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









                   THE IMPLEMENTATION OF THE MEDICARE
                   ACCESS & CHIP REAUTHORIZATION ACT
                            OF 2015 (MACRA)

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

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

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 11, 2016

                               __________

                          Serial No. 114-HL07

                               __________

         Printed for the use of the Committee on Ways and Means




[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]












                        U.S. GOVERNMENT PUBLISHING OFFICE 

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                      COMMITTEE ON WAYS AND MEANS

                      KEVIN BRADY, Texas, Chairman

SAM JOHNSON, Texas                   SANDER M. LEVIN, Michigan
DEVIN NUNES, California              CHARLES B. RANGEL, New York
PATRICK J. TIBERI, Ohio              JIM MCDERMOTT, Washington
DAVID G. REICHERT, Washington        JOHN LEWIS, Georgia
CHARLES W. BOUSTANY, JR., Louisiana  RICHARD E. NEAL, Massachusetts
PETER J. ROSKAM, Illinois            XAVIER BECERRA, California
TOM PRICE, Georgia                   LLOYD DOGGETT, Texas
VERN BUCHANAN, Florida               MIKE THOMPSON, California
ADRIAN SMITH, Nebraska               JOHN B. LARSON, Connecticut
LYNN JENKINS, Kansas                 EARL BLUMENAUER, Oregon
ERIK PAULSEN, Minnesota              RON KIND, Wisconsin
KENNY MARCHANT, Texas                BILL PASCRELL, JR., New Jersey
DIANE BLACK, Tennessee               JOSEPH CROWLEY, New York
TOM REED, New York                   DANNY DAVIS, Illinois
TODD YOUNG, Indiana                  LINDA SANCHEZ, California
MIKE KELLY, Pennsylvania
JIM RENACCI, Ohio
PAT MEEHAN, Pennsylvania
KRISTI NOEM, South Dakota
GEORGE HOLDING, North Carolina
JASON SMITH, Missouri
ROBERT J. DOLD, Illinois
TOM RICE, South Carolina

                     David Stewart, Staff Director

                   Nick Gwyn, Minority Chief of Staff

                                 ______

                         SUBCOMMITTEE ON HEALTH

                   PATRICK J. TIBERI, Ohio, Chairman

SAM JOHNSON, Texas                   JIM MCDERMOTT, Washington
DEVIN NUNES, California              MIKE THOMPSON, California
PETER J. ROSKAM, Illinois            RON KIND, Wisconsin
TOM PRICE, Georgia                   EARL BLUMENAUER, Oregon
VERN BUCHANAN, Florida               BILL PASCRELL, JR., New Jersey
ADRIAN SMITH, Nebraska               DANNY DAVIS, Illinois
LYNN JENKINS, Kansas                 JOHN LEWIS, Georgia
KENNY MARCHANT, Texas
DIANE BLACK, Tennessee
ERIK PAULSEN, Minnesota























                            C O N T E N T S

                               __________

                                                                   Page

Advisory of May 11, 2016 announcing the hearing..................     2

                                WITNESS

Andrew Slavitt, Acting Administrator, Centers for Medicare & 
  Medicaid Services..............................................     5

                        QUESTIONS FOR THE RECORD

Questions from Representative George Holding of North Carolina to 
  Andrew Slavitt.................................................    43
Questions from Representative Tom Price of Georgia to Andrew 
  Slavitt........................................................    44

                       SUBMISSIONS FOR THE RECORD

The Impact of IRS Activities on At Risk Citizens.................    58
American Society of Clinical Oncology (ASCO).....................    60
Institute for Child Success (i(cs))..............................    68
 
                   THE IMPLEMENTATION OF THE MEDICARE
                   ACCESS & CHIP REAUTHORIZATION ACT
                            OF 2015 (MACRA)

                              ----------                              


                        WEDNESDAY, MAY 11, 2016

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

    The Subcommittee met, pursuant to call, at 2:05 p.m., in 
Room 1100, Longworth House Office Building, Hon. Pat Tiberi 
[Chairman of the Subcommittee] presiding.

    [The advisory announcing the hearing follows:]

ADVISORY

FROM THE 
COMMITTEE
 ON WAYS 
AND 
MEANS

                         SUBCOMMITTEE ON HEALTH

                                                CONTACT: (202) 225-3943
FOR IMMEDIATE RELEASE
Wednesday, May 4, 2016
No. HL-07

             Chairman Tiberi Announces Health Subcommittee

             Hearing on the Implementation of the Medicare

                   Access & CHIP Reauthorization Act

                            of 2015 (MACRA)

    House Ways and Means Health Subcommittee Chairman Pat Tiberi (R-OH) 
today announced that the Subcommittee will hold a hearing entitled 
``The Implementation of the Medicare Access & CHIP Reauthorization Act 
of 2015 (MACRA).'' The hearing will take place on Wednesday, May 11, 
2016, in Room 1100 of the Longworth House Office Building, beginning at 
2:00 p.m.

      
    Oral testimony at this hearing will be from the invited witnesses 
only. However, any individual or organization may submit a written 
statement for consideration by the Committee and for inclusion in the 
printed record of the hearing.

      

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

      
    Please Note: Any person(s) and/or organization(s) wishing to submit 
written comments for the hearing record must follow the appropriate 
link on the hearing page of the Committee website and complete the 
informational forms. From the Committee homepage, http://
waysandmeans.house.gov, select ``Hearings.'' Select the hearing for 
which you would like to make a submission, and click on the link 
entitled, ``Click here to provide a submission for the record.'' Once 
you have followed the online instructions, submit all requested 
information. ATTACH your submission as a Word document, in compliance 
with the formatting requirements listed below, by the close of business 
on Wednesday, May 25, 2016. For questions, or if you encounter 
technical problems, please call (202) 225-3943 or (202) 225-3625.

      

FORMATTING REQUIREMENTS:

      
    The Committee relies on electronic submissions for printing the 
official hearing record. As always, submissions will be included in the 
record according to the discretion of the Committee. The Committee will 
not alter the content of your submission, but we reserve the right to 
format it according to our guidelines. Any submission provided to the 
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and any written comments in response to a request for written comments 
must conform to the guidelines listed below. Any submission not in 
compliance with these guidelines will not be printed, but will be 
maintained in the Committee files for review and use by the Committee.

      
    1. All submissions and supplementary materials must be submitted in 
a single document via email, provided in Word format and must not 
exceed a total of 10 pages. Witnesses and submitters are advised that 
the Committee relies on electronic submissions for printing the 
official hearing record.

      
    2. All submissions must include a list of all clients, persons and/
or organizations on whose behalf the witness appears. The name, 
company, address, telephone, and fax numbers of each witness must be 
included in the body of the email. Please exclude any personal 
identifiable information in the attached submission.

      
    3. Failure to follow the formatting requirements may result in the 
exclusion of a submission. All submissions for the record are final.

    The Committee seeks to make its facilities accessible to persons 
with disabilities. If you are in need of special accommodations, please 
call 202-225-1721 or 202-226-3411 TDD/TTY in advance of the event (four 
business days notice is requested). Questions with regard to special 
accommodation needs in general (including availability of Committee 
materials in alternative formats) may be directed to the Committee as 
noted above.
      
    Note: All Committee advisories and news releases are available on 
the World Wide Web at http://www.waysandmeans.house.gov/.

                                 

