more emphasis is placed on creating a healing environment of care.10,11 The ICU remains the hospital location of choice for rapid and coordinated resuscitation and stabilization. But now there is equal emphasis on creating an environment that is more attuned to patient privacy and comfort, support of visiting family and loved ones, and effective infection control. As discussed by Halpern,2 the form and function of the modern ICU room should be designed to meet the dual needs of effective patient care for life-threatening illness and injury and of a supportive environment for healing and well-being of patients, visitors, and staff. Perhaps the most substantial change in modern ICUs has been the progressive integration of information systems and the vast array of electronic devices. The goal is for comprehensive electronic integration of the patient with all aspects of care and transformation of patient-related data into useful and actionable information.3 Early efforts in informatics and electronic processes focused on computerized order entry and bedside physiologic monitoring. More recently there has been rapid expansion of electronic medical records into ICUs. This has been followed by development of systems for data management and decision support of electronic medical record data that enhance the quality and efficiency of patient care—an aspect of ICU design that holds great promise. Real-time data analysis can support “smart” alerts that identify patients at risk for clinical deterioration or for harm from preventable untoward events, such as a drug-drug interaction. Some proprietary systems integrate such alerts into dashboards and may be linked to telemedicine monitoring remotely.12 Other electronic advances that enhance patient safety include bar code scanners and infusion pump drug libraries and dosing limits. Although electronic integration of the many devices commonly used in ICU care, such as physiologic monitors, infusion pumps, mechanical ventilators, dialysis machines, and point-of-care testing instruments, has historically been challenging, interoperability can be enhanced through the use of “middleware,” as outlined by Halpern.3 In summary, creation of “smart” ICUs, including a logical structure of the entire ICU, well-conceived ICU room layouts and integrated electronic devices, and robust information systems leveraged to deliver useful and timely information, can contribute to the important goals of better patient outcomes, enhanced patient safety, and a supportive environment for patients, their loved ones, and health-care workers. Curtis N. Sessler, MD, FCCP Richmond, VA Affiliations: From the Center for Adult Critical Care, Medical Respiratory ICU, Medical College of Virginia Hospitals and Physicians, Virginia Commonwealth University Health System. 206

Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Curtis N. Sessler, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Box 980050, Richmond, VA 23298; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-2746

References 1. Halpern NA. Innovative designs for the smart ICU: part 1: from initial thoughts to occupancy. Chest. 2014;145(2):399-403. 2. Halpern NA. Innovative designs for the smart ICU: part 2: the ICU. Chest. In press. doi:10.1378/chest.13-0004. 3. Halpern NA. Innovative designs for the smart ICU: part 3: advanced ICU informatics. Chest. In press. doi:10.1378/ chest.13-0005. 4. Halpern NA, Pastores SM. Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med. 2010;38(1):65-71. 5. Prin M, Wunsch H. International comparisons of intensive care: informing outcomes and improving standards. Curr Opin Crit Care. 2012;18(6):700-706. 6. Robert R, Reignier J, Tournoux-Facon C, et al; Association des Réanimateurs du Centre Ouest Group. Refusal of intensive care unit admission due to a full unit: impact on mortality. Am J Respir Crit Care Med. 2012;185(10):1081-1087. 7. Simchen E, Sprung CL, Galai N, et al. Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds. Crit Care Med. 2004;32(8): 1654-1661. 8. Wunsch H, Wagner J, Herlim M, Chong DH, Kramer AA, Halpern SD. ICU occupancy and mechanical ventilator use in the United States. Crit Care Med. 2013;41(12):2712-2719. 9. Leaf DE, Homel P, Factor PH. Relationship between ICU design and mortality. Chest. 2010;137(5):1022-1027. 10. Bartley J, Streifel AJ. Design of the environment of care for safety of patients and personnel: does form follow function or vice versa in the intensive care unit? Crit Care Med. 2010; 38(suppl 8):S388-S398. 11. Kesecioglu J, Schneider MME, van der Kooi AW, Bion J. Structure and function: planning a new ICU to optimize patient care. Curr Opin Crit Care. 2012;18(6):688-692. 12. Lilly CM, Cody S, Zhao H, et al; University of Massachusetts Memorial Critical Care Operations Group. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011;305(21):2175-2183.

