[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
MACRA AND MIPS: AN UPDATE ON THE MERIT BASED INCENTIVE PAYMENT SYSTEM
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
JULY 26, 2018
__________
Serial No. 115-160
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
36-027 WASHINGTON : 2019
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COMMITTEE ON ENERGY AND COMMERCE
GREG WALDEN, Oregon
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Vice Chairman Ranking Member
FRED UPTON, Michigan BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
MICHAEL C. BURGESS, Texas ELIOT L. ENGEL, New York
MARSHA BLACKBURN, Tennessee GENE GREEN, Texas
STEVE SCALISE, Louisiana DIANA DeGETTE, Colorado
ROBERT E. LATTA, Ohio MICHAEL F. DOYLE, Pennsylvania
CATHY McMORRIS RODGERS, Washington JANICE D. SCHAKOWSKY, Illinois
GREGG HARPER, Mississippi G.K. BUTTERFIELD, North Carolina
LEONARD LANCE, New Jersey DORIS O. MATSUI, California
BRETT GUTHRIE, Kentucky KATHY CASTOR, Florida
PETE OLSON, Texas JOHN P. SARBANES, Maryland
DAVID B. McKINLEY, West Virginia JERRY McNERNEY, California
ADAM KINZINGER, Illinois PETER WELCH, Vermont
H. MORGAN GRIFFITH, Virginia BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida PAUL TONKO, New York
BILL JOHNSON, Ohio YVETTE D. CLARKE, New York
BILLY LONG, Missouri DAVID LOEBSACK, Iowa
LARRY BUCSHON, Indiana KURT SCHRADER, Oregon
BILL FLORES, Texas JOSEPH P. KENNEDY, III,
SUSAN W. BROOKS, Indiana Massachusetts
MARKWAYNE MULLIN, Oklahoma TONY CARDENAS, California
RICHARD HUDSON, North Carolina RAUL RUIZ, California
CHRIS COLLINS, New York SCOTT H. PETERS, California
KEVIN CRAMER, North Dakota DEBBIE DINGELL, Michigan
TIM WALBERG, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia
JEFF DUNCAN, South Carolina
Subcommittee on Health
MICHAEL C. BURGESS, Texas
Chairman
BRETT GUTHRIE, Kentucky GENE GREEN, Texas
Vice Chairman Ranking Member
JOE BARTON, Texas ELIOT L. ENGEL, New York
FRED UPTON, Michigan JANICE D. SCHAKOWSKY, Illinois
JOHN SHIMKUS, Illinois G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee DORIS O. MATSUI, California
ROBERT E. LATTA, Ohio KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia KURT SCHRADER, Oregon
GUS M. BILIRAKIS, Florida JOSEPH P. KENNEDY, III,
BILLY LONG, Missouri Massachusetts
LARRY BUCSHON, Indiana TONY CARDENAS, California
SUSAN W. BROOKS, Indiana ANNA G. ESHOO, California
MARKWAYNE MULLIN, Oklahoma DIANA DeGETTE, Colorado
RICHARD HUDSON, North Carolina FRANK PALLONE, Jr., New Jersey (ex
CHRIS COLLINS, New York officio)
EARL L. ``BUDDY'' CARTER, Georgia
GREG WALDEN, Oregon (ex officio)
C O N T E N T S
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Page
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 1
Prepared statement........................................... 3
Hon. Gene Green, a Representative in Congress from the State of
Texas, opening statement....................................... 4
Prepared statement........................................... 5
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, prepared statement........................ 87
Witnesses
David Barbe, Immediate Past President, American Medical
Association.................................................... 7
Prepared statement........................................... 9
Frank Opelka, Medical Director, Quality and Health Policy,
American College of Surgeons................................... 15
Prepared statement........................................... 17
Ashok Rai, Chairman of the Board, American Medical Group
Association.................................................... 31
Prepared statement........................................... 33
Parag Parekh, American Society of Cataract and Refractive Surgery 36
Prepared statement........................................... 38
Kurt Ransohoff, Chairman of the Board, America's Physician Groups 55
Prepared statement........................................... 57
Submitted Material
Statement of the American Academy of Dermatology Association..... 88
Statement of the American Academy of Family Physicians........... 92
Statement of the American College of Physicians.................. 94
Statement of Connected Health.................................... 103
Statement of the American Society of Clinical Oncology........... 106
Statement of the Infectious Disease Society of America........... 108
Statement of the Medical Group Management Association............ 113
MACRA AND MIPS: AN UPDATE ON THE MERIT-BASED INCENTIVE PAYMENT SYSTEM
----------
THURSDAY, JULY 26, 2018
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:00 a.m., in
room 2123 Rayburn House Office Building, Hon. Michael Burgess
(chairman of the subcommittee) presiding.
Members present: Representatives Burgess, Guthrie, Shimkus,
Latta, Lance, Griffith, Bilirakis, Long, Bucshon, Brooks,
Hudson, Collins, Carter, Green, Engel, Matsui, Castor,
Schrader, Kennedy, Eshoo, and Pallone (ex officio).
Staff present: Mike Bloomquist, Staff Director; Samantha
Bopp, Staff Assistant; Adam Buckalew, Professional Staff
Member, Health; Daniel Butler, Legislative Clerk, Health;
Jordan Davis, Senior Advisor; Adam Fromm, Director of Outreach
and Coalitions; Caleb Graff, Professional Staff Member, Health;
Jay Gulshen, Legislative Associate, Health; Ed Kim, Policy
Coordinator, Health; Ryan Long, Deputy Staff Director; Drew
McDowell, Executive Assistant; James Paluskiewicz, Professional
Staff, Health; Brannon Rains, Staff Assistant; Jennifer
Sherman, Press Secretary; Josh Trent, Chief Health Counsel,
Health; Hamlin Wade, Special Advisor, External Affairs; Jeff
Carroll, Minority Staff Director; Tiffany Guarascio, Minority
Deputy Staff Director and Chief Health Advisor; Una Lee,
Minority Senior Health Counsel; and Samantha Satchell, Minority
Policy Analyst.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess [presiding]. The Subcommittee on Health will
now come to order. And I recognize myself for 5 minutes for an
opening statement.
Today's hearing is one that has been in the works for quite
some time. As many of you know, this hearing has been
rescheduled twice. But, given that we have now enacted
important technical changes, providers having information on
their first performance year, and this year's Quality Payment
Program rules to discuss, this hearing is timely now. I am glad
we can complete our due diligence, as members of the Health
Subcommittee, and conduct oversight and the implementation of
the Medicare Access and CHIP Reauthorization Act of 2015.
This bill, which came through the 114th Congress, is a
product of careful, intricate bipartisan negotiations and was
passed by both chambers of Congress with broad support. Signed
into law on April 16, 2015, this bill repealed the sustainable
growth rate formula for all time. The sustainable growth rate
formula was for calculating annual updates to physician payment
rates under Medicare. We now know that the formula, which was
enacted as part of the Balanced Budget Act of 1997, turned out
to be unwise.
As an OB/GYN prior to coming to Congress, I was frustrated
with the annual exercise of the sustainable growth rate
formula, as were many other physicians, as were Members of
Congress. I would like to take a moment to remind members of
what the world of physician payments looked like before the
repeal or before the passage of the Medicare Access and CHIP
Reauthorization Act.
Congress consistently passed legislation to override the
SGR. That resulted in hundreds of billions of dollars spent
that could have gone to bolstering Medicare and other health
programs. Medicare providers and their patients by extension
were under the constant threat of payment cuts under the
sustainable growth rate formula. The formula's unrealistic
assumptions of spending and efficiency have plagued the
healthcare profession and our Medicare beneficiaries for a long
time. The Medicare Access and CHIP Reauthorization Act repealed
the SGR, provided for statutory updates to allow improved
beneficiary access, and got medicine to concentrate on moving
to broad adoption of a quality reporting system.
One of the most important provisions in the law was a shift
from a fee schedule system toward a merit-based incentive
payment system. The law left behind a pass/fail quality
reporting regime whose measures were too often set up against a
``one-size-fits-all'' generic standard of care with no
financial upside for providers. Since the merit-based system
was set to go into full effect on January 1st, 2019, the first
payment consequence year, from reporting provided in 2017, it
is critical that we hold this hearing and hear from our
witnesses, in a sense, what is working, how the transition is
progressing, and where improvements have been made while
seeking ways to simultaneously encourage stronger participation
and reward providers already invested in the MIPS track.
The Medicare Access and CHIP Reauthorization Act required
the Secretary of Health and Human Services to establish a
methodology to assess merit-eligible practitioners and give
each one a performance score which determines payments based on
a scale of 1 to 100. In the first year, the performance
benchmark was set at 3. This year it was set at 15, and the
Centers for Medicare and Medicaid Services recently proposed
raising it to 30 for 2019. The merit-based incentive payment
system incorporated specific performance categories, including
quality, resource use, clinical practice improvement
activities, and meaningful use of electronic health records.
The eligible population was also set to change over time. And
the Centers for Medicare and Medicaid Services recently
proposed to add a slate of additional providers to the program.
Overall, stakeholders and physicians have been supportive
of the transition. In our third hearing, we heard from
providers getting the benefits of savings by participating in
the advanced alternative payment model. That said, the Medicare
Access and CHIP Reauthorization Act was a long-term project and
a viable fee-for-service model in the form of the merit-based
incentive payment system needed to exist. In continuing to
follow the Medicare Access and CHIP Reauthorization Act
implementation, certain decisions were made by the Centers for
Medicare and Medicaid Services that were for the benefit of a
smooth transition, but had consequences, consequences that
affected the agency's trajectory of setting the performance
threshold. Given this and other developments, I believed that
the law would benefit from technical updates to improve the
implementation based on real-time factors. The Bipartisan
Budget Act of 2018 included three technical fixes. This was
done by myself, Ranking Member Green, and Representatives
Roskam and Levin from the Ways and Means Committee.
The Medicare Access and CHIP Reauthorization Act changed
the world of Medicare provider payments. It has laid the
groundwork for increased access to quality care for
beneficiaries by eliminating the uncertainty of the past,
reducing physician burden, and providing incentives where
previously there were none. It was never a law that was going
to be fully implemented with the flip of a switch or a signing
ceremony. It was designed as a long-term effort to move the
Medicare program down the value continuum.
So, once again, I want to thank our witnesses for joining
us today. I look forward to hearing from each of you about how
the implementation of this important law is progressing.
I yield back the balance of my time and recognize the
ranking member of the subcommittee, Mr. Green, 5 minutes for an
opening statement.
[The prepared statement of Mr. Burgess follows:]
Prepared statement of Hon. Michael C. Burgess
Today's hearing is one that has been in the works for quite
some time. As many of you know, this hearing has been
rescheduled twice, but given that we now have enacted important
technical changes; providers having information on their first
performance year; and this year's Quality Payment Program
Proposed Rule to discuss, I think the hearing will be better
for it. So, I am glad we can now complete our due diligence as
members of the Health Subcommittee and conduct oversight of the
implementation of the Medicare Access and CHIP Reauthorization
Act of 2015, also known as MACRA.
MACRA, which I championed through the 114th Congress, is
the product of careful, intricate, bipartisan negotiations and
passed both chambers of Congress with broad support. It was
signed into law on April 16, 2015. Most notably, this bill
repealed the sustainable growth rate (SGR) formula for
calculating annual updates to physician payment rates under
Medicare. We now know the SGR formula which was enacted as part
of the Balanced Budget Act of 1997 was a misguided attempt to
restrain federal spending in Medicare Part B.
As an OB/GYN prior to coming to Congress, I was
overwhelmingly frustrated with the annual exercise of the SGR,
as were many other physicians and members of Congress. I would
like to take a moment to remind members what the world of
physician payments looked like before MACRA.
