[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]

MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT OF 2015: EXAMINING
PHYSICIAN EFFORTS TO PREPARE FOR MEDICARE PAYMENT REFORMS

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

HEARING

BEFORE THE

SUBCOMMITTEE ON HEALTH

OF THE

COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES

ONE HUNDRED FOURTEENTH CONGRESS

SECOND SESSION

__________

APRIL 19, 2016

__________

Serial No. 114-137

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

Printed for the use of the Committee on Energy and Commerce

energycommerce.house.gov

___________

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COMMITTEE ON ENERGY AND COMMERCE

FRED UPTON, Michigan
Chairman

JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Chairman Emeritus Ranking Member
ED WHITFIELD, Kentucky BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
JOSEPH R. PITTS, Pennsylvania ELIOT L. ENGEL, New York
GREG WALDEN, Oregon GENE GREEN, Texas
TIM MURPHY, Pennsylvania DIANA DeGETTE, Colorado
MICHAEL C. BURGESS, Texas LOIS CAPPS, California
MARSHA BLACKBURN, Tennessee MICHAEL F. DOYLE, Pennsylvania
Vice Chairman JANICE D. SCHAKOWSKY, Illinois
STEVE SCALISE, Louisiana G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington KATHY CASTOR, Florida
GREGG HARPER, Mississippi JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey JERRY McNERNEY, California
BRETT GUTHRIE, Kentucky PETER WELCH, Vermont
PETE OLSON, Texas BEN RAY LUJAN, New Mexico
DAVID B. McKINLEY, West Virginia PAUL TONKO, New York
MIKE POMPEO, Kansas JOHN A. YARMUTH, Kentucky
ADAM KINZINGER, Illinois YVETTE D. CLARKE, New York
H. MORGAN GRIFFITH, Virginia DAVID LOEBSACK, Iowa
GUS M. BILIRAKIS, Florida KURT SCHRADER, Oregon
BILL JOHNSON, Ohio JOSEPH P. KENNEDY, III,
BILLY LONG, Missouri Massachusetts
RENEE L. ELLMERS, North Carolina TONY CARDENAS, California
LARRY BUCSHON, Indiana
BILL FLORES, Texas
SUSAN W. BROOKS, Indiana
MARKWAYNE MULLIN, Oklahoma
RICHARD HUDSON, North Carolina
CHRIS COLLINS, New York
KEVIN CRAMER, North Dakota

Subcommittee on Health

JOSEPH R. PITTS, Pennsylvania
Chairman
BRETT GUTHRIE, Kentucky GENE GREEN, Texas
Vice Chairman Ranking Member
ED WHITFIELD, Kentucky ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois LOIS CAPPS, California
TIM MURPHY, Pennsylvania JANICE D. SCHAKOWSKY, Illinois
MICHAEL C. BURGESS, Texas G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey DORIS O. MATSUI, California
H. MORGAN GRIFFITH, Virginia BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida KURT SCHRADER, Oregon
BILLY LONG, Missouri JOSEPH P. KENNEDY, III,
RENEE L. ELLMERS, North Carolina Massachusetts
LARRY BUCSHON, Indiana TONY CARDENAS, California
SUSAN W. BROOKS, Indiana FRANK PALLONE, Jr., New Jersey (ex
CHRIS COLLINS, New York officio)
JOE BARTON, Texas
FRED UPTON, Michigan (ex officio)

(ii)

C O N T E N T S

----------
Page
Hon. Joseph R. Pitts, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 1
Prepared statement........................................... 2
Hon. Gene Green, a Representative in Congress from the State of
Texas, opening statement....................................... 3
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 5
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 7
Prepared statement........................................... 7

Witnesses

Robert McLean, M.D., Member, Board of Regents, and Chair, Medical
Practice and Quality Committee, American College of Physicians. 9
Prepared statement........................................... 12
Answers to submitted questions............................... 140
Robert Wergin, M.D., Board Chair, American Academy of Family
Physicians..................................................... 36
Prepared statement........................................... 38
Answers to submitted questions............................... 150
Barbara L. McAneny, M.D., Immediate Past Chair, Board of
Trustees, American Medical Association......................... 44
Prepared statement........................................... 46
Answers to submitted questions............................... 159
Jeffrey Bailet, M.D., Co-President, Aurora Health Care Medical
Group.......................................................... 53
Prepared statement........................................... 55
Answers to submitted questions............................... 166

Submitted Material

Statement of the American College of Cardiology, April 19, 2016,
submitted by Mr. Pitts......................................... 86
Statement of the American College of Surgeons by David Hoyt,
Executive Director, April 19, 2016, submitted by Mr. Pitts..... 88
Statement of the Alliance of Specialty Medicine, April 19, 2016,
submitted by Mr. Pitts......................................... 97
Statement of the American Society of Clinical Oncology by Julie
Vose, President, April 19, 2016, submitted by Mr. Pitts........ 101
Letter of April 19, 2016, from the Advanced Practice Registered
Nursing Organization to Mr. Pitts and Mr. Green, submitted by
Mr. Pitts...................................................... 106
Letter of April 15, 2016, from Johan S. Bakken, President,
Infectious Diseases Society of America, to Mr. Pitts and Mr.
Green, submitted by Mr. Pitts.................................. 112
Letter of November 17, 2015, from Halee Fischer-Wright, President
and Chief Executive Officer, Medical Group Management
Association, to Andrew Slavitt, Acting Administrator, Centers
for Medicare & Medicaid Services, Department of Health and
Human Services, submitted by Mr. Pitts......................... 118
Statement of the Medical Group Management Association, April 18,
2016, submitted by Mr. Pitts................................... 136

MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT OF 2015: EXAMINING
PHYSICIAN EFFORTS TO PREPARE FOR MEDICARE PAYMENT REFORMS

----------

TUESDAY, APRIL 19, 2016

House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:14 a.m., in
room 2322 Rayburn House Office Building, Hon. Joseph R. Pitts
(chairman of the subcommittee) presiding.
Members present: Representatives Pitts, Guthrie, Shimkus,
Burgess, Bilirakis, Long, Ellmers, Bucshon, Brooks, Green,
Castor, Sarbanes, Matsui, Schrader, Kennedy, Cardenas, and
Pallone (ex officio).
Staff present: Gary Andres, Staff Director; Rebecca Card,
Assistant Press Secretary; James Paluskiewicz, Professional
Staff Member, Health; Graham Pittman, Legislative Clerk;
Jennifer Sherman, Press Secretary; Heidi Stirrup, Policy
Coordinator, Health; Kyle Fischer, Democratic Health Fellow;
Tiffany Guarascio, Democratic Deputy Staff Director and Chief
Health Advisor; Samantha Satchell, Democratic Policy Analyst;
Andrew Souvall, Democratic Director of Communications,
Outreach, and Member Services; and Arielle Woronoff, Democratic
Health Counsel.
Mr. Pitts. The time of 10:15 having arrived, the
subcommittee will come to order. The Chair will recognize
himself for an opening statement.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

Today's hearing is a sequel to our Health Subcommittee's
earlier review of the implementation progress of the Medicare
payment reforms as included in the Medicare Access and CHIP
Reauthorization Act of 2015--MACRA--which repealed the
sustainable growth rate and replaced it with new payment models
and other reforms.
Through a variety of incentives, MACRA encourages
physicians to engage in activities to improve quality, patient
experience and outcomes and reduce costs.
Prior to MACRA, physicians not only faced the threat of
unsustainable cuts from the SGR, but a series of well-meaning
but uncoordinated requirements stacked on top of each other
from a variety of reporting requirements.
MACRA seeks to consolidate, streamline and integrate these
efforts into a single program. However, rather than wait until
CMS issues a proposed rule on how they plan to implement these
incentives and program changes, there are steps every
practitioner can be taking right now.
Physicians should be thinking about ways they can modernize
their practices and participate in current programs to act as a
springboard for their preparation for MACRA.
Provider organizations should be developing measures to aid
their members and help MACRA's goal of creating meaningful
measurements that every provider feels are relevant to them.
Physicians should also start evaluating options available
to them, whether the Merit-based Incentive Payment System--
MIPS--or the Alternative Payment Methods--APMs--is right for
them both for tomorrow and where they want to direct their
practice in the future.
Our hearing today will examine options for ensuring the
smoothest transition for our providers, based on what we know
today. We expect to hear today from our witnesses who come from
diverse backgrounds and training and practice from all over the
country in rural and urban settings.
Each are practicing physicians in different arrangements
and all have worked with their organizations to provide tools
and best practices that other physicians can utilize and learn
from to be better positioned to succeed under MACRA.
By the conclusion of today's hearing, our Health
Subcommittee will have held two oversight hearings on the
implementation of MACRA prior to the issuance of CMS' proposed
rule.
As we have demonstrated in our commitment so far, the
Energy and Commerce Committee will continue to be vigilant in
our bipartisan oversight to ensure MACRA is a success and this
will certainly not be our last hearing on the matter.
[The prepared statement of Mr. Pitts follows:]

Prepared statement of Hon. Joseph R. Pitts

Today's hearing is a sequel to our Health Subcommittee's
earlier review of the implementation progress of the Medicare
payment reforms as included in the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA) which repealed the
Sustained Growth Rate (SGR) and replaced it with new payment
models and other reforms.
Through a variety of incentives, MACRA encourages
physicians to engage in activities to improve quality, patient
experience and outcomes and reduce costs.
Prior to MACRA, physicians not only faced the threat of
unsustainable cuts from the SGR, but a series of well-meaning
but uncoordinated requirements stacked on top of each other
from a variety of reporting requirements. MACRA seeks to
consolidate, streamline and integrate these efforts into a
single program.
However, rather than wait until CMS issues a proposed rule
on how they plan to implement these incentives and program
changes, there are steps every practitioner can be taking right
now.
Physicians should be thinking about ways they can modernize
their practices and participate in current programs to act as a
springboard for their preparation for MACRA.
Provider organizations should be developing measures to aid
their members and help MACRA's goal of creating meaningful
measurements that every provider feels are relevant to them.
Physicians should also start evaluating options available
to them--whether the Merit-based Incentive Payment System
(MIPS) or Alternative Payment Methods (APMs), is right for them
both for tomorrow and where they want to direct their practice
in the future.
Our hearing today will examine options for ensuring the
smoothest transition for our providers based on what we know
today.
We expect to hear today from our witnesses who come from
diverse backgrounds and training and practice from all over the
country in rural and urban settings. Each are practicing
physicians, in different arrangements and all have worked with
their organizations to provide tools and best practices that
other physicians can utilize and learn from to be better
positioned to succeed under MACRA.
By the conclusion of today's hearing, our Health
Subcommittee will have held two oversight hearings on the
implementation of MACRA prior to the issuance of CMS' proposed
rule.
As we have demonstrated in our commitment so far, the
Energy and Commerce Committee will continue to be vigilant in
our bipartisan oversight to ensure MACRA is a success. This
will certainly not be our last hearing on the matter.

Mr. Pitts. My time is expired. I now yield to the ranking
member, Mr. Green, 5 minutes for his opening statement.

OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS

Mr. Green. Thank you, Mr. Chairman, and I thank our
witnesses for being here today and I want to thank you for
this--the hearing, the second part of our subcommittee's
hearing on the implementation of MACRA.
As we know, the Medicare Access and CHIP Reauthorization
Act, or MACRA, was signed into law a little over 1 year ago.
This landmark legislation repealed the flawed sustainable
growth rate, the SGR, formulated to provide long-term stability
to the Medicare physician fee schedule and reward value over
volume.
It was critically important that Congress pass and the CMS
institute a reasonable responsible payment policy for
physicians and Incentivize quality care that spends our dollars
wisely.
Now that the historic achievement of finally repealing and
replacing the SGR has been made, staunch oversight over the
implementation of MACRA is critical.
This will ensure that we do not make the same mistakes of
the past. To do so, we need a system that's set up that's fair,
smart and sophisticated enough to meet the unique challenges of
a variety of providers participating in the Medicare system and
their patients.
The physician stakeholder community provided extensive
feedback during the development of MACRA and publicly supported
and voted the bill through the passage into law.
Like all of us, the provider community appreciates this
important step toward a more rational payment system and share
a sense of ownership over it.
I want to thank the stakeholders who continue to work with
this subcommittee and CMS to ensure that the legislation works
for the spectrum of providers and their Medicare patients.
The emphasis on quality and value that underpins MACRA is
consistent with the broader mission that Congress and the
administration have engaged in over the last decade beginning
with the Affordable Care Act.
As we know, MACRA provides stable updates for 5 years and
ensures no changes are made to the current payment system for 4
years. In 2018 it establishes a streamlined improvement
incentive payment program that will focus the fee for service
system on providing quality and value.
The incentive payment program refer erred to as Merit-based
Incentive Payment System, or MIPS, consolidates the three
existing incentive programs continuing to focus on quality,
resource use and a meaningful electronic health record use.
But unlike the past, it does this in a cohesive program
that avoids redundancies. MACRA also provides another route to
incentivize the movement away from volume-based payments by
giving financial bonuses to providers who participate in
alternative payment models, or APMs.
APMs hold great promise but their viability and
effectiveness requires sophisticated construction and
implementation.
I look forward to hearing from our witnesses about their
vision for the APMs, specifically how the model will be
designed so that they are relevant to different specialties,
different sizes of practice and in line with State-based
initiatives and private insurance models.
APM should prioritize measures on outcome, patient
experience, care coordination and measures of appropriate use
of services. They should also take into account gaps in quality
measurements and applicability of such measures across the
various healthcare settings.
It is the intent of Congress that specific quality metrics
used will be tailored to different provider specialties and
each eligible professional will receive a composite quality
score.
The challenges with constructing a system that fully
accounts for the variabilities in providers and the type of
care they're trained to provide and the patient mix as well as
how to meaningfully evaluate quality are significant.
But I believe it can be accomplished. To do so, the Centers
for Medicare and Medicaid, CMS, has initiated a rule making
process. A rule is imminent. I know everyone in this room is
looking forward to its release by CMS.
When the rule is announced I'm confident we'll see
additional stakeholder engagement, collaboration, continuation
of the transparent and public process throughout the course of
implementation.
MIPs and the opportunity to participate in APMs is just
around the corner. Now it's time to start preparing. I look
forward to hearing from our panel on how they're instructing
their peers to begin to prepare for transition.
This subcommittee will continue to exercise oversight over
MACRA implementation, not just today but throughout the rule
making process.
And again, Mr. Chairman, I thank you for calling the
hearing and a follow-up and I hope we'll have other ones as we
go along. Again, we don't want to repeat the problems of 1997.
I yield back.
Mr. Pitts. The Chair thanks the gentleman. Now, filling in
for the chair of the committee, Dr. Burgess, 5 minutes for
opening statement.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS

Mr. Burgess. Thank you, Mr. Chairman, and thank you,
Ranking Member Green, for reminding me why I wake up in a cold
sweat at 4:00 o'clock every morning. The word is that the next
part of this act does not go as well as the first part.
But last week we had the 1-year anniversary of the passage
of H.R. 2. Big deal. And this--now we're all reflecting on the
historic accomplishment of permanently and forever repealing
the sustainable growth rate formula. And just take--worthwhile
to take a moment to acknowledge.
It could not have come to pass without the commitment of
the medical community and the leadership of the Energy and
Commerce Committee on both sides of the dais.
The hard work is far from over, however, and we've entered
into what I like to consider a 5-year cessation of hostilities
between the Congress, the agency, and doctors, and we need to
make certain, as Ranking Member Green pointed out, that we get
it right during this interval.
So we are now having our second hearing on the
implementation phase of the Medicare Access and CHIP
Reauthorization Act and I'm glad that this committee does
remain dedicated to ensuring that we get this next phase of
payment reform right.
In the act, we sought to put power back in the hands of
those who actually provide the care so the doctors, not
agencies, will help shape Government care payments systems of
the future.
And I am encouraged that when CMS began the process of
implementation of this reform it began with a request for
information and I was even more encouraged by the response from
doctors.
We had 560-odd responses to that request for information.
It is important to note that doctors actively engaging in the
regulatory process can't just be at the beginning.
We've got to see this through, and certainly the societies
have some obligation to help doctors actually prepare for the
implementation of this.
Medicare participation should never subject doctors to the
things that we've--we want our doctors to take care of our
Medicare patients.
Some would argue that Congress shouldn't even be in the
business but we are and we've been there for 50 years. We might
as well do it right if we're going to do it and part of doing
it right is we shouldn't punish doctors.
But right now, doctors have to do this--all of these
different quality incentive programs. The piecemeal initiatives
have undermined their ability to focus on quality.
So to resolve that problem, the MACRA requires CMS--all
these acronyms--MACRA requires CMS to streamline the current
programs into a single value-based payment structure.
This is called the Merit-based Incentive Payment System and
the system is designed to incentivize quality whether a doctor
is an independent in rural practice or in a large integrated
healthcare system, and that was an extremely important part of
just getting H.R. 2 done.
We had to allow for success in whatever practice or
arrangement a doctor was in. We had to meet them where they
were.
Now, this transition is not going to happen overnight and I
am certain that--what I am certain of right now is that no
doctor is going to face the double digit cuts that they were
facing under the SGR. But really, truly, we don't want our
doctors to wait until 2019 to begin to take action.
Congress currently is universally condemned for being
dysfunctional, ineffective. Not a headline there to the guys
writing for the press. I know that.
But when you stop and think about what we accomplished with
the overwhelmingly bipartisan passage of H.R. 2, and I would
note I went to all the celebratory things down at the White
House where the president took credit for it. But, honestly, it
wasn't the president's deal. It was the committee's deal and we
brought the other committees of jurisdiction, both the House
and Senate, along with us and it was truly that bipartisan
effort.
Henry Waxman was my co-sponsor on H.R. 2. I mean, that's
phenomenal in and of itself when you think of it.
But it isn't just--and when you look at some of the
successes and failures of major healthcare policy that have
come through Congress in the past it's also--you know, they
always say the devil's in the details.
So this is where the devil's in the details and we've got
to get this--we've got to get this right.
It took two decades to replace the SGR because it was hard
to do and it required a certain commitment and a certain
suspension of hostilities between Republicans and Democrats on
the dais. But we did it because it was the right thing to do,
and we're going to be called upon to do that again in the
future.
I don't know what form that will take but in other
healthcare policy that certainly we could--people would do well
to follow the template that we provided in the Energy and
Commerce Committee.
The policies outlined in H.R. 2 are the result of an open
and transparent process which sought input and participation
from every doctor, patient, member of Congress, administrative
agency and anyone else who professed an interest.
We're at this critical juncture in physician payment reform
and we'll only get it right if implementation follows that same
open, transparent and bipartisan structure that we use to get
this to the president's desk.
I want to thank all of our witnesses for being here today.
I sincerely appreciate the efforts of all of the provider
groups to help us in going forward.
I look forward to your testimony today and look forward to
the next in what will be a series of hearings, Mr. Chairman.
I'll yield back.
Mr. Pitts. The Chair thanks the gentleman.
The ranking member wants to say something.
Mr. Green. Chairman, I just want to thank my colleague from
north Texas. But, you know, I felt the same way about the
President because he got the Affordable Care Act called
Obamacare and all he had to do is sign his name to it. We had
to do the legwork. So I understand how you feel.
Mr. Burgess. Some of us did not do that legwork, nor did we
vote for it, nor will we ever, Mr. Green. So if you want me to
refer to that as Greencare in the future, I'll be glad to do
that.
Mr. Green. All right.
Mr. Burgess. I will be honored to do that because I said
that.
Mr. Pitts. OK. The Chair now recognizes the ranking member
of the full committee, Mr. Pallone, 5 minutes for opening
statement.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY

Mr. Pallone. Thank you, Mr. Chairman.
I think this is an important hearing and I thank the
witnesses for being here today.
We're meeting to continue our discussion on one of the
great bipartisan success stories of this committee, the
Medicare Access and CHIP Reauthorization Act, or MACRA.
Our panel of witnesses practice in a variety of settings
across the country and represent diverse expertise and
training. They each have the unique perspective to share with
us regarding the implementation of MACRA.
The law put in place a dual track system for providers
instead of the patchwork of quality reporting systems that
providers currently use. They will instead use the Merit-based
Incentive Payment System, or MIPS, and MIPS will streamline
quality reporting for providers and incentivize high-quality
efficient care.
Providers are most enthused to use alternative payment
models, or APMs, which have also proven to increase quality and
lower costs.
Today we'll discuss the steps all providers can take to
modernize their practices, provide higher quality care for
their patients and successfully transition to the new payment
models established by MACRA, and this will be our second
hearing on MACRA implementation. I'm pleased this committee is
performing such thoughtful oversight.
While we know that MACRA is already showing promising
results, these hearings are necessary to ensure that the law
reaches its full potential and I look forward to discussing the
tools and best practices physicians can employ to help make
MACRA work effectively for all.
[The prepared statement of Mr. Pallone follows:]

Prepared statement of Hon. Frank Pallone, Jr.

Good morning. Thank you, Mr. Chairman, for holding this
important hearing, and thank you to the witnesses for being
here today.
We're meeting to continue our discussion on one of the
great bipartisan success stories of this committee, the
Medicare Access and CHIP Reauthorization Act of 2015, or MACRA.
Our panel of witnesses practice in a variety of settings across
the country and represent diverse expertise and training. They
each have a unique perspective to share with us regarding the
implementation of MACRA.
The law put in place a dual track system for providers.
Instead of the patchwork of quality reporting systems that
providers currently use, they will instead use the Merit-Based
Incentive Payment System or MIPS. MIPS will streamline quality
reporting for providers and incentivize high-quality efficient
care. Providers can also choose to use Alternative Payment
Models or A-P-Ms, which have proven to increase quality and
lower costs.
Today we will discuss the steps all providers can take to
modernize their practices, provide higher quality care for
their patients, and successfully transition to the new payment
models established by MACRA.
This will be our second hearing on MACRA implementation and
I'm pleased that this committee is performing such thoughtful
oversight. While we know that MACRA is already showing
promising results, these hearings are necessary to ensure that
the law reaches its full potential. I look forward to
discussing the tools and best practices physicians can employ
to help make MACRA work effectively for all. Thank you.

Mr. Pallone. So I just want to yield the remainder of my
time to Congresswoman Matsui from California.
Ms. Matsui. Thank you for yielding.
Thank you, Mr. Chairman, for holding this second hearing on
MACRA. Last year, we joined together in overhauling the broken
SGR system, replacing it with one that incentivizes quality
over quantity of care, rewards efficiency and encourages the
use of breakthrough technologies that will provide more people
access to health care across this country.
I am looking forward to discussing ways we can advance the
transitions that are already happening and will accelerate with
MACRA.
Today, we are joined by physicians who offer important
perspectives and best practices for ensuring that delivery
systems continue to make inroads in providing high-quality
efficient health care to patients.
One of the ways I believe that we can expand access to care
and improve outcomes is through the incorporation of
telemedicine and to this new value-based system.
Through telemedicine we truly have the opportunity to
better engage patients and their families, improve care
coordination with loved ones and maximize efficiency of
resources.
As we make inroads into this health system transformation,
I look forward to working with you and hearing your
perspectives on these important issues. Thank you and I yield
back.
Mr. Pitts. The Chair thanks the gentlelady. As usual, all
the members' written opening statements will be made a part of
the record. I'd like to submit the following documents for the
record: statements from the American College of Cardiology, the
American College of Surgeons, the Alliance of Specialty
Medicine, the American Society of Clinical Oncology, the
Advanced Practice Registered Nursing Organizations, the
Infectious Diseases Society of America, and comments and a
statement from the Medical Group Management Association.
Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Pitts. We have one panel today. I'll introduce them in
the order of their presentations.
First, Dr. Robert McLean, MD, FACP member of the Board of
Regents, chair of the Medical Practice in Quality Committee,
American College of Physicians; then Dr. Robert Wergin, MD,
FAAFP, board chair of the American Academy of Family
Physicians; Dr. Barbara McAneny, MD, immediate past chair of
the American Medical Association, and finally, Dr. Jeffery
Bailet, MD, MSPH, FACS, executive vice president of the Aurora
Health Care, co-president of the Aurora Health Care Medical
Group.
Thank you for coming today. Your written testimony will be
made a part of the record. You'll be each given 5 minutes to
summarize your testimony.
And so we'll begin by recognizing Dr. McLean for 5 minutes
for his summary.

