[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]

MEDPAC'S ANNUAL
MARCH REPORT TO CONGRESS

=======================================================================

HEARING

before the

SUBCOMMITTEE ON HEALTH

of the

COMMITTEE ON WAYS AND MEANS
U.S. HOUSE OF REPRESENTATIVES

ONE HUNDRED TWELFTH CONGRESS

FIRST SESSION

__________

MARCH 15, 2011

__________

Serial No. 112-HL1

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Printed for the use of the Committee on Ways and Means

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COMMITTEE ON WAYS AND MEANS

DAVE CAMP, Michigan, Chairman

WALLY HERGER, California SANDER M. LEVIN, Michigan
SAM JOHNSON, Texas CHARLES B. RANGEL, New York
KEVIN BRADY, Texas FORTNEY PETE STARK, California
PAUL RYAN, Wisconsin JIM MCDERMOTT, Washington
DEVIN NUNES, California JOHN LEWIS, Georgia
PATRICK J. TIBERI, Ohio RICHARD E. NEAL, Massachusetts
GEOFF DAVIS, Kentucky XAVIER BECERRA, California
DAVID G. REICHERT, Washington LLOYD DOGGETT, Texas
CHARLES W. BOUSTANY, JR., Louisiana MIKE THOMPSON, California
DEAN HELLER, Nevada JOHN B. LARSON, Connecticut
PETER J. ROSKAM, Illinois EARL BLUMENAUER, Oregon
JIM GERLACH, Pennsylvania RON KIND, Wisconsin
TOM PRICE, Georgia BILL PASCRELL, JR., New Jersey
VERN BUCHANAN, Florida SHELLEY BERKLEY, Nevada
ADRIAN SMITH, Nebraska JOSEPH CROWLEY, New York
AARON SCHOCK, Illinois
CHRISTOPHER LEE, New York
LYNN JENKINS, Kansas
ERIK PAULSEN, Minnesota
RICK BERG, North Dakota
DIANE BLACK, Tennessee

Jon Traub, Staff Director

Janice Mays, Minority Staff Director

______

Subcommittee on Health

WALLY HERGER, California, Chairman

SAM JOHNSON, Texas FORTNEY PETE STARK, California
PAUL RYAN, Wisconsin MIKE THOMPSON, California
DEVIN NUNES, California RON KIND, Wisconsin
DAVID G. REICHERT, Washington EARL BLUMENAUER, Oregon
DEAN HELLER, Nevada BILL PASCRELL, JR., New Jersey
PETER J. ROSKAM, Illinois
JIM GERLACH, Pennsylvania
TOM PRICE, Georgia

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
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unintentional errors or omissions. Such occurrences are inherent in the
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C O N T E N T S

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Page

Advisory of March 8, 2011, announcing the hearing................ 2

WITNESS

Glen M. Hackbarth, Chairman, Medicare Payment Advisory Commission 5

SUBMISSIONS FOR THE RECORD

American College of Radiology, statement......................... 64
The American Health Care Association, statement.................. 67

MEDPAC'S ANNUAL
MARCH REPORT TO CONGRESS

----------

TUESDAY, MARCH 15, 2011

U.S. House of Representatives,
Committee on Ways and Means,
Subcommittee on Health,
Washington, DC.

The Subcommittee met, pursuant to call, at 1:07 p.m., in
Room 1100, Longworth House Office Building, Hon. Wally Herger
[Chairman of the Subcommittee] presiding.
[The advisory announcing the hearing follows:]

ADVISORY FROM THE COMMITTEE ON WAYS AND MEANS

SUBCOMMITTEE ON HEALTH

CONTACT: (202) 225-1721
FOR IMMEDIATE RELEASE
March 8, 2011
HL-1

Chairman Herger Announces a Hearing on

MedPAC's Annual March Report to Congress

House Ways and Means Health Subcommittee Chairman Wally Herger (R-
CA) today announced that the Subcommittee on Health will hold a hearing
on the Medicare Payment Advisory Commission's (MedPAC) annual March
Report to the Congress which details the Commission's recommendations
for updating Medicare payment policies. The Subcommittee will hear from
MedPAC's Chairman, Glenn Hackbarth. The hearing will take place on
Tuesday, March 15, 2011, in 1100 Longworth House Office Building,
beginning at 1:00 p.m.

In view of the limited time available to hear the witness, oral
testimony at this hearing will be from the invited witness 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:

MedPAC advises Congress on Medicare payment policy. The Commission
is required by law to submit its annual advice and recommendations on
Medicare payment policy by March 15. In its March report to the
Congress, MedPAC is required to review and make recommendations on
payment policies for specific provider groups, including hospitals,
skilled nursing facilities, physicians, Medicare Advantage plans, and
other providers.

In announcing the hearing, Chairman Herger stated, ``MedPAC
provides valuable technical advice and counsel to Congress on the
Medicare program, ranging from recommendations on payment adequacy to
ways in which we can improve the delivery and quality of care for
seniors and people with disabilities. This hearing will offer the
Subcommittee an opportunity for an indepth exploration of MedPAC's
recent recommendations and their impact on the Medicare program and its
beneficiaries. As we confront the issues surrounding implementation of
the health care overhaul law passed last year and the continued need to
reform entitlement programs, the information we receive from MedPAC
will be more important than ever.''

FOCUS OF THE HEARING:

The hearing will focus on MedPAC's March 2011 Report to the
Congress on Medicare payment policies.

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Chairman HERGER. The Subcommittee will come to order. I
want to welcome everyone to the first hearing in the
Subcommittee on Health for the 112th Congress. Today we will be
hearing from the Medicare Payment Advisory Commission, MedPAC,
on the recommendations from their March 2011 report on Medicare
payment policies.
During this Congress, we must come together to address a
fiscal crisis of monumental proportions. Every program, no
matter how important, must be scrutinized to ensure that scarce
taxpayer dollars are being used appropriately and efficiently.
Therefore, I find it fitting that in our inaugural meeting
we would hear from MedPAC. The insight and guidance we receive
from MedPAC will be very important as we seek ways to reform
the Medicare program and improve the accuracy of provider
payments while also ensuring that Medicare beneficiaries have
access to high-quality care.
Congress relies on MedPAC's Medicare provider payment
recommendations because they are based on sound policy and
strong data analysis. Traditionally Medicare spending has
outpaced growth in the economy at large and is a major driver
of our long-term debt. The Congressional Budget Office projects
that Medicare spending will nearly double as a share of the
U.S. economy over the next 25 years.
By 2050 the Big Three Federal entitlement programs--
Medicare, Medicaid and Social Security--are expected to exceed
total tax revenue, with Medicare being the largest of the
three. We cannot bring about a fiscally sustainable future if
these trends continue.
MedPAC's analysis is invaluable in helping us better
understand when growth in Medicare spending is appropriate and
when Medicare payments need to be adjusted.
Last year Congress passed a massive health care overhaul
law that permanently reduces Medicare payments to a number of
providers. Less than 3 percent of the more than one-half
trillion dollars in cuts from Medicare came from actual
delivery reforms.
We must do better than that, which is why we also rely on
MedPAC's June report to Congress to guide us toward proposals
that offer real reform instead of just turning payment dials up
or down. This will help ensure that Medicare savings yield
better outcomes for Medicare's beneficiaries.
I think I speak for all of us up here, Republicans and
Democrats alike, that we are still looking for the silver
bullet that will permanently reform the physician payment
system in a fiscally responsible manner, and look forward to
working with MedPAC to find such a solution.
I want to offer a warm welcome to our invited witness,
MedPAC's Chairman Glenn Hackbarth. Thank you for joining us
today and I look forward to hearing your testimony.
I would also like to extend a special word of thanks to
MedPAC's executive director, Mark Miller, and the entire MedPAC
staff for their hard work on this report.
Before I recognize Ranking Member Stark for the purpose of
an opening statement, I ask unanimous consent that all Members'
written statements be included in the record.
Without objection, so ordered.
I now recognize Ranking Member Stark for his opening
statement.
Mr. STARK. Thank you, Mr. Chairman. I would like to join
you in welcoming Glenn and MedPAC. It is the efforts of MedPAC
and their staff that have helped us in the past. Many of the
recommendations in the current law's provisions are MedPAC's
work, and they have formed a number of the reforms that are in
the law that modernize the delivery of health care that Federal
rewards value over volume and encourages better coordination.
They have helped us with ideas to lower their rate of
preventable readmissions, the testing of bundled payments,
medical homes, and hospital value-based purchasing.
We have made difficult decisions in order to rein in rising
health care costs, and it would not have been possible without
the advice of MedPAC.
The end result: A program with improved benefits that lower
costs for beneficiaries, create taxpayer savings, and
innovations that we hope will improve patient care and
strengthen finances for the Medicare solvency for an additional
number of years. This, we think, is better than the program
that favors vouchers or shifting of costs to the very
beneficiaries who Medicare was created to serve.
While my Republican colleagues and I have many areas where
we disagree, there are several areas where we work together,
including Medicare's broken physician payment system. The House
Democrats passed comprehensive reform for the physician payment
system in the last Congress, and I hope getting a long-term
solution is at the top of our to-do list.
As this year progresses, I look forward to getting
continued input and advice from Mr. Hackbarth and the MedPAC
staff, and will continue to rely on your expertise and advice
as we undertake our Medicare and oversight responsibilities.
Thank you, Mr. Chairman.
Chairman HERGER. Mr. Hackbarth, I would like you to go
ahead and proceed with your testimony. We do have two votes
going on now, so I would like to have you give your testimony,
and then we will recess until following those two votes, and
then we will come back. If you would proceed with your
testimony, please.