Congress consistently passed legislation to override the
SGR, which resulted in hundreds of billions in spent funds that
could have gone to bolstering Medicare and other vital health
care programs. Medicare providers, and their patients by
extension, were under constant threat of payment cuts under the
SGR. The formula's unrealistic assumptions of spending and
efficiency have plagued the healthcare profession and our
Medicare beneficiaries for 13 years. MACRA finally repealed the
SGR, provided for statutory updates to allow improved
beneficiary access, and got medicine to concentrate on moving
to broad adoption of the unified MACRA quality reporting
system.
One of the most important provisions in the law was the
shift from a fee schedule system towards the merit-based
incentive payment system, or MIPS. The law left behind a pass/
fail quality reporting regime whose measures were too often set
against a ``one size fits all'' generic standard of care with
no financial upside for providers. Since MIPS is set to go into
full effect on January 1, 2019--the first payment consequence
year from reporting provided in 2017--it is critical that we
hold this hearing and assess what is working, how the
transition is progressing, and where improvements have been
made, while seeking ways to simultaneously encourage stronger
participation and reward providers already invested in the MIPS
track.
MACRA required the Secretary of Health and Human Services
to establish a methodology to assess MIPS-eligible
practitioners and give each one a performance score which
determines their payments based on a scale of 1 to 100. In the
first year, the performance benchmark was set at 3. This year,
it was set at 15 and the Centers for Medicare and Medicaid
Services recently proposed raising it to 30 for 2019. MIPS
incorporated specific performance categories, including,
quality, resource use, clinical practice improvement
activities, and meaningful use of electronic health records.
The eligible population was also set to change over time, and
the Centers for Medicare and Medicaid Services recently
proposed to add a slate of additional providers to the program.
Overall, stakeholders and physicians have been supportive
of the transition to MIPS and to value-based payments. In our
third hearing, we heard from providers reaping the benefits and
savings by participating in an Advanced Alternative Payment
Model. That said, MACRA was not a sprint but a marathon and a
viable fee-for-service model, in the form of MIPS, needed to
exist. In continuing to follow MACRA implementation, certain
decisions were made by the Center for Medicare and Medicaid
Services that were for the benefit of a smooth transition, but
had consequences that would have affected the agency's
trajectory of setting the performance threshold. Given this and
other developments, I believed the law would benefit from some
technical updates to improve the implementation of MIPS based
on real-time factors. The Bipartisan Budget Act of 2018
included three MACRA technical fixes authored by myself along
with Ranking Member Green, Representatives Roskam and Levin.
MACRA changed the world of Medicare provider payments as we
knew it. It has laid the groundwork for increased access to
quality care for beneficiaries by eliminating the uncertainty
of the past, reducing physician burden, and providing
incentives where there were none. MACRA was never a law that
was going to be fully implemented with a flip of a switch, it
was designed as a long term effort to move the Medicare program
down the value continuum.
I want to thank all of our witnesses for joining us today.
I look forward to hearing from each of you and learning more
about how the implementation of this important law is
progressing.
OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS
Mr. Green. Thank you, Mr. Chairman, for holding today's
hearing on the Medicare Access and CHIP Reauthorization, MACRA,
and the merit-based incentive payment system, MIPS.
I also thank our esteemed panelists for joining us this
morning.
The sustainable growth rate, SGR, was a thorn in the side
of Medicare and doctors who treated Medicare patients for over
decade after it was created in 1997. SGR's formula led to a
reduction of physician payments, starting in 2002, that had to
be patched annually by Congress.
In 2014 and 2015, our committee, along with other
committees with jurisdiction, came together and passed
bipartisan legislation, the Medicare Access and CHIP
Reauthorization Act, which permanently repealed the SGR. MACRA
did more than just repeal the flawed SGR formula. It was
designed to overhaul and realign payment incentives for
Medicare and transition of our health system to one that
rewards value instead of just the volume of care. MACRA
provides civility to Medicare payments for providers for the
years immediately after the enactment and made it easier for
providers to report on and deliver high-quality care.
Critically, MACRA encourages providers to move away from
fee-for-service and participate in a new delivery model that
would reduce costs while increasing quality. Under the law,
physicians who treat Medicare beneficiaries have a choice
between participating in MIPS or the advanced alternative to
payment plan, APMs, to make the shift from fee-for-service and
volume-based payment system to a value-based payment system.
MIPS streamlined three prior quality incentive programs that
were sunset in 2016 and have been replaced by a new MIPS
category, quality, improvement activities, meaningful use, and
cost.
Since starting in 2017, healthcare providers could choose
whether to participate in APM or MIPS. Providers are exempt
from MIPS if they fall below the low-volume threshold. For
2017, the Centers for Medicare and Medicaid set the low-volume
threshold for providers who see fewer than 100 Medicare Part B
patients or have less than $30,000 in Part B charges annually.
For 2018, CMS increased the low-volume threshold to $90,000 in
Part B charges or fewer than 200 Medicare patients per year.
And for the next year, CMS has proposed maintaining the low-
volume threshold for MIPS while adding a third exemption route
for clinicians providing less than 200 covered services. CMS
has proposed allowing clinicians who meet the exemption
criteria to opt into MIPS.
Under MACRA, the Department of Health and Human Services is
required to set the performance threshold by 2019 at the mean
or median of final scores for all MIPS-eligible clinicians. In
February, Congress passed legislation changing the timeline to
ease the burden of the MIPS transition. The Bipartisan Budget
Act of 2018 granted HHS an additional 3 years to ensure
gradual, incremental transition to the mean or median of
performance.
I look forward to hearing from our panelists regarding
their experience with MIPS and recent changes made by Congress,
whether additional action is necessary to ensure physicians
participating in MIPS is generating savings to Medicare and
improving patient outcomes.
Thank you, Mr. Chairman. I yield back my time. There is
nobody on our side. So, I don't think they want any time.
[The prepared statement of Mr. Green follows:]
Prepared statement of Hon. Gene Green
Mr. Chairman, thank you for holding today's hearing on the
Medicare Access and CHIP Reauthorization Act (MACRA) and the
Merit-Based Incentive Payment System (MIPS).
I also thank our esteemed panelists for joining us this
morning.
The Sustainable Growth Rate (SGR) was a thorn in the side
of Medicare and doctors who treated Medicare patients for over
a decade after its creation in 1997.
SGR's formula led to a reduction of physician payments
starting in 2002 and had to be patched annually by Congress.
In 2014 and 2015, our committee, along with other
committees of jurisdiction, came together and passed bipartisan
legislation, the Medicare Access and CHIP Reauthorization Act,
which permanently repealed the SGR.
MACRA did more than just repeal the flawed SGR formula. It
was designed to overhaul and realign payment incentives for
Medicare and transition our health system to one that rewards
value instead of just volume of care.
MACRA provides stability in Medicare payments for providers
for the years immediately after its enactment and made it
easier for providers to report on and deliver high quality
care.
Critically, MACRA encourages providers to move away from
fee-for-service and participate in a new delivery model that
will reduce costs while increasing quality.
Under the law, physicians who treat Medicare beneficiaries
have a choice between participating in MIPS or the Advanced
Alternative Payment Models (APMs) to make the shift from fee-
for-service and volume-based payment system to a value-based
payment system.
MIPS streamlined three prior quality incentive programs
that were sunset in 2016 and have been replaced by new MIPS
categories: Quality, Improvement Activities, Meaningful Use,
and Cost.
Starting in 2017, health care providers could choose
whether to participate in an APM or MIPS. Providers are exempt
from MIPS if they fall below the ``low volume'' threshold. For
2017, the Centers for Medicare and Medicaid Services (CMS) set
the low volume threshold for providers who see fewer than 100
Medicare Part B patients or have less than $30,000 in Part B
charges annually.
For 2018, CMS increased the low volume threshold to $90,000
in Part B charges, or fewer than 200 Medicare patients per
year. And for next year, CMS has proposed maintaining the low
volume threshold for MIPS, while adding a third exemption route
for clinicians providing less than 200 covered services.
CMS has also proposed allowing clinicians that meet the
exemption criteria to opt into MIPS.
Under MACRA, the Department of Health and Human Services is
required to set the performance threshold by 2019 at the mean
or median of final scores for all MIPS eligible clinicians.
In February, Congress passed legislation changing the
timeline to ease the burden of the MIPS transition period.
The Bipartisan Budget Act of 2018 granted HHS an additional
three years to ensure a gradual and incremental transition to
the mean or median of performance.
I look forward to hearing from our panelists regarding
their experience with MIPS, the recent changes made by
Congress, and whether additional action is necessary to ensure
physicians participating in MIPS are generating savings to
Medicare and improving patient outcomes.
Thank you, Mr. Chairman. I yield the remainder of my time.
Mr. Burgess. I thank the gentleman for yielding back. The
gentleman does yield back.
There is 3 minutes left on the vote on the floor. We are
going to recess until immediately after the vote on the floor.
[Recess.]
Mr. Burgess. I call the committee back to order.
We are still waiting on the return of the ranking member
and the chairman of the full committee, but anticipating that
they will arrive, let's thank our witnesses for being here
today and taking time to testify before the subcommittee.
Each witness is going to have the opportunity to give an
opening statement, followed by questions from members. Today we
will hear from Dr. David Barbe, the Immediate Past President of
the American Medical Association; Dr. Frank Opelka, Medical
Director, Quality and Health Policy, American College of
Surgeons; Dr. Ashok Rai, Chairman of the Board, American
Medical Group Association; Dr. Parag Parekh, American Society
of Cataract and Refractive Surgery, and Kurt Ransohoff,
Chairman of the Board, America's Physician Groups.
We appreciate you being here today, Doctors.
And, Dr. Barbe, you are now recognized for 5 minutes to
give an opening statement, please.
STATEMENTS OF DR. DAVID BARBE, IMMEDIATE PAST PRESIDENT,
AMERICAN MEDICAL ASSOCIATION; DR. FRANK OPELKA, MEDICAL
DIRECTOR, QUALITY AND HEALTH POLICY, AMERICAN COLLEGE OF
SURGEONS; DR. ASHOK RAI, CHAIRMAN OF THE BOARD, AMERICAN
MEDICAL GROUP ASSOCIATION; DR. PARAG PAREKH, AMERICAN SOCIETY
OF CATARACT AND REFRACTIVE SURGERY, AND DR. KURT RANSOHOFF,
CHAIRMAN OF THE BOARD, AMERICA'S PHYSICIAN GROUPS
STATEMENT OF DR. DAVID BARBE
Dr. Barbe. Chairman Burgess, Ranking Member Green, and
committee members, thank you very much for the opportunity to
come here today and to update you on the continuing
implementation of MACRA.
I am a practicing family physician from rural southern
Missouri, actually in Congressman Long's neck of the woods, and
as you say, Past President of the AMA.
Physicians are familiar with value-based payment
mechanisms. We have been subject to those for over 10 years,
starting with PQRI, which was the original quality-based
program. That was in 2007. Meaningful use came in in 2009.
Value-based payments began in 2013. But each of these programs
came in at separate times under separate bills, were never
harmonized, never even contemplated working together. And all
of them started as incentive programs, but most of them have
transitioned into penalty programs which are additive.
As of now, a physician who is not able to perform, for
whatever reason, in those programs could be subject to up to
11-percent negative adjustment in their Medicare reimbursement.
That was simply not sustainable, and we thank you and the
others that worked so hard on MACRA in 2015. That is a
significant step forward. Not only did it repeal the SGR, as
has been noted, but it began to harmonize these programs,
bringing them under one administration, if you will, and it
also reset, very importantly, the incentive and penalty
corridor, such that for performance in the first year of 2017,
it was a plus or minus 4 percent, certainly a better
opportunity for physicians to succeed under that particular
framework. So, we appreciate the work that went into that.
We share a common goal with you in seeing that these new
quality payment programs are implemented appropriately, that
the transition is smooth. Because we believe that the success
of these programs has a real opportunity to improve quality for
patients, to bend the cost curve. But, for them to be
successful, physicians have to be able to succeed under these
programs as well. Again, MACRA took us a significant step
toward physician success and improving these programs.