    Chairman TIBERI. The Subcommittee will come to order. Good 
afternoon everybody. So we are going to begin. I am really 
excited to finally be having this hearing.
    When I came to Congress back in 2001, the sustainable 
growth rate, or SGR as we all know it by, a provision in the 
Balanced Budget Act of 1997, was in the process of being 
implemented, and under this payment formula, any yearly 
increase in per beneficiary spending that exceeded growth in 
GDP could result in a negative adjustment for physician payment 
in Medicare.
    Dr. Price was really well aware of that. Clearly, this 
policy or the math didn't work, and for the next 15 years we 
had almost yearly struggles over what was aptly named the ``doc 
fix.'' Seventeen of these doc fixes later takes us to last 
March when we came together in a bipartisan fashion with 
stakeholder input and CMS technical support to pass the 
Medicare Access and CHIP Reauthorization Act of 2015, or now 
commonly known as MACRA. With nearly 400 votes in the House, 
this legislation finally put an end to the sustainable growth 
rate so that doctors could focus on patient care and not worry 
about unpredictable payments.
    We have called this hearing today to take our first look at 
the regulations released by CMS on April 27. We will look 
closely at how these regulations match up with congressional 
intent and what our Members and CMS are hearing from 
stakeholders as they digest 950 plus pages of regulations.
    That is the scope of the hearing, to discuss the 
implementation of this truly historic legislative feat, and 
there is a lot in the proposed rule to discuss. So I know that 
on a bipartisan basis we are going to dive in, in a deep way.
    Furthermore, I would like to take a moment to encourage 
Members of both sides of the aisle, as you hear from 
stakeholders and constituents regarding concerns or thoughts 
about the proposed rule, please bring them to the attention of 
the bipartisan Committee staff so that we can continue to do 
robust oversight and keep CMS up to date on the information as 
they formulate their final regulation.
    The passage of MACRA last year confirmed our commitment on 
both sides of the aisle to keep Medicare strong for America's 
seniors. This is particularly important to me as well as many 
of you, especially after we just celebrated Mother's Day as 
both my parents, back in my district in Ohio, depend on this 
important Medicare program.
    By replacing the way that physicians are paid and 
consolidating the separate quality measurement systems, we have 
taken a great step toward the ultimate goal of fully-integrated 
value-based care through the incentivization of high-quality 
care. Now our role, as Congress, is to provide oversight, and 
in conjunction with CMS, to provide education on how this new 
law will work for the various types of clinicians and provider 
groups.
    We need to answer how this rule will affect individual and 
small group providers versus larger groups. How will this rule 
affect specialty groups versus primary care physicians? How 
will the timing work for implementation under some potentially 
tight timelines? These are questions that I hope to get clarity 
on today in going forward through the implementation process.
    As we move forward with implementation, I want to make sure 
that we, as Congress, recognize some very important facts 
regarding the law that we passed. The merit based incentive 
payment system, or MIPS is, and was, created as a budget 
neutral program. High-quality value-based care will take 
effort.
    As I said before, such efforts must be recognized within 
the environmental and timing factors based in reality. And 
additionally, the thresholds for providers to qualify as 
advanced alternative payment models are high and are set in 
statute. Working on a bipartisan basis with stakeholders from 
every corner of our country in an open dialogue, with 
cooperation from CMS, will allow us to follow MACRA into the 
next generation of value-based health care.
    Now we can go to work. With that, I would like to yield to 
the distinguished Ranking Member, Dr. McDermott, for the 
purposes of an opening statement.
    Mr. MCDERMOTT. Thank you, Mr. Tiberi.
    When Medicare was put in place some 50 years ago, a 
critical decision was made by the medical association in order 
to have them join in the effort, and they demanded that they be 
paid their usual and customary fees, and we, on this Committee, 
have been, since that time, trying to get back the keys to the 
Treasury. This is another effort here.
    Now, the proposal by MACRA, or the MACRA rule from CMS is 
really as a result of our efforts, as Mr. Tiberi says, of 15 
years of realizing what we put in place didn't work. It took us 
15 years to figure out that we have to try to do something 
different.
    Now, I hope this is the beginning of a constructive 
bipartisan conversation about how to advance our shared goal of 
controlling costs and improving the delivery of health care in 
the country. Passing MACRA was a tremendous bipartisan 
accomplishment in that it put an end to a cycle of dysfunction. 
We had the same thing happen every year. We are going to have a 
20 percent cut in doctor's pay, so there would be a big rush 
around here and we would put a patch on it. And then we go on 
for another year, and next year it will be a 24 percent cut in 
doctors pay, and we put a patch on it. We did that again and 
again.
    For years we lurched from crisis to crisis. And to avoid 
what were draconian cuts in the physician's payment, we ended 
up by spending more on those temporary delays than it would 
have cost to do away with the SGR in the beginning.
    But last year, we put an end to this cycle once and for all 
by passing MACRA. I was trying to step forward, as MACRA is 
much more than just simple repeal of SGR. It is also the most 
significant payment reform the Medicare program has seen in 
years.
    Thanks to MACRA, we have set Medicare on a more sustainable 
course that will allow us to pay for volume in health care--or 
excuse me, value in health care, rather than volume. The law 
modernizes and streamlines physician's payment. Instead of a 
patchwork of incentives and alternative payment models, it 
consolidates various programs into a single framework, it will 
allow flexibility for providers, it will allow them to practice 
medicine independently while still holding them accountable for 
providing high-value care.
    These are complicated issues, and we are still in the early 
stages of digesting this proposed rule. It is big enough. It 
will take awhile. But what we have seen so far has been 
encouraging. The Administration has worked diligently to 
implement the law as intended through a process that is 
responsive to the needs of the public.
    The proposed rule is consistent with the goals of MACRA. It 
provides flexibility to participate either in the merit-based 
incentive payment program, or alternative payment methods that 
reward high-value care. This will make sure providers do not 
end up in a one-size-fits-all approach that doesn't make sense 
to them or their patients. It is the product of an open and 
transparent process that began months ago through active 
outreach, consideration of extensive comments, and public 
workshops with stakeholders. The agency has heard from a range 
of viewpoints, and the proposal reflects careful consideration 
of that input.
    I am confident the Administration will continue to be 
responsive to the needs of the public as it develops the final 
rule. This is an ongoing conversation. We still have much more 
to learn as we work toward our shared goal of making the 
implementation of this landmark law a success.
    Getting the people covered by health care is one thing. 
Controlling the cost is another thing, and this is about 
controlling the cost, and I don't believe we have our arms 
around it yet, but we are in the process, and that is why we 
welcome you here, Mr. Slavitt, to make this presentation. Thank 
you.
    Chairman TIBERI. Thank you, Dr. McDermott. Without 
objection, other Members' opening statements will be made part 
of the record.
    Today's witness panel includes just one expert, and we are 
lucky to have him, Andy Slavitt, Acting Administrator at the 
Centers for Medicare & Medicaid Services, who, along with his 
colleagues, have the daunting task of implementing this very 
important law.
    On a personal note, thank you for having me at your office 
yesterday. It was nice to get to know you and members of your 
team, and I look forward to continuing dialogue in the future.
    With that, Mr. Slavitt, please proceed with your testimony, 
and we appreciate you being here today.

STATEMENT OF ANDREW SLAVITT, ACTING ADMINISTRATOR, CENTERS FOR 
        MEDICARE & MEDICAID SERVICES (WASHINGTON, D.C.)

    Mr. SLAVITT. Thank you. Thank you, Chairman Tiberi, Ranking 
Member McDermott, Members of the Subcommittee, and thank you 
for the opportunity to discuss CMS' work to implement the 
Medicare Access and CHIP Reauthorization Act of 2015.
    We greatly appreciate your leadership in passing this 
important law, which gives us the unique opportunity to move 
away from the annual uncertainty created by the sustainable 
growth rate to a new system that promotes quality, coordinated 
care for patients, and sets the Medicare program on a more 
sustainable path. Our number one priority is patient care. And 
thanks to Congress, MACRA streamlined the patchwork of programs 
that currently measure value and quality, into a single 
framework called the ``Quality Payment Program'' where every 
physician and clinician has the opportunity to be paid more for 
providing better care for their patients.
    In recognition of the diversity of physician practices, 
Congress created two paths. The first allows physicians and 
other clinicians a new flexibility to participate in a single 
simplified program with lower reporting burden and new 
flexibility in delivering quality care.
    The second path recognizes those physicians and clinicians 
who choose to take a further step toward care coordination by 
participating in more advanced models like medical homes. Our 
goal is to make both of these paths flexible, transparent, and 
simple so physicians can focus on patient care, not reporting 
or scorekeeping.
    We have approached this implementation with the belief that 
physicians know best how to provide high-quality care to our 
beneficiaries, and we have taken an unprecedented effort to 
draft a proposal that is based directly on input from those on 
the frontline of care delivery. We have reached out and 
listened to over 6,000 stakeholders, including State medical 
societies, physician groups, and patient groups to understand 
how the changes we are proposing may positively impact care and 
how to avoid unintended consequences.
    The feedback we received shaped our proposal in important 
ways, and the dialogue is continuing. Based on what we learned, 
our approach to implementation has been guided by three 
principles.
    First, patients are and must remain the key focus. 
Financial incentives should work in the background to support 
physician and clinician efforts to provide the highest quality 
care and create incentives to more coordinated care.
    Second, we are focused on adopting approaches that can be 
driven at the practice level, not one-size-fits-all from 
Washington. It will be important to allow physicians to define 
the measures of care most fitting with their patients.
    Third, we must aim for simplicity in everything we do. 
Physician practices are already busy, and we are seeking every 
opportunity possible to minimize distractions from patient care 
by reducing, automating, and streamlining existing programs. 
Among the many places that we seek feedback during the comment 
period, this is among the most important as the burdens on 
small and rural practices, in particular, have increased over 
the last several years.
    One of the important opportunities will be for physicians 
to define and propose new payment models so that we can create 
an array of customized approaches that reflects the diversity 
of care across the country, and particularly as it relates to 
the various specialties that provide care.
    Congress had the foresight to create a formal voice for 
physicians through the Physician-Focused Payment Model 
Technical Advisory Committee. I had the opportunity to meet 
with them last week and can tell you that they are very eager 
to move forward with their important work, and we are eager to 
work with them.
    With all the work that went into this proposal, it is 
critical that we receive direct feedback from physicians and 
other stakeholders and are undertaking significant outreach 
efforts. Our proposed rule is the first step in the process, 
and we look forward to receiving and reviewing comments to 
refine and improve our approach.
    In the month of May alone, we have 35 scheduled events and 
listening sessions to hear from a wide range of stakeholders, 
and this outreach will remain an important part of our work. I 
personally have been meeting regularly with physician groups, 
including smaller and rural practices, and have spoken to 
thousands of physicians in different parts of the country about 
their work, the opportunities and challenges they face, and 
what this proposal means for them and their patients.
    Throughout this, I have appreciated the open dialogue with 
this Subcommittee and the larger Committee, and it is clear to 
me that we share the goals of creating a more sustainable 
system with smarter spending that keeps people healthier.
    We are striving to do just that in the implementation of 
MACRA, but it will take work and broad participation to get it 
right. I look forward to hearing your further thoughts on this 
implementation and to answering your questions. Thank you.
    [The prepared statement of Mr. Slavitt follows:]
    