STATEMENT OF GLENN M. HACKBARTH,
CHAIRMAN, MEDICARE PAYMENT ADVISORY COMMISSION

Mr. HACKBARTH. Thank you, Mr. Chairman and Mr. Stark. I
especially appreciate the warm welcome and the acknowledgment
of the work of the MedPAC staff. We have a terrific staff and
without them we couldn't do our work.
As you know, MedPAC is a nonpartisan congressional advisory
body, so our goal, our mission, our sole mission is to help you
with the difficult decisions that you must make each year. Each
year we produce two reports, a March report which usually
focuses primarily on payment updates, and then a June report
that ranges more broadly across Medicare issues.
We have 17 commissioners, as you know. Six of them have
clinical training as either physicians or RNs. Six of our
commissioners have high-level executive experience with health
care delivery organizations; four high-level government
experience; and then six academics who publish frequently in
peer-reviewed journals. And some of us have more than one of
these credentials.
I mention the credentials to emphasize that we are people
who have experience in different facets of the Medicare
program, and our goal is to bring that experience to bear for
the benefit of the program, the beneficiaries it serves, and
the taxpayers who finance it.
Because we have a lot of experience, it doesn't necessarily
mean that we are always right. We can be right or wrong, like
everybody else, but you can be assured that our agenda as a
Commission is the same as yours: High-quality care for Medicare
beneficiaries at the lowest possible cost for taxpayers.
Despite the diversity of the MedPAC commissioners, we
typically have a high degree of consensus on our
recommendations. This March report is no exception. There are
12 recommendations in our March report that represents a total
of 187 ``yes'' votes, versus only two ``no'' votes, and three
abstentions.
The March report, as I say, here is the summary of the
major recommendations in the March report. There are
recommendations on payment updates for each of the payment
systems that Medicare uses. For physicians, hospital inpatient
and outpatient dialysis services and hospice services, we are
recommending a 1-percent increase in the Medicare rates. For
ambulatory surgery centers, one-half of 1-percent increase in
the rates, and then zero update for skilled nursing facilities,
home health agencies, inpatient rehab facilities, and long-term
care hospitals.
In the case of home health services, we are recommending a
rebasing of the rates as we have in the previous year, as well
as some changes in the case mix system and a per-episode copay
for Medicare beneficiaries.
And then, as we do each year in our March report, we also
do a status report on the Part C Medicare Advantage Program and
Part D, the prescription drug program.
I want to pick up, Chairman Herger, on one of the points
that you made in your introduction. This report is principally
about how much the unit prices should change for Medicare
services. But we can't get to where we want to go in terms of
an efficient Medicare program, providing high-quality care to
Medicare beneficiaries at a reasonable cost for taxpayers, if
we focus only on the unit prices.
In addition to that, we must look at the relative values
that we pay for different types of services. We must also look
at the payment methods that we use and try new, innovative
payment methods that create better incentives for high-value
care. And then, finally, we must also look at the incentives
for Medicare beneficiaries.
So, Mr. Chairman, those are my summary of comments and I
look forward to the opportunity to talk further about our
report.
Chairman HERGER. Thank you very much.
[The statement of Mr. Hackbarth follows:]