In your opening remarks, you mentioned BBA 2018 and the
significant improvements and technical fixes that were made. We
really appreciated those as well. We will continue to work
closely with you because, as you also suggested, this wasn't a
one-and-done. This is an evolving process. And hearings like
this today, allowing us to update you, are critical in
continuing to improve that process for patients, physicians,
and for the Medicare program.
As a part of the BBA 2018, we strongly support the Part B
drug cost exclusion. We support flexibility for CMS to re-
weight the cost performance measures. We appreciate the
performance threshold flexibility that you gave CMS. We need
now for CMS to use the flexibility that you gave them to make
this transition appropriate. So, we will continue to work with
them. We have made multiple suggestions already, and we will
continue to try to make this transition appropriate.
One of the other pretty important parts of what you enabled
was for PTAC to consult with physician groups as we develop
physician-focused payment models. The PTAC has been doing what
you have wanted it to do. They have received dozens of
proposals, and they have even recommended about 10 of those
onto CMS. Unfortunately, CMS has not seen fit to adopt any of
those yet, and I think it is thwarting the creativity and
innovation that physicians are willing to bring to the table.
So, we will continue to work with CMS to try to get them to
consider and adopt some of those alternative payments models
that are physician-focused that PTAC has recommended.
And I think, lastly, you may hear some discussion today
about the limitation of the upside opportunity to something in
the 2-percent range, rather than the 4 percent that was
originally contemplated. Again, the goal is to help physicians
succeed. All of the organizations represented here represent a
wide range of physician practices, physician styles. The AMA
certainly does. We represent physicians from all specialties,
all practice types.
It is critically important that all those physicians have
an opportunity to succeed under this program. Whether you are a
large megagroup like the one I am in or whether you are a
single, independent physician practicing someplace else in
Missouri, you need an opportunity. And so, CMS needs
flexibility. We need a smooth transition, and we really
appreciate the continued opportunity we have to dialog with you
on this.
[The prepared statement of Dr. Barbe follows:]
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Dr. Barbe.
Dr. Opelka, you are recognized for 5 minutes, please.
STATEMENT OF DR. FRANK OPELKA
Dr. Opelka. Chairman Burgess, Ranking Member Green, members
of the committee, on behalf of the 80,000 members of the
American College of Surgeons, we appreciate the invitation to
share our thoughts with you today.
The American College of Surgeons again expresses our thanks
to Congress for the aspects of MACRA which have eliminated the
sustainable growth rate and led to efforts designed to link
payment more closely to quality and value. Congress' efforts
have not only reduced maximum penalties, your efforts seek to
phase in new incentives and provide potential for positive
updates. Particularly noteworthy are the congressional efforts
to combine and simplify value-based goals for measuring quality
improvement. After all, we measure, so that we can improve, not
just get paid. We also appreciate the congressional directives
for moving from fee-for-service to alternative payment models.
We would wish CMS would improve their efforts to work with the
American College of Surgeons', ACS, physician-focused payment
model. We are mindful of Congress' interest in oversight of
CMS's implementation of MACRA.
In order for clinicians to assume risk in value-based
payment programs, physicians must have reliable and valid
measures of both quality and the cost of care. The American
College of Surgeons seeks to support the congressional intent
of MACRA through our work product for building meaningful
quality measures for surgical patients and surgeons, as well as
proffering the CMS our APMs which are based on true total cost
of care.
The American College of Surgeons began over 100 years ago,
when America had more hospitals than we have today. They were
small and care was not standardized. To standardize quality, we
formed the College of Surgeons, and we created the first
hospital accreditation. In later years, this became The Joint
Commission. Today, we continue those verification programs in
order to promote standards for quality of care in trauma
centers, such as Level I, Level II, and Level III trauma
centers.
Neither the Federal Government nor commercial payers do
much to recognize the over 200 quality standards we create to
maintain a national trauma system for this country. Our
verification programs are a model which measure what matters to
patients. We measure the team and the totality of care. We
worry less about measuring the individual surgeon and focus
more about measuring the outcome to patients. We, then, credit
the entire team with its successes and we use the knowledge
gained from our programs to create learning networks which
teach others and spread improvement widely, none of this
recognized in payment programs.
In much the same way, we have created cancer verification,
breast care verification, bariatric care, pediatric surgical
care, and now more. Yet, CMS offers meaningless measures which
do little to help the surgical patient. CMS feels constrained
from measuring team-based measures, instead seeking simply
constructed measures such as surgeons having to track patients'
immunizations, rather than measuring the surgical team. The end
result is measures become meaningless, burdensome, and
distractions. Hospital CEOs end up defunding valued surgical
quality programs to chase the wrong measures, simply because
that is how they get paid.
It is time we, as the American College of Surgeons, seek
congressional directives for CMS to build a strong surgical
quality program for each major surgical domain, just as the
College has done in our team-based models for hospitals for
trauma, for cancer, and more. It is time that we measure what
matters. It is time for payment models to align with clinical
care and not force clinical care to conform to payment.
Lastly, the American College of Surgeons serves as a leader
in digital information and health IT. We are focused on
patient-centered digital records, not just EHRs, since
patients' lives exist in more than one EHR. This calls for an
expansion of our thinking beyond EHRs into a world of
interoperability, connecting patients across EHRs, across smart
devices, across clinical registries, for activities such as
clinical decision support, machine learning, and artificial
intelligence. There is so much more we can do for quality and
for lowering cost by leveraging digital information. We have to
stop thinking of EHRs and think beyond them. We could use your
support in promoting this level of interoperability to make an
interoperable digital patient medical record. We look forward
to working with the Congress to help surgeons care for
patients.
Thank you very much.
[The prepared statement of Dr. Opelka follows:]
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Mr. Burgess. Thank you, Doctor.
And, Dr. Rai, you are recognized for 5 minutes, please.
STATEMENT OF DR. ASHOK RAI
Dr. Rai. Chairman Burgess, Ranking Member Green, and
distinguished members of the Energy and Commerce Committee on
Health, thank you for the opportunity to testify today.
I am Dr. Ashok Rai, and I am here today as Chair of AMGA,
which represents multi-specialty medical groups and integrated
delivery systems. Our membership provides care for one in three
Americans.
I am a board-certified internist with 17 years of
experience, providing care to patients in Green Bay, Wisconsin.
Since 2009, I have served as the President and CEO of Prevea
Health, a multi-specialty medical group which employs more than
350 providers, including 60 medical specialties. In total, we
employ more than 2,000 people, and I am proud of the impact we
have on the people of Wisconsin.
I wanted to express my appreciation to Congress for
repealing the SGR formula for Medicare Part B payments. The
annual SGR cliffs were obstacles to sound planning and hindered
our ability to make strategic decisions that would help us care
for patients.
I applaud the committee's leadership role in passing the
much-needed MACRA law which puts providers on a path towards
value-based care. We agree with Congress that the current fee-
for-service payment system is not sustainable, nor is it good
for our patients. We need to move to a system where the payment
aligns with the way medical groups focus on the health of a
population, rather than only the sickness of patients.
Under MACRA, CMS combined existing programs such as the
physician quality reporting system, the value-based modifier,
and meaningful use programs to create the merit-based incentive
payment system, better known as MIPS. Under the MACRA statute,
MIPS providers would have the opportunity to have positive or
negative payment adjustments based on their performance,
starting at plus or minus 4 percent in 2019 and eventually plus
or minus 9 percent in 2023.
By putting provider reimbursement at risk, I believe
Congress intended to move Medicare to a value-based payment
model where high performance was rewarded and poor performers
were incented to improve with lower payment rates. In fact,
high-performing groups like Prevea Health have been preparing
for this value transition for years by participating in MIPS's
legacy programs such as PQRS, VM, and MU. As a result, our
efforts to perform in these legacy programs have improved the
value of care provided through increased quality and decreased
cost.
But the problem we face now as healthcare providers is that
CMS is excluding a majority of providers from the MIPS program.
CMS has bypassed the intent of MACRA by excluding 58 percent of
providers from MIPS requirements for performance year 2019 and
the recently-proposed quality payment program, or MACRA rule.
This will result in the 2021 payment year adjustment being
around 2 percent for high-performers, instead of closer to 7
percent, which the statute dictates. Last year, CMS excluded 60
percent of eligible clinicians, which collapsed the potential
reward for high-performers from 5 percent to 1.5 percent.
To give you a real-life example of how this works, in the
four Tax Identification Numbers that Prevea Health bills under
in partnership with our hospital partners, Hospital Sisters
Health System, Prevea Health scored three perfect scores of 100
and one of 97. However, because of the MIPS exclusions, our
payment adjustment was only 2 percent. Why is this important?
To get to value, to create change is incredibly difficult. It
requires changes in how we deliver care, how we set up our
administrative and financial processes. It means investing
millions of dollars in information technology and people.
Importantly, it requires buy-in from every member of the team,
especially the providers.
The changed management challenges presented by creating a
new value-based delivery system are enormous. And Prevea Health
undertook this challenge because we viewed MACRA as the
incentive program that would reward us for making these changes
and doing well by our patients. Now, though, I have to go back
to the physicians and providers at my group and say the
investments we made, they weren't rewarded. The better care we
delivered was not recognized. That is a difficult message to
deliver, and I don't think that is the message that this
committee or Congress wanted us to make, but it is the one we
have to tell providers at Prevea because of the way MACRA is
being implemented.
I appreciate the concerns so ably expressed today by my
colleagues for physicians practicing in solo or smaller
practices. The reporting burden on them is real. However, I
have to point out that the MIPS program is a continuation of
quality programs that have been in existence for years, and no
one is excluded from these programs, certainly not 58 percent
of them. I firmly believe Congress passed MACRA to push the
transition to value in Medicare Part B. Ironically, by
excluding the majority of clinicians from MIPS, if anything, we
have taken a step back from this transition. These exclusions
need to end. Only then can MACRA meet your goal of moving
Medicare meaningfully towards value. AMGA stands ready to work
with Congress and CMS to ensure MIPS, and MACRA, serves as the
transition tool to value, as it was intended to be.
Thank you.
[The prepared statement of Dr. Rai follows:]
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Doctor.
Dr. Parekh, you are recognized for 5 minutes, please.
STATEMENT OF DR. PARAG PAREKH
Dr. Parekh. Chairman Burgess, Ranking Member Green, and
members of the Health Subcommittee, thank you for the
opportunity to provide feedback on MACRA implementation.
I am here today on behalf of the Alliance of Specialty
Medicine, a coalition of 15 medical specialty societies,
representing more than 100,000 physicians and surgeons. My name
is Dr. Parag Parekh. I am a private-practicing eye surgeon in
rural western Pennsylvania and the only board-certified,
fellowship-trained ophthalmologist specializing in cataract and
refractive surgery as well as cornea and glaucoma surgery in
that entire geographic area. I chair the Government Relations
Committee of the American Society of Cataract and Refractive
Surgery, one of the alliance member organizations.
The alliance greatly appreciates your leadership to repeal
the SGR, create MACRA, and revamp the legacy quality reporting
programs. Listening to physicians' concerns, Congress created
MIPS, which streamlined the existing programs and allows
physicians to focus on the measures and activities that most
closely align with our practices. Successful implementation and
long-term viability is important, since MIPS is the only pay-
for-performance option for many specialists. We also appreciate
the technical corrections advanced earlier this year, which
strengthen the law, continue progress made to date, and will
improve the ability of specialty physicians to engage in
quality improvement activities.
MACRA provides two value-based reimbursement tracks for
physicians under Medicare. Under one, physicians can opt to
remain in fee-for-service and participate in MIPS. In the
other, physicians can participate in advanced alternative
payment models. For many specialists, including
ophthalmologists like me, MIPS is the only meaningful and
viable pathway. Many specialists have no opportunities to
participate in advanced APMs, given that they are designed with
a primary care focus.
While there is always more work to be done, many
specialists have made significant strides to deliver high-
quality and efficient care. In the last 50 years,
ophthalmologists have made tremendous strides in cataract
surgery by reducing complications and the variations in cost.