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    
    Chairman TIBERI. Thank you, Mr. Slavitt. As you know, in my 
district, I represent urban, suburban, rural, and most of the 
concerns I have heard with respect to MACRA and the future 
implementation of MACRA is from small and rural providers' 
practices.
    So the proposed regulation assigns three levels of risk 
required for entities participating in the APMs, the 
alternative payment models. And what I have not seen are any 
tiers or variabilities in the amount of risk for participation 
between an individual and small group clinician and large group 
clinicians.
    Have you heard concern from providers about this?
    Mr. SLAVITT. Thank you for the question. I think the topic 
of particularly small practices and making sure that they can 
succeed is of utmost importance, and our data shows that 
physicians that are in small and solo practices, so long as 
they report, can do just as well as physicians in larger size 
practices.
    So we know, however, that there is a burden on us to make 
the reporting as easy as possible. We also know there are a 
number of other steps that we need to be looking for, and 
looking out for, to make sure we make things as easy as 
possible and accommodate smaller practices.
    So importantly, we are looking for additional steps and 
ideas as people review the rule, but I will say that we are 
focusing on technical assistance, providing access through 
medical home models, opportunities to report in groups, and 
using a reporting process that automatically feeds data, 
reduces the number of measures, and overall lowers the burden 
for small practices.
    Chairman TIBERI. So in a followup to that, in reading 
through the regulation, there are several areas that seem to 
allow a little more flexibility for individual and small group 
practices. Can you outline some of the major differences in 
reporting for individual and small group practices versus the 
larger groups that could maybe ease the burden or send the 
message to the smaller groups that there is sensitivity there?
    Mr. SLAVITT. Sure. Absolutely. First of all, at the request 
of the physician--we met with a lot of physicians and physician 
groups and small practices in this process. One of their key 
requests was that if they are already participating in 
something like a clinical registry or some other way of getting 
data across that may be an accountable care organization or 
clinical registry, that we use that information rather than 
requiring them to send it again, and our proposal does indeed 
allow multiple ways for us to get information.
    Second, we are required to measure the cost of care, and we 
are going to be able to do that automatically by getting a 
claims fee, so it is going to require physicians to send us no 
information whatsoever. And then there are a number of areas 
where they will simply need to attest to whether they are doing 
a certain activity, which we think will reduce the burden, and 
we are looking more broadly at the overall experience for 
physicians. Small physicians can report in groups in many 
categories where they hadn't been able to before, and then 
finally, I would say, there are a large number of physicians 
who won't have to report at all because they will be underneath 
their minimum threshold. Congress put forward that if 
physicians don't see enough Medicare patients or meet the 
minimum threshold through Medicare, they don't have to report 
at all.
    So all of those things, I think, are there. And again, we 
also look for additional steps, if there are some, that we can 
take.
    Chairman TIBERI. Just a final thought, and I don't mean to 
put you on the spot on this, but do you think there is any more 
that we can do, those of us on this side of the dais, and you 
and your team at CMS, to ensure that, as we lay the foundation 
for MACRA going forward and there is buy-in, complete buy-in 
from the physician community, that the system is not built with 
an inherent fairness or fairness issues--again, going back to 
the rural provider or the two-person provider group that has a 
bunch of angst right now----
    Mr. SLAVITT. Right.
    Chairman TIBERI [continuing]. As this has begun to unfold. 
Is there anymore that we can do, or you can do, or we can work 
together on?
    Mr. SLAVITT. Yeah. I think it has to be a vital continuous 
effort. Last week I met with small physician practices from 
southern Arkansas, southern Oregon, and New Jersey. We had a 
meeting on Friday with Rural Health Association at their annual 
meeting. We went out to Kansas City last week to meet with the 
Family Practice Association, and we do hear a lot from small 
physicians who are concerned, and I think they are particularly 
concerned if people in Washington are making centralized 
decisions that are going to impact their quality of care.
    And what they tell us over and over again, and we need to 
keep talking to them and getting more feedback, is give us the 
freedom to take care of these patients. We know how to do it, 
let us define quality, let us select the measures that are 
right for our practice, give us more flexibility, and don't 
make us focus on reporting. Let us focus on patient care. And 
it is really critical, I think, as we work together and as you 
hear input, that you get this to us and that we hold ourselves 
very much to that standard that physicians across the country 
are holding us to.
    Chairman TIBERI. Thank you, sir. With that, I recognize Dr. 
McDermott for 5 minutes.
    Mr. MCDERMOTT. Thank you. One of the issues that the 
questions Mr. Tiberi is raising about small practices sort of 
leads me to the question of consolidation and driving doctors 
together in larger and larger groups. The question then comes 
to my mind--I practiced both as an individual, and in the 
military, and in a group practice, so I have been in all sorts 
of forums. One of the things that strikes me that is going to 
be difficult to deal with here is the whole question of what is 
the best care.
    If you have a large organization and they have an MRI and 
they don't want to use it, or they want to use it, they can 
crank a lot of people through an MRI for everything, or they 
can say don't use an MRI, and there will be patients out there 
who do not benefit from what they could find. I can give you an 
example of a young woman, 34 years old who had pain in her 
back, and was told there was--you know, you are riding a 
bicycle, and there is a lot of reasons why, you know, you are 
young, and blah, blah, blah.
    At 35, they did an MRI and found a tumor in her spine. Now, 
if they had done that, they would have found it 5 years 
earlier, but the organization was encouraging people not to 
use. So how are we going to make our judgment about whether we 
have quality of care, if the major factor is going to be money? 
I mean, what is built into this to actually look at the quality 
of care?
    Mr. SLAVITT. Yeah. So I think at the heart of the question, 
the most important thing above all else is making sure patients 
get high-quality care, and we do believe that if patients are 
getting high-quality care, that is going to lead to better cost 
control because if someone gets the right surgery, they won't 
need to have a second surgery.
    Likewise, quality is also defined as making sure the care 
is coordinated, so if somebody needs to have a followup visit 
or has a prescription or something with an instruction, that 
they understand what that is, it is explained to them and that 
the system works and supports them. So our job here is to 
enforce that, number one.
    Number two, I think our job isn't to define quality here 
ourselves as much as it is to take the best standards of care 
that the specialists and the physicians around the country have 
defined as quality and make sure that we keep up with that and 
that we keep those measures as the things that physicians 
decide, as a group, that they should be measured on, and those 
are the things--and then third, as I said earlier, that at the 
practice--things actually differ at the practice level.
    And we believe the practice is, by and large, are the 
people that know best for what is right with their patients, 
and that the dialogue between the patient and the physician--so 
nothing we are doing should be seen to be interfering with that 
in any way. And in fact, we ought to be reinforcing those 
things, and I think MACRA gives us the opportunity to say if 
you are delivering a better quality of care outcome for your 
patient, you ought to be rewarded for that.
    Mr. MCDERMOTT. You are suggesting the whole question of 
evidence-based medicine, that is, I mean, I have been to the 
doctor recently, and they send out, from the University of 
Washington, a sheet to me, and it says did you have good care. 
Well, was he polite, was he nicely dressed, and blah, blah, 
blah, down at the bottom, were you satisfied with your care?
    Now, for some people, if they don't get a prescription or 
they don't get an X-ray or they don't get a blood test or they 
don't get something, they haven't had--the doctor hasn't done 
anything.
    Mr. SLAVITT. Right.
    Mr. MCDERMOTT. So how do you measure then the patient who 
says, well, I wasn't satisfied because I went away and I still 
ain't got--my sinuses are a mess and he didn't give me 
antibiotics. How do you deal with that issue in the quality of 
care?
    Mr. SLAVITT. Sure. I think one of the nicest things is--I 
will give you an example. I was sitting down with some 
physicians that are practicing medicine in southern rural 
Arkansas, I referred to them recently. They are in one of these 
models, a medical home model, where they have a per member, per 
month payment they get in order to coordinate the care, and 
they have hired care coordinators, and what they told me was, 
the physician I was talking to told me, he said, now I actually 
can get paid to practice medicine the way that I am supposed to 
practice medicine instead of practicing medicine the right way 
and getting paid on something completely different.
    So I think the more we evolve our healthcare system to a 
way that reinforces what physicians know are the right things 
to do in delivering quality of care to patients, the better off 
we are going to be, as opposed to a system where if you don't 
make a cut in someone's skin or give them a prescription or 
something that they leave the office with, that is not success.
    Mr. MCDERMOTT. I have a medical home at the University of 
Washington. Thank you.
    Chairman TIBERI. Thank you, Dr. McDermott. That was really 
good. We agree on something.
    Mr. Slavitt, thank you so much. You know, I have 12 
different questions I could ask you on 12 different topics, and 
my mom has one that she shared with me last night she wanted me 
to ask you. But it doesn't have to do with MACRA, so that is 
for another day, and I would like to remind all Members to try 
to keep the topic to this important law that we passed.
    With that, Mr. Johnson is recognized for 5 minutes.
    Mr. JOHNSON. Thank you, Mr. Chairman.
    Mr. Slavitt, welcome. You have said that CMS is working to 
regain the hearts and minds of physicians through 
implementation of MACRA, and that is great because many 
physicians in solo and small practices have really struggled to 
stay afloat in recent years.
    And while there are a lot of good things in the proposed 
rule, I have one issue I would like to raise with you. I am 
concerned by the estimates in table 64 where CMS projects the 
greatest negative impact on payments to practices with 9 or 
fewer doctors and the least harm to large systems with 100 or 
more docs. If CMS is trying to win back the hearts and minds of 
physicians, this proposal falls short since it will continue to 
push physicians out of their solo or small practices.