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Chairman HERGER. Again, as I mentioned earlier, to allow
our Members to vote, we have two votes going on, we are going
to recess and we will reconvene immediately after the second
vote. With that, we stand in recess.
[Recess.]
Chairman HERGER. The Health Subcommittee of the Ways and
Means Committee will reconvene.
Mr. Hackbarth, I want to thank you for your testimony. In
MedPAC's report, you recommend that Congress should freeze
Medicare rates for inpatient rehabilitation facilities, long-
term care hospitals, and skilled nursing facilities.
Can you explain what led the Commission to recommend
freezing payment rates for these providers?
Mr. HACKBARTH. Mr. Chairman, the analysis that we go
through for each of the provider sectors takes into account a
variety of different factors, one of which is their financial
margin on Medicare business where that data is available, but
we also look at access to capital, the quality of services to
Medicare beneficiaries, whether facilities are opening or
closing.
So it is sort of a multifactorial analysis that we go
through, so the specifics for each of those sectors varies a
little bit. But in general, what they have in common is that
the projected margins are pretty healthy for each of those, and
we think that there is ample room for efficient providers of
those services to operate within the existing rates, so no
increase in the rates is necessary.
Chairman HERGER. Thank you. Currently there is no copayment
for home health care. In the March report, MedPAC recommends
that most Medicare beneficiaries be required to pay a copayment
for each episode of home health care they receive. The
commissioners recommended that exceptions be made for low-
income beneficiaries and those being discharged from the
hospital.
Could you explain why the Commission arrived at this
recommendation and the impact it would have on overutilization
and fraud?
Mr. HACKBARTH. Yes. Well, this is a challenging issue for
MedPAC. This is an issue where we actually did have a
dissenting vote and an abstention, which, as I indicated
earlier, is fairly unusual for us.
We concluded, the majority of us concluded, the vast
majority of us concluded that a $150 per episode copay was an
appropriate and necessary step to help curb unnecessary
utilization of home health services. As you know, home health
is an area where utilization has increased rapidly and, in
particular, in some parts of the country. And by its nature, it
is a service where there aren't clear, clinical guidelines as
to appropriate use of the service. And under those
circumstances, we think it is an appropriate thing to do to ask
the beneficiaries to pay a modest copay.
To put the $150 per episode copay in context, for a
beneficiary with a typical number of visits, home health visits
in an episode, it would work out to about $8 per visit, so a
smaller amount than that same beneficiary would pay for a
physician office visit or an outpatient therapy visit. So it is
modest, but we think it is appropriate.
And I would emphasize the point that you picked up on,
which is it is targeted to apply only to beneficiaries who are
admitted to home health from the community. It doesn't apply to
Medicare beneficiaries following a hospital stay or a stay in a
skilled nursing facility, and there is also an exemption from
the copay for beneficiaries who use four or fewer home health
visits.
Chairman HERGER. Thank you for that.
Some have expressed concerns that the addition of a home
health copayment would drive seniors to other sites of care
such as outpatient facilities. Are seniors currently required
to pay a copayment for the care they receive in these
outpatient settings?
Mr. HACKBARTH. Yes, that is true. They are required to pay
copays. Home health is one of the few services where Medicare
beneficiaries are not required to pay a copay.
And as I indicated in what we thought was an appropriate
home health copay, we took into account how much beneficiaries
paid for some of these alternative services.
Chairman HERGER. So in your opinion, home health copayments
would not shift a beneficiary to other sites of service?
Mr. HACKBARTH. That is our expectation, yes. It would not
shift them, yes.
Chairman HERGER. I thank you again for your testimony.
Now, the gentleman from California, Mr. Thompson, is
recognized for 5 minutes.
Mr. THOMPSON. Thank you, Mr. Chairman. Thank you, Mr.
Hackbarth, for being here.
In your March 10, 2010 report, you state that Medicare is
the single largest payer in regard to Medicare, in regard to
health care. And you also go on to say that for the next decade
that that cost is going to slow vis-a-vis the previous decade.
I think it was are you looking at 6-percent growth between now
and 2019? It was about almost 10 percent in the past decade.
And I am assuming that part of that reason is because of the
health care reform legislation that was passed, and the idea
was to pass legislation that bends that cost that we have heard
so much about that, and at the same time creating better care,
better health, and lower costs.
There was a very interesting article in the National
Journal, I think it was last Friday, that is entitled, Adapt or
Else. And they state that whether it wants to or not, the
health care system is being forced to reinvent itself. The
health care law is a clearinghouse of sorts for policies that
have circulated among health care analysts for years but
struggled to gain traction.
Isn't the truth of the matter that much of what was put
into the health care reform bill either came from MedPAC advice
or proposals that MedPAC itself put forward?
Mr. HACKBARTH. Well, certainly there were many provisions
that were linked to past recommendations of MedPAC.
Mr. THOMPSON. So bundling around hospital administrations?
Mr. HACKBARTH. Yes.
Mr. THOMPSON. That was one of your recommendations that was
in there.
Mr. HACKBARTH. Yes, that is correct.
Mr. THOMPSON. Reducing hospital readmissions, that was a
MedPAC recommendation?
Mr. HACKBARTH. Yes.
Mr. THOMPSON. Value-based purchasing aimed at rewarding
quality?
Mr. HACKBARTH. Yes.
Mr. THOMPSON. Primary care investments and expanded primary
care reimbursement?
Mr. HACKBARTH. Yes.
Mr. THOMPSON. Payment accuracy including reducing Medicare
Advantage overpayments?
Mr. HACKBARTH. Yes.
Mr. THOMPSON. Adoption of comparative effectiveness
research?
Mr. HACKBARTH. Yes.
Mr. THOMPSON. And expanded fraud fighting authorities?
Mr. HACKBARTH. Yes.
Mr. THOMPSON. Thank you.
The other question I have is, as you know I think
firsthand, I am very concerned about representation for rural
areas. And as cochair of the bipartisan Rural Health Care
Coalition, we have been very, very active in trying to bring
attention to that issue.
And rural health care delivery has a lot of unique
challenges, shortages of health care providers, and probably
spills over into other underserved areas as well, but
geographic remoteness, low-patient volume with
disproportionately high Medicare populations, limited access to
integrated health care systems, and a lack of electronic
networks to efficiently manage health care.
I understand that it is probably a challenge for you too,
and I know you don't do it personally, but it is a challenge to
get that appropriateness, or proportionateness on the
Commission. But in your report, there is not even a mention of
the word ``rural.'' And I think it is a concern for those of us
who live in rural areas and represent rural areas.
Is there anything that you can tell us that we can look
forward to? Are we going to address this issue? Are we going to
get proportional representation on that board?
Mr. HACKBARTH. Well, thank you, Mr. Thompson, for raising
this. We have talked about this issue before.
We share your concern about ensuring access to quality care
for beneficiaries in rural areas and assuring appropriate
payment for providers in rural areas. In fact, the very first
report that I did, on becoming chairman of MedPAC, is
``Medicare in Rural America,'' a typically thick MedPAC report.
And in every report since, in every March report since, there
are in fact lots of analyses directed specifically at the issue
of fair payment for rural providers.
Let me cite a couple of examples.
Mr. THOMPSON. I said ``report,'' I meant your testimony. I
apologize for that.
Mr. HACKBARTH. Okay. Well, in this March report, let me
just highlight a couple of examples that are important. We have
recommended changes in the payment systems for lots of
different Medicare providers, but in this particular report we
talk about fairness and payment for skilled nursing facilities
and home health agencies, and we have made recommendations in
changing the case mix system used to allocate those payments.
Among the benefits from those changes would be increased
payments for rural providers of home health services and
skilled nursing facility services. So throughout all of our
reports, there are issues like that where we are trying to
assure accuracy and fairness in payment, which we think is very
important.
On the specific issue of representation, we have four
commissioners that have significant rural experience out of our
17. We have two physicians and then two people----
Chairman HERGER. The gentleman's time has expired. Thank
you.
The gentleman from Texas, Mr. Johnson, is recognized for 5
minutes.
Mr. JOHNSON. Thank you, Mr. Chairman.
Thank you for being here today. I appreciate you saying you
are out to get good value for what we spend in Medicare. I am
committed to making sure that Medicare has provided high-
quality care while at the same time being wise with taxpayer
dollars.
Your report mentions the variations between Medicare
payments for the same services in different settings. Medicare
generally pays more for a service in a hospital than in an
ambulatory surgical center.
Does this create an incentive for care to be provided in
one setting over another, based on higher reimbursement?
Mr. HACKBARTH. Yes, that is our concern, Mr. Johnson, and
it is a growing concern. And we see some shift toward hospital-
based services that may be driven, at least in part, by higher
payment levels.
Mr. JOHNSON. Are you looking to do something about it?
Mr. HACKBARTH. We are, in fact. It is a tricky issue to
deal with for a variety of reasons, but in particular, because
the patients are often different. So it can be the exact same
service--for example, some type of ambulatory surgery--but the
patients that go to the hospital are sicker on average. They
have more underlying conditions. They are at higher risk of a
bad event. So they are done at the hospital outpatient
department so that they are closer to backup in case something
goes wrong.
And so if you go to equal payment, you have to make sure
that it is properly risk-adjusted for the different types of
patients seen in the different settings.
Mr. JOHNSON. Yes, I understand that, but you ought to be
able to work that problem I think.
Mr. HACKBARTH. And we are working on that, and I hope we
will be making some recommendations.
Mr. JOHNSON. Thank you. So you have got a plan for studying
these payment variations?
Mr. HACKBARTH. Yes, sir.
Mr. JOHNSON. I appreciate that. Our health care delivery
system needs to focus on the right procedures to the right
patient at the right time and place. Does the current payment
system make that hard to achieve?
Mr. HACKBARTH. It does. It creates incentives often for
more costly services than are absolutely necessary for patients
and, as we just discussed a minute ago, sometimes not in the
lowest cost, most efficient setting.
Mr. JOHNSON. Okay. We know you are interested in combating
waste, fraud and abuse in the Medicare system, and we have
heard about the problems across all areas of the country,
including reports of alleged fraud in home health services
occurring near my district in Dallas. Secretary Sebelius has
said that her Agency is setting up new checks to screen
providers before they are ever accepted into the system.
Can you comment on what progress has been made in becoming
more proactive rather than reactive in preventing fraud?
Mr. HACKBARTH. Well, we are not specifically engaged in the
operational side of enforcement, but we have recommended that
the Secretary monitor home health use for unusual patterns,
very high levels of use, and that the Congress give the
Secretary the authority to do things like limit new providers,
limit payment when abberant patterns of home health use are
found.
And so our contribution to this has been to mostly identify