Ophthalmology has developed meaningful outcomes measures,
including for cataract surgery, which are being reported
through the MIPS program. And CMS proposed to include cataract
episode cost measures as well. Therefore, it is critically
important that Congress maintain a viable fee-for-service
option in Medicare Part B, along with the MIPS program, to
ensure that specialists can continue to meaningful engage in
the quality improvement initiatives and deliver high-quality
care.
The MIPS technical corrections gives CMS additional
flexibility to determine the appropriate weight of the MIPS
cost category, allow CMS to gradually increase the performance
threshold before reaching the mean or median standard, and
exclude Medicare Part B drugs from MIPS payment adjustments and
eligibility determination.
However, additional modifications are needed to support
more meaningful measures and lessen the complexity of reporting
and scoring. Currently, clinicians must comply with four
performance categories, each with distinct requirements and
scoring methodologies. Allowing clinicians to get credit across
multiple MIPS categories by engaging in a single set of actions
would make the program much less confusing.
For example, tracking outcomes through a clinical data
registry and using such data to improve patient care should
count for multiple categories of MIPS. Alliance specialty
societies continue to invest heavily in the development of
quality measures, including outcome measures and those reported
by patients, and have established robust clinical data
registries that have been qualified for use in the MIPS
program. In my own specialty, the American Academy of
Ophthalmology has the IRIS registry, which serves as a key tool
in reporting MIPS data and tracking outcomes.
Measure implementation is another ongoing challenge. Our
member societies continue to develop new specialty-focused
measures, but CMS threatens to eliminate them when they do not
immediately produce enough data to set reliable performance
benchmarks. In addition, for more established measures
previously developed by specialties, CMS has determined some of
them to be topped-out and, then, remove them from the program,
even though these measures continue to improve care and
continue to be meaningful to specialty physicians. Removing
them from the program limits our ability to participate in
MIPS.
Finally, the alliance opposes MedPAC's recommendation to
eliminate the MIPS program and replace it with the voluntary
value program, which relies on population-based measures geared
towards primary care and eliminates the one program, MIPS, that
specialists can actually use to demonstrate and improve their
quality and overall value. The VBP would discourage specialists
from developing relevant quality and outcomes measures,
disincentivize the use of high-value clinical data registries
to track patterns of care, and thwart efforts to collect and
report performance data.
Again, thank you for your work to ensure successful and
timely implementation of MIPS.
[The prepared statement of Dr. Parekh follows:]
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Doctor.
And, Dr. Ransohoff, you are recognized for 5 minutes,
please.
STATEMENT OF DR. KURT RANSOHOFF
Dr. Ransohoff. Thank you, Chairman Burgess, Ranking Member
Green, and esteemed members of the committee, for inviting me
to present today.
For the last few years, my group, Sansum Clinic in Santa
Barbara, California, has been on a journey going from the SGR
payment system to become a devoted MIPS provider, only to
evolve into a Track 1+ ACO. Our journey will provide some
insight into what is good and what is less good about the
recent shifting of the tectonic plates on which the Medicare
physician payment system stands.
Before going further, let me tell you about me and my
group. I am a general internist. I have practiced in the same
exam rooms for the last 26 years. I have been doing this long
enough to recall handwriting my patient progress notes and to
have cared for multiple generations of families. I have been
able to say to a 70-year-old man, ``Your murmur sounds exactly
like your dad's did at your age.'' I have been honored to have
practiced for that long in the same setting.
Sansum Clinic is a nearly 100-year-old not-for-profit
medical foundation with 200 doctors. It is an oddity in that it
is not affiliated with a hospital. We have participated in the
whole alphabet soup of modern health insurance from HMOs to
PPOs to ACOs.
For the last 2 years, I have been the Board Chair of
America's Physician Groups. APG is a professional association
representing more than 300 of the nation's most advanced
medical groups in the country, many of whom take full financial
risk in caring for their patients.
With that background, let me return to our story of our
journey from the SGR days to being a Track 1+ ACO. Whatever
criticisms there are about MIPS and MACRA, almost all doctors
will say thank you, as all of us have, to Congress for doing
away with that flawed process. In the SGR days, our budgeting
process was basically chaos. The cut that was generated by the
formula would mean that we would be entirely unable to balance
our books. So, we just ignored it and prayed that the
implementation would be put off, as it was every year, usually
at the 11th hour. We also had a great sigh of relief when the
SGR was repealed.
Then, there was this new process, MACRA, on the scene. Over
the last few years, our clinic became a very successful MIPS
participant. We got 100 and we made lot of investments in care
processes to enhance the health of our populations and
patients. And yet, we have left MIPS and we have gone on to
become a Track 1+ ACO. The details in the journey are included
in my remarks, but I will try to summarize the take-home
messages of our journey.
What have we learned? SGR was really problematic, and
though there remains some issues within the MIPS program that
need to be addressed, it is far and away a better system than
the dreaded ``doc fix'' gamble that we all had to rely on for
years. The way MIPS has been implemented is not the way it was
planned. It is an asymmetric process. The intended larger
reward for high scorers is gone, but the intended large loss
for those who score poorly is still there. Most of that is
because so many doctors are excluded from MIPS, more than half
a million, according to The Federal Register.
We fully recognize that exemptions are necessary in some
cases, but this level of exemptions undermines the spirit of
the law and impedes the goal of moving our nation's healthcare
system to value. There are real benefits to the patients and to
the healthcare system that come from the clinical processes
that are put in place to try to do this work well. At the same
time, the metrics on which doctors are graded need to be
relevant for their specialty and their practice.
Here are a few suggestions that we think can encourage the
movement from volume to value:
Lower the threshold for excluding groups entirely from MIPS
and, thereby, increase the number of physicians participating
in the program. At the same time, in recognition of the fact
that smaller groups have fewer resources, MIPS for smaller
groups may need to look different than MIPS for larger groups.
In other words, give smaller groups a different test more
suitable for their resources, instead of excluding them
entirely.
Even if there are flaws in MIPS, there is value for
individual patients and populations and, importantly, the payer
of all of this, the American taxpayer, in encouraging data
collection and encouraging the use of, and the reporting of,
high-quality and high-value care. The processes that are
created to do that will help move Medicare from volume to
value. We should find ways of making it feasible for more
providers to participate in that process, instead of excluding
them. MIPS can and should be fixed. It should not be discarded.
Thank you for allowing me to speak, and I will be happy to
answer any questions.
[The prepared statement of Dr. Ransohoff follows:]
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Dr. Ransohoff.
I don't see our chairman or the ranking member of the full
committee back yet. So, we will proceed with the question-and-
answer portion of the hearing. If either the chairman or the
ranking member do show up, we will, obviously, yield to them
for their statements as well.
And I, again, want to thank each of you for being here.
Many of you have mentioned different milestones along the
journey that took us from where we were in the early 2000s to
where we are now. I will just say, when I first got here, the
goal of repealing the SGR became one my primary focus, and
early on it was to repeal the sustainable growth rate formula.
I thought if I replaced that with the Medicare Economic Index
plus an inflation factor every year, so MEI plus 1 sounded
reasonable to me, pretty simple and straightforward. So, that
was my original proposal. The Congressional Budget Office threw
about $300 billion of cold water on that idea, and I attracted
no supporters, and I literally was pursuing that by myself, I
think through two Congresses.
So, that is part of what led to the journey of where we are
now. Obviously, things have happened along the way. The PQRS,
many of you mentioned having to come to a conclusion at the end
of every year and provide a ``doc fix''. And how many remember
PQRS in 2006 was sort of Bill Thomas' parting gift to medicine,
if I can use that term? But PQRS was to pay for the ``doc
fix,'' right? That is how we got PQRS, and PQRS is one of those
legacy programs that now finds itself in MIPS.
One of the largest contacts I get on social media is about
a new payment rule for labs in Medicare, and I appreciate that
it is causing some stress. That is based upon a provision in
what was really literally the last ``doc fix'' in 2014, a bill
called PAMA that, again, provided the dollars to bring us to
``doc fix''.
So, underscoring everything else, the SGR is gone and we
are not having to deal with the ``doc fix'' at the end of the
year, as I think, Dr. Barbe, you mentioned having to go to your
banker every year and explain, ``Well, it isn't really going to
happen.'' Right? ``They say it, but it isn't really going to
happen.'' So, that burden also has been lifted. And now that it
is no longer there, we kind of forget that it was something
that literally it was the end of every Congress every December
of every year that I was here for quite some time.
So, having provided that background, obviously, I am going
to ask the easy question first, and I do want everyone to
answer. In the tradition of Chairman Dingell, I am going to
make this a yes-or-no question. Better off today under the
system that we have or were we better off under the SGR legacy?
Dr. Barbe, I will start with you. Better off today?
Dr. Barbe. Much better.
Mr. Burgess. Dr. Opelka?
Dr. Opelka. Absolutely.
Mr. Burgess. And Dr. Rai?
Dr. Rai. We are better today.
Mr. Burgess. That is an affirmative.
Dr. Parekh?
Dr. Parekh. Much, much better.
Mr. Burgess. Affirmative also.
And Dr. Ransohoff?
Dr. Ransohoff. A rare opportunity for five doctors to
agree.
[Laughter.]
Mr. Burgess. OK. I wasn't going to do this, but you
reminded me. One of my greatest wishes is to someday come into
this committee hearing, having five doctors at the table who
are going to discuss how economists should be paid.
[Laughter.]
We will save that for another day. This group gets it.
The economists don't think that is funny, and I have tried
that on them from time to time.
So, no program is absolutely perfect, and I appreciate, I
guess, Dr. Ransohoff, your journey that took you, first, to the
direction of the small practice and, then, to the alternative
payment method.
And I will also add, as we were going through the
discussions that led to this bill finally getting firmed up, I
believed it would take 10 years in this process. Once again, I
had a simple formula; let's do 10 years with a 1-percent update
every year. That seemed like a good fit. Again, the CBO threw a
bunch of cold water on that idea, and it was condensed down to
5 years at a 0.5-percent update, which actually got a little
further lowered after that. But I always thought it would take
longer.
This is a big change, and more than just having the change
and having the bill signed, it is important to get it right.
And I hope, if nothing else, this hearing today--this is the
fourth hearing we have had on the implementation of this law.
And if anyone at the agency is listening, I want them to
understand this as well. It is important that we get it right.
It is not important that we passed the bill and that we had a
signing ceremony down at the White House. It is important that
we get it right, because, obviously, patients are counting on
it. Obviously, doctors are counting on it, and the taxpayer is
also one of the variables in this equation that we have to
consider as well.
So, I think I have heard the answer to this question during
your testimony, but I will ask you for the record. Would it be
better for Congress to continue to work with the agency, with
the Centers for Medicare and Medicaid Services, to implement
the merit-based system as laid out in statute or just scrap it
entirely and go back to the drawing board?
Dr. Barbe, we will start with you.
Dr. Barbe. We are eager to continue to work on this. We
think it has potential.
Mr. Burgess. Thank you.
Dr. Opelka?
Dr. Opelka. Mr. Chairman, quality is a never-ending cycle.
We have to continuously work on this.
Mr. Burgess. That is great. Thank you. I am going to steal
that quote.
Dr. Rai?
Dr. Rai. I would agree that we need to continue to work
with you on MIPS.
Mr. Burgess. Dr. Parekh?
Dr. Parekh. I also agree. In business school, they teach us
about continuous quality improvement, and I think that
principle applies here, too.
Mr. Burgess. Yes, sir.
Dr. Ransohoff?
Dr. Ransohoff. There is a lot of good to this program, and
it should be continued to be worked on.
Mr. Burgess. I have some other questions, but I will submit
them for the record.
Just one last story about the journey that got us here.
There was one morning when the then-Majority Leader came up to
me, and I was whining about this problem not having been
solved. And he said, ``Well, Doc, would it be easier if we put
everybody into an ACO?'' Well, the short answer to his question
is, yes, it would be easier, but it wasn't the right thing.