STATEMENTS OF ROBERT MCLEAN, M.D., MEMBER, BOARD OF REGENTS,
AND CHAIR, MEDICAL PRACTICE AND QUALITY COMMITTEE, AMERICAN
COLLEGE OF PHYSICIANS; ROBERT WERGIN, M.D., BOARD CHAIR,
AMERICAN ACADEMY OF FAMILY PHYSICIANS; BARBARA L. MCANENY,
M.D., IMMEDIATE PAST CHAIR, BOARD OF TRUSTEES, AMERICAN MEDICAL
ASSOCIATION; JEFFREY BAILET, M.D., CO-PRESIDENT, AURORA HEALTH
CARE MEDICAL GROUP

STATEMENT OF ROBERT MCLEAN

Dr. McLean. Thank you.
My name is Robert McLean. I am pleased to share with you
the perspectives of the American College of Physicians on the
key issues we believe should be addressed in the implementation
of MACRA and what we are doing to prepare our members to be
successful under it.
On behalf of the college, I wish to express our
appreciation to Chairman Pitts and Ranking Member Green for
convening this hearing.
I'm a member of the college's Board of Regents and chair of
its medical practice and quality committee. ACP is the Nation's
largest medical specialty organization representing 143,000
internal medicine physicians and medical student members.
In addition to teaching medical students, residents and
fellows Yale, I'm also a full time practicing physician who
sees over 80 patients per week as part of the Northeast Medical
Group of the Yale New Haven health system.
We sometimes forget even though it has been only a year
what has been achieved by repealing the SGR and replacing it
with MACRA.
For years, many looking to improve our healthcare system
have embraced the laudatory goals of the triple aim--improve
the patient experience of care, improve the health of
populations and reduce per capita healthcare costs.
However, when I would mention this to my colleagues in
practice I frequently received glazed looks and given their
list of real world concerns such as I'm struggling with my
electronic health record--I am overwhelmed with these
regulations--I'm given data on clinical metrics and do not know
what to do with it--my patients are unhappy because I am taking
visit time away from them to deal with all of these hassles,
and before MACRA repealed the SGR, they would then add and I
have to worry every year that my Medicare fees will be cut up
to 20 percent or more due to some crazy formula. In that
environment, can anyone wonder why there is such concern about
physician burnout?
Since MACRA became law, though, I can truly tell my
colleagues that there is reason for hope. I tell them that the
MACRA law will align and simplify some of the measures and
reporting. It will truly reward those who have made investments
in advanced practice structures like the patient-centered
medical homes and will eliminate the yearly financial anxiety
created by the dreaded SGR. Then those glazed and frustrated
looks change dramatically.
With surprise, I'm then asked, you mean that this law
really does things that will simplify our lives and practice
and allow us to focus more on delivering high-quality care to
our patients, and I tell them yes.
One way that MACRA does this is by giving physicians more
control over our Medicare payments. As you're aware, the SGR
resulted in ever physician's conversion factor being cut by the
same scheduled amount no matter how cost effective they were or
the quality of care they provided the patients.
MACRA fundamentally changes this because the annual
adjustment in each physician's conversion factor starting in
2019 will be based on each physician's own contribution to
improving quality and providing care more effectively, giving
physicians more control over their annual payments while
benefitting patients with better outcomes. I truly believe that
MACRA can be a shot in the arm to combat burnout if it is
rolled out as Congress intended.
To this end, the college has provided CMS with our views on
the priorities it must address as MACRA is implemented. There
are three in particular that I'd like to highlight.
Number one, CMS must improve the measures to be used in the
quality performance category of MIPS and established less
burdensome reporting as Congress clearly intended when it
harmonized existing Medicare quality reporting programs into
MIPS.
Number two, ACP is very pleased that MACRA supports
patient-centered medical homes through both the MIPS program
and as an alternative payment model and has urged CMS to create
multiple realistic ways for medical homes to obtain
certification.
We are encouraged by CMS' announcement just last week of
the Comprehensive Primary Care Plus program, a multipayer
patient-centered medical home initiative which potentially
could enable participating practices to qualify for higher
payments under MACRA.
And number three, CMS should promote innovation by
employing a very broad definition of entities that should be
considered eligible APMs as well as create pathways for
multiple physician-focused APMs to be accepted.
It isn't just up to CMS to ensure that MACRA is implemented
successfully. Professional associations including the ACP must
do our part. Our educational efforts include online resources,
guides, presentations, articles in our publications and
practical tools, all designed to help our members prepare for
MACRA. This includes MACRA-specific sessions at our annual
scientific meeting to be held here in Washington, DC, just two
weeks from now.
One thing I would like to highlight is the ACP practice
advisor, an online interactive tool that offers practices the
ability to conduct significant evidence-based quality
improvement based on the most up to date clinical guidelines,
improve performance on clinical quality measures, implement the
principles in the medical home model and improve the overall
management of their practice.
While the practice advisor serves to facilitate practice
transformation independent of any given payment model, it is
particularly relevant to preparing physicians to be successful
under MACRA.
Thank you for giving the ACP the opportunity today to share
our perspective on what CMS needs to do to ensure that MACRA is
implemented as Congress intended and on what we are doing to
help our members be prepared to succeed under this landmark
law.
Thank you.
[The prepared statement of Dr. McLean follows:]
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Mr. Pitts. The Chair thanks the gentleman. Thank you for
your testimony.
We're still having trouble with the mics. So Dr. Wergin,
make sure you pull that close to you and make sure the mic is
on.
The Chair now recognizes Dr. Wergin, 5 minutes for an
opening statement.

STATEMENT OF ROBERT WERGIN

Dr. Wergin. Chairman Pitts, Ranking Member Green and
members of the subcommittee, thank you for this opportunity to
address you this morning.
My name is Dr. Robert Wergin. I chair the American Academy
of Family Physicians board of directors. The AAFP is an
organization of 120,000 members. I am pleased to be asked to
speak about Medicare Access and CHIP Reauthorization Act
implementation.
First of all, I want to thank all of you for your effective
bipartisan leadership in repealing the much-despised Medicare
SGR and putting into place payment reforms that clearly
emphasize value-based health care.
More importantly, thank you for putting together
legislation that will make a real and positive different in the
lives of your constituents.
MACRA implementation will be a major shift in Medicare in a
very short period of time. These changes, as dramatic as they
may be in the coming years, are consistent with the key
principles of practice transformation that the AAFP has
supported for over a decade.
For example, almost 10 years ago the AAFP, along with four
major primary care organizations developed the joint principles
for the patients that are in a medical home that promotes
coordinated care, quality and safety and patient access.
Consistent with those principle we believe that the
practice transformation necessary to make MACRA successful will
mean better care for patients, better professional experiences
for our physicians and better control of healthcare costs.
We hope it will also bring back the joy of the practice of
medicine to our members. As I travel from State to State
meeting with AAFP chapters I hear a lot of anxiety related to
MACRA, particularly for my colleagues in rural and underserved
areas.
I challenge my colleagues to be optimistic. MACRA reform
will not be easy but it's much better than what physicians
faced before the law was enacted. Instead, I urge them to take
advantage of the AAFP resources they can utilize to begin
transforming their practices now.
The AAFP believes MACRA is by intent and design a law aimed
at transforming our healthcare delivery system into one that is
based on a strong foundation of primary care.
As I fully explained in my written testimony, the whole
person and complex care that primary care physicians provide
helps improve patients' outcomes and constrain overall
healthcare costs, which are also consistent with the law's
intention.
Also, the alternative payment models will improve how
healthcare systems value primary care and the services that are
fundamental to disease prevention, chronic care management and
population health--all areas of health care that a fee for
service system cannot adequately address.
Although MACRA is among the most significant reforms to
occur in decades, many of our members may not be aware of the
upcoming changes or do not know their level of readiness for
MACRA implementation.
As a result of that, the AAFP has launched a comprehensive
multiyear member education and communications effort designed
to simplify this transition.
Called MACRA Ready, the effort will include a variety of
tactics designed to get the word out to our members starting
with a dedicated content page on afp.org.
One of the best primers is an article in the April/March
issue of Family Practice Management. Other MACRA content
already available to AAFP members are MACRA 101, frequently
asked questions, MACRA time line, AAFP news articles, MACRA
readiness assessment tool and a MIPS APM calculator and
decision tree tool as well.
The AAFP is dedicating considerable time and thought into
preparing our members for MACRA and that is reflected in our
wealth of available resources. The AAFP is also supporting
MACRA implementation by advising CMS about the agency, how the
agency might handle many features of the new law which are
fully outlined in my written statement. They include but are
not limited to the critical importance of an interoperable
electronic health record. The AAFP has also shared
recommendations regarding the importance of issuing regulations
that are less cumbersome and more user friendly for physicians.
Ultimately, we believe these concerns could be address as
the process moves forward and we truly believe that the vision
for practice transformation, better patient care, lowering
costs and return to the love of the practice of medicine is
achievable.
Once again, I want to thank you for your kind invitation to
speak about MACRA and its implementation. I look forward to
answering your questions.
[The prepared statement of Dr. Wergin follows:]
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Mr. Pitts. The Chair thanks the gentleman.
Now recognizes Dr. McAneny, 5 minutes for her opening
statement.

STATEMENT OF BARBARA L. MCANENY

Dr. McAneny. Good morning. I'm Dr. Barbara McAneny, a
hematologist oncologist from New Mexico and immediate past
chair of the American Medical Association board of trustees.
Thank you for inviting us to this hearing on MACRA focusing
on physician efforts to prepare for Medicare payment reform.
As background, my practice is the New Mexico Cancer Center,
which provides multidisciplinary outpatient cancer care at
multiple sites including under served rural areas.
As a practicing physician, I felt the burden of a broken
SGR payment system for many years. With half of my patients
covered by Medicare, the threat of significant payment cuts was
very real and jeopardized the viability of my practice every
year.
How could I justify hiring people to provide patient
education and care coordination when I would have to lay them
off if Medicare cuts went through?
How could I continue to provide services in our most under
served area, my Gallup clinic, if the Medicare cuts meant that
I couldn't make payroll?
The passage of MACRA now provides physicians with the
opportunity to focus on our patients by creating a single
performance reporting program, known as MIPS. The law gives us
the opportunity to streamline measures, reduce reporting burden
and create flexibility to encourage physicians in every
specialty to participate and improve care.
MACRA also promotes innovation by encouraging new
alternative payment models. APMs can be tailored to specific
patient populations to drive care improvement, leverage
technology and promote new treatments.
Importantly, the law acknowledges physician leadership is
needed in developing APMs which not only promotes participation
but protects patients and can drive down costs.
To ensure physicians can take advantages of these MACRA
improvements, the AMA is providing information and resources to
physicians. We know that physicians are in many different
stages of readiness for MACRA and few have detailed knowledge
of the law's requirements.
The AMA is eager to work with CMS so that together we can
teach all physicians how to avoid the penalties that could
threaten the existence of their practices, especially those
working in medically under served areas who lack the resources
of larger more affluent areas.
To improve outreach, the AMA has created numerous free
online tools and resources to guide physicians. This includes
basic information for those with little understanding of MACRA.
The AMA had also created CME training modules that can
provide assistance on key issues for MACRAs such as EHR
implementation and team-based care.
We are also helping physicians decide what path, either
MIPS or APMs, is right for them by creating a payment evaluator
tool to assess their practice. For those interested in moving
to alternative payment models, the AMA has created this guide
on physician-focused APMs.
This tool walks through seven different models describing
the components and benefits of each including examples on how
the model could be implemented.
My own experience with APMs have shown that when physicians
have the opportunity to innovate, these models can be
successful.
In 2012, I received a CMMI grant to replicate across the
country how my practice was providing cancer patients with
better care at a lower cost.
By implementing a medical home model, we were able to cut
hospitalizations in half. This is a model for chronic care
management.
CMS must now implement MACRA to ensure that the law
successfully achieves the goals intended by Congress. Knowing
that the devil can be in the details, the AMA has provided CMS
with guidance from physicians to inform its proposed rule.
We have convened specialty and State societies to build
consensus and have created a MACRA task for as well as two work
groups, one on MIPS and another on APMs, to examine specific
issues related to our program.
In addition to our comment letters and responses to RFIs
we've also held listening sessions for CMS and other
stakeholders to inform MACRA implementation.
In conclusion, we are hoping the forthcoming regulations
from CMS will promote the smooth and successful implementation
of MACRA by consolidating and improving current reporting
programs, providing broad opportunities for participation in
the APMs, addressing current concerns with methodologies of
performance measurement and providing physician practices with
CMS data needed to evaluate the models.
MACRA provides the opportunity to help every physician in
every practice setting make the changes that provide meaningful
improvements in the care they give to the patients they serve.
We thank the subcommittee for your continued efforts on
this issue and look forward to working with you to ensure a
successful start to MACRA.
[The prepared statement of Dr. McAneny follows:]
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Mr. Pitts. The Chair thanks the gentlelady and now
recognizes Dr. Bailet, 5 minutes for his opening statement.