some of these very unusual patterns. So in some areas of the
country, you will see home health use that is like seven times
the national average, and we think that sort of analysis is a
useful screening tool for the Secretary and the Justice
Department to use.
Mr. JOHNSON. Do you think she has taken your statistics and
done anything with them?
Mr. HACKBARTH. Our understanding is that they are
intensifying their focus on Medicare fraud in general, but in
particular in the home health area.
Mr. JOHNSON. That is an interesting word you chose,
``intensify.''
Thank you, Mr. Chairman, I appreciate the time.
Chairman HERGER. Thank you. The gentleman yields back.
The gentleman from New Jersey, Mr. Pascrell, is recognized
for 5 minutes.
Mr. PASCRELL. Thank you, Mr. Chairman. Mr. Chairman, I
think that Glenn Hackbarth brings some unique qualities to our
Committee in that the recommendations from MedPAC, many of them
were incorporated into the affordable health care bill, which
is now the law of the land.
And so when people talk about they made cuts but they
didn't get into the entitlements where the real money is, we
all know Social Security did not add to the debt; and now they
miss the point about the health care legislation, because one-
third of it dealt with Medicare and Medicaid, addressing the
entitlement but specifically adopting many of your
recommendations. That is a fact of life.
We can point out chapter and verse where the
recommendations the Commission made are in there. This is
entitlement reform.
And what was the purpose of your recommendations? Well, if
you read your report, and not just read what somebody else said
about it, but if you read your report, you are saying that this
is--you didn't use the word ``reform,'' this is changing how we
look at Medicare and Medicaid.
So one of the fundamental problems we face in health care
deliverance--I mean, no use putting a system together if we
don't have the people to deliver it. So we spend quite a bit of
time on work force. I know when we are putting the legislation
together, quite a bit of time, doctors and nurses, how to get
more doctors and nurses.
We know about the shortages. But you are going to cripple
the system, regardless of what the system is and how we want to
deliver it to the patient, if you don't have the personnel that
is properly trained, updated, et cetera.
You offer two solutions, both of which were involved or
implemented, put into the health care reform, which we hope
will be implemented: the idea of a payment reform, like paying
for quality outcomes and delivery system reforms, such as
medical homes and the accountable care organizations. You were
very, very specific.
Do you think that these reforms, these two reforms, will
help improve the delivery of health care for Medicare
beneficiaries and, more importantly, do you think that these
are essential changes to Medicare itself?
Mr. HACKBARTH. Well, it is certainly our hope and
expectation that those two reforms would both improve quality
of care for Medicare beneficiaries and, we hope, also reduced
the cost. In each case, medical homes and ACOs, there are a lot
of important issues to be worked out. And each idea, I am sure,
will evolve over time, but we think that they are promising
steps.
Mr. PASCRELL. Mr. Chairman, I want to bring to your
attention something. Most of these reforms and changes were
never scored, never scored', which means we do not have a true
picture of the amount of savings when we move from pay-per-
service to proper care and help for the patient.
We don't know really what the results will be. That was
never scored by CBO. And I would contend to you, if you look at
your recommendations, and you look at very specifically the
Health Care Reform Act, that you can find areas where it
doesn't take too much to conclude that there must be a savings
from moving away from fee-for-service and into those specific
things which you just mentioned.
Would you agree with me?
Mr. HACKBARTH. Well, certainly that is why we recommended
them is that we think by moving away from straight fee-for-
service payment, changing the incentives for providers, helping
them focus on value, changing the organization of care
delivery, can result in better care at lower cost.
Mr. PASCRELL. So those editorials and those politicians and
Congressmen on both sides of the aisle, I am going to ask you
the question; let me make the statement, and it is like when
did you stop beating your wife this time?
Chairman HERGER. The gentleman's time has expired.
Mr. PASCRELL. Can I finish the question?
Chairman HERGER. Very quickly, please.
Mr. PASCRELL. Then I will try to answer it. The question
is, the editorials and those Congressmen on both sides of the
aisle who said, very specifically, that we need to get to
entitlement in order for us to have true cuts in the budget----
Chairman HERGER. The gentleman's time has expired.
You can ask if we get a second round, or you can submit in
writing.
Chairman HERGER. Again, the gentleman's time has expired.
I might also mention several of these issues that you
brought up were scored, but they scored so small they weren't
listed.
Mr. PASCRELL. Many of them were not, Mr. Chairman. I will
go over them one by one with you if you wish.
Chairman HERGER. The gentleman's time has expired.
Mr. PASCRELL. Thank you, Mr. Chairman.
Chairman HERGER. With that, the gentleman from Georgia, Dr.
Price, is recognized for 5 minutes.
Mr. PRICE. Thank you, Mr. Chairman.
In your assessment of the handout that we got, you have the
volume growth increasing significantly. Can you cite for us the
main drivers of that volume briefly?
Mr. HACKBARTH. So, Dr. Price, you are referring to this
one?
Mr. PRICE. I think this one.
Mr. HACKBARTH. Right. So the principal drivers are the top
line, the red line, is spending per Medicare beneficiary. So a
small piece of it is due to the annual updates and payment
rates. That is the lowest line, sort of gold update line.
The difference between the red line and the yellow line is
due to changes in the volume and intensity of service. So more
visits, more procedures, more imaging tests, things of nature.
Mr. PRICE. What would you say would be the--are there
incentivizations in the program itself that drive that volume?
Mr. HACKBARTH. Well, the amount that we pay for a service
can influence volume, and one of the issues that we----
Mr. PRICE. Anything else?
Mr. HACKBARTH. Differences in, you know, burden of illness
from year to year can affect volume. Changes in technology as
new technology develops; concerns about malpractice can be a
factor in volume growth.
Mr. PRICE. Would you say that there are folks out there in
the community, in the medical arena, that are working to
decrease those costs as well on their own?
Mr. HACKBARTH. Sure. Absolutely.
Mr. PRICE. And when we as a government or as a society
identify those, shouldn't we use some of those as best
practices?
Mr. HACKBARTH. Absolutely. As somebody who ran a large
physician practice, that was one of the things that we tried to
do most often was learn from colleagues and practices.
Mr. PRICE. Exactly. That is kind of the hallmark of health
care, isn't it, to find what works best and use it.
Mr. HACKBARTH. It is best.
Mr. PRICE. Then I would like you to address, please, the
issue of physician-owned facilities, hospitals, ambulatory
surgery centers. All of the reports that I have seen and read
and all of my personal experience leads me to believe that they
are one--oftentimes drive the highest quality of care at the
greatest efficiency and the lowest possible cost per patient.
Yet we as a society disincent and, in fact, punish them for
doing what they are doing.
How would you address that?
Mr. HACKBARTH. Well, it is a tricky issue, Dr. Price. On
the one hand, I ran a large multispecialty practice where we
brought all kinds of services in-house; and so we were self-
referring through our colleagues, and we thought that was good
for patients.
On the other hand, there are instances where that sort of
self-referral can cause problems.
Mr. PRICE. Then shouldn't we be addressing, then, the self-
referral, as opposed to saying you can't have any of those
things anymore?
Mr. HACKBARTH. Yes.
Mr. PRICE. Do you disagree with the fact that physician-
owned entities out there oftentimes have the highest quality at
the lowest cost per patient?
Mr. HACKBARTH. No, I don't disagree with that. I think that
can often be the case.
Mr. PRICE. Do you agree or disagree with the statement that
we as a Congress and as a government have put in place policies
that will actually diminish the ability of those kinds of
services to be in existence?
Mr. HACKBARTH. Yes, there are some policies. But here is
the tricky part about it. The problem isn't physician ownership
per se or self-referral per se; it is the combination of self-
referral with fee-for-service payment that rewards more volume
and intensity, and often missed pricing of services that
creates real substantial profit opportunities.
Mr. PRICE. So I hear you say, then, that if we had a level
playing field and allowed physician-owned entities to compete
with other entities, level playing field, same pricing
mechanism and the like, the same reimbursement mechanism, that
you would be supportive of that opportunity; is that right?
Mr. HACKBARTH. The first step is to try to get the prices
right so there aren't undue profit opportunities.
The second step is to try to move to new payment systems
that don't reward volume intensity, but reward better care.
Mr. PRICE. Mr. Chairman, let me just say if I may, because
my time is very, very brief, I think we are missing a huge
opportunity by not rewarding those individuals that actually
provide the highest quality of care at the lowest possible
cost; and, in fact, we are punishing those individuals for
doing what they are doing. And I look forward to my second
round.
Chairman HERGER. I thank the gentleman. The gentleman's
time has expired.
The gentleman from Washington, Mr. Reichert, is recognized
for 5 minutes.
Mr. REICHERT. Thank you, Mr. Chairman. Welcome, thanks for
being here today.
There is a movement among employers toward what people have
called a value-based benefit design where preventive primary
and chronic disease care is cheaper for employees and things
like high-end imaging and unnecessary emergency room visits,
which we sort of touched on a little bit already, or high-cost
drugs, those things that have been identified as not having I
guess any, proven value, are more expensive.
These coverage programs are combined with wellness programs
and incentives for things like improved physical activity and
nutrition. There are some great examples from Washington State,
including Group Health, Costco, Boeing, which all use different
approaches to providing very structured, purposeful health care
to their employees.
Medicare, by comparison, seems to be behind the curve a
little bit. Some have said maybe even in the dark ages. But
Medicare Advantage offers promise, though, for coordinated
care. Would you agree with that?
Mr. HACKBARTH. Yes, I would.
Mr. REICHERT. And MedPAC has encouraged Congress and CMS to
add pay-for-quality components to the fee-for-service payment
system in Medicare, but this is just one step. Could Medicare
actually change its benefit structure to be more innovative and
value-based?
Mr. HACKBARTH. Yes.
Mr. REICHERT. It even sort of goes to the doctor's question
of best practices.
Mr. HACKBARTH. Yes. In fact, it is an issue that is
currently on the MedPAC agenda, and we will have a chapter on
the subject in our June report this coming June, and we are
looking hopefully to moving toward some recommendations on
redesign of the Medicare benefit package.
Mr. REICHERT. Would it be possible for you to share some of
those ideas that you are looking at today?
Mr. HACKBARTH. Well, we are not to the point of concrete
recommendations. We are drawn to the idea of value-based
insurance design. In fact, one of the MedPAC commissioners,
Mike Chernew, is one of the leading academic thinkers behind
the value-based insurance design movement.
Mr. REICHERT. So your discussion and your recommendations,
how long has that discussion been ongoing?
Mr. HACKBARTH. Well, on this particular issue, I think we
had one session last year, and then we had a session in
February, and then our upcoming meeting in a couple of weeks.
Mr. REICHERT. So your awareness of this issue and
discussion was started last year. You have had another meeting
since, so we are sort of behind the curve here on this issue.