I appreciate the journey that you have been on, Dr.
Ransohoff, and I think that kind of told me what, in fact, I
was telling the Majority Leader that morning. We are not quite
sure about what the journey that different practices will have
to take, and it is important for the entire panoply of
practices to be able to prosper in the environment.
And I will yield back and recognize Mr. Green for 5
minutes, please.
Mr. Green. Thank you, Mr. Chairman.
And thank each of you for joining us today.
MACRA was an important step forward for our healthcare
system, building on the successes of the Affordable Care Act.
One of the key goals was to further reforms that would promote
value over volume and incentivize providers to find new ways to
offer more coordinated and efficient care. In order to further
that goal, MACRA created the Physician-Focused Payment Model
Technical Advisory Committee, PTAC, and to make recommendations
to the Secretary for proposals for physician-focused payment
models that would help control healthcare spending and improve
quality.
Dr. Opelka, can you describe why MACRA and the creation of
PTAC was so critical to our efforts toward delivery system
reform?
Dr. Opelka. I think the key here is--and we really
appreciate the congressional action to create the physician
input into business models--the care models have changed, and
they change every year. They have changed over the last 50
years. The payment model has been stuck from 50 years ago. So,
we need to take the care model and put a business model on top
of it that works, which means that the payer community,
particularly in our case the agency, needs to listen to us and
figure out how are we going to incentivize quality; how are we
going to reach the congressional goal of value by actually
putting a payment model that maps to the care model? And having
that relationship, the Congress open that door, and what we
need now is for an agency that is willing to, and has the
resources to, accept that.
Mr. Green. Does anyone else on the panel want to comment on
how it was working with the PTAC?
Yes, sir, Doctor?
Dr. Barbe. Thanks for asking that. As I mentioned earlier,
physicians want to be engaged and involved in this process.
PTAC was created for that very reason. They have received
dozens of proposals that come from the ground level, physicians
that are practicing that know what will work in their
practices, and perhaps in their specialty. And yet, none of
these have been adopted by CMS or, really, we think given
serious consideration. And these span everything from very
focused proposals in GI medicine to reduce rehospitalization in
Crohn's patients, all the way up to the end-stage renal disease
that could have a very broad effect on improving care and
reducing costs for dialysis patients. So, we think there is
great opportunity there if CMS will listen to us.
Mr. Green. Any other comments?
[No response.]
Which gets me to my point, I want to turn to the CMS
decision not to test many of the models that the PTAC has
submitted for testing.
And, Dr. Barbe, you get the first one. Can you expand on
your remarks in your testimony about the Secretary of HHS
decision not to implement or test most of the physician-focused
models that PTAC has submitted for testing? Why is it so
problematic for MACRA implementation?
Dr. Barbe. So, the original ideas, these very innovative
ideas were brought forth from the ground level. PTAC was
designed to evaluate these, look at the merit, look at the
rigor, and make recommendations. And they have not recommended
positively on all of these proposals, but they have recommended
positively on 10. Again, up to this point, CMS has not seen fit
to continue to work on those, to dialog and say, ``Well, this
is what we don't like'' or ``what we do like about this
proposal. If you could change it, maybe we could adopt it.''
They seem to be interested in coming up with ideas on their
own, and I think that is not only reinventing the wheel
potentially, but it is not taking advantage of some very
creative and innovative proposals that have come forward.
Mr. Green. Anyone else?
Yes, sir, Dr. Opelka?
Dr. Opelka. So, Congressman Green, we did propose to the
PTAC. We were early on accepted. We were, then, accepted in a
letter by the Secretary for consideration by the Innovation
Center. The Innovation Center had a few conference calls with
us and one 2-hour in-person meeting on a product that we
developed that took almost 5 years in the making. There is no
resources and no capability in the Innovation Center to
complete a design and, then, to create an implementation and
have a sandbox or a pilot area in which to test.
And so, the PTAC has done a fantastic job. The Secretary
vetted us. And I think we are the only one that went from the
Secretary and was recommended to the Innovation Center, and it
died in there because it is just not wired to really innovate.
And we really need to turn that on.
Mr. Green. Dr. Barbe, or anyone else, has the AMA or any
other specialty societies received further feedback from HHS or
CMS on why HHS is not testing these models that the PTAC has
recommended? Have you gotten any feedback other than--well, I
want to hear from Dr. Barbe.
Dr. Barbe. We have submitted just a month ago a four-page
letter outlining what we believe are some merits of a few of
the very specific proposals that PTAC recommended on up to CMS.
And while they acknowledge receipt of those, they acknowledge
the work that the PTAC has done, they really have not offered
any explanation. As I said, we would be happy to work through
PTAC with them to modify, if there was a deficiency they saw in
the model and they said the idea is good, but it won't go for
this reason. I think we are all eager to work with them. We are
3 years into a 6-year program on this particular issue and
still don't have a model that physicians can embrace and use
that has been approved.
Mr. Green. Mr. Chairman, my time is out, but somewhere
along the way HHS should clarify and have coordination between
not just AMA, but also the specialty societies, because, as you
know, specialties sometimes are different than a doctor down
the road. And we need to see whether our subcommittee can maybe
encourage HHS and CMS to give feedback and coordinate with you
on where we are going with this.
Thank you.
Mr. Burgess. I don't disagree. A future hearing that would
include both the agency and stakeholders on PTAC issue seems
like a good idea.
The Chair recognizes Mr. Guthrie, 5 minutes for questions,
please.
Mr. Guthrie. Thank you very much, Mr. Chairman.
Thank you, everybody, for being here.
And I know you have touched on some of this in your opening
statements, but I know that the 5 minutes is kind of limited.
So, I want to just go back and give you each a chance to ask--I
will do these two questions together.
So, my question is, for each of you, what specifically has
each of you done, or are doing, in your own practices to daily
set yourselves up for success under MIPS, and if you went
through MIPS and out of MIPS specifically? And what can
physicians do right now to position themselves to succeed in
MIPS?
So, I will just start with Dr. Barbe. Or, no, let me go
right to left, since we went the other way. Dr. Ransohoff, I
will start with you, then, and go left.
Dr. Ransohoff. Thanks. That is an excellent question,
Congressman.
I will give an example. We became a patient-centered
medical home. We had a long history of capitated care. So, we
are a very integrated medical group. But, going into MIPS, even
we, who are pretty far along, decided that we needed to have a
culture change within our organization. And so, we adopted this
PCMH model, which really has changed the way we do things. Our
medical assistant, our nurse will, as the patient is coming
into the room, will find out have you had a mammogram that we
don't know about; have you had a vaccination that we don't know
about. So, we can update it in our system. It is a small thing,
but it turns out that is actually an important culture change
because it has engaged us in a much more team-focused approach
to care. So, that is one example of how MIPS has sort of
propelled us along in what we think is the right direction.
Mr. Guthrie. OK. Thank you.
Dr. Parekh?
Dr. Parekh. Thank you for the question.
I would say that there is a two-pronged approach to
answering your question. One is on a personal level, and then,
the other one is our professional society. So, within the eye
doctor, eye surgeon community, we have, of course, my
organization, the American Society of Cataract and Refractive
Surgery, and we have the American Academy of Ophthalmology. We
work very closely together to develop measures that are
relevant to my day-to-day practice and that align very much
with what patients want, I think with what you all want, and
with what we want in terms of what is best for our patients.
So, part of it is developing outcome measures, which we
have, developing cost measures. It is not an easy task. I
personally serve on some of these committees. We spend hours
and hours and hours on this, but it is hugely important on a
global level to have that, your professional society helping to
create those measures.
And then, it's like a one-two punch almost. On a personal
level, I will tell you, participating in MIPS and getting good
scores has not been very difficult. My EMR makes it very
simple. I have a coach through my EMR system. We talk
regularly. We email regularly. I can keep track of my score of
how I am doing this year. And so, having the good measures is
very important, and then, having a good EMR system, and then,
just putting forth the personal effort to pay attention to
those measures. And then, improve my deficiencies, become a
better surgeon, become a better doctor, and also keep track of
those measures. So, it has been a two-pronged approach.
Mr. Guthrie. Thank you.
Dr. Rai?
Dr. Rai. So, to answer your first question, what have we
done to prepare for MIPS and MACRA, really, it is redesigning
how we practice. The physician is no longer the center of the
healthcare system. The patient should be. And we have
redesigned all of our practices, both primary care and
specialty care, to put the patient in the middle and establish
team-based care, making sure that nurse care managers are
interacting with patients, making sure that if you have a
chronic disease, your visit never ends. It is just how often we
connect with you.
And we have also made significant investments in data
infrastructure. An EMR without the ability to draw the data in
is just a really expensive word processor. And we have had to
make significant investments in drawing the data out, but,
then, also make significant digital investments that are
patient-facing and forward to identify gaps in their care, to
establish online scheduling, all of which we have done in this
last year.
Your other question, what should other physicians do to
prepare, really, it is no longer focusing on the sickness of
our patients, but the health of our population. We need to make
more investments on keeping people out of the hospital, even
out of our clinics, which isn't always financially viable, but
we, through MACRA, through MIPS investments, are rewarded for
that. And we have to use those value rewards to redesign how we
practice medicine.
Mr. Guthrie. OK. Thanks.
Dr. Opelka, we are about out of time. So, go ahead, if you
have got a couple----
Dr. Opelka. Very quickly, for the most part, MIPS does not
measure surgical care. So, we do the best we can to help our
surgeons get the credit they need for payment purposes, but,
then, we try to refocus them on the quality metrics programs
that we have separate from MIPS.
Mr. Guthrie. OK. Dr. Barbe, do you have just one quick
thought?
Dr. Barbe. Our group has been very successful, but we have
invested heavily over a decade in order to be successful. I am
concerned that some of these programs now simply don't give
physicians enough upside opportunity to invest like that in
order to be successful.
Mr. Guthrie. OK. Thank you.
And I yield back.
Mr. Burgess. The Chair thanks the gentleman. The gentleman
yields back.
The Chair recognizes the gentleman from Oregon, Dr.
Schrader, 5 minutes for your questions, please.
Mr. Schrader. Well, thank you, Mr. Chairman.
Dr. Rai, why are 58 percent of the practices excluded from
MIPS? What is your opinion?
Dr. Rai. I think CMS created those exclusions because
physicians felt they weren't ready to participate. But, for
MIPS to be successful, for MACRA to be successful, there has to
be a plus and a negative. It is a budget-neutral program. So,
there has to be a carrot and a stick.
The 58 percent really came from CMS----
Mr. Schrader. But why are they excluded? Why are they not
ready?
Dr. Rai. Why are they not ready? I think some consider
themselves not ready because they have not made the investments
or are willing to make the investments or take the risks that
are involved in now making that transition from fee-for-service
to value.
Mr. Schrader. Investments in terms of expensive computers,
or whatever, or what are you talking about?
Dr. Rai. I think the investments are multi-fold. I think
probably the most significant investment that we have made is
in people, in making sure that we redesign how we practice
healthcare. It is in staff. It is not only in staff, but in----
Mr. Schrader. So, it is basically a decision by those
offices not to engage, frankly, in the new era of modern
medicine?
Dr. Rai. It is. It is. It is people that would really like
to hang on to fee-for-service for as long as they can.
Mr. Schrader. All right. All right.
So, I guess, Dr. Parekh, why is MIPS the only option for a
specialist? I would understand that you are not a primary home
model type of thing, but why is that the only APM? Or why
doesn't some other form of APM work for you?
Dr. Parekh. Again, I will give you my answer, multiple key
reasons. First and foremost, most practically speaking, there
are no APMs in my area that I could join, even if I wanted to.
Mr. Schrader. Sure.
Dr. Parekh. So, there is just a geographic barrier to that.
You will know better than I about the spread of those APMs
through the country, but, certainly, in my area it is just not
a choice.