    Can you tell me specifically what CMS is doing to ensure 
that solo practitioners and small groups can succeed under the 
MIPS and participate in alternative payment models by 2019?
    Mr. SLAVITT. Thank you. Thank you, Congressman Johnson, for 
the question, and I really would actually welcome the 
opportunity to address this table, and for anyone who hasn't 
seen the table, the table is designed to estimate what the 
impact of these regulations could be on practices of various 
sizes.
    And the first thing I want to make very clear is that the 
question of making sure that small groups and solo 
practitioners can be successful is of utmost importance, and I 
would also indicate that despite what that table shows, our 
data shows that physicians who are in small and solo practices 
can do just as well and actually do just as well as physicians 
that are in practices that are larger than that.
    Now, the reason that table looks the way it does is for one 
very simple and important reason. It accounts for the fact that 
in 2014, when the table the data uses, most physicians in small 
and solo practices did not even report on their quality, and 
this is important for a couple of reasons.
    First of all, I should say that in 2015 and subsequent 
years, the reporting went up, so at best, this table would be 
very, very conservative, and of course, as I explained to 
Chairman Tiberi, reporting is going to get far easier going 
forward.
    But it does point to a couple of things that I think we 
would be wise to pay attention to. One, making sure that it is 
as easy as possible for physicians to report. One of the 
reasons why we don't have the hearts and minds of physicians is 
because there is just too much paperwork in health care.
    Mr. JOHNSON. I would agree.
    Mr. SLAVITT. They need to be practicing medicine, not doing 
paperwork. So there has been a tremendous amount of effort so 
far, and this is just a proposal. So this next period of time 
for comments is a time when we are hoping people can give us 
even further ideas and further ways that we can reduce the 
administrative and reporting burden. But to be very clear, 
there is absolutely every opportunity, and in fact, an equal 
opportunity for small and solo practices to be successful.
    Mr. JOHNSON. Well, thank you. Maybe we better indoctrinate 
the nurses, too. Don't they do most of that?
    I thank you, Mr. Chairman. I yield back my time.
    Chairman TIBERI. Thank you, Mr. Johnson.
    Mr. Kind is recognized for 5 minutes.
    Mr. KIND. Thank you, Mr. Chairman. Thank you, Mr. Slavitt, 
for your testimony here today. Needless to say, I think 
Congress, in passing MACRA, gave you a huge undertaking, and 
now with a 900-page rule, I think it is pretty obvious that we 
are going to need to keep the lines of communication open, and 
hopefully your outreach with the stakeholder groups will 
continue as it has been, with not just physician but patient 
feedback as well.
    I know many Members of this Committee, myself included, 
have been pushing hard to move to a more integrated coordinated 
healthcare delivery system. I come from a region of the country 
in Wisconsin that established models of care, and has been 
pushing aggressively in this direction for quite some time. And 
then ultimately, you know, alternative payment methods so we 
get the quality, value-based, outcome-based reimbursements. And 
again, that is kind of the directive that MACRA gave you.
    But also a lot of my providers were early stage first 
generation ACO models. My question is, what more can be done in 
order to provide an on-ramp for advanced APM payments to those 
early stage ACOs, or are they going to have to just leapfrog 
and go on to Gen 2, Gen 3, Gen 4?
    Mr. SLAVITT. So you are raising a very important question, 
which is where physicians have an opportunity--as we mentioned, 
all physicians in every program will have the opportunity to 
get rewarded for quality care, but where physicians have an 
opportunity to and have had the opportunity over the last 
several years, to join with other physicians in these more 
coordinated care models, the medical home would be one example, 
we think those are a good idea. We think they are a good idea 
if they are right for the physician, if the physician thinks 
they make sense for their patients, and of course, it creates 
an opportunity in its own right to earn more.
    What MACRA does is it gives physicians an even additional 
opportunity, an opportunity to earn 5 percent additional bonus 
on top of what they may already be earning in these advanced 
models. So the question is: What is the requirement to get 
access to that 5 percent bonus? And the legislation puts 
forward a number of requirements, and the requirement really, 
in a nutshell, if I were going to simplify it, is that there 
has to be a higher degree of shared accountability from the 
physician, and that shared accountability is shared 
accountability for the outcome to the patient and a minimal 
sharing of the costs with the Medicare program itself.
    So in other words, in order to qualify for this 5 percent 
bonus, I think the words that are in the legislation are there 
has to be a more than nominal risk.
    So our job in putting this regulation together is to put 
the definition around what is that nominal risk. We have tried 
to do that in as consistent a way as possible and as simple a 
way as possible, but really it is one of the areas where we 
really are inviting feedback. And then all of our models, 
whatever model we are in, will have to qualify based upon that 
definition.
    And so even if a physician is in a model that doesn't 
qualify because there is not as much nominal risk, there is 
still great opportunities, and there is still opportunities for 
them to grow into other models.
    Mr. KIND. Well, finally, you know, the great cost driver in 
our society, and it is true at the Federal level at the budget, 
at State and local, for families and businesses alike, is 
rising healthcare costs. So with the direction this rule is 
taking, can we sit here with reasonable confidence that this 
may ultimately lead to some cost savings but without 
jeopardizing the outcome or quality of care that our patients 
are receiving? Or is this going to turn into a Lake Wobegon 
type of situation where everyone is above average, everyone is 
qualifying for bonus payments, and there is no real cost 
savings at the end of the day?
    Mr. SLAVITT. Right. Well, I think, first of all, we all are 
striving for a higher quality healthcare system. We all want 
our money spent more wisely, and we don't want to do it in a 
way that people feel like they are getting--skimping on their 
care. We have 10,000 new seniors every day in America, and our 
jobs are to be able to figure out how to take care of them 
better for less money. And that means being able to take care 
of them in lower cost settings, more comfortable settings like 
their homes rather than in institutions like hospitals, and so 
those types of incentives are vital to this program.
    Within the regulation, there are--the pool balances out, 
and so we are going to have to allocate money and have upward 
and downward adjustments as part of this program in order to be 
able to meet the sustainability test you talked about. That is 
nothing new. There are upward and downward adjustments in 
programs today. What is new is that this will be a simpler more 
aligned program that is easier to measure and keep track of.
    Mr. KIND. Great. Thank you. Thank you, Mr. Chairman.
    Chairman TIBERI. Mr. Roskam is recognized for 5 minutes.
    Mr. ROSKAM. Thank you, Mr. Chairman. Mr. Chairman, I have 
an observation, a point, and a nudge.
    My observation is this: There is a level of anxiety that is 
out there in our public life today because people look at 
Congress and they say nothing is happening. And yet here we 
have this issue where both sides of the aisle, the White House, 
everybody came together, wrestled a very complicated issue to 
the ground, came up with a solution, and it doesn't involve 
snarling at one another on television, it doesn't involve, you 
know, a hyperbole and so forth, but there was this very serious 
effort, and we are on the verge of, I think, some good things.
    So just a little shout out, and that is, three cheers for 
something getting done, and I think there is an encouraging 
element to that.
    My point is that debate matters. I would argue that one of 
the reasons that we were able to have that discussion, when 
Speaker Boehner and leader Pelosi were able to come together, 
and the two of them really drove the discussion, it was because 
it had been well wrestled through in the United States over the 
past several years that we need to do something on Medicare. 
And both sides have different views of the world and so forth, 
but it had become normalized in that sense that these things 
had to change.
    So debate does matter, and I think we are better off if our 
debate doesn't involve snarling at one another, and it is two 
various points, but debate matters because debate is a prelude 
to action. Margaret Thatcher said: First you win the debate, 
then you win the vote.
    Okay. Now here is the nudge, and this is the nudge for you, 
Mr. Slavitt. One of the things that I think you and I have 
talked about offline, and you have alluded to some of this, 
too, a minute ago, there is this tension that is out there, and 
there is a tension that manifests--and let me just tell you a 
quick story.
    I served in the State legislature, and we had some 
education testing issues that came before us, and you know how 
this works. There is always a new test, there is always a new 
standard, so I called a friend of mine, who is an old friend 
from high school, who is a high school administrator, and I 
said: Give me the straight scoop on these tests.
    And he said: Peter, look, will you just pick a test and 
stick with it and not change it every 4 years? He goes: We are 
happy to be accountable, but stick with the test, stick with 
the program. And that deeply resonated with me.
    So the tension is that I think healthcare providers want a 
standard, they want something that is predictable, but now, 
also, the tension is they don't want something that is 
declarative and dispositive and can never be revisited because 
that is big and that is overwhelming and that is what SGR had--
that is what we had to do for, you know, the doc fix for all 
those years. That was declarative. It was an 
overcharacterization, and it failed. And the proof that it 
failed was you had to kick--we all had to kick the can down the 
road.
    So my nudge is this: As you are going through and you are 
figuring this out--and I really appreciate the disposition and 
the attitude and the open rule time that you have now and the 
comments that you are taking in, if you could really be mindful 
of those smaller practices that Mr. Johnson mentioned, the 
point that Mr. McDermott made, and that is, how is it that a 
physician that is stewarding antibiotics correctly or not 
giving in to patient pressure for a prescription, how is that 
physician protected? Also, I hadn't thought about it until Mr. 
Kind mentioned it, are the bonus payments a new floor, and does 
the average become the expectation?
    So, I am here, and I think that the Chairman has set the 
great tone here, and that is for us to listen and to learn, but 
as you are navigating through those natural tensions of having 
something that can be predictable but also maintaining that 
level of flexibility where it can be revisited and changed, I 
think is the best of both worlds.
    And with that, you don't need to respond. I'll yield back. 
Thank you.
    Chairman TIBERI. If you would like to respond, you may. It 
is up to you.
    Mr. SLAVITT. We had this conversation, including a little 