So we have gone a year; what is the expectation on your
recommendations being presented, published?
Mr. HACKBARTH. Well, you know, I don't want to get in front
of my colleagues and presume a final conclusion.
As I say, I think we will have a chapter in our June
report. It could--it won't include recommendations, bold-faced
recommendations, but it could have some clear directional
signals. And then if we have agreement in June, we would come
back next year and potentially consider----
Mr. REICHERT. It could be a while before we see a value-
based system, then, in Medicare?
Mr. HACKBARTH. It will. And, of course, it would require
legislation to change.
Mr. REICHERT. All right. What could Congress do to help you
speed the process up or probably, more likely, slow it down?
Mr. HACKBARTH. Well, we are well aware of the interest in
Congress in the issue, and there is a lot of interest among
MedPAC commissioners. So it isn't for a lack of interest or
effort, but it is a complex issue to change the Medicare
benefit package.
Mr. REICHERT. So are we looking at 2 years, 3 years, 4
years?
Mr. HACKBARTH. Well, I would hope, if we are going to make
recommendations, that it would be in our next cycle. We operate
upon a September-to-June cycle so we would take them up in the
fall.
Mr. REICHERT. When is your next meeting?
Mr. HACKBARTH. In 2 weeks.
Mr. REICHERT. Is it a public meeting?
Mr. HACKBARTH. All of our meetings are public.
Mr. REICHERT. Could you provide me with the date and time
of the meeting, please?
Mr. HACKBARTH. Oh, absolutely.
Mr. REICHERT. Thank you. I yield back, Mr. Chairman.
Chairman HERGER. The gentleman yields back. The gentleman
from California, the Ranking Member, Mr. Stark, is recognized
for 5 minutes.
Mr. STARK. Thank you, Mr. Chairman. Glenn, thank you again
for all the good work that MedPAC does.
I know Mr. Herger has been concerned about copayment for
certain beneficiaries that use home health services. It is my
understanding that home health users are older, poorer, more
frail, more likely to be female, than the overall Medicare
population, and I am concerned about putting further cost-
sharing on this population. I gather some MedPAC commissioners
were as well, given that the Commission, as I understand it,
was not unanimous on this proposal.
What were the concerns of those who didn't support the
idea?
Mr. HACKBARTH. Mr. Stark, they are much like what you just
described; that the copay would fall disproportionately on a
vulnerable portion of the Medicare population, which was an
issue that all of us, including those of us who voted ``yes''
on the recommendation, took very seriously. And so what we
tried to do was tailor our recommendation in ways that would
minimize although not eliminate that impact.
And it is also important to keep in mind, as you well know,
that using copays is not new in Medicare; it is the norm in
Medicare. And they inevitably fall on users of services who
tend to be sicker and the like.
So it is always a challenging balancing act. We think by
having a modest copay, $150 targeted on admissions from the
community, that we have tailored in a way that minimizes the
adverse impact.
Mr. STARK. Okay. And I know that you have a long history,
MedPAC does, of recommending parity in payments between
Medicare Advantage and the fee-for-service side. And your
recent report summarizes your earlier recommendations about
Medicare Advantage and the estimates that Medicare Advantage
plans are paid, on average, 113 percent of the traditional fee-
for-service.
Didn't private managed care plans originally come into
Medicare saying they could do more for less; in other words,
for 20 years they were paid 95 percent of our fee-for-service
rate, I believe, or thereabouts, and over time we have actually
moved from demanding they do better and trying to demand that
they break even.
You have long recommended that there be a financial
neutrality between Medicare Advantage and fee-for-service. I
think that is correct.
Mr. HACKBARTH. That is correct.
Mr. STARK. And the Affordable Care Act takes steps to begin
to bring financial neutrality between those two programs. Can
you tell us what MedPAC is seeing in the 2011 landscape in
terms of Medicare Advantage availability, enrollment, and
premiums?
Mr. HACKBARTH. Yeah. Well, enrollment is up. The number of
plans is down somewhat, and the reduction is primarily due to
the reduction in private fee-for-service plans.
Mr. STARK. Okay.
Mr. HACKBARTH. Because of the requirement enacted, not in
PPACA, but several years ago in MIPPA, that fee-for-service
plans could not operate if there were coordinated care,
coordinated network plans available. So some of the private
fee-for-service plans have left the program, and that is the
single biggest factor in reduction in the number of available
plans.
Membership is, as I say, up in the most recent numbers.
Mr. STARK. Again, thank you very much for your advice to
this Committee. We appreciate it, appreciate the work you do.
Thank you, Mr. Chairman.
Chairman HERGER. I thank the gentleman who yields back.
I now recognize for 5 minutes the gentleman from
Pennsylvania, Mr. Gerlach, to inquire.
Mr. GERLACH. Thank you, Mr. Chairman. I have a question
with regard to your recommendations relative to radiologic and
other imaging services. Can you briefly give me a summary of
what your recommendations there are?
Mr. HACKBARTH. Well, on the specific issue of the imaging
in this report, I don't think we made any specific
recommendations in this report. In the past, in previous
reports, we have made a number of recommendations related to
how the price for imaging services is set. In some instances we
think those prices have been too high, and we have recommended
specific changes to reduce price.
Mr. GERLACH. I understand that there is a professional
component and a technical component to the reimbursement
structure.
Mr. HACKBARTH. That is correct.
Mr. GERLACH. That there has already been an adjustment
downward for the technical component. Is there also a
recommendation that you want to implement to also reduce the
professional component of that reimbursement for radiological
services?
Mr. HACKBARTH. We have looked at recommendations for
reducing the professional component as well.
Mr. GERLACH. What is that based on?
Mr. HACKBARTH. For duplication of work would be an example.
When two tests are done on the same patient at the same time,
the amount of work is reduced because you don't have to do some
things twice. It is the same patient at the same time, and that
may justify reduction in the professional component.
Mr. GERLACH. Okay. So you are obviously concerned about
utilization overall, and therefore by reducing the professional
component aspect of that, you can reduce utilization?
Mr. HACKBARTH. Well, certainly there are indications that
when the price is too high, you get more utilization. People go
to areas that are more profitable, they invest in equipment if
there is significant profit in that area. So it is very
important to keep the prices right, as close to the cost of
delivery as possible.
Mr. GERLACH. Is there an understanding in your review
process of how the services come about to begin with? For
example, if a radiologist--I am thinking of one in one of my
hospitals who does a service based upon a referral from another
physician--if there is a reduction in the professional
component of that radiologist's service but the radiologist
didn't initiate the service, the radiologist just took a
referral, how would a referral-based system, cutting the
professional component for service based on a referral from
somebody from the outside, how would that affect utilization?
Mr. HACKBARTH. So what you are suggesting, I just want to
make sure I understand the situation. So this is a radiologist
who has received a referral for imaging service. And you are
saying if their professional component is reduced?
Mr. GERLACH. Yeah. As I understand, what you are talking
about is reducing the professional component for that service.
Mr. HACKBARTH. Again what we have talked about are making
adjustments in very specific instances; for example, when you
are doing multiple images on the same visit.
Mr. GERLACH. Okay.
Mr. HACKBARTH. Then we think there are some economies in
doing it that way, and it is appropriate to reduce the
professional component in instances like that.
We have not just said across the board, oh, let's reduce
imaging services because we think we want to try to suppress
utilization. We take a much more targeted approach than that.
Mr. GERLACH. Is it only in cases of multiple services or
imaging work being done with one patient at one time that you
are suggesting that change?
Mr. HACKBARTH. Specifically on the work component, I think
it is multiple services. There have been, in the physician fee
schedule also, changes in the practice expense for physician
services that have changed the payment levels for different
types of service.
Mr. GERLACH. Okay. And in coming up with this
recommendation, who did you talk to within the profession to
get a sense of how patients come to undertake those imaging--
have those imaging services undertaken, both referral and, in
some instances, the physician is able to do imaging on his own
or her own, based upon how they are set up as a practice. Who
did you talk to in essence to come up with the conclusion that
there ought to be a change in the professional component of
those services of being reimbursed?
Mr. HACKBARTH. Well, one of the things that I am most proud
of in that MedPAC is that we do reach out to all of the
relevant professional associations. As you well know, in this
particular area there are also some coalitions of people in the
imaging field, professional physicians and imaging equipment
manufacturers. And we hear, believe me, often from those people
and exchange ideas. All of our recommendations, when we make
them we have open public discussion. Draft recommendation is
discussed in a public meeting. We solicit input from affected
parties on those recommendations before we finally act. We have
a very open process.
Chairman HERGER. The gentleman's time has expired.
Mr. GERLACH. Thank you. I yield back.
Chairman HERGER. The gentleman from California, Mr. Nunes
is recognized for 5 minutes.
Mr. NUNES. Thank you, Mr. Chairman. I would like to yield 5
minutes to the gentleman from Georgia, Mr. Price.
Mr. PRICE. I thank my friend from California for yielding,
and I appreciate the continued response that you give me.
I want to follow up on the comments that Mr. Gerlach was
just making, or the line of questioning on the multiple tests.
For example, if a patient is coming for a certain MRI
procedure, one procedure, the costs of that procedure that are
borne by the facility and by the physician involved in
interpreting that are pretty much fixed, correct?
Mr. HACKBARTH. On the interpretation side or the technical
component related to the equipment?
Mr. PRICE. Both.
Mr. HACKBARTH. Well, the cost of operating the equipment is
influenced by the volume of service provided. So you make a
capital expenditure. The more you use that equipment, the lower
your unit cost for the capital expense, you spread it over more
units.
Mr. PRICE. The machine doesn't know whether it is one
patient or two patients who are getting the two different
procedures, right? The volume is the number of procedures
itself; it is not how many patients there are.
Mr. HACKBARTH. That is right. It doesn't matter whether
they are distinct patients or not.
Mr. PRICE. All right. You have a patient coming in for an
MRI of a cervical spine and a patient coming in for an MRI of a
lumbar spine. Those two procedures are separate, distinct, and
require the use of the machine itself, the technical side; and
the interpretive side physician is using his or her best
knowledge and information and expertise to interpret that. You
wouldn't say that that had a volume component, would you?
Mr. HACKBARTH. In terms of interpreting----
Mr. PRICE. Yeah.
Mr. HACKBARTH. No.
Mr. PRICE. Okay. So the physician side ought to be fixed
you just said, right?
Mr. HACKBARTH. Professional.
Mr. PRICE. We ought not decrease physician reimbursement
based on whether or not it is one patient or two patients.
Mr. HACKBARTH. Well, based on whether it is one versus two,
no. But as new technology, imaging being one example, becomes
more widely used, more frequently used, I do think it is
reasonable for the cost per unit of service, as the experience
level goes up, to go down.
Mr. PRICE. That----
Mr. HACKBARTH. That happens in almost every market for