STATEMENT OF JEFFREY BAILET

Dr. Bailet. Chairman Pitts, Ranking Member Green, and
distinguished members of the Energy and Commerce Subcommittee
on Health, thank you for the opportunity to testify on behalf
of Aurora Health Care, the largest private employer and the
largest integrated healthcare delivery system in the State of
Wisconsin.
I am Dr. Jeffery Bailet, co-president of Aurora Health Care
Medical Group and one of the largest multispecialty medical
groups in the Nation.
As an otolaryngologist head and neck surgeon and medical
group co-president, I am responsible for co-leading 2,600
physicians and advanced practice clinicians who provide care to
1.3 million unique patients.
Aurora's diverse delivery system includes several rural
community hospitals, urban hospitals, a psychiatric hospital as
well as Aurora St. Luke's Medical Center, the State of
Wisconsin's largest hospital.
Thank you for extending this opportunity to speak on behalf
of MACRA. I am pleased to be a leader of this transition not
only as a medical group physician leader but also as co-chair
of the physician-focused Payment-Model Technical Advisory
Committee, or PTAC.
I applaud Congress, particularly this committee, for
incorporating the PTAC in MACRA as an advisory panel to
consider physicians and other stakeholders' proposals for new
models of high value care.
I am also fortunate to serve as chair-elect of the American
Medical Group Association representing medical groups and
health systems including some of the Nation's largest most
prestigious integrated delivery systems.
I am pleased when standing in front of the physicians I
support or speaking with physicians across the country that
there's no longer debate about the need to transition to value-
based care delivery.
Shifting the culture of the healthcare community to the
importance of value is a huge accomplishment and our patients
across the country will benefit. It is equally important,
however, that regulators appreciate the need to proceed
cautiously during this transition.
Many physicians are in various stages of readiness for a
value-based payment system. There is and will continue to be a
significant learning curve as providers begin to take on
financial risk.
When implementing the regulations for MACRA's payment
systems, CMS should recognize that the healthcare system will
need time to adapt and learn how to function in this new
payment environment. Providing an incremental approach that
includes flexibility and rational exposure for financial risk
will be vital in ensuring a successful transition to value-
based payment.
Congressional oversight of this process is needed and
welcomed. Physicians, whether they are in small group
practices, larger multispecialty medical groups or high-
performing integrated delivery systems must make significant
investments to succeed in a risk-based environment.
For example, Aurora launched a predictive analytic pilot
focusing on preventing hospital admissions and readmissions.
Using a predictive analytic tool, Aurora was able to stratify a
population of heart failure patients who had an 80 percent or
higher likelihood of needing to be hospitalized as a result of
their disease.
We then redesigned our care approach using health coaches,
frequent proactive outreach and engaged patients to take active
ownership of their treatment and health status. This effort
helped Aurora reduce our congestive heart failure-related
admissions by 60 percent.
To help solo and small group practices participate, Aurora
is developing clinically integrated networks across our
geographic area. For example, we helped found About Health, a
clinically integrated network that enhances clinical quality,
increases efficiency and improves customer experiences,
providing access to care for about 94 percent of Wisconsin's
population.
About Health is an example of how partnerships in Wisconsin
between integrated delivery systems and small group practices
can create a culture of learning and fostering of best
practices to improve quality of care and reduce costs. This
effort also helps small groups and solo practices that wish to
maintain their independence the ability to do so.
It is vital that CMS continues to engage the stakeholder
community. The healthcare provider community is eager to share
its insights with CMS and to date CMS is making a sincere
effort to engage.
I encourage CMS to build upon these efforts as value-based
parameters are being clearly defined. MACRA represents a
realistic opportunity for healthcare providers to improve the
quality of care while reducing healthcare spending.
High-quality patient outcomes is paramount and the
continuous improvement initiatives and redesigned
infrastructure we have implemented at Aurora can serve as a
guide to other providers.
Also, Aurora seeks out better, more effective ways to
deliver care from our colleagues around the country. Moving
forward, Aurora is prepared to fully participate in the
development of new risk-based payment models that have the
potential to improve patient care and bend the cost curve.
Thank you.
[The prepared statement of Dr. Bailet follows:]
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Mr. Pitts. The Chair thanks the gentleman. Thanks to each
of you for your opening statements. We'll now begin
questioning. I'll recognize myself for 5 minutes for that
purpose.
I'd like to begin with the APMs and then go to MIPS and we
only have 5 minutes so we'll just go down the line. Dr. McLean,
what can physicians do right now to position themselves to
succeed under an APM?
Dr. McLean. Well, I think an APM is a larger entity. For
either of the two, let me say, to start off I think physicians
need to realize that they need to have a good electronic
records system.
Most of what we're dealing with now is really dealing with
lots of data and a lot of physicians and smaller practices have
not had to do that.
They've had to start to if they've been keeping up with
PQRS and some of those things, but you may know that PQRS I
think recently showed that something like 50 percent of
physicians in the country didn't even report.
It just wasn't worth the effort to them. They'd rather take
the financial hit than kind of put the systems in place to do
so. Now with some of these things I think there's a lot more
motivation for physicians and physician groups to actually do
that.
So the first thing they need to do is make sure they have
an electronic records system that's able to do a lot of the
things that are required here and simplistically.
Mr. Pitts. All right. That's good.
Dr. Wergin, what can physicians do right now to position
themselves to succeed in MIPS?
Dr. Wergin. They can go to our Web site and look at the
resources we have.
But for a starting point is recognize quality measures we
hope that can be standardized and the collaborative quality
measures will be measured and report to PQRS. You need to be a
meaningful use provider of electronic health records, which can
be challenging.
In my own practice, I made it on the 90th day in the last
few hours. I had to call two patients to call me with a
question, which was hard because I practice in a Mennonite
community who don't have TVs or radios and they don't have
computers. So I had to find some non-Mennonites.
You need to do that, and we recommend to our members to
move towards the patient-centered medical home. In the MIPS or
eventually an alternative payment model we feel that's where
you need to move.
Even under MIPS on the fourth criteria you'll get full
credit for that, and we believe that's a better delivery of
care.
Mr. Pitts. Thank you.
Dr. McAneny, as you may know, this is our second oversight
hearing on MACRA even before the proposed rule and this
committee will continue to be vigilant in our bipartisan
oversight to ensure that MACRA is a success.
Can you speak from both your organization's perspective and
that of a physician of why oversight is important and the
message you believe it sends to the physician community?
Dr. McAneny. Thank you, Mr. Chairman, for that question. I
think it's a very important one. The change in the opinions
from CMS that we are now going to have a partnership with
physicians to move forward in creating alternative payment
mechanisms is probably the most important change that we've
seen for a while.
As a practicing physician now I have the opportunity to
have Medicare payment reflect what I actually do for my
patients to free me from the face to face required encounters
and let me actually create a system that will manage patients
more effectively provides an incredible opportunity.
From the AMA standpoint, we are working very hard to
continue to work with CMS. We have provided information at
their request for information. We've had listening sessions
with CMS.
We continue to convene specialty societies from all around
the country to be able to work with their own specialty to try
to create alternative payment methodologies that will work in
that specific specialty and we recognize that in different
communities with different needs and different levels of
resources it will take a different method to provide these
alternative payments for them.
So we really have worked a lot with our physician guide to
alternative payments, with our Web site offerings, our Steps
Forward program to teach physicians what they need to know
right now as they prepare and we very much look forward to
seeing the proposed rule.
Mr. Pitts. Before I go to Dr. Bailet, how would you
characterize the general physician's knowledge on the repeal of
SGR and the passage of MACRA?
Dr. McAneny. Well, I think the general physician is
thrilled to have the SGR repealed and to have that taken out
from the sword that's hanging over our heads.
The average physician has--well, there's a huge variation
in the amount of information about MACRA. People know that it's
there but they don't quite know how it's going to apply to them
yet. So all of the specialty societies have their work cut out
for them.
Mr. Pitts. Thank you. Thank you.
Dr. Bailet, you note the importance of engaging with the
specialist community in the development of APMs. Can you
elaborate on where you see growth potential in the future for
specialists playing a bigger role in new care delivery models?
Dr. Bailet. Yes. Specialty care, being a specialist myself,
they have a lot of influence on some of the care that's
delivered that has a higher price tag and the specialists that
I talk to around the country are very actively engaged in
trying to influence efficiencies and care delivery and they're
very sensitive and aware of the treatments that they're
offering and the cost associated with them.
Again, it's a learning curve so the physicians are becoming
more familiar with the costs and essentially the end product of
the care they deliver and it is a partnership. It is no longer
silos of primary care and silos of specialty care.
In order for us to be effective and efficient we need to
work together as a team and it's not just physicians, it's also
advanced practice clinicians. It's nursing. It's your care
team. That is the only way we're going to maximize the
potential of the health system and deliver the care the
patients deserve at the expense and cost that is rational that
will carry us forward.
Mr. Pitts. Thank you. My time has expired.
The Chair recognizes Mr. Green, 5 minutes for questions.
Mr. Green. Thank you, Mr. Chairman.
Again, I want to thank our panel and you each represent
different specialties and I just want to appreciate you taking
your time and away from your practice.
My question of each--what are you instructing your members
to do to prepare for the transition whether under MIPS, fee for
service or the alternative payment methods?
Dr. McLean.
Dr. McLean. Well, I think the testimony gets into a little
more detail but as other organizations the ACP has been working
very hard to put resources together that are available online
as well as in multiple publications.
The ACP has worked for years on trying to help internal
medicine and its subspecialty practices kind of do the right
thing through the practice organization. So for a number of
years, there's been stuff on their Web site and resources about
becoming a patient-centered medical home and on how to pick out
health records something called EHR partners. So there are
resources available to try to make it easier for physicians to
go through some decision making on some of those things.
As we now have MIPS and APMs we're taking some of those
resources that were already there and developing them into
something that's really germane to what we're talking about now
so the physicians can have help making the decision. You know,
do I--am I in an organization that's going to qualify as an APM
or do I need to kind of go the MIPS path because that's kind of
one major fork in the road that people or that physicians will
need to decide.
Mr. Green. Thank you.
Dr. Wergin.
Dr. Wergin. Well, I think it's--I hope this is on--I think
it's a challenge for our diverse group. We go from rural
communities like mine of 2,000 people up to large healthcare
systems. So we have to go where our members are.
But I think in the long run it still comes down to
comprehensive coordinated care. That's what we can provide to
an APM. When I go out to States, I am kind of amazed. A lot of
people have heard of MACRA but not a lot of details. So we try
to begin the education. They're holding back.
We said now is the time to act and move forward to, you
know, to being the transformation of your practices to prepare
for MACRA.
So we have tools on our Web sites. When I'm there talking
to them for the smaller practice virtual groups or the TPNs or
some of the assist granted money that that way can do it to
band together and create the infrastructure to keep them alive.
They're important and when they complain I said, do you
want to go back to 20 percent cut. In my practice, it's 35
percent Medicare. It would have probably been the end of my
practice. I couldn't boutique it. They're my neighbors.
I can't say I can't see Medicare anymore. Couldn't anyway
from a business plan. So we want to prepare all our members in
whatever form their practices take and give them the resource
to prepare for it.
Mr. Green. Dr. McAneny.
Dr. McAneny. Thank you very much.
Again, we start out with the idea that we need to have a
tool and we've created one that will help physicians try to
learn whether they're better off in MIPS or in MACRA or in the
alternative payment model of MACRA.
We also are working very hard to make EMRs--electronic
health records--into the functionality that they need to have.
One of the very important things that all practices are
going to need is to be able to have the date both their own
internal data and claims data back from Medicare so that we
know how we're doing. And it doesn't help us at all if we get
data six months or a year later. How can you change when that
happens? You've already lost a year.
So we're trying to work with CMS to modify the electronic
health records meaningful use processes so that those become
tools that really help us as we engage in patients and not just
data collection instruments and we will continue to work, as
the others have mentioned, with educating our members as to
what their options are, how to get prepared for this, how they