bit, yesterday. I think this idea of making sure that people 
don't feel like the game is changing on them, made porous, is 
critical. So there is enough in this legislation that allows us 
to tell folks going in, hey, here is how it works, in advance. 
I think there is nothing more frustrating than being told after 
you took the test how it is being graded.
    And then I think you make an important point as well, which 
is how do you trade off making sure you are predictable, with 
staying current with the state of the art of the state of 
medicine, and what physicians are saying that they want, and I 
think we have a process for that, we take comment on that 
process, we think it is an effective process, but it is also 
important that physicians have the flexibility to navigate the 
process, particularly at different times in their practice.
    Chairman TIBERI. Thank you. Mr. Thompson is recognized for 
5 minutes.
    Mr. THOMPSON. Thank you, Mr. Chairman, for having the 
hearing today. Thank you, sir, for being here. I am sorry I had 
to step out, so I hope I am not going to be repetitive here.
    But we are all very, very interested, I think you can tell 
by the tone of all the questions, that this law works. We have 
a very vested interest in that, not only as a Committee of 
jurisdiction, but also these are the people, providers, and 
patients that we represent at home, and we want to make sure 
that it works.
    And so to that end, I would like to hear what the 
Administration is doing to help providers get ready ahead of 
the 2017 start date, and what would you recommend providers be 
doing to get ready, and is there anything that we, as Members 
of Congress, should be doing to help facilitate this 
transition?
    Mr. SLAVITT. Yeah. Thank you. So I guess maybe I will start 
to direct that question as if what I would say to a physician 
who was wondering what does this all mean, and it is a 
conversation that I get to have frequently because I have been 
having a lot of conversations with physicians, and I think 
there are probably 5 things I would say that I would keep in 
mind as a physician or from, I think, our perspective.
    Number one and most importantly, keep focusing on your 
patients and on patient care. Don't worry about the 
scorekeeping. It will be our job to put this forward in a way 
where it becomes easier, and indeed, it will be easier and more 
streamlined than the processes that people have to go through 
today, so that is the good news, and that is the first thing.
    The second thing is, we have to continue to talk to people 
and educate people as there are opportunities. As the 
Chairman's question implied earlier, because physicians will 
have the opportunity to decide which measures and which ways 
the measuring quality they want to be measured on, at some 
point they will be able to think about what those things are 
and they will be able to put those in motion, and that is 
really one of the important early things.
    I think if there are opportunities to participate in these 
more advanced models, these care coordination models like 
medical homes, they should obviously consider those because 
there are some extra rewards for that, but it won't be until 
the spring of 2018 that physicians would first need to report 
on MACRA. And so it is important that they not get too 
concerned about that.
    And then the final thing I would say, and I think what we 
are trying to encourage for everybody, is to provide us 
feedback. During this comment period, we really want physicians 
to be able to review this. We are setting up a number of 
sessions. I talked to 3,000 physicians yesterday on a call. We 
do twice a week webinars to get your questions answered and 
then ask you to give us feedback on how you think this is going 
to affect your practice.
    Mr. THOMPSON. And as far as us being able to do anything to 
help facilitate the transition, any comments for the Committee?
    Mr. SLAVITT. I think the more listening sessions and open 
forums that there can be with physicians, and giving physicians 
an opportunity not just to hear what is in the rule but to tell 
us how it is going to impact them--I spoke with one of the 
Members of the Subcommittee who asked me to participate in one 
of those sessions with people in his district. I think we have 
a lot of the staff at CMS that are available to do phone calls 
and other things to reach out directly, so let us know what you 
are hearing from your constituents, and our job is to be 
responsive.
    Mr. THOMPSON. And so in my particular case, would you 
rather do a phone call to the Napa Valley or would you rather 
come out and do it in person? I yield back.
    Chairman TIBERI. Maybe a future Subcommittee hearing.
    Dr. Price is recognized for 5 minutes.
    Mr. PRICE. Thank you, Mr. Chairman, and thank you, Mr. 
Slavitt, for joining us today. I think, as has been said, I 
think we are moving in a better direction, but we still have a 
long way to go, and if we are going to make it so that 
physicians can once again be able to care for patients without 
an inordinate amount of influence or burden from outside, we 
have to continue to work through this, and I appreciate your 
willingness to do so.
    I have a couple of specific areas, and then I want to tick 
through.
    One is you have the moving from meaningful use to ACI, 
whatever we want to call it, we have the 365-day rule. In the 
past, it has always been a 90-day rule, which means that the 
practice has to demonstrate that they comply for a 90-day 
continuous period within a 365-day period.
    It only makes sense, nobody is perfect every day, and if 
they are going to get dinged because they are not able to 
comply 1 day or 2 days or 3 days, then we have simply got to 
move to a 90-day, and I hope that you are able to work in that 
direction.
    Mr. SLAVITT. So it is one of the key areas we are inviting 
comment right now during the comment period.
    Mr. PRICE. Good. So I invite comment as well from folks 
from whom I have heard.
    Mr. SLAVITT. Okay.
    Mr. PRICE. On the alternative payment models. You have a 
lot of folks out there, a lot of docs, guys, and gals who have 
already modified what they are doing. The bundled payment, BPCI 
programs, the future CJR program, and yet it appears that those 
programs, that CMS has pushed on docs, and encouraged docs, and 
incentivized docs, don't even qualify for APMs. That doesn't 
make any sense at all.
    So I hope you are looking at just grandfathering those or 
moving them in or allowing them to qualify as APMs.
    Mr. SLAVITT. So Congressman, one of the things that I think 
we have to do now that the law is being implemented is to go 
back and look at all of our models and see where we can make 
changes to them so that the participants in them can qualify. 
And I know that Dr. Conway is very much directing the team to 
look for ways to do that where possible. They have to meet--
there are certain requirements that have to be met.
    An example would be what percentage of the patients I am 
seeing are part of this bundled payment, and so that is because 
that is in the statute and the law, we have to look at how we 
can modify these programs or work with you on what our 
flexibility is to be able to----
    Mr. PRICE. I agree. If you expand the ability for them to 
use their entire practice instead of just Medicare, that 
oftentimes gets them to that point.
    Mr. SLAVITT. Right.
    Mr. PRICE. So I would urge you to look at that.
    Mr. SLAVITT. Okay.
    Mr. PRICE. Docs are really frustrated with things for which 
they are being held accountable that they have no control over. 
One of them is on the meaningful use, ACI issue, this data 
blocking that is occurring by the vendors. Docs don't have any 
control over what the vendors do at all, so how we can have a 
system that actually punishes docs or potentially punishes docs 
because of what somebody else does that they don't have any 
control over, again, that doesn't make any sense at all, and 
they are pulling their hair out trying to comply with this, so 
if you can look at that, that would be appreciated as well.
    Mr. SLAVITT. Will do.
    Mr. PRICE. I want to touch on the nominal risk that you 
talked about. The nominal risk, as I understand it, is a 
minimum of 4 percent of total spending to be qualified under an 
APM.
    Mr. SLAVITT. That is correct.
    Mr. PRICE. And as you know, the physicians control, I don't 
know, pick your number, 14, 15, 16 percent of total spending. 
So 4 percent of total spending is really a 25, 30 percent hit 
for the docs. So how can we have a system that punishes the 
people that are--where the rubber hits the road, trying to care 
for these patients, and again for which they have little 
control over? Shouldn't that be 4 percent of the physician 
total reimbursement?
    Mr. SLAVITT. One of the areas where we are looking for 
feedback in the comment period is both what is nominal risk 
quantitatively? We have chosen a number that was consistent 
across the MIPS program, but that is just in the proposal.
    Mr. PRICE. Doesn't that presume that the physician controls 
every dollar of spending?
    Mr. SLAVITT. And that is the second area where we seek 
feedback, which is, under what universe total cost of care, 
which of course the benefit of a total cost of care is a 
primary care physician has the opportunity to get rewarded for 
being able to keep the patient out of the hospital when they 
don't belong there and so forth. Of course, as you point out, 
it is an area where we are looking for feedback and very much 
hearing that perspective.
    Mr. PRICE. A lot of those things are out of their control.
    Mr. SLAVITT. Sure.
    Mr. PRICE. We would like to believe that they control them, 
but in an ideal world, that might be nice, but a lot of those 
things are out of their control.
    I have a few seconds left, and I just want to point out, 
once again, the table that you identified, table 64, which by 
your own data, stipulates that 87 percent of solo practitioners 
are going to see a negative adjustment. This is your own data. 
Granted, it is 2 years old, but it is going to be 2-year-old 
data that is going to reward them in 2019 based upon what 
happens in 2017, so I would urge you to relook at how you are 
adjusting that, and in realtime, providing an update.
    Mr. SLAVITT. Right. Right. And we are going to look in the 
final rule at having the most updated and most accurate 
information in that table. Again, while that table would not be 
good news for reality, I don't believe it is reality, however I 
will say that the silver lining is I think drawing attention to 
the impact of this regulation on small and solo practices is a 
good thing, and so I think it is where we need to have 
dialogue, and so despite the fact that I don't think that table 
represents the reality, I do think that the reality of how 
difficult it is to practice medicine in a small or solo 
practice is very real, and so we are looking for ways to make 
sure we make it better.
    Mr. PRICE. Great. Thank you very much. Thank you, Mr. 
Chairman.
    Chairman TIBERI. Thank you. I think you might be sensing a 
theme up here.
    Mr. Blumenauer, you are recognized for 5 minutes.
    Mr. BLUMENAUER. Thank you, Mr. Chairman. I appreciate the 
opportunity to have the conversation today. Mr. Administrator, 
I appreciate the approach that you folks have taken to help us 
turn the corner.
    I personally have found the charade we went through for 
some 17 years kind of embarrassing, dancing away from an event 
we know nobody had any expectation should happen. We were 
dealing with a budget fiction.
    I think the agreement that was struck is reasonable. There 
is still much value to be squeezed out of the system, but I 
appreciate the fact and some of the references from my friend, 