every service in the economy.
Mr. PRICE. I might be able, if it was two C-spine MRIs on
the same patient, at the same time; but we are talking about
two different procedures on the same patient, requiring the
same use of the machine, and the different brain power of the
physician involved to interpret it. And so it is astounding to
us--unless your goal is to simply decrease the cost, not worry
about the quality and the access--if your goal is simply to
decrease the cost, then that might make sense. But if you are
interested in maintaining access to care and maintaining
quality to care, then many of us believe that you are cutting
right at the core of it.
Mr. HACKBARTH. A couple points are key here, Dr. Price.
First of all, the method for setting the relative values. As
you know, MedPAC does not do that, CMS does not do that. An
AMA-sponsored RUC does that. So it is people from the
professional societies sit down together and determine the
relative values for the work element.
Mr. PRICE. If a specialty society says no, that is not the
appropriate reimbursement for this procedure, do they have any
ultimate authority in that?
Mr. HACKBARTH. There is a very elaborate process.
Mr. PRICE. Who makes the final decision?
Mr. HACKBARTH. The ultimate decision on the fee schedule is
in CMS.
Mr. PRICE. There you go.
Mr. HACKBARTH. But in the vast majority of cases, they
adopt the recommendations from the AMA-sponsored RUC.
Mr. PRICE. Can you name a single procedure? Because the
cost that the government reimburses physicians, pays physicians
for the care, allows for the access to care, right?
Mr. HACKBARTH. That is true.
Mr. PRICE. Okay. So can you name a single procedure for
which physicians are being reimbursed in real dollars more
today than when they were 15 years ago?
Mr. HACKBARTH. Not off the top of my head.
Mr. PRICE. Yeah. And I would love to have you get back,
because I don't think there is one. I say that in all sincerity
and honesty. What we are doing is drastically limiting the
access, availability, of patients--your mom, your folks,
seniors across this country--to access to care because of how
we are dealing with reimbursement issues. That is where we
ought to be looking for----
Mr. HACKBARTH. What I would like do is, if we could put
this slide up. Medicare payments to physicians have been going
up quite rapidly in fact.
Mr. PRICE. If I may, Mr. Chairman, the payment per--for a
procedure for physicians, for visitation, the cost of a patient
to come to an office for a visit is drastically reduced from
where it was 15 years ago.
Mr. HACKBARTH. Yeah.
Mr. PRICE. Right?
Mr. HACKBARTH. I am not trying to be argumentative.
Mr. PRICE. Nor am I.
Mr. HACKBARTH. But there is an important point here, Mr.
Chairman. The unit prices you and I would agree--the increase
in unit prices, the price per office visit, the price per
procedure, has gone up relatively slowly. That is that bottom
line on this graph. But the amount of income that physicians
get from Medicare has gone up rapidly, the red line.
Mr. PRICE. In real dollars, the inflation-adjusted dollars,
that line goes below the access, as you well now.
Mr. HACKBARTH. The red line represents a 5\1/2\-percent
increase, average increase per year per beneficiary, since the
year 2000.
Chairman HERGER. The gentleman's time has expired.
Mr. PRICE. Thank you.
Chairman HERGER. If time permits, we may try to go for a
second round of questioning.
Now the gentleman from Oregon, Mr. Blumenauer, is
recognized for 5 minutes.
Mr. BLUMENAUER. Thank you, Mr. Chairman. Welcome, Doctor, a
Northwesterner here.
Before I get to my questions, though, I want to just allow
you to finish your thought that you had with my good friend
from Georgia, because we watch a certain amount of different
impulses. There are some who suggest that the solution to
exploding Medicare costs is to basically voucher this and index
it at a level that is dramatically below the cost of inflation,
medical inflation, something that would be the curve going
down, down. And if there are problems associated--and you folks
try and split the difference. I mean, you are cognizant of the
problems, you deal with practice patterns, you recommend year
after year, after year, after year, to Congress and the
Administration things that could help bend that cost curve.
There is quite a bit of bipartisan pushback over the years. I
mean, that is not political, that is just--because people get
pinched and they don't want to reduce that cost.
My impression is that, as we constructed the Affordable
Care Act, that we actually included most of the recommendations
over the--they don't maybe have the teeth that some would like,
they don't implement them instantly. There are too many, maybe
pilot projects and test this, but they are there.
I am curious if you want to just finish answering the
question, because if the spending per beneficiary is going up
compounded over 5 percent per year, it suggests that there are
a whole lot of procedures and a whole lot of more expensive
somethings that are going on there. And I just want to make
sure you are able to complete your thought.
Mr. HACKBARTH. All right. So I guess I would summarize our
view on this with a few points.
One is, overall, it is our sense that there is enough money
in the physician fee schedule; Medicare pays enough for
physician services overall to assure adequate access for
Medicare beneficiaries. However, we are concerned about how the
money is distributed.
We think we pay too much for some types of services and too
little for other types of services. Primary care would be an
example where we are worried that the payments are too low. So
we think some redistribution of the payments is appropriate.
And then finally we think it ought to be a high-priority
goal for Medicare to move to new payment systems that don't
just reward more volume and intensity, but reward higher value
care for both Medicare beneficiaries and the program.
I would agree that just holding down the unit price
increase, the way the yellow line has, is not the best way to
get good care for Medicare beneficiaries.
Mr. BLUMENAUER. And that, of course, is why we attempted to
have a comprehensive approach that incorporated these elements
in, and hopefully they can be implemented sooner rather than
later, after they are tested, to be able to make a system that
does reward health care value over volume.
Mr. HACKBARTH. Right.
Mr. BLUMENAUER. I find it a little bit ironic that some of
my Republican friends talk about massive cuts in, for example,
Medicare Advantage, when in fact it is a move to try and deal
with the quality of the system. And they propose to replace it
with something that would be far more draconian than any modest
adjustment in Medicare Advantage.
Mr. HACKBARTH. Mr. Blumenauer, if I may, could I just pick
up on----
Mr. BLUMENAUER. Well, I only have 30 seconds left, and I
gave 3 minutes to you.
Mr. HACKBARTH. You were generous, I am sorry, go ahead.
Mr. BLUMENAUER. But there is just one area that I wanted to
leave for your review, because we are watching palliative care
and hospice kind of merge, and there is an opportunity for us
to be able to give higher quality care for our people. We used
to talk about in the last 6 months of life, but we are finding
because of palliative care, because of changes in treatment
patterns, sometimes people in ``hospice'' live longer than
people who are given intensive treatments, ICUs and chemo,
expensive and really painful chemotherapies.
I am wondering if there is a way going forward that we can
work with you to think a little bit about the recalibration of
what hospice care means, ways that better meet the needs of
patients and families, actually might end up being less
expensive but certainly better care.
Chairman HERGER. The gentleman's time has expired.
Mr. BLUMENAUER. Thank you.
Chairman HERGER. The gentlelady from Tennessee, Ms. Black,
is recognized for 5 minutes.
Mrs. BLACK. Thank you, Mr. Chairman.
Mr. Hackbarth, I want to go to the issue of outpatient
settings. And your report verifies something that I have heard
within the district, in that there is a significant variation
in the amount of Medicare payments for similar services that
are provided in outpatient settings, with Medicare generally
paying more for services that are furnished in a hospital
outpatient department than in an ambulatory surgical center or
in a physician's office. And this variation of course results
in an undesirable financial incentive, such as those ambulatory
surgical centers being organized as more a hospital outpatient
department, at least in part, to receive the higher payments.
Does the Commission have a plan for studying this? And if
so, do you have a sense for where those policy options will be
that may result from this review?
Mr. HACKBARTH. Yes. It is an issue that we are actively
looking at. We are concerned that the disparities in payment
for the same service, based on the location where it is
provided, can cause problems. And there is some evidence that,
in fact, it is causing problems. As you indicate, people are
converting to hospital status simply to get the benefit of the
higher payment, and clearly that is a problem.
As I indicated earlier in response to Mr. Johnson's
question, it is a little bit tricky in the sense that, although
the service might be the same--for example, a given ambulatory
surgical procedure--the patients receiving it could be
different between the ASC and the hospital outpatient
department. I know this from experience, having run a large
group. We did surgery in both ASCs and hospital outpatient
departments. And we would send, quite consciously, the more
difficult patients to the hospital outpatient department; same
surgery, but the riskier patients, because of comorbidities and
the like. And we wanted them to be at the hospital in case
something went wrong and we needed backup.
Because they were sicker patients, we paid the hospital
more for the same surgical procedure that we paid the ASC. It
was an adjustment in effect for the higher risk of the patient.
So what we need to do is move toward equal rates for the
same service on a risk-adjusted basis. And that last part is
the tricky part in this that we are looking at.
Mrs. BLACK. Thank you. And that certainly makes sense. But
at the current time where you look at apples to apples, it
doesn't appear to be that way. So I think that certainly is a
wise thing to take a look at.
Additional question. In your latest report the Commission
notes that beneficiaries who receive the Part D low-income
subsidy, they account for nearly 22 percent of all enrollees,
and yet more than half--of them reach the doughnut hole.
Further, these low-income subsidy enrollees account for about 2
million of the 2.4 million enrollees who reached that Part D
catastrophic spending cap in 2008.
Your report also notes that average per-capita spending for
the low-income subsidy enrollees were double that of the non
low-income subsidy enrollees. And I know that these low-income
enrollees are probably for the most part sicker, and they
require more medication, but this disparity really is very
alarming.
Do you have any recommendations on how we might be able to
better control the cost for this population?
Mr. HACKBARTH. We have not looked specifically at that. We
have done some research that suggests that there may be
differences in risk that aren't fully captured by the existing
risk-adjustment systems, and that may be a reason for the
higher utilization. Because you are talking about a low-income
population, the tool of using copays to try to limit access
utilization is not one that is really available to serve people
that don't have much income and appropriately need to be
protected from excessive copays. If we don't do that, then
there is the risk that they won't get needed drugs, and we will
have higher costs.
Mrs. BLACK. I don't discount that, but I think what I have
seen in my experience as an emergency room nurse is that when
people have an opportunity to have a smorgasbord, or more
services available for them, they tend to overutilize those
services just because they are available. And I am not casting
any stones there. Because if we all go into a buffet, we eat a
whole lot more food at the buffet than we would if we ordered
an individual plate.
And so trying to get at how do you do a better job while
making sure that the services that are being required are
actually services that are really needed and not just being
utilized because they are there.
Chairman HERGER. The gentlelady's time has expired. The