can look at creating quality measures.
The other thing that's very important that I think the AMA
is doing is working with multiple specialty societies to create
quality measures that are not only good measures but are
actually useful as they work to transform their own practices.
Mr. Green. OK. I only have a few seconds left.
Dr. Bailet, I was just wondering--you know, Congress
subjected physicians for 18 years to the SGR and uncertainty.
Electronic medical records is such a vital part of what we're
doing.
Your accountable care organization, Aurora, is redesigning
several approaches to patient care, especially in the area of
heart failure and COPD. Can you describe these and also if
you're suggesting in your practice and your other physicians
anything different than what the other specialties make?
Dr. Bailet. Well, I'm answering the question from the
perspective of a medical group leader and I will say that there
is anxiety amongst the physicians that I support mostly from
not knowing exactly what the rules are going to be, how this is
going to play through their practice at the individual level
and it behooves us as leaders to support them and to help them
understand that we're here--we're here for that support and
unburdening their practice.
I want to be clear: The electronic health record is the
foundation, but it is nowhere going to get us where we need to
be if we cannot take the data, analyze it and reflect it back
to the practice in ways that are actionable, that are actually
going to impact patient care, then it will just be noise that's
out there and the physicians will get continually frustrated
and they won't be able to do what they need to do for their
patients.
So we have to develop a culture of learning, a culture of
continuous improvement and to maximize the data in a way, as I
said, that it becomes actionable at the patient level. And that
is not a small initiative and undertaking. I want to be clear
that yes, you can buy an electronic health record, yes, you can
deploy it and yes, you can teach your physicians and clinicians
to use it. But until you develop the infrastructure that can
analyze it, compartmentalize it, can stratify your patients
where you're going to need to deploy your resources in the most
critical areas, you're not going to be able to provide the kind
of care at the cost that is going to make this successful.
So I just want to caution that it's going to take time
build all that infrastructure in and my concern, and maybe
that's too strong a word, but my cautions is that we cannot
move too quickly.
I know there's a pressing urgency to move forward and I
respect that. But I also think if we go too fast and we strip
out the physicians who are already struggling with burnout--one
of my colleagues mentioned that today--this could tip things
out of balance and that would take something as wonderful as
MACRA and essentially harm its ability and its effectiveness
and I really don't want that to happen.
Mr. Green. Thank you, Mr. Chairman. Thank you.
Mr. Pitts. Chair thanks the gentleman. I now recognize Dr.
Burgess, 5 minutes for questions.
Mr. Burgess. Thank you, Mr. Chairman, and I hope our
friends at the press table were paying attention to that
discussion of Dr. McAneny and Dr. Bailet--that you all--I mean,
that was some of the most optimistic forward-looking stuff that
I've heard. The ability to use predictive analytics, the
ability to use data in real time, not 2 years later--this is
what doctors want to do and the thing that used to bug me about
pay for performances I never drove to work in the morning
saying, boy, I hope I'm average today.
No, you go to work every day and do your best work and
you're talking about why don't we make things so that they can
provide doctors the platform to do their best work and that's
enormously optimistic.
Dr. Bailet, I'm like you. I mean, I get to go talk to
doctor groups all over the country. I recognize that most of
the people in the room are my age or older and most of them, if
they're not burned out, they're very close and by the time I
finish my talk about what we're going to do in their practices
they're checking their retirement plan to see how--you know,
how many more days they have to work, not how many more years.
So this is important. We all recognize we have a
personpower problem--manpower, womanpower problem in health
care, especially in our physicians and we run the risk of
making it worse. And this is one of the things that was so
important to me when we tried to reform this.
I think, Dr. Wergin, you said--you used the phrase it takes
the joy out of practice, and I've used that phrase on the floor
of the House. Nothing pulls the joy out of the practice of
medicine like realizing your Congress is going to whack you off
at the knees December 31st every year for, what was it, 17
years.
I mean, that is--that is a joy-killing exercise if there
ever was one. So, again, this is an optimistic hearing today
and it's forward-looking hearing and I'm grateful for that.
Dr. McLean, on the--on this wonderful brochure that--is
this yours or is it Dr. Wergin's? Dr. Wergin. And, you know,
unfortunately we don't have this where everyone can see it.
But, you know, if you just run through your physician payment
time line that you've got over there on the--on the right hand
side, OK, the doctor says, I'm just not going to do a darn
thing--I'm sick of Congress, I'm sick of rules, I'm sick of
CMS--I'm not going to do a darn thing.
Well, actually you might wake up in 2019 and realize oh my
gosh, I got a 4 percent ding. Now, you didn't get a 27 percent
ding so that's an important point right there but you got a 4
percent ding and you could have gotten a 4 percent bump if
you'd just done a little.
So the important thing--the message here is for those
people who are so frustrated they will not lift a finger until
2019 and then they look across the hall and say well, that guy
got a 4 percent bump and I got a 4 percent ding--what do I have
to do so I'm in the bump and not the ding group, you can
actually start catching up then.
And the folks at Legislative Council and Congressional
Research Service and CMS referred to this as everybody gets an
A. Well, it's not quite that simple but we wanted it to be
simple and we wanted there--and I think I certainly recognize
that there was so much frustration out there that, OK, you come
at me with a hundred new PLAs--that's three-letter acronyms--
I'm not--I'm not there. I'm not going to participate.
In fact, I'm going to retire--I'm getting out. But if they
don't get out and they look around in 2019 I can go from the
ding to the bump group and it is not that hard. Many of the
things I'm already doing.
I might already be emailing a patient. I might already be
involved--engaged in performance practice enhancement
activities and so be eligible for that.
So thank you for making that kind of--I think it's just
critical that doctors do understand that yes, a lot of this
stuff is really hard in the healthcare policy but some of it's
not and some of it makes sense.
Your Mennonite stuff doesn't make sense with a meaningful
use but some of it makes sense. I will also confess to you I
used to consider myself basically a medical home for my
patients when I was in practice and I was the medical home
until the wizards at CMS with administrative pricing decided I
wasn't worth it and didn't pay me for it anymore.
So I ran for Congress and that medical home is now
abandoned. But it is that concept--let's do the things for
people that actually facilitate what we need done.
And Dr. McAneny, you talked about physician leadership and,
you know, that is so critical and this leadership has to come
from within medicine itself. It's not going to come from a
consultant. It's certainly not going to come from CMS. God
knows it's not coming from the Congress.
It's got to come from inside medicine itself. So think you
for your efforts in making certain that your constituent
members understand that and I'll leave my last second for you
to respond to that if you'd like.
Dr. McAneny. If I may, Mr. Chairman.
Mr. Pitts. You may proceed.
Dr. McAneny. The point that you made about we want
everybody to get an A is the most important point because we
can't afford to leave any physicians behind when we are facing
a physician shortage. We need to find a path forward for
everyone and we need to understand that we're not going to get
it right with the first set of regulations.
But we need to make this a rapid-learning process where
physicians can try something, not be penalized for it but to
have CMS as a partner with all of the specialty societies they
work with to be able to move forward and come up with something
that better serves the patients of the country.
Mr. Burgess. Great. Leave no doc behind, Mr. Chairman.
Mr. Pitts. The Chair thanks the gentleman and now
recognizes the gentlelady from Florida, Ms. Castor, 5 minutes
for questions.
Ms. Castor. Thank you, Mr. Chairman, and thank you all very
much for being here today. It's great to hear from folks on the
front lines who are taking care of our families and neighbors
back home.
You all sound like many of the doctors and physicians that
I interact with back home in the Tampa Bay area. They really
are enthused about the opportunities of practicing medicine and
focusing on value over volume but are a little bit concerned
about the transition ahead. So we're really going to need your
help and advice as we go along.
First of all, for all of you just a quick answer. Is CMS
being proactive with you? Are they open to your comments? I
know it's still fairly early in this. Are they--and do you
believe they have the expertise to work with you to develop
these alternative payment methods?
Dr. McLean. So thank you. Yes, absolutely. I think that
from the get-go since they rolled out the first, I guess, RFI
last fall and the ACP--at least I can speak for them--sent in I
think 40 pages of comments and question/answers and received
tremendous feedback on that. There's been an ongoing dialogue
between our organization and people at CMS, and then with the
second round of questions in the last month or two. So as with
everyone else, we're clearly very anxious to see what the final
rules are going to be because I'm sure it's not going to be
perfect.
Nothing ever is. But I think that thus far CMS has proven
to be a very willing participant in conversations as is willing
to listen and that's critical.
Ms. Castor. Do you all agree with that?
Dr. Wergin. Yes.
Ms. Castor. OK. Great.
Dr. Wergin. I would say the same, and our response is we
feel like they're listening and we respond and try to be very
specific and positive in what we would suggest and a key thing
is keep it simple and reduce our administrative burden.
Ms. Castor. And Dr. McAneny, you--in your testimony you
raise some points. The population all across the country is not
the same and you talked about how these alternative payment
methods and MIPS are going to have to be tailored for
populations.
How do you think that's going to work in areas of great
health disparities? How do we ensure that doctors are available
to take on those complex cases that are going to be especially
difficult? You wouldn't want medical professionals to be--to
have a disincentive for taking care of those populations.
Dr. McAneny. Well, I think that's very important to avoid
any of the disincentives. We need to make sure that as we do
quality measures or performance measures that they are very
useful for each individual practice.
Making a physician take time away from the patients they
serve to answer questions and fill out data fields that have
nothing to do with what they do all day takes away a valuable
resource of physician time.
What we are trying to do at the AMA is to make sure that we
have a variety of tools and recognize that this is going to
have to come from the bottom up with CMS and Congress as a
partnership rather than as a punitive entity so that when a
physician says this would be what would benefit my patients
we're hoping that when the proposed rule comes out there will
be enough flexibility in that to allow the creativity of
physicians to be tested and, if it doesn't work--and not all
the models will work--we need to have the ability then to go
back and change things without imposing penalties that threaten
the existence, particularly of those rural practices and under
served areas who are often hanging on by their fingernails now.
Ms. Castor. I agree, and I think we're going to have to be
especially mindful.
Dr. McLean, we have a very serious issue with graduate
medical education and this arbitrary cap, I think, after the
SGR the Congress, with all of your help, we have got to tackle
this doctor shortage and focus on GME as well. But setting that
aside, are we training the doctors of tomorrow to be ready for
this kind of practice?
Maybe we have been all along and then the SGR and volume
over value took its toll but what do you see as the future of
medical----
Dr. McLean. Interesting question. I think in the last
several years when you look at where graduating medical
students go into residency there has been an uptick in primary
care in medical fields.
Until that time I think some of the finances of medical
school debt and what potentially am I going to go into as a
practice situation--am I going to--you know, my income is going
to be related to what debt I have to pay was a big issue for I
think a lot of physicians and helped drive physicians away from
some of the primary care specialties which tend to be lower
paying in aggregate.
I think that the SGR being removed takes that cloud away
somewhat. Is it going to drive, you know, a real difference I
don't know yet. At the same time, I think people who go into
medical care now are going into it really for the right
reasons.
They know that it's a complex field and it's remarkably
complex and they want to take care of patients, and in some
cases I think there's much more education on systems and big
data and how do you fix populations. Population health is
really a new concept in the last 5 or 10 years and I think
there's a bit more education about it at medical schools. So I
think that they have a better sense of what they're going to
need to deal with going forward.
Ms. Castor. Thank you very much.
Mr. Pitts. The gentlelady's time has expired. The Chair now
recognizes the vice chair of the subcommittee, Mr. Guthrie, 5
minutes for questions.
Mr. Guthrie. Thank you. Thank you all for being here, and I
met with a group--a physician group yesterday and they were
asking a lot of questions about alternative payment models and
so forth, and my point to them was if--you know, if a few dozen
people or so sit in Washington, DC in a room and design all of
this it's not going to be successful. It's got to be from
physicians up--from practitioners moving up so that we can take
it into account.
So this panel is important and I appreciate the opportunity
to have you guys before us and eagerly look for your input as
we move forward because that's how it's going to work.
But we're also eagerly awaiting the proposed rule but I
want to know about the proposed rule what are you guys most
excited about? I'll just open it to the panel. I'll start to my
left and start with Dr. McLean. What are you the most excited
about by the opportunities that MACRA offers?