The ACOs are very primary care-focused. When I think of how
an ACO works and what the potential is to save money and to
improve quality of care, it makes the most sense for primary
care to be doing that because they are the quarterbacks of the
team. They help coordinate the entire ship. My wife is an
internist. I mean, we have this discussion at the dinner table
all the time.
When we in ophthalmology are trying to improve our
patients' care, I mean, think of it from our perspective. I am
trying to do a good job on cataract surgery. I am trying to
lower my patient's eye pressure from glaucoma, so that they
don't go blind. But, if we were in a big model, those measures
are likely not going to be used. So, they wouldn't actually do
anything for my patients. They wouldn't actually give me a
solid, meaningful measure that I could do, I could measure
myself; I could say, oh, I am deficient; I want to improve.
That is not going to exist because the system is so big. So, I
think we lose something when you have such a massive system.
The primary care gets the weight of that in these bigger
systems and I think the specialists are lost.
MIPS, on the other hand, gives me a measure that directly
affects what I do. If I am----
Mr. Schrader. Do you interface with primary care systems at
all? Is there any primary care system in your geography?
Dr. Parekh. No.
Mr. Schrader. OK. All right. In rural Oregon, we have been
able to make that happen. I am not talking to your situation,
but just for the sake of the panel and others, there are ways
to make APM systems work, ACOs work in rural settings. It is a
culture, and after a while you figure out how to do it, like
you all are doing as you adopt new practices and stuff.
So, Dr. Ransohoff, you suggested maybe lowering the
exclusion threshold in the MIPS program. Could you elaborate on
that a little bit? To my investments, I mean, I would assume
that the outcomes, whether you are a large practice or a small
practice, the outcomes shouldn't really change. If it is
patient-centered, you want the patient to be healthy, less
readmissions, less time between surgeries, whatever the option
is. Could you talk a little bit about that?
Dr. Ransohoff. Yes. I think that the main issue is just
trying to get more doctors involved in the process. The way it
is set up now, in a way what you have is you have a bunch of
people who are believers, if you will, and are kind of going
down that path, and then, you have a bunch of people who are
just saying, ``Thank goodness this doesn't affect me,'' and are
not making any efforts to change.
Mr. Schrader. Right.
Dr. Ransohoff. I think that, in the absence of change, I
don't understand how any of this gets to be affordable. And so,
I do think there is going to have to be some change. By
lowering the threshold from $90,000 to some number less than
that, you would start a gradual transition. People would know
it was coming.
I do think that, as my colleague here in solo practice
points out, I think that this is doable. It is just that people
don't want to do it.
Mr. Schrader. So, maybe some sort of phase-in with the
thresholds, so that people can see a path or eventually develop
a path going forward?
Dr. Ransohoff. Correct.
Mr. Schrader. So, the last question real quick, Dr. Barbe,
everyone has pretty much referenced electronic medical records
and EHR. I am very, very concerned that, while individual
practices and groups are making huge investments--originally,
there was some money from the Federal Government to help out;
gone now. Maybe that is something we should continue or think
of strictly for small practices. But I am concerned about the
systems--and you guys have alluded to this--not talking to one
another. And there is a vested interest, with all due respect
to our EHR developers, to keep that system pretty proprietary
and pretty unique, so that you have got to buy their stuff.
Could you talk a little bit about trying to broaden that out?
Is there a role for the Federal Government to require some of
these developers to make it easier for doctors to share their
information across specialties, primary care, frankly,
nutritionists, the whole gamut?
Dr. Barbe. So, yes, we believe the Office of the National
Coordinator can facilitate better interoperability. Many groups
are trying workarounds now, all the way from health information
exchanges to other cloud-based. Dr. Opelka earlier referenced
activities of the American College of Surgeons. The AMA has
significant activities around an IHMI, or Integrated Health
Model Initiative, that we believe has some great potential. But
all of those are workarounds because the industry has not made
data interoperable and, in fact, has blocked data in many
cases.
Mr. Schrader. Thank you. And my time is up, but I think
that is a critical issue for this committee to address, if we
are going to be successful going forward.
Thank you very much, Mr. Chairman.
Mr. Burgess. Thank you, Dr. Schrader.
I would just point out that the third title in the Cures
bill that we were planning on having oversight of the
implementation was the electronic health records. We did have
the mental health title evaluation earlier this week, I think,
or was it last week? But, in any case, that has been held up
because a rule has been stuck at the Office of Management and
Budget, and we had initially planned to have that hearing in
June and it was postponed because of that reason. Then, we are
eventually just likely going to have to have the hearing
without the rule having been finalized or released by OMB.
I would now like to recognize the gentleman from Illinois,
the chairman of the Subcommittee on Energy and Environment,
Chairman Shimkus, 5 minutes.
Mr. Shimkus. Thank you, Mr. Chairman. This is a great
hearing. Tough names out there. So, if I butcher them, I
apologize for that.
For Dr. Schrader, I think we do need to look at this as an
exemption issue. If this is a movement forward, and there are
cost challenges, we ought to get everybody onboard on the
quality bandwagon.
I can't remember who mentioned it in their opening
statement, but someone, one of you mentioned that high-
performers are not getting rewarded. Can you just address that
a minute? Because, obviously, you mentioned, I think--correct
me if I am wrong--poor-performers are being identified, but
high-performers are not being rewarded.
Dr. Rai. Yes, I think both Kurt and I mentioned that. At
the end of the day, for the budget neutrality to work, there
has to be just as many people involved in this. And that is
what the exclusions created, was the incentive was cut in half
for high-performers. Because there weren't as many people in
there, the threshold was changed. So, from expecting a 4-
percent to a 2-percent increase, yet making all the investments
to value, is where we felt that high-performers were literally
being penalized for making the right investments.
Mr. Shimkus. Any more? Dr. Ransohoff, I am going to go with
you to the next question, too. So, why don't you answer that
also?
Dr. Ransohoff. Yes, we have the same issues. We spent
probably half--we will get a 2.02-percent reward for getting
100--we probably spent half of that trying to get it. Now we
had done that because we thought that the reward would be
significantly more, and it is the right thing to do, but there
is an economic issue with it.
Mr. Shimkus. Yes, and I am going to talk economics a little
bit, too. But I want to go back. What intrigued me about your
comment to another question was, electronic health records or
whatever, EMR, or whatever you want to call them, asking
patients about indices that they may not be there for. We have
been dealing with that with the opioid issue and trying to
change law, so that there is a little more conversation. As you
all know, there are catastrophic stories of the firewall
between information, which has turned out deadly, and this
whole committee has been trying to do things that we can do to
address that. So, I applaud that, and hopefully, the
legislation that we are moving forward, hopefully, with the
Senate concurrence and a presidential signature, will start
making that a little more available.
The concern is always going to be data privacy, personal
privacy, and the like. So, you are the folks in the field and
you are the ones who have to really help us see and help direct
us on protection versus sharing of information throughout the
practice. Especially if we are doing a patient center, as you
guys were mentioning, holistic, with different people around,
that information has to be shared throughout the practice. So,
excellent point.
I wanted to ask, I wanted to kind of go off, not totally
off-script, and I am not trying to get this partisan or
political, but in this current world today how much is, what
are you paying--how do you want to answer this question. I have
always been worried about uncompensated care. Even with a
government-run healthcare policy, high deductibles, can you
talk to me about--and that is all the time I am going to have.
So, whoever wants to talk to me about, even in a system where
we are doing Medicare and Medicaid, that doesn't pay costs,
even if we are moving to high performance. So, if we are not
paying the cost of care, and then, you have folks, and then,
you are eating uncompensated care, that is where I think our
system just breaks down. Anyone want to talk about
uncompensated care or charity writeoffs, or however you want to
define it?
Dr. Barbe. So, what the AMA would like to see is no
uncompensated care not from our side, but because that means
patients have coverage that will help them get access to care.
That is the bottom line here. So, it is not a matter of how we
handle uncompensated care. It is how do we get more people
covered, so that they can have access?
Mr. Shimkus. Quickly, anybody else want to jump in?
Everybody else is compensated fully and there are no writeoffs?
That is what you are saying? Or you just don't want to go into
this debate right now?
Dr. Opelka. Well, you have opened up a very complex subject
matter.
Mr. Shimkus. Yes, right.
Dr. Opelka. The bottom line is that the uncompensated care
patients, when they come in to seek surgical care, it is
already too late. They are way behind the power curve. And that
is the most unfortunate thing. We all see them. We all treat
them. We take care of them.
Mr. Shimkus. We should take care of them in the internist
level or early intervention and provide that care----
Dr. Opelka. Their cancers are diagnosed late. So, they have
a poor outcome. Let's get in front of the disease, and the
uncompensated care patients come in a day late and a dollar
short.
Mr. Shimkus. My time has expired. Thank you, Mr. Chairman.
Mr. Burgess. The Chair thanks the gentleman. The gentleman
yields back.
The Chair will recognize the gentlelady from California,
Ms. Matsui, 5 minutes for questions, please.
Ms. Matsui. Thank you, Mr. Chairman.
And I thank the witnesses for being here today.
We were talking about telehealth, and a group of us on the
Energy and Commerce worked together to advance telehealth
legislation, legislative and with the administration. As we
have worked on legislative efforts, we have found CMS and CBO
to be resistant to expanding access to telehealth due to cost
concerns. Expansion has often been judged as adding a new
service that could be overbilled, rather than taking into
account that reducing hospital and ER visits would result in
better care that could result from getting patients access to
care sooner and more conveniently.
I am encouraged that CMS has taken steps in this recently-
proposed rule to expand access to telehealth in Medicare, as
this is what we have been working toward. There will be no way
to prove success in the Medicare population without covering
services. And I am curious to hear from our witnesses about the
types of telehealth services that they currently implement.
Starting with you, Dr. Barbe.
Dr. Rai. I would be happy to start.
Currently, in our organization we provide telestroke
coverages to rural hospitals.
Ms. Matsui. OK.
Dr. Rai. We also are opening up very small cities in
Wisconsin, northern Wisconsin, so just Ladysmith at the new
site, and we would love to provide more services to there. Some
of our specialists live 5 to 6 hours from there----
Ms. Matsui. Right.
Dr. Rai [continuing]. But easily could provide followup
services or counseling services. There is not a lot of times in
medical specialties especially, such as endocrinology, that we
generally necessarily need to examine the patient. We need to
be able to have that conversation and counsel that patient, or
other services that are not even physician-based. But,
unfortunately, we run into the wall with CMS and other payers
without an ability to pay for that infrastructure, which does
not come cheap. But we have done it with telestroke. We have
done it. We have done it very well. We hope to do more.
Ms. Matsui. OK. That is great.
Anyone else want to comment on that?
Dr. Barbe. So, there are many types of services and sites
of services----
Ms. Matsui. Right.
Dr. Barbe [continuing]. That are actually prohibited from
participating in telehealth or digital medicine. We can start
by getting rid of some of those restrictions. We can start by
unbundling some of these payment codes, so that we can charge
differently for consults versus remote patient monitoring.
Ms. Matsui. Right.
Dr. Barbe. My particular group is very robust in what we
call virtual care, which is digital medicine, and we put
monitoring devices in patients' homes. We will even run the
internet to their home, because in rural southern Missouri many
don't have that. So, there are a lot of things, but we can's do
this because there is no direct payment. The only reason we can
do it now is we are in some risk-sharing arrangements.
Ms. Matsui. All right. Anyone else here?
Dr. Opelka. Just very quickly, where there are capitated
environments, all these barriers to payment go away, and
telehealth actually becomes very creative and innovative. In a
capitated environment, in my former practice we dealt with
rural, like was mentioned, but we also dealt with prisoners,
and putting telehealth in the prison became a very effective
way of getting better care to the prisoner, rather than having
to transport somebody with all kinds of guards and other
security. Telehealth was a savior.
Ms. Matsui. OK. Let me just go on. One of my legislative
efforts with Representative Bill Johnson on Energy and Commerce
is H.R. 3482, which would remove originating site and
geographic restrictions on telehealth in Medicare. And the
steps CMS has taken to pay for virtual check-ins is very much
in line with this idea. We passed a limited version of that
bill for opioid service in the House opioids packages, and I
hope the Senate will move to take this important legislation.