gentleman from Wisconsin, Mr. Kind, is recognized for 5
minutes.
The Ranking Member is recognized.
Mr. STARK. Mr. Chairman, I ask unanimous consent to put in
this National Journal article from Mr. Thompson.
Chairman HERGER. Without objection.
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Chairman HERGER. The gentleman from Wisconsin for 5
minutes.
Mr. KIND. Thank you. Thank you, Mr. Chairman, and thank
you, Mr. Hackbarth and your staff, for the update that you are
giving us today. And I think this is a very important hearing,
just hearing the recommendations that you are making. We
appreciate all the work that you put into this and the effort
to provide us guidance and where we are going to go with the
Medicare program.
Now, I notice in your January 2011 report, you reported on
various geographic variations in the health care system,
utilization variation. And you found in that report that one
area that was high, one are of utilization tended to be high in
all areas of utilization. In fact, you specifically noted that
the area with the greatest service use, Miami, is nearly twice
the level of utilization than the least use area, which is my
hometown of La Crosse, Wisconsin. And yet in the report then
and today, you are not making any recommendations on how to
deal with this geographic payment variation or utilization
variation around the country.
I am wondering why you are not being a little more explicit
in the recommendations, and will you in the future provide
greater guidance in this area?
Mr. HACKBARTH. We think, Mr. Kind, that the best way to
reward high-value health care delivery, whether it is in La
Crosse or perhaps a provider in Miami, is through changing the
payment system, moving away from fee-for-service payment to new
payment methods.
Mr. KIND. I agree. But are you going to come up with
specific proposals on how do that?
Mr. HACKBARTH. We have made many proposals, medical home,
ACOs, bundling around hospital admissions, many of them picked
up in PPACA. And so we think payment reform is the best way to
move to value.
Mr. KIND. Most of that is already in the Affordable Care
Act.
Mr. HACKBARTH. That is correct.
Mr. KIND. Again, relying on your recommendations in the
past. But what about systematic reform----
Mr. HACKBARTH. There is a lot of discussion in recent years
about geographic variation. And one of the points that I think
has been missed in that we can talk about regions of the
country, and Florida is more expensive than Wisconsin, but
there is variation within Wisconsin, there is variation within
Florida. And so if you apply a geographic approach and say we
want to reward Wisconsin and penalize Florida, there is going
to be a lot of collateral damage.
Mr. KIND. I agree, and that is the point. And that is the
point that many of us have been trying to make for the last 2
or 3 years is this geographic variation is occurring within
congressional districts, within communities themselves. So it
is less Wisconsin versus Florida as it is from individual
providers, no matter where you find them.
And that is the point on payment reform. And you even
recognize on page 4 of your March report--you are right--we
recognize that managing updates and relative payment rates
alone will not solve a fundamental problem with the current
Medicare fee-for-service payment system; that providers are
generally paid more when they deliver more services, without
regard to the quality or value of those additional services.
I think that is going to be the key and the ultimate
verdict on health care reform. If we can move to a different
reimbursement or payment system, outcome and value, and that I
think will solve a lot of the problems.
As far as the cost curve that we were just talking about,
but also the quality of care that we are striving for out
there, and I was hoping MedPAC throughout the years would have
been a little more affirmative in the recommendations in how we
can get there other than through pilots and ACOs and medical
homes and bundling, which is all necessary and good, but
something more dramatic in proposal.
Mr. HACKBARTH. Well, the challenge that we have--you know,
everybody says that fee-for-service is bad because there are
rewards of volume and intensity of service. And for sure, that
is true. But from my perspective the worst legacy of fee-for-
service is that we have a fragmented delivery system.
Mr. KIND. Right.
Mr. HACKBARTH. Where people don't work together to improve
care for patients. In too many instances they operate
separately, they don't communicate well, they don't coordinate
well. And the difficult thing about payment reform is that you
can change payment methods, but there has to be somebody at the
other end to receive it.
Mr. KIND. Right.
Mr. HACKBARTH. There has to be a reorganization.
Mr. KIND. I agree. And you are probably aware that, again,
under the Affordable Care Act, two things are going to happen,
both through the Institute of Medicine. They are going to have
an update for the first time in the Medicare reimbursement
formula, using real data, realtime instead of the proxy data,
which I think is long overdue.
But second and most importantly, they have embarked on a 2-
year study now to come up with an actionable plan to change
fee-for-service to a fee-for-value reimbursement system. That
then can go to the Administration, and the IPAT Commission for
implementation, which again I think is going to be key. That is
already moving forward under health care reform, which again I
think is going to be the key to sustaining the system that we
have in a much more affordable basis but getting better
outcomes, too.
The thing with the accountable care organizations, medical
homes bundling, that is fine for pilots, but it is basically
saying you need to structure yourself in this fashion to be
rewarded, instead of saying you will be rewarded for value and
outcome of care; you figure it out as far as what is the best
approach to achieve it. Because, obviously, smaller groups are
going to have a little more difficulty than the larger
providers to form in ACOs or some type of medical home model,
wouldn't you agree?
Mr. HACKBARTH. Yeah. In fact one of the challenges with
small providers, for example, physicians in solo practice, is
it is difficult to assess their performance because of small--
--
Chairman HERGER. The gentleman's time has expired.
Mr. KIND. That is right. Thank you.
Chairman HERGER. We have--everyone has asked a question,
maybe there are a couple of Members who would like to ask a
second question, so we will begin to move to that. The
gentleman from Georgia, Dr. Price, for 5 minutes.
Mr. PRICE. Thank you, Mr. Chairman. I look forward--there
are so many questions. I look forward to being able to provide
some for you and respond in writing.
The part A, primarily hospital services, part B, primarily
physician services, is described. What percent of part B is
physician reimbursement?
Mr. HACKBARTH. Actually to M.D.s as opposed to other health
professionals?
Mr. PRICE. Yes.
Mr. HACKBARTH. It is about 12 or 13 percent of total
spending for physicians. Is that the number you are looking
for?
Mr. PRICE. Yes.
Mr. HACKBARTH. Or what share of part B is physicians?
Mr. PRICE. Well, both. But 12 or 13 percent is fine,
because I think there is this sense by many that if you just
whack away, and whack away, and whack away at the docs, that
you will be able to control the cost. And in fact if we
continue as a society to whack away at what the physicians are
able to gain for their services, for their caring,
compassionate, and knowledgeable services, we will truly harm
the access to quality care in this country, because physicians
are saying, ``I can't do that anymore, I can't do that
anymore.''
And that is what I hear from my colleagues, former medical
colleagues at home and across the country, who say--what I was
trying to get to with the previous line of questioning, on not
having any--any significant increase in reimbursement. And all
insurance pegs itself to Medicare now, basically, in terms of
reimbursement. So the Federal Government controls the payments
to physicians for virtually every single procedure in this
country.
I want to talk about a couple other items in the short time
that I have available. You mentioned about the RUC, having the
availability to have significant input into the cost--payment
for physician services; also agreed that it was CMS that had
the final say.
Mr. HACKBARTH. Right.
Mr. PRICE. The RUC itself, as I understand it, has
significant responsibility from the 90 percent of the costs--
the payment for the services that are provided. That number may
or may not be right. About half of Medicare visits are through
primary care, yet the number of primary care physicians on the
RUC is in the teens, and maybe even lower, maybe even single
digits in terms of a percent. How do you reconcile that?
Mr. HACKBARTH. Well, certainly that has been a sore point
among primary care physicians, that they felt they have been
underrepresented and that the process is skewed against them in
various ways.
Mr. PRICE. Isn't that part of the problem, though, of
setting up the kind of apparatus that we currently have, is
that you rarely if ever can get to the right answer, because
you rarely have the right people in the room.
Mr. HACKBARTH. Yeah. Medicare has very complicated payment
systems, as you know. Better than most people, I am aware of
not only the complexity but also some of the weaknesses. The
problem, however, is that it is not like we can say, Oh, it is
these Medicare-administered prices or prices set by the
competitive market. As you just indicated, private insurers
tend to say, Oh, Medicare's way is better than what we were
using, so we are going to adopt Medicare's fee schedule.
Mr. PRICE. So what we have is essentially price-fixing from
the Federal Government.
Mr. HACKBARTH. It is a difficult system, but there aren't
clear, better alternatives. One point on the----
Mr. PRICE. If there are clear, better alternatives, then I
look forward to that discussion.
Mr. HACKBARTH. Well, I would look forward to that as well.
But let me just make one point how private insurers use the
Medicare system. Typically what they use is the relative
values, but they set their own conversion factor.
Mr. PRICE. Let me talk about----
Mr. HACKBARTH. But the price is not the same.
Mr. PRICE. That is true. It is 90 percent or 110 percent or
130.
Let me talk about one of those relative values and that is
the E&M codes, evaluation and management; the doc visit codes,
if you will. My understanding--what evidence or what science
went into the setting of those codes? Are you aware of the
initiation of the----
Mr. HACKBARTH. Well, the original system back in the early
nineties was based on an extensive research project done by
Bill Showell at Harvard to set initial relative values. And
then the RUC process was established for purposes of
maintaining the system.
Mr. PRICE. And ``maintaining'' is the right word. Because
there hasn't been, as I understand it, a critical evaluation of
the E&M codes and what we are incenting in terms of office
visits and----
Mr. HACKBARTH. Well, actually by law there is a 5-year
review. Each 5 years they do a comprehensive review of the work
values. That doesn't mean every single code, but it is a far-
reaching review of the work.
Mr. PRICE. And it compares to what has been--I would
suggest it compares to what has been the occurrence as opposed
to looking at whether or not we are getting the desired----
Mr. HACKBARTH. In fact, a critical question in the whole
system is do we want to base the prices for different services
on estimates of the cost of producing them, or do we want to
take into account the value of the service to patients?
Mr. PRICE. Which brings me to a value question. All of the
values comments seem to imply that every single patient can
have an ideal outcome regardless of the diagnosis and
regardless of the clinical status. How do you pay for value in
a patient who has a terminal disease, is at the end of life,
and needs caring, compassionate care for that? It will have a
lousy outcome.
Mr. HACKBARTH. Well, when I talk about pay for value, I am
talking about, number one, looking at populations served and
not individual cases, as I think you are pointing out.
Individual cases, sometimes there are unavoidable bad results.
That is not a sign of poor care. So you look across broader
populations, you risk-adjust for the underlying conditions, and
you use measures that take into account things like patient
