategies to reduce violence in our communities and to fluoridate drinking water.
Partnership for Prevention espouses three components of a comprehensive prevention program: (1) clinical preventive services, such as immunizations, screening tests, and counseling interventions; (2) community-based preventive services and public health activities, such as health education, surveillance of health status and monitoring of air, water and food; and (3) prevention-oriented social and economic policies, such as legal and regulatory actions that reduce exposure to harmful substances and education and financial incentives that reinforce healthy behaviors. Partnership for Prevention advocates integrating prevention, in all its varied forms, into our health care and public health system.
Partnership also strongly supports strategies that foster such integration, including programs and tools that encourage healthful behaviors and the self-management of chronic and acute conditions. For example, evidence is mounting that consumers who have access to self-management tools, such as self-care books and nurse help lines, tend to use medical services less frequently and make informed decisions about their lifestyles and treatment options. As an added bonus, some studies show that such ''self-care'' strategies may save money—something in which I know the members of this Subcommittee are interested!
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Preventive Services for Older Americans and the Contribution of H.R. 15
H.R. 15 addresses a critical component of a comprehensive prevention strategy: access and utilization of clinical preventive service