And I really do look forward to having it expand further, and I
think it would be helpful for all of you.
I have been working to advance interoperability between
electronic health records, and the proposed rule has
implemented a performance measurement in order to promote
interoperability. I guess, Dr. Opelka, you have talked about
this. What success have providers had in working toward a goal
of interoperability? Do you feel that the implementation of
MACRA has been helpful?
Dr. Opelka. I don't know that MACRA itself has actually
drawn attention to this. When we moved away from dealing with
the EHRs and we created a patient cloud, and we began moving
data into the cloud environment, in which we could represent
information either to a patient or to a clinician from wherever
that patient was seen, those models are now emerging separate
from the EHR vendors. It is making a huge difference in care in
those environments. That is the direction we need to go in, and
that is where we need to actually educate the government to
help us push incentives that drive us more to a patient cloud
environment, rather than to say, this hospital, this EHR, it is
this patient and all the hospitals they get care in.
Ms. Matsui. Right. OK.
I think I have run out of time. I yield back. Thank you.
Mr. Burgess. The Chair thanks the gentlelady. The
gentlelady yields back.
The Chair recognizes the gentleman from Ohio, Mr. Latta, 5
minutes for questions, please.
Mr. Latta. Thank you. Thank you, Mr. Chairman. I want to
thank you for the hearing today.
And I want to thank all of you for being with us today.
Because I am sitting here looking at you thinking to myself of
all the patients you would be seeing right now in the time that
you are taking to testify before us on this important matter.
One of the great things that we get to do, we travel around
in our districts. We talk to our docs back home. And we also
have the ability to see a lot of the third-year, four-year
medical students from our states come through. They are working
on a lot of their specialties and everything else, but, at the
same time, they kind of bring up with you all the sundry things
that they are going to have to be doing to practice medicine.
And I wonder if you all would mind answering a question for
me, just going down the line, if you wouldn't mind. How much
time do you take out, if you took a percentage, that you are
practicing medicine or you are doing the administrative side of
your job?
Dr. Barbe. I can answer that very precisely. The AMA has
done two studies. It shows that physicians spend about two
hours in front of their computer screen or doing other
paperwork for every hour they have in direct clinical contact.
We did a second study that shows, for primary care physicians,
they spent 60 percent of their day in non-direct-patient-care
activities.
Dr. Opelka. And it is roughly about 20 percent of their
time doing administrative burden.
Dr. Rai. It is ballpark around that same number. We at our
own organization started to look at EMR utilization after 5:00
or 6:00 p.m., when they log in from home after dinner, and how
long they are on it. A significant amount of our primary care
physicians are logging in late at night to complete their day,
which is definitely leading to a nationwide situation with
burnout.
Dr. Parekh. I will echo the comments. I mentioned earlier
my wife is an internist, and the kids go to bed around 9:00
p.m. and we get on our computers.
Dr. Ransohoff. We have done the same kind of study. We see
that internists, it varies somewhat by specialty, but in
primary care it is not uncommon for doctors to spend 20 hours a
week after hours doing documentation on the computer.
Mr. Latta. And I know they are calling votes on us right
here. I am going to ask just one question then. The clinical
data registries and the certified EHRs that are envisioned by
MACRA as serving as critical reporting mechanisms for providers
to interact with the Medicare, would these represent a decrease
in that administrative burden then? And just go down the line.
Dr. Barbe. They haven't yet. The EHRs still just don't work
for physicians. There is too much point, click, move from one
field to the next. Even in the certified technologies, which we
have, we are still burdened significantly by that.
Dr. Opelka. So, the clinical data registries, we run about
seven international registries. They actually pull data in and
generate knowledge, and that knowledge is delivered at the
moment of care that allows for clinical decision support, that
allows for better care, higher quality, et cetera. So, while
they may take on time, they actually reduce burden and improve
patient outcome. So, they are very welcome.
Dr. Rai. I would echo that. The registries are welcome.
They help us identify gaps in care that patients may need on an
active basis, on a more timely basis, and the ability to access
a patient to make sure that we get in front of them before they
get in front of us in an acute situation.
Dr. Parekh. As I mentioned in my testimony, the Academy of
Ophthalmology created the IRIS, I-R-I-S, registry, and it has
been a huge help. I will give you an example. Let's say, 2 days
ago, I was doing surgery. My EMR records the date of the
surgery on the right eye, for example. And then, when we see
the patient back, of course, we record how the vision is doing.
And one of our measures is, is the patient 24/40 or better
within 90 days? So, it is an outcome measure, like I said, very
important to our specialty, very important to our patients. And
so, as soon as that vision reaches that threshold, the EMR
automatically captures that data. The point is, we are getting
outcomes data and it is very little additional work because the
registry is able to grab that info without me typing it in
again for the registry. So, it has been great.
Dr. Ransohoff. There is nothing faster than ineligible
handwriting that is not shared with anyone.
[Laughter.]
And I practiced in those days. The computer systems that
are out there now are more time-consuming. I do think they are
much better.
I prescribed recently--the patient was on two unusual
medications, and they computer said there is going to be a drug
interaction. And so, there are real benefits to it, but it is
definitely more time-consuming.
Mr. Latta. OK. Well, Mr. Chairman, my time has expired, and
I yield back.
And I thank our witnesses again for spending time with us
today. Thank you.
Mr. Burgess. The gentleman yields back. The Chair thanks
the gentleman.
The Chair does acknowledge there is nothing faster than bad
handwriting, particularly if you are lefthanded.
The Chair now recognizes the gentlelady from California,
Ms. Eshoo, 5 minutes for questions, please.
Ms. Eshoo. Thank you, Mr. Chairman.
And thank you to the witnesses. You represent so many that
practice medicine across our country in the different
disciplines, and have headed up, and do head up, organizations
that are representing them.
I would like to go to Dr. Rai and Dr. Ransohoff with this
question. Earlier this month, CMS released a proposed rule that
estimated that 42 percent of physicians participating in
Medicare will need to comply with MACRA. So, my question to
both of you is, with so many physicians that are exempt from
both APMs and MIPS, has CMS undermined the original intent of
MACRA? Would that be your take? And with so many physicians
exempt, will MACRA meet the original payment reform goals it
set out to achieve?
Dr. Rai. I do believe CMS has gone against the intent of
MACRA with the exemptions. For this to work, for us to truly
move to value, the intent of MIPS, as one of my colleagues has
been quoted to say, MIPS was the on-ramp to value and CMS has
created an exit ramp.
Ms. Eshoo. Why do you think they are doing this?
Dr. Rai. Change is never easy. The change of going from
fee-for-service to value, to taking risks----
Ms. Eshoo. Oh, we have been doing that for a long time.
This isn't exactly something that happened in the last 90 days.
We have been in transition since I first came into the Congress
on this thing, and I have been here for a while.
Dr. Rai. I don't disagree with you at all. The legacy
programs did not have the exemptions. And now, all of a sudden,
we are exempting people, and it is truly preventing--it is
another kick-the-can-down-the-road. It is becoming SGR 2.0 if
they continue that behavior.
Ms. Eshoo. Well, how do you think CMS can improve the MIPS
implementation?
Dr. Rai. Implement it as it was written. Really implement
what you passed.
Ms. Eshoo. Great. Good answer. Good. All right. Well, that
is confidence in the work that we have done, Mr. Chairman.
To Dr. Opelka and Dr. Parekh--is it ``Parak'' or
``Paresh''?
Dr. Parekh. Parekh.
Ms. Eshoo. Parekh.
I have heard from physicians in my congressional district--
it is the Silicon Valley district in California--that those in
small practice and who practice specialty care face barriers in
participating in MIPS. Do you face barriers, as some of my
physicians have reported? And if so, what are they?
Dr. Parekh. Thank you for the question.
As an ophthalmologist, again, I feel very lucky. We have
amazing professional societies. We have been working for a long
time, as you said, coming up with measures. We have been
preparing for this moment for a while, coming up with outcomes
measures, coming up with process measures, creating cost
measures, having a registry. So, I am very fortunate--knock on
wood, I thank our professional societies--it hasn't been that
hard for us in ophthalmology.
Ms. Eshoo. Well, that is good. Do you know Dr. Chang?
Dr. Parekh. Dr. David Chang.
Ms. Eshoo. Dr. David Chang, yes.
Dr. Parekh. Yes, he is one of my very good friends. In
fact, he knew that I was coming today and sent me a very kind
email.
In ophthalmology, I think our numbers to some extent back
up what I am saying. I think people who participated in our
registry, I think 85 percent got a score of 100, getting the 2
percent that was mentioned earlier, and I think 99 percent got
some type of bonus. So, again, we have been working very hard
at this, and I think it is blossoming.
Ms. Eshoo. Would you recommend anything to us that would
lessen the burden on physicians, so that you can more actively
participate in MIPS or do you think it is just working
swimmingly?
Dr. Parekh. I think there is always room for improvement.
Ms. Eshoo. Always, yes.
Dr. Parekh. Like I said, it is a continuous quality
improvement mindset that we have to have.
Ms. Eshoo. But do you have something, anything specific?
Anyone have anything specific?
Dr. Opelka. Sure. So, this whole matter of participating or
exclusions, if you don't measure what matters, putting money
and investments into something that is senseless, nobody wants
to participate.
Ms. Eshoo. And that is what we are doing?
Dr. Opelka. So, all the surgical specialties, all of them,
including ophthalmology, the majority of their measures have
nothing to do with surgical care.
Ms. Eshoo. Wow.
Dr. Opelka. They are measuring primary care. So, it doesn't
surprise me that primary care says everyone should be in, but
it also doesn't surprise me when surgery care says, ``It
doesn't matter to the patients I am treating. So, why am I
spending money in my practice to send CMS tobacco cessation and
immunization rates?'' Nobody comes to me as a surgeon with
breast cancer to talk about those things. We are not measuring
what matters. And so, as long as we are going to measure silly
things, everyone is going to say, ``I want to be excluded.'' If
you want to measure what matters, put me in. Put me in, coach.
I want to play. But that is not what we are getting.
Ms. Eshoo. Well, I think that that is highly instructive to
us, Mr. Chairman.
Mr. Burgess. That is the reason we are having the hearing.
Ms. Eshoo. Yes. Well, that is what happens in hearings.
Mr. Burgess. And I appreciate your----
Ms. Eshoo. But what I am suggesting is that we work with
CMS to get rid of what was just described as the--did you use
the word ``silliness''?
Dr. Opelka. Yes.
Ms. Eshoo. OK. Thank you to all of you. You are the healers
of the Nation. So, thank you for what you have devoted
yourselves to, and taking on the extra responsibility of
heading up organizations.
Mr. Burgess. If the gentlelady will conclude her
soliloquy----
Ms. Eshoo. Thank you.
Mr. Burgess [continuing]. We have about a minute left on a
vote on the floor.
Ms. Eshoo. I yield back.
Mr. Burgess. I am going to recess after I acknowledge the
presence of Dr. Boustany, former Member of Congress and member
of the Ways and Means Committee. We appreciate your attendance
here today.
And we will stand in recess until after this vote.
[Recess.]
Mr. Guthrie [presiding]. The committee will come back to
order. Thank you.
There will be other members that are voting and will be
back shortly to ask questions, but we are going to continue the
question period.
All right. The Chair recognizes Dr. Bucshon for 5 minutes
to ask questions.
Mr. Bucshon. Thank you, Mr. Chairman. I appreciate that.
And thank you to all the witnesses for being here. I was a
cardiothoracic surgeon before coming to Congress, and this is
critically important for our patients at the end of the day,
right? And that is what I try to focus on.
As you know, the participation in MIPS is low. Everyone
outlined roughly 60 percent of physicians are excluded from the
program, leaving only $118 million of the $70 billion baseline
for incentive payments for practices. Participation in the
alternative payment models in MACRA is even smaller, with only
5 percent of physicians enrolled in an APM. CMMI has not
approved a single APM submitted from PTAC, and PTAC cancelled
its June meeting due to lack of APMs to review.