Whether a Bill Becomes a Law of us remember the classic Saturday morning MostSchool House Rock segment, “I’m Just a Bill,”

which taught us the steps on how a bill becomes a law. While entertaining and informative, it did not address the many other factors that often determine whether a bill makes it into law. Before identifying those factors, I want to discuss challenges and opportunities regarding the future of the Medicare program. Medicare is critically important,


but faces a funding crisis. The Hospital Insurance Trust Fund, which is used to pay for health care in facilities and is funded through a payroll tax, has paid out more than it has taken in for a number of years. So it is no surprise that the Hospital Insurance Trust Fund is projected to go bankrupt in 2026.1 Separately, spending for outpatient health care and medicine is projected to rise so dramatically that it puts a strain on taxpayers and will likely crowd out federal investments in other priority areas.1 This trend is troubling, and it gets worse. The independent Medicare actuaries publish an alternative illustrative scenario that acknowledges that Congress will override scheduled cuts to health-care providers that might drive them to discontinue participation.2 This more realistic scenario assumes that Congress, among other things, will avert pending cuts to physician payments called for under the flawed sustainable growth rate (SGR) formula system used to update physician payments. George R. R. Martin wrote, “Most men would rather deny a hard truth than face it.”3 I worry that this is true for too many in Washington, DC, when it comes to Medicare. It is imperative that Congress act now to save Medicare. I am working with Ways and Means Committee Chairman Dave Camp and other lawmakers to do just that now. We have called attention to reform ideas that have bipartisan support and solidify the structure of Medicare.4 The committee is also working on bipartisan, bicameral policy to repeal the SGR and create a reliable, predictable, and fair payment system. Achieving this long-sought goal would not only reverse the trend of fewer doctors seeing new Medicare patients but also would result in more honest, accurate budgeting. You cannot save Medicare until you first solve how to pay local doctors fairly to see our seniors. Real solutions are within reach. But the time to act is short. The longer Congress waits, the more dramatic and disruptive its policy options.5 The responsibility of Congress extends beyond the program structure and sector-specific payment systems. It also includes the specific type of services that Medicare pays for and which professionals can provide them. This brings me to a bill currently before Congress and is debated in this issue of CHEST (see pages 210218)6-9: the Medicare Respiratory Therapist Access Act of 2013 (HR 2619).10 Analysis by Fuhrman and Aranson6,8 asserts that Congress should pass HR 2619 to pay for pulmonary self-management and education training services when provided by respiratory therapists working under physician supervision for beneficiaries with COPD. The authors state that an insufficient physician supply necessitates expanded

recognition of respiratory therapists and other professionals. In taking the opposing view, Courtright and Manaker7,9 cite insufficient evidence, potential higher costs, and the possibility of abusive billing. This type of disagreement on a piece of legislation is the rule, not the exception. I write not to take a side in this debate, but to shed light on the factors that determine whether a bill becomes a law. Let me start by saying that though many bills are introduced, few become law. Of the . 12,000 bills introduced in the 112th Congress, only 2% became law, perhaps for good reason.11 Members introduce bills to promote a particular policy position. While the impetus for the policy can take many forms, it is often in response to a constituent experience or concern. A member may even have a personal connection to the issue, which can help a bill gain traction. The visibility of a bill increases with its number of supporters or cosponsors. The sponsor and those who support it are key to securing cosponsors. One member will approach another in the hallway or while voting on another bill to make the case for support. Effective stakeholder groups also encourage constituents to ask for support. Active opposition to a bill can limit the number of cosponsors. Sorting through conflicting stakeholder positions is a difficult, though not insurmountable, challenge from a policy and political perspective. Advocates of a bill need to be persistent and patient. Bills that become law have often been introduced in multiple prior Congresses. Advocates may modify a bill over time to address opposition concerns. HR 2619, in fact, provides an example, as coverage of selfmanagement educational activities only for beneficiaries with COPD represents a more narrow approach.12 Even bills with many cosponsors, strong advocates, and little opposition face strong headwinds. Putting a bill through the regular order is preferred. Regular order entails a public hearing held by a committee with jurisdiction to discuss the merits and then a markup session that enables committee members to propose amendments to the bill. Numerous priorities and limited time make it hard to adhere to this regular process. The House can vote on a bill as a stand-alone piece of legislation, but individual bills are often combined into a larger legislative package. For better or worse, Congress has legislated in recent years by packaging multiple issues in the face of hard deadlines. Such a dynamic can limit the scope of the policies added to the mix. Expanding must-pass legislation, such as funds to keep the government operating, to tangential issues can jeopardize its passage. Even if a bill makes it as far as consideration for a vote, a few “inside baseball” steps weigh heavy on its CHEST / 145 / 2 / FEBRUARY 2014