Dr. McLean. You know, I think to echo what Dr. Bailet said,
I think the idea that we can take a lot of data that's been
floating around out there that we've been collecting in many
ways and actually make it actionable incentivize is extremely
exciting.
There's a lot of information on clinical guidelines that
come out of there. Sometimes they changed from week to week,
depending upon the topic and the organization that puts it out
there.
But physicians are confused--do I need to follow this or
not. But clinical guidelines are a part of clinical practice.
There are clinical measures that have been out there.
Some are good, some are bad. How do we use them? If those
kind of elements of clinical practice and trying to improve how
well we can deliver high-quality care can be systematically
kind of put into a situation where doctors are incentivized to
use this data well.
The electronic records that to some extent are almost a
necessity are configured to use those elements well we can make
a part of daily flow--work flow--and patients' care will be
better and more reliable and safer and physicians will be
happier because they're not checking off all these boxes just
because CMS told them to. There's actually a rhyme behind the
reason and it's been missing that up until now, I think.
Mr. Guthrie. OK. Do you want to add? That was a pretty
comprehensive answer but we'll--go ahead, I'll let you guys----
Dr. Wergin. I would just say personally and for my members
we're excited about the opportunity to value primary care
appropriately which hasn't always been done and it was
mentioned we need more primary care family physicians across
this country in any setting--urban, rural, under served--and
that's an opportunity that finally moved us up to the plate.
We're excited about transforming our practices to patient-
centered medical homes whether they be in the MIPS or APM
models because our studies show that the physicians are
happier.
They're there to see patients, not click boxes, not try to
meet all these arbitrary guidelines or requirements, and I
think that's what team-based patient-centered medical home can
do.
So I think valuing primary care more appropriately will
give us resources to think outside the box, not face to face
care all the time--all the other parameters that we can use. So
we're excited about it.
Dr. McAneny. Thank you for that question. Personally what
I'm most excited about is that a week and a half ago my
practice was selected to participate in the oncology care
model, which is one of the, hopefully, alternative payments and
we're one of ten practices in the country that's certified as
an oncology medical home. So I'm hoping that the proposed rule
will come out and say yes, that is an alternative payment.
I'm also very excited about the idea that electronic
medical records will become interoperable so I can share data
with other people who are taking care of my patients without
having to fax records back and forth and to be able to use the
alternative payment from the oncology care model to maybe be
able to hire a social worker.
I haven't been able to afford a social worker. Or perhaps a
dietician to help my patients or nurses to have more time to
spend educating patients about their choices.
So I think what I see in my own particular practice will
translate very well across the country and the AMA is going to
work very hard with all of the specialty societies to find
models that can make them as excited about what they're doing
as I am about what I'm doing.
Mr. Guthrie. OK. So let me ask another question. We'll
start with you, Dr. Bailet, and we'll work back the other way
this time.
So when we passed MACRA we envisioned it as a means to
provide greater flexibility for physicians and not impose new
burdens. Can you speak to the current burdens associated with
quality programs in your practices and how you believe MACRA
can lower the administrative burden while focusing on quality?
Dr. Bailet. I think my colleagues will agree there's so
much repetitive reporting, overlap, gaps. It's incredibly
burdensome on the reporting today and I'm hopeful that in--you
know, hopeful that the legislation will address that going
forward.
I think that that's one of the biggest pieces and also how
we engage the physicians with the reporting. I mean, there is
in my own practice to some degree there is--there are gaps and
disconnects where the reporting is a little down field.
It's not direct line of sight. So physicians want to do the
right thing and we have to provide the information to them in a
way that allows them to make changes that are relevant in the
moment.
And I would say that our current system doesn't allow us to
do that. I know you changed your question but I had an answer.
Mr. Guthrie. Go ahead.
Dr. Bailet. But it's 0K----
Mr. Guthrie. Yes, as long as the chair----
Mr. Pitts. Go ahead.
Dr. Bailet. I think MACRA has the opportunity to unleash
innovation. We are essentially going to transform the care
delivery. This is a very single moment in time where we're
going to make an impact and rally physicians and clinicians
around giving them ways and tools to better manage their
patients and provide and reflect back to them results that
actually make a difference.
And we need to create the aura of desirability at a
national level where it becomes group agnostic. The best
practices, once identified, need to get pushed out quickly and
I think these incentives will help foster that. So that, to me,
is one of the most exciting things about the position that
we're in now.
Mr. Guthrie. Thank you. I do have more questions but I'm
out of time so I'll yield back.
Mr. Pitts. The Chair thanks the gentleman and now
recognized the gentleman, Dr. Schrader, 5 minutes for
questions.
Mr. Schrader. Thank you, Mr. Chairman. Interesting panel
and interesting discussion. It is nice to hear a fairly upbeat
panel in front of us these days and you're at the ground zero
for making this whole thing work and I guess our job is to
hopefully help you that way.
A question--doesn't matter, Dr. Wergin, I guess--how to the
incentives, in your opinion, on MIPS and the APMs align in
terms of the dollar value?
Dr. Wergin. Well, I think one of the things we supplied to
CMS is if you base your quality payments or your value-based
payments on the old fee for service world, we were relatively
under valued. So we hope that they won't use those criteria--
the complexity and intensity of visits we have.
But in general, I think we're not afraid to be--step
forward and have that comprehensive coordinated care piece that
we do and I'd be remiss if I didn't mention quality measures.
When I have diabetics come into my practice and say what
should my numbers be, doctor, I have to ask them what insurance
do you have because if you're Blue Cross, it's this--if it's
United Health Care, it's that.
Huge opportunity for MACRA to say these are evidence-based
standardized guidelines. Then I know what the field is like and
can get them there.
Mr. Schrader. So who decides the quality measures that
are--how much do the physicians or other medical providers play
into that?
Dr. Wergin. Well, again, it goes back to the payers and I
think CMS has had a collaborative group, said 21, not 165--
that's the other thing that can be great.
Usually in my area with six or seven different plans,
payers, it's set by the payer and there is physician input in
that but they vary slightly, each one. So you can be a prime
five-star physician in one and a one-star bum in the other,
just depending on where you're at and how they set their
parameters.
Mr. Schrader. So Dr. McAneny, is there--is there a form
right now for medical providers to share in ways to succeed
under a MIPS or APM model?
Dr. McAneny. I don't think we have a--set up a forum for
that. But one of the things we're trying to do both through our
innovators committee and through the AMA network of physicians
working with all the specialty societies is to try to do some
rapid learning and bring some of those forward.
Mr. Schrader. I think it would be a good idea to make sure
folks could share and, you know, hey, I'm on--I'm doing the
MIPS thing and here's how I succeed--here's--I'm going APMs and
here's a way you could succeed there.
You know, a lot of--to your guys' points these are small
business men and women just trying to, you know, keep their
practice open in addition to practicing great medicine and so
they're going to need some help. Their practice managers,
hopefully, would be able to access some of the--some of the
data.
Dr. Bailet, with regard to EHR, I mean, I hear a lot of
conflicting things when I go back home from my medical
community. It's yes, it's really good--we're getting into that
interoperability or geez, it's terrible--I can't get my lab
report to speak to my physician office, you know, and my--I
come from Oregon.
In my State it's all pretty much Epic and so I'm totally
confused as to if we're winning or losing on the EHR front. And
then to your comment, you know, the feedback to the physician
or to the office--maybe it's not the physician, maybe it's the
practice manager about hey, you know, I'm reading all this
stuff and it looks like if I treat this pancreatic patient this
way, based on national data that we've helped supply, is that
stuff out there or is that the stuff you're talking about
hopefully will come?
Dr. Bailet. Well, I think it's embryonic. I mean, it's
coming on but it is not ubiquitous across the system right now.
I think that, you know, electronic health records are not
perfect and no one has quite figured it out.
Epic, obviously, comes from Wisconsin. We transitioned. We
were Cerner's largest client in the United States. We had
deployed it fully across our system and we decided after 20
years it did not give us the lift that we needed going forward
and we changed it out, $300 million later.
That is no small undertaking and I do believe there's not a
CPT code that you can charge for changing out your EHR.
Mr. Schrader. Probably not.
Dr. Bailet. But we believed, again, that's just the
platform. So, yes, there are predictive analytic models out
there and I'm not advertising for one versus the other.
But they're just beginning to demonstrate the power and,
again, approaching the diseases that matter. So heart failure,
COPD, diabetes--these are the diseases where a lot of funds are
being expended on behalf of our patients and I know a lot of
our conversation has been talking about the financial piece.
Obviously, that's important. But I think we cannot--we
cannot minimize the impact on really transforming patients and
what we were able to do at Aurora by changing their health
status.
So they were going down a track of outcomes. We were able
to take them off that track and improve their health status
which, again, that's where the predictive analytic tool
provided us the insights to be able to do that. That is
significant.
Mr. Schrader. Excellent. I yield back, Mr. Chairman. Thank
you all very much.
Mr. Pitts. Chair thanks the gentleman and now recognizes
the gentleman from Indiana, Dr. Bucshon, 5 minutes for
questions.
Mr. Bucshon. Thank you, Mr. Chairman. Thank you for holding
this hearing. Thank you all for being here.
I was a healthcare provider before and a heart surgeon, as
probably many of you may or may not know. I trained at the
Medical College of Wisconsin in Milwaukee, which Dr. Bailet is
familiar with.
Dr. Bailet. Yes. Yes, I am.
Mr. Bucshon. I'm going to make a couple of things--first of
all, just to remind everyone, you know, provider reimbursement
is about 8 to 10 percent of the overall healthcare dollar.
Obviously, MACRA was really--is extremely important but
getting it right is even more important. But I think it's
important for the American public to know that we still
continue to have cost challenges in our healthcare system and
addressing things at the provider level is only one part of the
equation.
That's where, you know, I hope we're not talking about a
zero sum game when it comes to specialists and primary care
because primary care clearly has been under valued in our
system.
That said, also as a specialist I can say that, you know,
specialists are also very important. And so if we end up doing
this very--this poorly where we address this as a zero sum
game, resulting in provider reimbursement cuts for quality care
depending on what type of medicine that you practice, the only
thing that's really going to result is access issues for the
America's seniors because of the--what I said earlier. It's
only 8 to 10 percent of the overall healthcare dollar. That's
why these hearings are extremely important.
So since I trained at the Medical College of Wisconsin I'm
going to ask Dr. Bailet----
Dr. Bailet. I knew it was coming--a question.
Mr. Bucshon. No, I know you're not testifying on behalf of
this, but you were selected to chair the Physician Technical
Advisory Committee, PTAC.
Dr. Bailet. Yes.
Mr. Bucshon. Can you just kind of go over and explain
briefly to the committee what you perceive as the role of
PTAC---
Dr. Bailet. Sure.
Mr. Bucshon [continuing]. Why you wanted to be part of it,
and what role you think it's going to play in development of
physician-led APMs.
Dr. Bailet. So PTAC was set up to be an independent
advisory committee that advises the secretary of HHS on
alternative payment models specifically related to physician-
focused payment models.
The committee started in January. We had our first public
meeting in February. We have our second public meeting in May.
As the chair, my goal is to because, again, the rules have
not been released so the activities of the committee we are
functioning and spending a lot of time familiarizing ourselves
with each other because this committee needs to work at a high
level.
We're also right now creating bylaws and rules of
engagement so that when the rules are out we will be prepared
to start looking at model proposals straightaway.
One of the areas that we're working on and we're looking at
stakeholder input right now is what is the scoring system the
committee is going to use to look at models--what are we going
to look at as it relates to important elements--what weight
will those individual elements get.
We want to be able to have a transparent process that the
stakeholders have input into developing with us but more
importantly that they understand when they're submitting models
that the process for submission is streamlined, they know what
needs to be in their models. We're going to provide assistance
as best we can for select submitters and, again, we're
advising.
If you ask me 2 years from now what would I consider a
success for the PTAC committee it would be that the committee
has the level of credibility with the stakeholders but also the
secretary and our recommendations have a high level of
influence and we are willing and able to put together
recommendations for models that in fact CMS will see the merits
and undertake them.
Mr. Bucshon. That's great, and I had a conversation with
CMS earlier this week about the RUC recommendations on provider
reimbursement and I also spoke to them about PTAC and my hope
would be as exactly as you say is that the recommendations that
you're going to be creating in a very thoughtful and fact-based
process, through a thoughtful and fact-based process we'll be
taking into serious consideration in contrast to sometimes RUC