Dr. Price.
    We have people who are in the middle of practice patterns, 
limitations on data, and just a whole host of other changes 
taking place, and I appreciate the commitment to do so in a 
thoughtful and deliberate fashion.
    You have also heard another theme emerge that people are 
keenly interested in making sure that we make this transition 
to rewarding value over volume, and that we have had problems 
in the past with some things, theoretically. I mean, I have 
strongly supported Medicare Advantage, but at the same time, 
parts of the Affordable Care Act to try to coax more value out 
of it because, theoretically, it should enable us to deliver 
care more efficiently, and we continue to have a pretty 
significant premium.
    The compromise that was struck, and one that I thought was 
healthy, was to provide bonuses based on performance and try to 
deal with some of the areas where there is some decidedly, I 
don't know if one wants to call them outliers, but there are 
some real performance problems being overcompensated, coming 
from one of those regions that we like to think that if 
everybody practiced medicine like they do in my congressional 
district, we wouldn't have the funding problems that we have.
    You know, I am looking at charts like this that kind of 
display how it is supposed to work over time. I wonder if you 
can just give us a sense of where you think the pinch points 
are, where will some of the things that we need to be prepared 
to be able to work with you be, if there are further 
adjustments legislatively, if there are things that we need to 
do a better job of just being able to understand ourselves, to 
explain to our community at home, where are the pinch points 
you think we need to zero in on?
    Mr. SLAVITT. Thank you, Congressman Blumenauer. I think I 
point to a couple of areas that I think are really critical 
focus areas for us. One is the education and communication 
process, particularly with smaller practices and individual 
solo physicians. It is vital that we hear their feedback and 
understand what the impact of the decisions that we are making 
here today will be on their practices several years from now. 
So that education process, I think, means a couple of things.
    One is that we talk in plain English instead of acronyms, 
which we are quite guilty of here, I know, but we are trying 
very hard to do a better job with that. We have created simple 
fact sheets, and training sessions, and PowerPoints, and as 
many options as possible to do that, and to the extent that you 
can help us do that and tell us what you are hearing, that is 
going to be critical.
    The second thing that I think we will need to continue to 
hear from you all on, and I think the conversation with 
Congressman Price is apropos to this, is where there are places 
where you think there should be flexibility and how we should 
be exercising flexibility, whether it is with smaller practices 
or whether it is in how we define the models that qualify for 
the 5 percent bonus, and in all of those areas, your feedback 
on our interpretations is critical because we really do want to 
get to the best answer.
    And I will tell you that we don't have a monopoly on that. 
We want to do that through the dialogue and the debate that 
Congressman Roskam referred to, and we also are going to have 
to make this an ongoing commitment because we will have to look 
at this program at the end of its first year and understand 
what worked well and what didn't and what can work better, and 
we can't be afraid to call out the things that didn't work as 
well and sit down together and try to figure out how to make 
those things better, whether it is with technical improvements 
or whether it is simply in how we are implementing things.
    Mr. BLUMENAUER. Mr. Chairman, I do appreciate the 
opportunity to get into something, which I hope we are able to 
periodically review and update. I appreciate that part of this 
is process and part of it is performance, and being able to 
strike that balance in a way that is protective of the people 
who depend on this service but also of the taxpayer, I think, 
is going to be a challenge for our friends at CMS and for the 
Committee, and I hope we can continue sort of zeroing in in 
that fashion. Thank you.
    Chairman TIBERI. Thank you. Well said. Mr. Smith of 
Nebraska is recognized for 5 minutes.
    Mr. SMITH OF NEBRASKA. Thank you, Mr. Chairman. Thank you, 
Administrator Slavitt, for being here today. I represent a very 
rural district, and some parts more rural than others, in fact. 
With 75 counties touching six States, obviously, we are very 
spread out. We are the number one agricultural district in the 
Nation, very productive. Of the nearly 60 hospitals in my 
district, about 54 are designated as critical access, and that 
might be a single designation, but that is about 54 different 
types of expertise and providers, and I am actually inspired by 
the work that they do serving communities from smaller than 
1,000 up to about 12,000 plus. Nonetheless, they have a very 
large task, and I guess so do you.
    Can you discuss the feedback you received from rural 
providers in response to the initial RFI and how you addressed 
that in producing the rule and then what rural providers and 
critical access hospitals can expect from this rule?
    Mr. SLAVITT. Yeah. Thank you, Congressman. And in your 
district, and I think throughout the country, you know, we face 
the challenge of not having enough physicians, in many cases 
enough specialties, and there are many districts around the 
country where there are, you know, only one or two providers in 
certain specialties. So we cannot allow the sideshow that goes 
along with the practice of medicine to make the practice of 
medicine less fulfilling and less rewarding.
    So as it relates to the small physician practices, the 
medical home models that many of them are participating in, we 
have had really terrific feedback from, and I think what I hear 
from small physicians is: give us the opportunity, find ways 
for us to have the opportunity to participate in some of these 
same opportunities, the models that people do in urban settings 
and make them work for us. So can you make changes to them that 
can work for us? That is, I think, one of the things we----
    And then on critical access hospitals. Obviously, for us, 
you know, so many of our Medicare beneficiaries get taken care 
of and get treated and rely on those critical access hospitals, 
and the economics of health care in rural America is different 
than it is in other places. And that is both a short-term issue 
that we have regulations, as you know, to set and deal with, 
but it is also a longer term question around how those 
hospitals are structured, what they provide, and how we support 
them in the appropriate way.
    Mr. SMITH OF NEBRASKA. Okay. In your response to the 
Chairman, you had mentioned a reporting exemption for small 
providers. At the same time I have heard questions from those 
who fall below the reporting threshold who would like to be 
able to report data. Will they have that opportunity?
    Mr. SLAVITT. So it is interesting you say that. I had that 
feedback last night when--in talking to a specialty society who 
said we want our specialty to be more engaged in the practice 
of medicine with seniors. And so even our physicians, who are 
only seeing small amounts, want to do that.
    I will tell you I heard feedback in both directions so that 
I think our job will be, over the comment period, to take all 
that in and figure out how to do the best job accommodating the 
most types of practices as possible.
    Mr. SMITH OF NEBRASKA. Okay. Well, I appreciate that. I 
know that the providers I talked to are constantly not just 
saying what the problem is but providing solutions and 
innovations, and I would hope that we can empower providers to 
care for their patients without the government getting in the 
way or messing things up.
    Thank you, Mr. Chairman. I yield back.
    Chairman TIBERI. Thank you. The former mayor of Paterson, 
New Jersey, Mr. Pascrell, is recognized for 5 minutes.
    Mr. PASCRELL. Thank you very much, Mr. Chairman.
    Administrator Slavitt, under your leadership, CMS has 
stressed the importance of better data to improve quality, to 
improve outcomes, and has made great strides in making that 
data available.
    MACRA included a provision that allows innovators to use QE 
data, to help us make smarter decisions. Do you agree that the 
medical devices used in care--and I will focus in on that--
particularly for the most common Medicare procedure, joint 
replacements, play a role in healthcare quality and outcomes?
    Medicare has no information on the medical devices 
implanted in Medicare beneficiaries. I think we should let that 
settle in for a few seconds. Extremely problematic, I think, 
from an oversight perspective, and most importantly, from a 
safety perspective. You and I have had discussions, there is a 
history here that we need to address.
    So shouldn't this information be made available?
    Mr. SLAVITT. Yeah.
    Mr. PASCRELL. Administrator.
    Mr. SLAVITT. Thank you, Congressman.
    So the question you raise is really one of--should there 
be, and how should we capture, a device identifier in a unique 
way on every device, and I think that is the goal. It is a goal 
that we share. It is a goal that the FDA shares. And it is 
critical for post-market surveillance to be able to understand 
the safety of how these devices work.
    So there are several, I think, critical things that we can 
do, and are doing, and are trying to do to make this possible. 
So despite our enthusiasm for this--and this is an issue that 
has long preceded me. As you know, it has been an issue for 
quite some time--there are a number of parties who have a say 
in the matter of how this happens.
    I think as a first step, we are moving forward with the 
incorporation of a unique device identifier into electronic 
health records. I think this is a strong step, particularly 
considering the dramatic growth in electronic health records. 
But I know that there is also an interest on claim forms that 
there is a way for providers who provide care to indicate the 
device identifier on the claim form. We think that also has 
merit, particularly from a research perspective.
    I think there are a couple of issues to making that a 
reality: One is the Committee that essentially designs the 
claim form, which is made up of a wide group of participants 
and hospitals and physician groups; second, is making sure that 
if we at CMS are given the charge to do this that we can fund 
it and have the funds to do it operationally; and then third, 
there will be an education and training process because the 
history is that physicians don't automatically put the 
information they need to down on a form unless it is critical 
to them getting paid.
    So I think we need to work through all of these issues with 
you. We have pledged to do this with your office, and we are 
working closely with the FDA to find the best path forward.
    Mr. PASCRELL. I think you have used the best word, 
``critical.'' But if we don't do it this time, then we have to 
wait another 15 years before we change those forms, and our 
seniors will not be well served. This is important. I have been 
frustrated with CMS' resistance to what I believe is a very 
important priority, particularly of safety, including the 
unique device identifiers on health insurance claims.
    In order for the UDI to be added to the claims form as part 
of the next update, it would go into effect, I think, in 2021. 
That is the soonest. We need to act now, and I think--I can't 
stress enough, Mr. Chairman, we are talking about the safety of 
the people who use these devices, and we all want to be on the 