satisfaction; it is not just outcomes. You know, a terminal
patient could receive good care, and acknowledge it is high-
quality, humane care, even though it is a bad outcome.
Mr. PRICE. Thank you.
Chairman HERGER. The gentleman's time has expired.
The gentleman from Washington, Mr. McDermott, is recognized
for 5 minutes.
Mr. MCDERMOTT. Thank you very much, Mr. Chairman. I was
sitting down in my office watching this on the television, and
I decided I better come up here and ask a question.
Mr. HACKBARTH. Okay.
Mr. MCDERMOTT. Because I think the least known Committee in
the medical industrial complex in the United States is the RUC
and the impact that they have.
And I would like to submit for the record a graph from the
Medical Group Management Association, Annual Physician
Compensation Productive Survey. It is 1992 to 2008.
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Mr. MCDERMOTT. And you can see when the RUC started, and
the top line is the specialist's income and the bottom line is
primary care.
And so I started looking at the RUC and figuring out who is
on the RUC and how do they do this, and they clearly submit
their recommendations to CMS. And nine times out of ten, or
more than that, maybe 95 times out of 100, the CMS accepts
their recommendation; is that correct?
Mr. HACKBARTH. That is correct, yes.
Mr. MCDERMOTT. So it is not being set by CMS, but is being
set by a private committee controlled by the American Medical
Association; is that correct?
Mr. HACKBARTH. That is correct. I would point out that what
we have recommended--and this was 2 or 3 years ago now--is that
CMS take a more assertive role and not just be a passive
receiver of recommendations, but be more directive in what they
need to look at, and change the dynamic that otherwise exists
within the RUC. And they have taken some steps in that
direction. That was the answer.
Mr. MCDERMOTT. I would like to submit another article for
the record, which is from the New England Journal of Medicine,
dated 22 March 2007, which says that in 2006 the RUC
recommendations--well, MedPAC went up on 227 services and down
on 26.
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Mr. MCDERMOTT. So there has never been any bending of the
curve on the basis of the RUC; is that correct?
Mr. HACKBARTH. And that is precisely our concern. The
dynamics of the RUC are that there are lots of incentives to
identify a service for higher payment. There is very little
incentive to collect data to document Oh, my service ought to
go down.
And so what we have said is that CMS needs to redress that
imbalance in incentives within the RUC by directing them to
look at particular services that are likely to be overvalued.
Mr. MCDERMOTT. Do you think it might be better just to
collect your own data and never mind the RUC? I mean, why
should the medical association be setting their own fees? How
are you ever going to get control of costs if you let the fox
decide what the keys to the hen house are going to be used for?
Mr. HACKBARTH. Well, what we have recommended is a hybrid
approach where CMS does not turn over the keys to the fox, is
much more assertive in the process, but then takes advantage of
the expertise of the relevant specialties to provide input to
that process. So it is a rebalancing of the system, we think
mirroring professional expertise with data analysis done by
CMS.
Mr. MCDERMOTT. How about a rebalancing of the components
inside the RUC? My looking at the list, depending how you look
at people and what you can figure out is that mostly it is
special--or it is a balance heavily weighted toward
specialists, not toward primary care physicians.
Mr. HACKBARTH. And that, too, is a concern of ours and
certainly it is a concern of many of the primary care
physicians in the relevant professional societies.
Mr. MCDERMOTT. It seems to me that the biggest problem that
those of us who are supporting of the President's plan still
have about what is going on, is that controlling costs is still
not very well done. We have done well at access, in including
more people through the exchanges and that sort of thing, but
the question is ultimately going to be how come we are spending
16 percent of GDP, or 17 percent of GDP, and the Swiss are
spending 11 percent, and the French are spending 12 and
whatever?
Where is that 5 percent coming from is what I have been
looking at trying to figure out. And I keep coming back to the
fact that Medicare allowed usual and customary fees in the
original legislation, and we are continuing it with RUC is
simply an extension of that as I see it. Am I misreading the
facts?
Mr. HACKBARTH. No. We believe how Medicare pays for
services is an important contributor to the level of
expenditure and the rate of growth. If we ever want to reduce
the rate of growth, let alone reduce the level of expenditure,
if we ever want to improve the value we get for our Medicare
expenditures, we need to change the payment methods.
Chairman HERGER. The gentleman's time has expired.
Mr. MCDERMOTT. Thank you, Mr. Chairman.
Chairman HERGER. The gentleman from New Jersey, Mr.
Pascrell, is recognized.
Mr. PASCRELL. Thank you, Mr. Chairman.
Mr. Chairman, I looked over the report from the Centers for
Medicare and Medicaid Services, the CMS report of April 22nd of
2010, that also is an interesting document. And I just wanted
to clarify something we started to get into before on the
previous question.
Clearly the CBO and the CMS scored all the legislative
language. I misspoke, but I am trying to get to the point, I
didn't finish my point. It did score all of the words in the
970 pages or so of that health care reform bill in that bill,
in the Act. They did not give as much credit, though, the point
I am trying to make, to delivery system reforms that we
believe, those of us who support the legislation, support the
Act, will lead to better care at lower costs.
Mr. HACKBARTH. Right.
Mr. PASCRELL. We had the--Mr. Chairman, we had the CMS
actuary here, if you remember, in this room last month.
Mr. HACKBARTH. Right.
Mr. PASCRELL. I asked him why these provisions weren't
worth--weren't credited with more savings. If you look at the
chart, they go--each one of the provisions, and you see a lot
of zeros, of course, and you see a lot of low numbers and some
other things, but things we were talking about before the pilot
testing for pay for performance.
The technical corrections to hospital value-based
purchasing, support the patient-centered medical homes, which
is only a small part of this. There is the whole list in the
report which we were provided. It is very, very clear.
The question, what we are saying, those of us who support
the legislation in the Act, why we think these things will lead
to better care and lower costs? Plus, why the hell did we put
the bill together in the first place? We had the actuary here
and I asked why those provisions weren't credited with more
savings than the charts would indicate. So you can score it and
not give credit for the savings. I don't think that is a score
that--you know, we probably wait for the results because we
didn't get any results. They said, We don't have enough
information.
Mr. HACKBARTH. Right.
Mr. PASCRELL. Is that correct?
Mr. HACKBARTH. That is my understanding of what they did.
Mr. PASCRELL. Now, he answered this; he answered that he
believed in their potential to save Medicare money, he stated
for the record, but that he didn't have enough data to estimate
the amount of savings they would be given. How am I doing so
far?
Mr. HACKBARTH. I think you have accurately described the
situation. The concepts can be sound. The concepts have to be
turned into operational payment systems and then you have to
get providers to convert to those new payment systems. There
are certain connections there----
Mr. PASCRELL. Not unlike the changes we made to Medicare
since its beginning in the sixties. We made dramatic changes to
the Medicare program. Made dramatic changes when we
prognosticate, when we went out from the point that we were at.
So this is not unusual, this is not something that we say,
Well, is it going to be in 2022? I mean the charts here go up
to 2019. I think they are very optimistic, but I hope that all
of us recognize these provisions.
These provisions, the breadth and the width of Medicare and
Medicaid entitlement changes, we are changing business in the
Health Care Act, aren't we, Mr. Hackbarth?
Mr. HACKBARTH. That is certainly the goal. That is why we
recommended various provisions that we did that were included
in the law. We think they have the potential to change.
Mr. PASCRELL. Okay. So if these ideas in health care reform
which would move us toward paying for the quality of care
rather than the quantity of care, something my friend from
Wisconsin keeps talking about, I would assume everybody
understands, I know there will be pushbacks from the medical
profession.
Chairman HERGER. The gentleman's time has expired.
Mr. PASCRELL. And you have heard them. Cannot be identified
as entitlement reform, then what the heck can be? Thank you,
Mr. Chairman.
Chairman HERGER. The gentleman's time has expired.
Mr. Hackbarth, the Commission intends to consider different
approaches to updating physician payments in an attempt to
provide options aimed at fixing the SGR problem. Can you
preview the timing and the substance of the Commission's work
on this pressing issue?
Mr. HACKBARTH. Yeah. Our hope is that we will have
recommendations in the fall, draft recommendations in
September, final recommendations for vote within the Commission
in October. That is a hope.
We have got to obviously do a lot of work between now and
then and forge a consensus on what to do. The work we think is
urgent. It is motivated by a growing concern among MedPAC
commissioners that the SGR is a growing threat to access to
services for Medicare beneficiaries.
I want to be clear; we don't see wide-scale evidence of
that right now, but our concern is that the repeated difficult
process of trying to avert large-scale cuts in physician
payments, doing that over and over, sometimes multiple times in
the same year, the cumulative effect of that exercise is
undermining both physician and beneficiary confidence in the
Medicare program.
So for a long time I have been able to sit before the
Subcommittee and say, yeah, SGR is a problem that we don't see
an imminent threat to access. We think we are getting closer to
that tipping point. And so we are looking at options for
potentially addressing that.
Just if I may, Mr. Chairman, just one last point. I don't
want to create the false expectation that we may come up with a
new payment system that is not going to have a budget score
attached to it; that the big SGR budget problem is going to go
away. I don't think that there is a rational policy option that
will make that number go away.
I think the question for the Congress is not whether we are
going to spend more than the SGR baseline says. I think
everybody in this room, the CMS actuary, the Medicare trustees,
everybody, knows we are going to spend more than the SGR says
we will. The only question now is whether we are going spend
more by making last-minute adjustments, plowing more money into
the existing payment system, or whether we are going to spend
more strategically to achieve important goals for the Medicare
program.
We think that the latter course is the wise course, and so
my hope is that we can develop a package that will have a cost,
a budget cost to it, but will achieve some important goals for
Medicare reform going forward. That is our goal.
Now whether I can, you know, get the consensus within
MedPAC, I won't know until we are further into the process, but
that is the mindset that I have.
Chairman HERGER. All right. I thank you for your comments.
And I am sure you know this is a bipartisan major concern that,
as Members of the Committee each of us deal with as we talk
with our physicians. It is one that we need to place; and it is
important for to you know, as I am sure you do, that this is a
high priority of us, of this Committee, and certainly of this
Subcommittee.
And, again, I want to thank our witness for your testimony
today.
As a reminder, any Member wishing to submit a question for
the record will have 14 days to do so. Mr. Hackbarth, if any
questions are submitted, I ask that you respond in a timely
manner. With that, the Subcommittee is adjourned.
[Whereupon, at 2:57 p.m., the Subcommittee was adjourned.]
[Submissions for the Record follow:]

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