recommendations on provider reimbursement which seem to mostly
be ignored.
So developing these APMs can be a--I don't want to
necessarily focus on you but this--but I have this question for
you. It can be very difficult for small specialties in diverse
skills and medicines.
Can you maybe--and anyone can discuss this--can you discuss
the challenges with that and how PTAC might be able to engage
in that discussion to help smaller practices and, you know, we
talk about rural communities and others developing and
participating in APMs.
Dr. Bailet. Well, I'll be brief and let my colleagues also
answer. The PTAC needs to be reflective of the fabric of the
United States and the care systems that are delivered from
rural communities.
We have communities in Wisconsin of towns of a thousand
that we have to provide care for. So we need to as we look at
models make sure that it's inclusive of the population that
we're trying to treat.
So yes, there will be large metropolitan communities and
specialties that can put forth models but we also have to make
sure that the elements of the model as we weight them reflect
and respect the smaller communities and allow them to
participate and----
Mr. Bucshon. My time has expired so----
Dr. Bailet. Oh, I'm sorry.
Mr. Bucshon [continuing]. And I appreciate that input, and
I would just reiterate that we do have to make sure that all of
our communities are included. Thank you.
Mr. Pitts. Chair thanks the gentleman and recognize Mr.
Cardenas, 5 minutes for questions.
Mr. Cardenas. So thank you very much for enlightening us
with your information, and hopefully we'll learn more about
what's going on in the streets and corridors of your side of
the world.
But in a nutshell, if you could please expand on at least
one example of how we could make sure that what is going on is
being implemented for the benefit of our constituents, maybe
some things that need to be clarified or at least one example
of what we can help you do better.
Dr. Wergin. I could start off. The one area that I think
it's interoperability of electronic health record, and again,
being a rural family physician that treats children to adults
who sometimes or in other urban ERs I get 18-page fax notes
from an ER that I have to go in and ask the patient why did you
go to the ER and what did they do--I can see your mother was of
Mediterranean descent but I don't think that's why you went to
the ER. There's lots of information there. It's faxed into my
record, making it nonsearchable.
So I think one thing we could do is set a platform to push
the vendors to say you have to have some level of
interoperability that it will help me take care of your mother
or your child when I have to coordinate that care, and that's
important.
And one other point I'd make, if you look at Medicare
expenditures 1 percent costs 23 percent, 5 percent costs 50
percent, I think the rule of thumb there is don't let them get
in the 5 percent or 1 percent. That's my job.
Dr. McAneny. I would add to that that one of the concerns
that we have is what is nominal risk and defining nominal risk
in such a way that I as a small practice managing physician can
cope with it.
For me, since I am not an insurance company, I do not have
reserves. There's other types of risk besides financial risk.
If I hire a new employee I'm guaranteeing a salary and
benefits.
To me, that's financial risk. If I'm leaving gaps in my
schedule for same day patients to me that's financial risk. So
one thing that Congress in particular and this committee
definitely can help with is to let CMS work with us for that
understanding of risk and also let practices as they develop
their measures give us a chance to try that.
Help us along with what we need to learn from the PTAC and
from the AMA and from other organizations so that we can try
things. Some of it won't work but don't put us out of business
if it doesn't work because then we can't serve the patients in
that community.
Mr. Cardenas. So we're not--just so the people watching on
SPAN are clear, you're not talking about trying things that
puts the patient at risk--you're just talking about
administrative aspects of how to be more efficient and do a
better job?
Dr. McAneny. I apologize for that. You're absolutely
correct. New structures of care--if we try a specific team
approach if it doesn't save money but it delivers better care
we don't want that one thrown out, the baby with the bath
water.
Dr. Bailet. Yes, I would agree. I think the flexibility is
absolutely key that things like the definition of what's
nominal risk that may come out in the proposed rules but I
think that's a big uncertainty--what does that mean--and I
think the goal is to broaden the appeal of this to different
size, different geographic area so that everyone can be trying
to do this right.
But it's going to take some trial and error in some ways in
terms of how physician practices do it. Clearly, we don't want
any sort of risk to be at the level of the patient.
mean, there are other things where I think things need to
be done well and carefully and thus far CMS has done, I think,
a good job of getting our organization's input on how to do it
right but things like patient attribution, risk adjustment--
those are really complicated concepts and I think it would
really frighten physicians if they thought that bureaucrats in
Washington were making those determinations and not the
physicians who actually understand that a bit better.
So I think really kind of making sure that CMS is going
through that process the right way with the appropriate input,
which they've done so far, is probably one of the most
important things that you guys can do.
Mr. Cardenas. In the interest of time, I would love to hear
more dialogue but my time is winding down. But how many of you
have had the opportunity to personally get to know how health
care is delivered in another country? So if you have, please
say yes. If you haven't--it's not a criticism. I'm just curious
because a lot of Americans think that we're embarking on models
and practices that nobody in the world has ever done and I
don't think that's true.
Heaven forbid we would admire another country for what they
do. We wouldn't do that as Americans but have any of you
actually been to another country in the healthcare space and
got to see what they do? Yes or no.
Dr. Bailet. Yes. Yes.
Mr. Cardenas. Yes? One? So two yes, two no. Well, in the
interest of time, a million more questions but not enough time.
But thank you so much, Doctor, Doctor, Doctor, Doctor. Thank
you.
Mr. Pitts. Chair thanks the gentleman and now recognizes
the gentlelady from North Carolina, Mrs. Ellmers, 5 minutes for
questions.
Ms. Ellmers. Thank you, Mr. Chairman, and thank you to our
panel. I'm going to follow up on the gentleman's line of
questioning because I was going to ask about nominal risk and
how we should be best defining and in your opinion--and this is
going to go to the entire panel--on some more of this
discussion because I think this is very, very important,
especially for individual physician practices.
You know, we sometimes take the hospital setting which,
obviously, has a little bit more ability to incorporate and
utilize those resources for a better product where our
physician practices, you know, really have minimal resources to
dedicate.
So, one, you know, and it goes into the discussion of
interoperability. That has to be part of what is considered in
that risk as well, I believe.
So I look at risk as how are we able to better empower our
physician offices to be able to--to have that ability to share
information, one, the infrastructure itself, the HIT--the
health records themselves and establishing the personnel.
And this is kind of that conversation that we've been
having now for a couple of years and the promises that were
made initially that, you know, we were just going to go through
this learning curve and everyone was going to be in a better
place obviously has not taken place yet and it's very difficult
for our physician offices, especially with all of the other
rules, regulations, changes in health care that have taken
place.
So I guess I just want to hear a little bit more
conversation from all of you on what we do need to be doing
here in Congress to help all those things, especially when it
comes to the interoperability.
How can we help physician offices to be able to have that
knowledge on that patient when they come to the office after
being seen in the emergency room? How can we make sure that
that information is being shared and how can we better help our
physicians to incorporate that as the risk that they're
assessing?
Dr. McLean. So I think that the interoperability is,
obviously, a big issue and I think has been one of the
frustrations that even as physicians have gotten into
electronic health records they can't access data elsewhere, and
what I'd mentioned earlier--big data.
You know, part of big data is big data at the small
practice level and what do I need to access and my patient, who
was at an ER at another part of the State. But then there's
also the big data of if in fact my practice small or large is
looking at my population of patients and my population health,
which is kind of whole other concept when you're looking at
trying to deliver good care, making sure that, you know, all of
my diabetics have X, Y and Z done because there are people that
fall between the cracks.
And until you're able to look at big data and have the
analytics to do it you don't even know that. Everyone thinks
they're doing a great job until they actually look at the data
and they realize that there are things that they're missing
despite their good intentions.
So interoperability is key to that and I think that while
there are different State initiatives that have tried to break
down some of those barriers I think at least in Connecticut it
has not worked well.
There was kind or a commission that was trying to do it. It
just didn't happen. I think other States have done it very
successfully. I think Rhode Island in particular, if I can
think of one.
But I think a Federal guide to making interoperability
happen because people need care across State lines. So even if
you have rules in one State, it's not going to necessarily, you
know, work.
So it's really incredibly important to allow for
accessibility of data for direct patient care but also for the
big picture of big data analytics and data management when
you're looking at trying to take care of your population of
people.
Ms. Ellmers. All right. Thank you.
Dr. Wergin. I had a comment about the virtual risk and,
especially, again, being in a small practice, which, you know,
there are actuarial pools of patients, but if you're in a
small, limited area or geographic, you can do it with virtual
groups to get larger numbers of patients.
But how do you define what the nominal risk is for that
pool, and that comes down also to the attribution process. We'd
hope it would be prospectus--that we know what patients were.
In primary care we're responsible for and set up treatment
plans and ahead of time rather than how it usually is. You get
a list of patients and say who are these 10 people--I don't
even know who they are.
So we need to know that, but a way to make these smaller
practices pull together if that's how they're going to define
nominal risk.
Dr. McAneny. A couple ideas that I would love to throw out.
One is that a lot of States have tried to create health
information exchanges yet some of the big institutions put
walls around their data so that they can keep the patients to
themselves and not let them go elsewhere.
Those walls need to come down so that we can take care of
patients wherever the patients want to be taken care of.
The law of small numbers concerns me a lot in the
attribution. If my primary care colleagues happen to have 10
patients with cancer that year instead of the 5 that they
thought they would and my expensive drugs become attributed to
them, they will have a problem in trying to be compared fairly.
So we're very concerned about being able to have good
attribution and that's still a science in its infancy. And the
other thing that will help a lot is if we can get Medicare
claims data back to us in a timely fashion because if I can see
a problem and I can figure out a way to fix it, that gives me a
lot more ability to take care of patients than if I learn about
something 2 years later when I don't even remember or have any
idea what I did right or wrong.
Ms. Ellmers. Right. Absolutely. And I do want to add to
your comment about, for instance, patients with cancer and, you
know, the smaller practice because I know that, you know, CMS
is proposing some more changes to Medicare Part B drug
reimbursement and that is going to play in--and just there
again if you don't mind commenting.
I didn't really want to go into that aspect of this because
it kind of gets into the weeds. But how do you think that plays
into this conversation that we're having today? Do you agree
that it'll become more difficult I guess is what I'm asking.
Dr. McAneny. Well, we didn't come here to talk about the
ASP changes so I'd be happy to talk with you offline about that
issue. But yes, it's very important to us.
Ms. Ellmers. And we will follow up with you on that. Thank
you.
Dr. McAneny. I will.
Ms. Ellmers. Dr. Bailet.
Dr. Bailet. So I concur the interoperability is a problem.
I think that feedback so the CMS is going to be tasked with
providing real time feedback on profiles of their effectiveness
particularly in the MIPS and alternative payment models.
So I, again, fundamentally believe, having led physicians
for a number of years they want to do the right thing and they
will respond to data that is meaningful and when they look at
it it says, you know, this reflects my practice.
So that feedback is going to be important. So getting
access to the claims data but in a way where, again, it's real
time and it can make a difference. If it's too far out of line
of sight the impact is going to be limited. So I think in the
interests of time I would stop there.
Ms. Ellmers. Well, I just thank you so much and we went way
over and I ask apology from the chairman. But thank you and
thank you to the panel.
Mr. Pitts. Chair thanks the gentlelady and now recognize
the gentleman from Missouri, Mr. Long, 5 minutes for questions.
Mr. Long. Thank you, Mr. Chairman, and I am not a doctor
but I did play one on the--play one on the radio for several
years and I remember my first trip to my doctor on one of my
semiannual visits after the passage of some call it Obamacare,
others call it Greencare.
But we--from somebody from Texas it's hard not to get the
word out. But on that visit to the doctor right after Obamacare
had passed I thought I was going to have to prescribe him a
blood pressure medication because he said--at the end of my
visit he said, you sit right there--he said, you're going to
sit there and I'm going to turn around and I've got to enter
all this into the computer.
He said it used to be--remember what used to happen? He
said, I'd send you out and you'd get your next visit and you'd
be out of here, but you sit right there while I enter this.
He was several years from retirement age, and he retired
about six months after that. Such as my district director's