same page. This is, I think, a good time for us to address this 
issue.
    A number of cases, a number of anecdotal stories about not 
only seniors, by the way, but--we talked about seniors here 
because we are talking about Medicare--people that have had the 
problems, and we need to address that in order to improve 
safety. Everybody on this Committee talks about it, and I 
believe them and their hearts. Here is a chance for us to do 
something about it.
    But I want to thank you, Mr. Slavitt. You have done a great 
job and thank you for putting up with us, but we are not going 
away. Thank you.
    Mr. SLAVITT. Thank you, Congressman.
    Chairman TIBERI. Thank you, Mr. Pascrell.
    Ms. Jenkins is recognized for 5 minutes.
    Ms. JENKINS. Thank you, Mr. Chairman.
    Thank you, Mr. Administrator, for joining us today.
    Medicare obviously plays an important role for many 
Kansans. It is the largest payer for medical services in 
America, a lifesaving benefit for many people. Last year, over 
485,000 Kansans had health coverage from Medicare. We were 
pleased MACRA passed last year in a bipartisan manner. With the 
passage of MACRA we repealed SGR and instead put in place what 
will hopefully lead to a better reimbursement system for 
physicians.
    Mr. Slavitt, the relationship between a physician and a 
beneficiary cannot be underscored in importance, and I believe 
this is especially true when talking about seniors. With the 
moves that MACRA makes toward higher-value care centered on the 
quality of care administered by clinicians, it is ever 
important to ensure that we encourage greater and greater 
communication around decisionmaking between the doctors and 
their patients. So as MACRA's implementation continues over the 
next several years, do you 
see room to begin including patient activation measures, 
placing greater responsibility on this relationship with the 
hopeful result of shared responsibility over healthcare 
maintenance and thus furthering the quality of care?
    Mr. SLAVITT. Yes. Thank you, Congresswoman, for that. I 
think that is a really important question, and I think there is 
an opportunity over the next several years to begin to 
incorporate those engagement measures in.
    There are a few things that are in the current proposal 
that I would point to that take steps in that direction: One is 
there is a practice improvement focus opportunity on the 
creation of a joint care plan between a patient and a 
physician; second, in the advancing care information area, 
there are opportunities that focus on measures around how 
patients and physicians are communicating using technology and 
making sure that information is being made available to 
patients electronically and through other means.
    But I think this is, as you point out, a ripe opportunity 
and a brand new area of focus for more patient engagement. We 
have been meeting with a number of patient groups as we have 
been putting this work together, and that is an important area 
of feedback for us.
    Ms. JENKINS. All right. Thank you, Mr. Chairman. I yield 
back.
    Chairman TIBERI. Thank you.
    Mr. Davis is recognized for 5 minutes.
    Mr. DAVIS. Thank you very much, Mr. Chairman.
    Let me welcome you, Mr. Slavitt. I know that you have spent 
considerable growing-up time in Evanston, Illinois, which isn't 
very far from my district. And I also know that your mother 
lives in my district, and I am pleased to tell you that I have 
not had any real complaints from her, and so that makes me feel 
good.
    Mr. SLAVITT. That makes one of us.
    Mr. DAVIS. But let me compliment you on your work. Medicine 
is a very complex environment, and there is tremendous 
complexity. And I also want to thank your staff. I have 24 
hospitals in my district, four large medical schools, a number 
of research institutions, and a very activated citizenry. So we 
get lots of inquiries, lots of calls for assistance, a lot of 
calls for clarification. And so we spend considerable time not 
pestering but certainly inquiring of your staff, and I want to 
thank them for the kinds of sensitivities they have displayed.
    I also have a very active medical community, physicians 
associations and organizations. Just last week I had a meeting 
with the Chicago Medical Society. But I have heard concerns 
that under the proposed rule that we are talking about, only a 
limited number of physicians will meet the alternative payment 
model, or APM, criteria to earn the payment bonus.
    By your own estimation, you have indicated that there may 
be only 30,000 to 90,000 physicians who meet these terms, which 
is a tiny fraction of the total Medicare-eligible doctors in 
the country, and I am certain that we will hear some more from 
these physician groups. They would like to know what could make 
it--or how likely is it that anything will make it easier for 
there to be more pathways to qualify for the APM bonus 
payments?
    And how can CMS improve the opportunities for our 
physicians to meet the advanced APM criteria, and achieve the 
incentive to drive better care that Congress intended?
    And would you consider additional pathways that qualify as 
advanced APMs to provide assistance for our physicians who wish 
to enter the current model?
    Mr. SLAVITT. Thank you, Congressman. And my mother made me 
promise to tell you that she was a teacher at Howe and working 
with Principal Pat Tyco (ph), she knows you well and so she 
made sure I said this publicly. So I have delivered that for my 
mother.
    Mr. DAVIS. Thank you.
    Mr. SLAVITT. And your question is an important question 
because all physicians who participate in the Medicare program 
are going to have a significant opportunity to get rewarded and 
get paid for providing quality medicine, which is exactly what 
we hear from physicians that they want. Some physicians will 
have the opportunity to go further, and I think the law allows 
those physicians to get a 5 percent bonus if they participate 
in these advanced payment models.
    So our goal is not just to make the core program good but 
to create as many opportunities for physicians as possible to 
move into these programs, and we can do that in a number of 
ways. One of the important ways to do that is to simply create 
more models and more opportunities. We also have to make it 
easy for people to move back and forth if they choose to 
between programs, and I think that is one of the things that we 
are striving to achieve.
    And then, as we talked about earlier with Dr. Price, we 
also have to look at--are there ways we can take existing 
models and make them compliant with this new law? So we are 
going to work on all three of those avenues because it is a 
goal for any physician that wants to move to one of these 
advanced APM or care coordination models that they have the 
opportunity to do so.
    Mr. DAVIS. Thank you very much.
    Thank you, Mr. Chairman. I yield back.
    Chairman TIBERI. Former Mayor Marchant of Texas is 
recognized for 5 minutes.
    Mr. MARCHANT. Thank you, Mr. Chairman.
    Mr. Slavitt, does the CMS have the resources to approve and 
implement the new alternative payment model proposals in a 
timely manner?
    Mr. SLAVITT. Yes. Thank you.
    I believe the question is can we implement new models in a 
timely manner, and one of the things that we have to do--and 
the answer is yes, we can. We need to, in concert with the 
committee that was set up by the Congress, the PTAC, we need to 
receive proposals from physicians because physicians can 
generate their own proposals for models and quality and then 
work with them to, as rapidly as possible, test them and put 
them into action.
    It is one of the things that we have had the opportunity to 
work on over the last 6 or 7 years through the innovation 
center. It is something that we have gotten better and better 
at, and we are eager to get going with this Committee to get as 
many models in as possible so that we can get more and more 
models approved. And I had a chance to speak with that 
committee and speak in front of that committee to try to 
encourage more model development.
    Mr. MARCHANT. And there is a deadline period, so you are 
confident that you can get all that done by the deadline?
    Mr. SLAVITT. Well, fortunately, this is something that will 
be ongoing, so as soon as we get models in we can get them 
tested. But this committee, I believe, will be standing for a 
number of years. I am not sure if I know the exact number of 
years, but it will be ongoing because physicians will be able 
to continue to develop new models.
    Mr. MARCHANT. So the transition in governments that is 
coming up won't have any affect on this process?
    Mr. SLAVITT. No. The staff at CMS will work with the new 
secretary, whoever that is, and continue moving that forward 
very much with that, and I think there is--as I have heard 
today and as I think we continue to hear--there is strong 
bipartisan commitment and a strong commitment to this program 
in moving this forward, so I don't see any concerns at this 
point.
    Mr. MARCHANT. And just some input in my district, I hear 
from two different groups, and this is concerning the new 
program where you basically are--let's say, a knee replacement 
or a hip replacement, you are basically going to fund a lump 
sum for that. I am hearing from seniors who think that the 
doctors and hospitals are going to cut corners so that they 
will make the most amount of profit and just hurry them through 
the system. And then I am hearing from the doctors and the 
hospitals who are afraid that they are not going to get enough 
money to take the kind of care of their patients that they need 
to take care of them.
    So I guess you have created a pretty positive--these two 
tensions that are working out there, could you just make a 
comment about that?
    Mr. SLAVITT. Sure. I think what you are referring to is a 
new type of payment approach, new for Medicare but it has been 
ongoing in health care for a long time, called the bundled 
payment.
    Mr. MARCHANT. Yeah.
    Mr. SLAVITT. And really the idea behind the bundled payment 
is so that people--everyone who is involved in the patient 
care, whether it is before they would have a surgery, the 
surgeon, the anesthesiologist, but also the people that take 
care of the patient afterwards, have an alignment to get on the 
same page to provide a high-quality outcome and to do it as a 
team.
    And so it is relatively new to Medicare. We have had good 
experience and good feedback so far. But as with anything new, 
we continue to look for feedback, for data, for our 
experiences, and in particular, if there are beneficiaries in 
your district or hospitals or physicians in your district that 
have experience with the program, we would love to get feedback 
for them from you or your staff.
    Mr. MARCHANT. Well, the group that I hear from the most is 
the in-home healthcare people, who feel like they are kind of 
at the tail end of the process and that they may be the ones--
and they feel like they are the most cost effective of all, yet 
they feel like at the end of that process there may be some 
shortchanging going on.
    Mr. SLAVITT. Thank you.
    Mr. MARCHANT. Okay. Thank you.
    Chairman TIBERI. Thank you.
    Mr. Lewis is recognized for 5 minutes.
    Mr. LEWIS. Thank you very much, Mr. Chairman, for holding 
this hearing today.
    Mr. Administrator, thank you for being with us. Thank you 
for all your great and good work.
    Can you talk more about what people on Medicare might 
experience as a result of this change of payment policy, how 
smaller provider groups would be impacted and the doctors who 
need help to get up to speed?
    Mr. SLAVITT. Thank you.
    I think the most important thing that we have an 
opportunity to focus on here is patient care and improving 
