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Roundtable on Critical Care Policy

February 10, 2011

Chairman Camp and Ranking Member Levin and other Members of the Committee, we thank you for holding this important hearing to examine the Patient Protection and Affordable Care Act’s (PPACA) impact on the Medicare program and its beneficiaries.  The Roundtable on Critical Care Policy supports the Committee’s commitment to ensuring that the reforms authorized by PPACA will be implemented in a way that improves the efficiency and effectiveness of our health care system by transforming the way health care is delivered in this country. 

Established in 2009, the Roundtable on Critical Care Policy is a nonprofit organization that provides a forum for leaders in critical care and public health to advance a common federal policy agenda designed to improve the quality, delivery and efficiency of critical care in the United States. The Roundtable brings together a broad cross-section of stakeholders, including the nation’s leading medical professionals with specialized training in critical care, patient groups, academia, public health advocacy and industry.

The Roundtable is supportive of Acting Administrator for the Centers for Medicare and Medicaid Don Berwick’s simultaneous pursuit of the “Triple Aim”: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.  However, as the Committee moves forward with overseeing the implementation of these goals and develops additional policies to strengthen and modernize Medicare, the Roundtable encourages the Committee to consider proposals focused on improving the care for those beneficiaries who are critically ill and injured. 

Each year, over five million Americans are admitted into traditional, surgical, pediatric, or neo-natal intensive care units (ICUs).[1]  The ICU is one of the most costly areas in the hospital, representing 13% of all hospital costs, with the total costs of critical care services in the U.S. exceeding $80 billion annually.[2]  Providers of critical care require specialized training, the care delivered in the ICU is technology-intensive, treatment is unusually complex due to what may be a patient’s system—or multiple system—challenges or failures, and outcomes have life or death consequences.  Approximately 540,000 individuals die each year after admission to the ICU, and almost 20% of all deaths in the U.S. occur during a hospitalization that involves care in the ICU.[3] 

Despite the significant role critical care medicine plays in providing high-quality health care, the PPACA did little to address the challenges that plague the critical care delivery system.   A failure to address these challenges could jeopardize patient safety and do little to bend the curve on rising health care costs.

Multiple studies have documented that the demands on the critical care workforce—including doctors, nurses, and respiratory therapists—are outpacing the supply of qualified critical care practitioners.  A 2006 study by the Health Resources & Services Administration found that the current demand for intensivists—physicians with special training in critical care— will continue to exceed the available supply due largely to the growing elderly population, as individuals over the age of 65 consume a large percentage of critical care services.[4]  Studies by patient safety organizations, such as the Leapfrog Group, have found that intensivist-led ICU teams have been “shown to reduce the risk of patients dying in the ICU by 40%”. [5]   The current and projected critical care workforce shortages pose significant patient safety concerns. 

While PPACA included several initiatives to expand the health care workforce, they were largely focused on expanding primary care.  However, a solution cannot be reached solely by adding to the workforce; we must also find ways to improve the efficiency of the existing workforce.  That is why the Roundtable enthusiastically supports a provision included in PPACA that prioritizes within the newly established Centers for Medicare and Medicaid Innovation (CMMI) the testing of models that make use of electronic monitoring—specifically by intensivists and critical care specialists— to improve inpatient care.

The Roundtable strongly urges the Committee to ensure that, as the Administration moves forward with new payment and delivery reforms, initiatives aimed at improving the quality of care delivered to the critically ill and injured are made a priority.  Earlier this year, researchers at the Johns Hopkins Bloomberg School of Public Health found that hospitals in Michigan that implemented the Keystone Project, an ICU quality improvement initiative funded by the Agency for Healthcare Research and Quality, decreased an elderly person’s likelihood of dying while hospitalized by 24 percent.”[6]  The Administration and Congress needs to support similar initiatives to ensure we continue to make progress in improving health outcomes for our critically ill and injured beneficiaries.  

The Roundtable also believes that policy changes are necessary to meet the needs of our most vulnerable patients during advanced illness.  A recent study by the Dartmouth Institute for Health Policy and Clinical Practice found that “one in three Medicare cancer patients spend their last days in hospitals and intensive care units,” and that “clinical teams aggressively treat patients with curative attempts they may not want, at the expense of improving the quality of their life in the last weeks and months.”[7] The Roundtable encourages the Committee and the Administration to find ways to work together on this issue.

And lastly, another challenge facing critical care medicine is the notable absence of research on the availability, appropriateness, and effectiveness of a wide array of medical treatments and modalities for the critically ill or injured. At present, many of the current, high-cost treatments delivered in the ICU lack comparative effectiveness data.  Yet in 2009 when the Institute of Medicine released its mandated report recommending 100 topics to be given priority for comparative effectiveness research funding, few of these topics related to critical care.  Moreover, current federal research efforts are partitioned and scattered across the government and throughout that National Institutes of Health’s (NIH) 27 institutes, making it difficult to coordinate existing research and identify gaps.   

As Members look to address these issues in the future, we hope that you will consider some of the reforms included in the “Critical Care Assessment and Improvement Act” that was introduced late last year by Congresswoman Tammy Baldwin and will be re-introduced this year.  The legislation would authorize a much needed assessment of the current state of the critical care delivery system, including its capacity, capabilities, and economic impact. In addition, the bill would establish a Critical Care Coordinating Council within the NIH to coordinate the collection and analysis of information on current critical care research, identify gaps in such research, and strengthen partnerships. Lastly, the bill authorizes a number of initiatives to bolster federal disaster preparedness efforts to care for the critically ill or injured.

The Roundtable on Critical Care Policy appreciates the opportunity to submit a statement for the record and looks forward to working with the Committee to strengthen our health care delivery system. 

Submitted by:  Executive Director Stephanie Silverman

[1] Society of Critical Care Medicine. Critical care statistics in the United States.

[2] Halpern Na, Pastores SM. “Critical Care Medicine in the United States 2000-2005: An analysis of bed number, occupancy rates, payer mix and costs,” Critical Care Medicine 37 no.1 (2010)

[3] Angus DC, Barnato AE, Linde-Zwirble WT, et al. “Use of Intensive care at the end of life in the United States: an epidemiologic study” Critical Care Medicine 32 (2004)

[4] Health Resources and Services Administration Report to Congress: The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians. Requested by: Senate Report 108-81. Available at: Accessed November 2010.

[6] Agency for Health Care Research and Quality, “Landmark Initiative to Reduce Healthcare-Associated Infections Cuts Death Among Medicare Patients in Michigan Intensive Care Units”, January 31, 2011

[7] The Dartmouth Institute For Health Policy & Clinical Practice, “Nearly One Third of Medicare Patients with Advanced Cancer Die in Hospitals and ICUs; About Half Get Hospice Care”  Press Release November 16, 2010