doctor also retired. I could go down the laundry list of people
that have retired--doctors that have retired.
And I do have something in common with the author of this,
Mr. Green. Both of us have daughters that are doctors, and my
daughter is a pediatrician who's in her first year--wrapping up
her first year of residency.
So I'm sure the young doctors out there as my daughter is
coming on want to know what's going to be out there in the
future.
So with that being said, Dr. Wergin, you bring several
unique perspectives to the panel. Can you describe some of the
specific challenges of practicing in rural areas?
I have a lot of rural areas in my congressional district
and the pressures providers in similar situations face to
remain in practice like my doctor.
Dr. Wergin. Yes, I think the rural providers that I
represent and I represent personally--I am one--that you have
limited resource. Mental health services, for one, are tough.
That's where telehealth might be able to help us. But we need
infrastructure to do that.
I mean, they don't do it. But really finding the resources
in your communities and identifying them and you have to be
in--meaning using church groups. I use church groups for people
that run out of food and it's kind of nice because I don't have
to give them 5 years of tax forms and all that. I just call the
minister and say, this lady is out of food. So identifying
resources in my rural areas and the challenges there.
The other thing is burnout. Your patients love you and they
almost love you to death. In primary care, our care is
delivered. We're a continuous time in a relationship,
tremendous confidence in my care.
Sometimes I even have trouble getting patients to go to
other providers and like Dr. Bucshon--they say, well, can't you
put my new aortic valve in, Dr. Wergin, and I have to say no, I
got to draw the line somewhere on comprehensive.
So I think that relationship-based care, and then I think
the other thing we see is how do you recruit people--the
millennials into rural-based care and in rural States I'm sure
you face that is how do you--debt relief, there's carrots out
there you can give them but who's going to take my place, et
cetera.
But the resource utilization you have, especially care, is
usually miles away but they're great in creating that and
systems like in Wisconsin are a way to do it.
But it's a rewarding career but we have to sell that to the
medical students and mainly their wives because they're going
to move to a rural area.
Dr. Bailet. Or husbands.
Mr. Long. Dr. Bailet, in your testimony you discussed
challenges faced by small, solo and rural practices also. Can
you speak to your efforts to provide these critical access
points of care with tools they can utilize to succeed,
particularly through your clinically integrated network?
Dr. Bailet. Yes. In these smaller communities we
philosophically believe the care is local and should be
delivered locally as best it can. But there are times when
patients have to leave these smaller communities to get
specialty care.
So we spend a lot of time making sure that the physicians
in these smaller towns and clinicians, because it's not just
physicians, have the resources--the support of a larger system.
We try to create virtual outreach. So we have TelePsych,
for example, that we're offering these physicians. Again, for
them to want to go into smaller communities they don't want to
be an island.
They want to be connected to the physician community at
large because, again, they want to have these assets for their
patients.
So the more we have these interconnected points with our
patients whether it's TelePsych or we have TeleStroke, we can
bring those attributes out to the community so these physicians
in smaller communities feel like they have a team behind them
to be able to manage the patients.
And yes, there are times when you have to convince the
patients to leave the community for their care. But we work
very hard to return those patients as soon as possible, again,
with that electronic record, with that team support so that the
physicians who are treating these patients feel like they have
a safety net to be able to manage them if there's a
complication or additional questions that come--that come up.
Mr. Long. OK. I think I'm out of time so if I had any I'd
yield it back.
Mr. Pitts. Chair thanks the gentleman. That concludes the
question from members present. We're going to go to one follow-
up per side. Chair recognizes Dr. Burgess, 5 minutes for a
follow-up question.
Mr. Burgess. Thank you, Mr. Chairman. This really has been
a wonderful panel. I do feel obligated to mention since
interoperability has come up so much this morning that yes,
part of the effort in passing the H.R. 2 was to deal with that
but then a larger effort is--has been included in H.R. 6, which
was the Cures for the 21st Century and that bill, of course,
passed the House last summer and is pending before the Senate.
So please don't think we've taken our eye off the ball on
interoperability. It remains an important marker to achieve.
Dr. McLean, let me just ask you, and you all have been very
thorough in your testimony today. But I'm always struck in
dealing with the stupid SGR that it was the update adjustment
factor that really did violence to doctors.
Now, that's the conversion factor. You talk about every
doctor gets their own--can create their own conversion factor.
And at the risk of being too wonky, can you kind of go through
that at a high level so our friends in the press can get that?
Dr. McLean. No, no. I thank you very much. I'm very happy
to answer that question. So I'm not certain how wonkish some of
the committee is.
But when the Medicare physician fee schedule is calculated
on a fee basis--you know, it's fee for service--there is every
item, procedure, office visit, E&M code--evaluation management
code, as we call it--has an RVU--relative value unit--kind of
number and this is what the RUC works on, kind of changing and
calculating year to year.
And that number, that RVU, is multiplied times a conversion
factor every year to end up giving you kind of the dollars per
visit for a--whatever.
And that conversion factor was changed--I mean, so with the
SGR, depending upon what the SGR kind of kicked out as what the
adjustment should be, that conversion factor for every
service--physician service was cut by a certain percentage to
begin with and then because the can got kicked down the hill it
kept going--growing and growing. So it was, whatever, 28
percent in the--at the end.
And so now it's effectively--the conversion factor will be
individualized based upon, for example, their MIPS score. So
it's tremendously empowering to physicians to kind of think
that if I'm actually doing a better job in some of these
various quality measures and things, I will be judged myself
for how I did.
And I think when we talked about burnout a little bit I
think one of the--one of the factors of burnout in addition to
regulation and trying to deal with EMR and other changes is
that financial anxiety and the fact that now at least they have
control over that anxiety I think is huge.
Mr. Burgess. What is the--you know, we talk about things
being iatrogenic in health care. What would be the
congressional equivalent of that? Because the anxiety--much of
the anxiety that many of you have spoken about this morning was
actually generated by Congress or the agency.
It wasn't directed--it wasn't generated by physicians or
the practice of medicine. There's enough anxieties in the
practice of medicine but we generated anxieties here.
Dr. Bailet, let me just ask you a question on that. We kind
of covered some of the stuff with the physicians technical
advisory committee.
But can you give us perhaps a bit of a sense of how this
compares and contrasts with the Center for Medicare and
Medicaid Innovation that was also--is also one of the things
that's been visited upon physicians?
Dr. Bailet. The CMMI?
Mr. Burgess. Yes.
Dr. Bailet. Yes. So I think that the work that was done
under CMMI was sort of planted the seeds of innovation and
those kinds of models and our care designs that came out of
that I believe they're going to be contributing to the
innovation that's injected into the models that the PTAC will
consider. I'm hoping I'm answering your question.
Mr. Burgess. Well, I guess the one philosophical difference
that I see, CMMI is driven by the agency and it may or may not
make sense to the practicing physicians.
PTAC is driven by docs.
Dr. Bailet. Yes.
Mr. Burgess. And my hope is that that will make sense to
the practicing physician. Is that a fair assessment?
Dr. Bailet. Yes. It has to.
Mr. Burgess. OK.
Dr. Bailet. And I think that I've heard and I can say--
speak for the committee to the individual level that is
absolutely paramount and that is--that is the desire of this
committee.
Again, we respectfully understand that it is an independent
body and an advisory body but absolutely, and we are--we are
doubling down on our efforts to listen to the stakeholders and,
frankly, our output is to some degree--to a large degree going
to be as good as the input of the stakeholders as they come
forward.
Mr. Burgess. Much of this--as the bill itself was into the
development stages, stakeholders, especially groups'
physicians, would come to us and say we've been doing this for
a while and we think this is a good idea.
But we've got no way for CMS to--no way to bring it to CMS
and have them evaluate it and incorporate it. And now PTAC
actually provides that avenue and, importantly, if it's not
accepted people have to be told why it wasn't accepted and my
hope is that will give them another opportunity to impact it.
Dr. Bailet. Resubmit. Right. Again, that is our plan, to
come up with a blueprint for people to be able to follow and to
provide advice and guidance to allow resubmission if there are
challenges or potential weaknesses with their proposals.
And, again, we want to be as comprehensive and transparency
is key here to make sure that once we get the feedback from the
specialty communities and the other societies that we develop a
model that is transparent and anybody wherever they are,
wherever they are in their readiness and abilities can look at
this and say look, I want to participate--I want to create a
model and they have--they have the blueprint that then they can
apply their potential proposal in order for the PTAC to
critically evaluate it, and right now we are right in the
middle of that--developing that process of analysis.
Mr. Burgess. Great. That's the right answer. It gives me
great peace.
Mr. Chairman, I would just say after well over 10 years on
this subcommittee one of my fondest wishes was to come in here
someday and have a panel of doctors tell us how much economists
should be paid. So if you all want to respond to that in
writing I'll be happy to listen.
Mr. Pitts. All right. The Chair thanks the gentleman and
now recognize Mr. Green, 5 minutes for questions follow-up.
Mr. Green. Thank you, Mr. Chairman.
Dr. Bailet, you brought up the potential impact of MACRA to
transform patient care. Can you describe how you can see the
APMs are beneficial to the--to the patients?
Dr. Bailet. Well, I mean, these models are--the
underpinnings of these models are to impact patient care to
provide high-quality care, enhanced patient care, obviously,
with smarter spending.
But the elements in the models will be--the underpinnings
will be moving the quality spectrum forward to make sure that
that outcomes, and that really is the point of the round here
is the actual outcome.
You know, there are--there are metrics A1C--there are
targets that we--that we strive for as a practice. But I also
think what these APMs will be able to do across populations is
actually look at outcomes, not just the fact that the diabetic
patient has an A1C less than seven but what are some of the
other parameters of their functionality, some of the other
morbidity and mortality associated with the disease--what are
we actually changing their health status and being impactful
and I believe the APMs will allow us to do that.
Mr. Green. Any of the other panel?
Dr. McAneny. Yes. I would like to add on that on a very
personal experience because in participating in my oncology
medical home process we've had--in order to have that money
from the innovation center come to us to be able to allow the
practices to spend money on nurse educators who could teach
patients what's going on, nurses doing triage on the phone.
We brought patients in, 15 to 20 same-day visits every day.
We cut the rate of hospitalization for cancer patients by over
half.
Patients were thrilled to be able to see us on the weekends
and on the same day that they needed to see us. And so it was a
very immediate way that we were providing patients because of
this APM with the care that they needed when they needed it and
where they could get it at a lower cost.
Mr. Green. Dr. Wergin.
Dr. Wergin. I just had a brief comment. Moving away from a
face to face volume-based system to an APM will give you the
resources that is focused on the patient and the patient-
centered home it starts with the name patient, and that's what
it means.
You focus on the patient, the care they need, when they
need it and that's been addressed. So I think APMs can move not
to just save money because I'm interested in that--more
importantly, I want to improve the health of the community I
live in.
Dr. McLean. I was just going to add I think that moving--
the APMs incentivize physicians and physician groups to get
into kind of systems or affiliations that allow them to, as I
mentioned before, to deal with big data, and that big data is
not just seeing how many people, you know, got their A1C done
in six months.
But it's looking at well, the people who didn't what's
different about them--what happened--why is this group of
people not getting, you know, diabetic foot exams.
It allows people to kind of intervene and make a difference
in health care, and when you're in small kind of groups
sometimes you don't have that big data to do and as I say
people fall between the cracks and you don't even realize where
the system is failing a lot of our patients.
There's less duplication, which saves money.
Interoperability helps with that. I mean, it just--it aligns
very many things into one kind of direction and that's really
one of the major things we've been lacking.
Mr. Green. OK. Thank you, Mr. Chairman. I yield back.
Mr. Pitts. Chair thanks the gentleman. That concludes the
follow-up questions. We will have other follow-up questions in
writing that we'll send to you and other members who aren't
here will have some questions.
We'll ask you please to respond promptly. I remind members
they have ten business days to submit questions for the record
and that means they should submit their questions by the close
of business on Tuesday, May the 3rd.
Excellent hearing, very thorough testimony. Really exciting
and optimistic hearing today. We'll monitor closely this
implementation. This is the second hearing. We will have more.
We look forward to working with you. Thank you very much
for coming and presenting your testimony and sharing your
expertise with us.
Without objection, the subcommittee stands adjourned.
[Whereupon, at 12:08 p.m., the hearing was adjourned.]
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