patient care. And I think the ways to do so are severalfold: 
First, is this new legislation allows us to pay physicians more 
for providing higher-quality care, and the objective is to do 
this in a way which allows the physician to define what they 
believe to be the highest quality care from a menu of options 
and reward them for achieving those benchmarks. And I think 
physicians have been asking for that in one form or another for 
quite some time.
    Second, though, it is important to do that in a way that 
frees up physicians to actually practice medicine instead of 
just keeping score. And too many programs result in a lot of 
paperwork and a lot of scorekeeping and a lot of reporting, and 
we need to minimize that by simplifying wherever possible.
    The role of small physician practices, which you also 
mentioned, is critical here. And as we mentioned earlier, we 
believe that small, solo, and solo practitioners have every 
opportunity to be just as successful as larger size practices, 
and our data suggests that that indeed happens so long as the 
smaller practices report. So that means we need to minimize 
paperwork.
    We have also put in place some accommodations for smaller 
practices, including some technical assistance, some additional 
models, and ways that they can get excluded from reporting if 
their volumes are too low.
    Mr. LEWIS. Thank you.
    Furthermore, Mr. Administrator, this is a very large 
regulation, over 900 pages. It is pretty big. It is a lot to 
digest, a lot to understand. If you had to tell your doctor the 
highlights of these changes, what would you tell her, what 
would your doctor need to know to maximize benefits and avoid 
payment cuts?
    Mr. SLAVITT. Great. That is a great question, and it may be 
one of the most important things that I can communicate today.
    First of all, it is key focusing on patient care. There is 
nothing in here that should distract anybody from patient care, 
and, in fact, it will make it easier by streamlining a 
patchwork of programs that are already out there today into 
something simpler. So that is first.
    Second is they will have the opportunity to select goals 
that they believe are right for their practice and right for 
their patient population, and at some point in time they will 
have an opportunity to do that.
    Third, I think, would be that over time there will be 
opportunities for them to participate in more advanced models, 
like the kinds you asked me about earlier.
    Fourth, is they don't need to really worry about reporting 
anything until spring of 2018, and we will make it clear what 
needs to be done well before then.
    And then finally, the last thing, and this is more my 
asking of them, is to provide feedback to this rule, whether it 
is through the medical society they belong to, the State 
medical society, or directly to us. We really need line 
physicians who are practicing medicine every day to give us 
their feedback on what works about this rule and what might be 
the unintended consequences.
    Mr. LEWIS. Thank you very much. And again, I appreciate 
your effort, your great and good work, and thank you for being 
willing to serve.
    Mr. SLAVITT. Thank you.
    Mr. LEWIS. Mr. Chairman, I yield back.
    Chairman TIBERI. Thank you, Mr. Lewis.
    Mr. Paulsen is recognized for 5 minutes.
    Mr. PAULSEN. Thank you, Mr. Chairman.
    And Mr. Slavitt, it is great to see you here today--
welcome--rather than on an airplane going back and forth to 
Minnesota.
    As has already been said, you know, last year both sides 
took very historic action to move forward to finally get rid of 
the flawed Medicare payment formula based on the SGR and we 
wonder if we are going to fix it every 6 months or every year. 
And like any law, passage is just the first step, right? It is 
the implementation that has to be carried out and followed 
through, making sure it is done correctly so that we are 
achieving the intended results.
    I just want to thank you at the outset for working with 
physicians, working with patients, having that connecting 
dialogue with all the appropriate stakeholders, including 
Members of the Committee, to make sure that we are implementing 
it in the correct fashion.
    I do want to continue on the comment theme and just mention 
at the outset that it is important to know that I continue to 
hear from folks back in Minnesota as well that aren't in large, 
integrated practices, solo practices, small group practices, et 
cetera, that do have that concern. And as you mentioned, you 
want to make sure that they have every opportunity to 
participate. And I think they want that reassurance and we just 
kind of need to keep monitoring that going forward. I thank you 
for that.
    Let me ask you this question: I have also heard from a lot 
of physicians and doctors in Minnesota about the meaningful-use 
program for electronic healthcare records and how it doesn't do 
a very good job of taking into account the way physicians treat 
patients and use their electronic healthcare records. Is this 
rule the same-old, same-old, or do you make real changes in how 
you are going to be encouraging doctors now to actually use 
their electronic healthcare records?
    Mr. SLAVITT. Thank you, Congressman. And I would agree that 
our district practices some of the best medicine.
    The meaningful-use program is something that we took an 
extremely hard look at. We took a step back, because the 
meaningful-use program actually is responsible for helping to 
make technology pervasive in medicine, and that is a very good 
thing. If we look back 5 or 6 years ago, most physician 
offices, most hospitals didn't have adequate information 
technology. Today, by and large, 97 percent of hospitals, 70 
percent of physician practices have technology.
    But as we look at how to go forward, we spend a lot of time 
talking to physicians and hearing exactly what you said, 
Congressman, which is that the meaningful-use program was 
focusing on making sure they were using their computers and not 
focusing on taking care of patients.
    We also heard that physicians want their technology to be 
more connected. They want to be able to get information back 
and forth from other physicians when they refer patients or 
from hospitals, and they are also frustrated that there isn't 
enough connectivity and the data doesn't flow as easily as it 
should.
    And so we have been asked to focus on it, and I believe 
have focused on, in this rule, changing the program so it 
becomes much more flexible, moves the focus to the patient and 
away from the use of the technology, focuses on the interaction 
and communication, and allowing the free flow of data to move 
back and forth. And those are the areas that we emphasize we 
look forward to comments on during the comment period about 
whether or not we have done that well.
    Mr. PAULSEN. Does it seem like the proposed rule, replacing 
meaningful-use with this new category, advancing care 
information, right, we have all these different acronyms, but 
accounting for 25 percent of a physician's performance score in 
the first year, is that going to essentially be 
interoperability now for electronic healthcare information for 
venders, for hospitals, for all the different actors and 
players, physicians and other providers? Is that the intent 
that this information is going to be that widely shared, that 
readily available, not just being on the computer but actually 
using information?
    Mr. SLAVITT. Right. That is the intent. I would say 
everybody has a job to do in that regard. If any of us here 
could wave our magic wand and make the healthcare system more 
interoperable, I think we would do it. But this really requires 
vendors to share data to publish to what they call open APIs, 
to not practice what we talk about is data blocking, which the 
Congress has expressly asked that vendors not do, and 
physicians, to a large extent are really a victim of what the 
technology allows.
    They all want to share data. I have not met a physician who 
when they refer a patient doesn't want to know what happened to 
that patient and get that back electronically. But it is the 
technology that really needs to do that job. We think in the 
EHR certification that just came out and in a number of the 
other activities, we think vendors are going to move in that 
direction. They need to move in that direction.
    Mr. PAULSEN. Thank you, Mr. Chairman. I appreciate it. I 
yield back.
    Chairman TIBERI. Thank you, Mr. Paulsen.
    Thank you, Mr. Slavitt.
    One comment related to that is--we can discuss this more--
as you develop a final rule and the performance period begins 
on January of 2017, vendors are going to have a limited time to 
reconcile with this new rule and then physicians are going to 
have to digest the new rule. So, you know, I hope that, again, 
particularly for the small group rural markets, I hope that you 
will work with us to make sure that that implementation is done 
smoothly.
    And related to that, I don't know if you think you have 
some authority in this area, but the gap of time between 
performance period and then the payment here for physicians is 
2 years, yet the clinician reporting period is a shorter period 
of time. Do you think CMS has the ability, the rulemaking, the 
authority to change that a little bit?
    Mr. SLAVITT. Yep. So one of the things that we do see 
comment on are the proposed measurement periods and payment 
periods. What I will say is a couple things: One is, we have 
two feedback periods built in so that--one in the middle of 
2017 and one in the middle of 2018, to provide information back 
to physicians. So there is a more current feedback loop.
    The second thing I would say is because we have focused so 
much on reducing burden and reducing the number of measures and 
so forth, that is--we have had some feedback that people want 
to make sure that that starts as early as possible. We have had 
other feedback, of course, which tells us make sure we have 
enough time, make sure we have enough time to do the things we 
need to do, make sure we don't get penalized unnecessarily 
because we didn't have enough time.
    And to your earlier question, Mr. Chairman, if people will 
begin on the older technology and move to the newer technology, 
they will not get penalized for that. So we are making those 
accommodations. But of course, the purpose of the comment 
period is for people to tell us what are the things we missed, 
what are the things that could have an impact on someone's 
practice or on their patients that we didn't think of.
    And that is one of the reasons why, if there is an 
important message today to get out, it is to please engage in 
the rule and give us the feedback that we need to hear.
    Chairman TIBERI. Well, I can't thank you enough for coming 
today. As you can tell, in a bipartisan way, Members have a lot 
of interest in this and not just at the Subcommittee level but 
the Committee as a whole, as well as the Congress.
    And we really appreciate you taking the time and look 
forward to working with you and your team as you continue to 
develop this and ultimately put it into practice the way that 
we all intended it to be. And I appreciate the fact that you 
were so kind yesterday as well.
    I look forward to working with you. Hopefully we have 
treated you nice enough that you will come back, as we have 
this bipartisan concern about the way this unfolds.
    So as a reminder, any Member wishing to submit a question 
for the record will have 14 days to do so. If any Members 
submit questions after the hearing, I ask that the witnesses 
respond in writing in a timely manner.
    With that, again, thank you and this Subcommittee is 
adjourned.
    [Whereupon, at 3:36 p.m., the Subcommittee was adjourned.]
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