fate. The federal agency that would be responsible for implementing the bill, the Centers for Medicare and Medicaid Services in the case of HR 2619, provides feedback on its feasibility. The nonpartisan official scorekeeper of a bill’s financial impact, the Congressional Budget Office, estimates whether it increases or decreases federal spending. How much something costs is particularly crucial. For all of the above reasons, the fate of Medicare structural reform, SGR reform, and HR 2619 remains unclear. Regardless, all Medicare issues—whether related to the solvency of the program, an entire payment system, or a particular payment policy—are important. The program, and the country, benefit from a rigorous, informed debate such as the one that takes place in this issue of CHEST. US Rep Kevin Brady, (Texas, 8th District, R) Washington, DC Affiliations: From the United States House of Representatives. Financial/nonfinancial disclosures: The author has reported to CHEST the following conflicts of interest: Kevin Brady is a Republican House member representing Texas’ 8th District. Representative Brady serves as the Chairman of the Ways and Means Subcommittee on Health, which has jurisdiction over Medicare issues. Correspondence to: Kevin Brady, United States House of Representatives, 301 Cannon House Office Bldg, Washington, DC 20515; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-2789

References 1. Lew JJ, Harris SD, Sebelius K, Colvin CW, Blahous CP III, Reischauer RD. 2013 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary



3. 4.




8. 9. 10. 11. 12.

Medical Insurance Trust Funds. Washington, DC: Centers for Medicare & Medicaid Services; 2013. Shatto JD, Clemens KM. Projected Medicare Expenditures Under Illustrative Scenarios With Alternative Payment Updates to Medicare Providers. Office of the Actuary. May 31, 2013. Baltimore, MD: Centers for Medicare and Medicaid Services; 2013. Martin GRR. A Game of Thrones. New York, NY: Bantam Spectra; 1996:126. Committee on Ways and Means. Entitlement reform: protecting, preserving and prolonging the life of our entitlement programs securing solutions to the challenges facing Social Security and Medicare. Committee on Ways and Means website. Accessed November 5, 2013. Blahous CP. Public Trustee for the Medicare Trust Funds. Statement before the Subcommittee on Health of the US House of Representatives Committee on Ways and Means. June 20, 2013. Washington, DC: Committee on Ways and Means; 2013. Fuhrman TM, Aranson R. Point: should Medicare allow respiratory therapists to independently practice and bill for educational activities related to COPD? Yes. Chest. 2014;145(2): 210-213. Courtright K, Manaker S. Counterpoint: should Medicare allow respiratory therapists to independently practice and bill for educational activities related to COPD? No. Chest. 2014; 145(2):213-216. Fuhrman TM, Aranson R. Rebuttal from Drs Fuhrman and Aranson. Chest. 2014;145(2):216-217. Courtright K, Manaker S. Rebuttal from Drs Courtright and Manaker. Chest. 2014;145(2):217-218. HR 2619–Medicare Respiratory Therapist Access Act of 2013. GovTrack website. hr2619/text. Accessed November 5, 2013. Bills by final status. GovTrack website. https://www.govtrack. us/congress/bills/statistics. Accessed November 5, 2013. Frequently asked questions: HR 2619–Medicare Respiratory Therapist Access Act of 2013. American Association for Respiratory Care website. FAQs_RTInitiative_2013_Aug_2013.pdf. Accessed November 5, 2013.


Whether a bill becomes a law.

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