I am interested in ways to increase participation in and
the number of APMs, which is why I introduced the Medicare Care
Coordination Improvement Act, H.R. 4206, which three of you on
the panel's organizations have signed a letter in support of--
and I will get to that in a minute--which would encourage
development, testing of participation in APMs by exempting
practices from the volume and value prohibitions in the Stark
law. After all, how can practices deliver on value-based care
if they cannot remunerate their physicians based on value?
Mr. Chairman, I ask unanimous consent to submit the letter
to the record.
Mr. Guthrie. Without objection, so ordered.
Mr. Bucshon. The American College of Surgeons, the American
Medical Association, and AMGA, among many others, have signed
onto the letter.
Basically, it says they are in strong support of the act
that we introduced and ``The legislation would substantially
improve care, coordination for patients, improve health
outcomes, and restrain costs by allowing physicians to
participate and succeed in alternative payment models.'' The
bill would modernize the Stark self-referral law enacted nearly
30 years ago.
The things that it would do is provide HHS with the same
authority to waive the prohibitions of the Stark law and
associated fraud and abuse laws for physicians seeking to
develop and operate APMs, as was provided for ACOs in the
Affordable Care Act; remove the volume or value prohibition in
the Stark law, so that physician practices can incentivize
physicians to abide by best practices and succeed in the new
value-based alternative payment models. This protection would
apply to physician practices that are developing or operating
an alternative payment model, including the advanced APMs, APMs
approved by the physician-focused payment model, the Technical
Advisory Committee, MIPS APMs and other APMs specified by the
Secretary; and finally, ensure that CMS's use of current
administrative authority promotes care coordination, quality
improvement, and resource conservation.
I guess I will ask the question of everyone. How do you
think changes to the Stark law would help physicians coordinate
and improve care and help MACRA succeed? And how important do
you think that would be in the overall success of what we are
trying to do with the MACRA legislation and, also, as you have
noted, transition to an outcome-based, patient-centered-based
way to reimburse providers?
I will just start that. If any of you aren't aware of what
we have done, that is OK. But we can start with the surgeons.
Dr. Opelka. Thank you very much.
First of all, yes, we are in strong support of this effort.
Specifically, the way that Stark is written, you can be held
accountable without intent, and that is a problem. So, when we
have alternative payment models with shared savings
opportunities between all the parties, legal counsel, when they
review these contracts, become extremely worried about how
clean are these waivers or exemptions from Stark. They have got
to be bulletproof because Stark is so broad and overreaching,
it is easy for a court to interpret things different than your
own counsel interpreted them.
For that reason, when we go to these alternative payment
models where there are parties that will be involved in shared
savings, or whatever different payment models are applied, we
need to be sure that there is clean, crisp lines that exempt or
waivers that are provided for Stark, so the parties can come
together. That is really what we see. When we put our own APM
forward to PTAC, we included the need for Stark waivers and the
exemptions. But we agree with you and fully support what you
are doing.
Dr. Ransohoff. In order to have an ACO, particularly an ACO
like this that requires risk-taking and risk-sharing, you need
to get a group of physicians together who are willing to work
together and share the risk and, also, generally, a hospital.
So, you need all of those parties to do that. Then, these laws
become a serious impediment to doing that. Just the legal
expenses of trying to make sure it is even OK to have a meeting
become daunting. So, I think if you are going to encourage
doctors and hospitals to try to take risks together in a fee-
for-service world, you do need to look at the regulatory
barriers that exist.
Mr. Bucshon. All right. Thank you.
Beg your indulgence, Mr. Chairman.
Anyone else have any comments quickly? Anyone else? Yes?
Dr. Rai. Stark made sense in a fee-for-service environment,
but if we are truly going to move to value, we need regulatory
relief, as explained by my colleagues.
Mr. Bucshon. OK. Thank you. I appreciate that.
Thanks, Mr. Chairman. I yield back.
Mr. Guthrie. Thank you. The gentleman yields back.
The Chair now recognizes Mr. Griffith of Virginia, 5
minutes for questions.
Mr. Griffith. Thank you very much, Mr. Chairman. I
appreciate it.
I appreciate you all being here. With two votes series
disrupting the committee, it is tough as witnesses, and I do
appreciate your patience.
Let me echo what my colleague just said about the Stark
Act. I think it is outdated probably in more ways than most
people do. And I find it inhibits some collaboration in rural
areas where we are underserved already. And why would we put
barriers up?
Does anybody disagree with that statement? I am looking at
the entire panel. Just for the record, none of them disagrees
with that statement.
All right. Let's see. Given that, now I have got a question
that we want to get on the record. On June 29th, CMS allowed
MIPS participants to see their performance score based on 2017
reporting. Would each of you please share what your scores
were?
Dr. Rai. I would be happy to start since I brought mine
with me.
Mr. Griffith. All right. That would be fine.
Dr. Rai. We bill under four Tax ID Numbers because of how
we are regionally divided. Three, we scored 100, and on the
fourth one we had a 97.
Mr. Griffith. OK. Anybody else weigh in who knows? Yes,
sir?
Dr. Parekh. I like your question because it also relates to
the previous issue of physician participation. I was in a big
group practice and I decided to start my own practice. And so,
it was the end of 2015 and into 2016 that I was doing that. The
2017 measurement, what you are asking about, is based on your
surgical volume or your volume at the end of 2016, but that is
when I was starting my practice.
I knew, of course, about our Academy's IRIS registry. I
knew myself. I knew that I could do a good job on those
measures, but there was no opportunity for me to participate. I
couldn't opt in. I couldn't believe that I couldn't opt in. So,
I asked multiple people. I am like, ``Are you sure I can't opt-
in? I would love to do this. This is great. That is a good
measure.'' Multiple people assured me I could not.
Mr. Griffith. OK.
Dr. Parekh. So, unfortunately, I was not eligible, even
though I wanted to be.
Mr. Griffith. All right.
Dr. Ransohoff. As I have said before, we bill under a
single Tax ID Number, and we did get 100.
Mr. Griffith. OK. And last, but not least.
Dr. Opelka. I am retired from practice.
Mr. Griffith. Yes? So, no data? All right. I appreciate
that. Thank you so much.
My concern, of course, is rural areas, as I mentioned
before, when I was talking about the Stark Act. So, when we are
looking at rural areas, can you describe or can any of you
illuminate us on the challenges of physicians practicing in the
rural areas and the pressures they face to remain in practice?
And how do the legacy programs add to those burdens? I know a
lot of the burdens they have already. But how do the legacy
programs add to those burdens, and has MIPS eased those
burdens? And even if it has eased them a little bit, what else
can we be doing to help our rural friends?
Dr. Barbe?
Dr. Barbe. Maybe I will weigh in on that first. So, I was
amazed when MACRA passed and we were looking at MIPS, and we
had a lot of physicians come out of the woodwork and say, ``Oh,
my gosh, how are we going to comply with MIPS?'' And I thought
in my mind, well, have they not been doing the legacy programs
already? And the answer is, no, they hadn't. Hundreds of
thousands of physicians didn't participate in all three or
didn't participate successfully. So, there are a lot of
physicians that are now working to make this transition.
Specifically, with regard to rural, Dr. Opelka said it very
well. We need meaningful measures that relate to that
individual physician's practice. We need to make them easy to
capture, and we need to make them, if you will, activities that
are applicable across more than one of those dimensions of
MIPS. If you have got a diabetic patient and you are changing
your processes and you are improving care, and you are using an
electric record, why don't you get credit across all three
domains?
Mr. Griffith. All right. Yes, sir?
Dr. Opelka. Very quickly, the trauma program is a classic
example where we have Level I, II, and III levels of service.
Typically, in the rural environment we are dealing with a Level
III. The number of standards they need to meet are
significantly less than the 200-plus standards for a Level I.
So, you need to tailor measurement down to the point of care
and the care model that that environment has. The MIPS program
does not do that. It is a one-size-fits-all program. So, the
rural element is no different than, in surgery, it is no
different than in the city. They are not meaningful and fit for
purpose. And therefore, the surgeons pay attention to it for
purposes of payment, but not for the purposes of quality of
care.
Mr. Griffith. OK. Anybody else? Yes?
Dr. Rai. We operate many rural clinics, but because they
are part of a larger multi-specialty group, we are able to
spread our infrastructure more efficiently to them.
And to your other question about was it easier under MACRA
to submit versus the legacy programs, I have talked to our
quality department. It was slightly easier this year to submit
to CMS. The mechanism of submitting all three at once was
easier than the previous legacy format.
Mr. Griffith. So, it was a little bit better?
Dr. Rai. A little bit better, yes, sir.
Dr. Parekh. I would echo all these comments. Understand
that rural medicine is very different than urban/suburban. And
I know in Washington oftentimes people talk about a bubble in
Washington, but coming from central Pennsylvania, it is a very
different environment here. Let me tell you, there are
hospitals where I can't get internet service. Just think about
that statement. And my EMR, of course, is a cloud-based EMR.
This is a true issue. But, again, I think MACRA has certainly
helped, to answer the second part of your question.
Mr. Griffith. Other parts of our committee are trying to
work on those internet issues.
Dr. Ransohoff?
Dr. Ransohoff. Technically, right now for someone who had
just done nothing, MIPS is actually better, just by the algebra
of it initially, because the cut would have been less.
But I agree with my colleagues, and I have said previously
I think for small practices in rural areas they just need a
different--they need relevant standards that resonate with
their practice, but they probably need to have a different
test, so that they can participate. Fewer measures I think
would be a very reasonable approach.
Mr. Griffith. All right. Thank you very much. I appreciate
it.
And my time is up and I yield back.
Mr. Guthrie. Thank you. The gentleman yields back.
The Chair now recognizes Mr. Carter from Georgia for 5
minutes for questions.
Mr. Carter. Thank you, Mr. Chairman.
And thank all of you for being here.
Before I begin my questions, I have to say this. Earlier in
the hearing there was a conversation about doctors'
handwriting. And I just want to say, I want to represent my
profession as a practicing pharmacist for over 30 years. So,
you get it? You understand what I am saying.
[Laughter.]
Anyway, I couldn't resist that and I apologize. Too many
times have I struggled to understand what a doctor was writing.
I wanted to talk to Dr. Rai. OK, I am sorry. I know I
butchered that.
But, nevertheless, as a pharmacist, I am a member of the
Doctors Caucus. We had sent a letter to CMS earlier this month
about MACRA and MIPS implementation and the $500 million that
had been authorized to ensure positive payment adjustments. But
one of the things that we have run into is that we just don't
have enough physicians who are participating. And I just wanted
to ask you. CMS estimates that it is over 60 percent that
aren't participating. What are the obstacles? What are some of
the obstacles that are preventing or prohibiting providers from
switching to this?
Dr. Rai. I think some of the obstacles are inherent to how
they have been practicing medicine and how their own structures
have been developed over time. Some may say they have not
followed the legacy programs, as was mentioned earlier. So,
they have not actually implemented the EMR or using it in a
meaningful way. They have not developed patient-centered
medical homes or have the ability to tap into registries. There
are a variety of reasons why people are not participating.
But for us to truly move to value, we need everybody to
participate. MACRA was written to be a carrot-and-a-stick
program. So, for it to work, everybody has to be in.
Mr. Carter. I suspect that I would be correct to say that
it is worse in rural areas than it is in urban areas. Is that
correct?
Dr. Rai. I haven't seen CMS's distribution of who is not
participating, but I think it is across the board. I think you
will see it in small single specialty in a very urban area.
But, yes, you will probably see it a lot in urban areas that
don't have a system infrastructure supporting them.
Mr. Carter. OK. Can you describe very briefly about some of
the investments that your organization has made in order to
participate in this?
Dr. Rai. I can break the investments into three categories,
the first being people. The most important category in
healthcare is continuously investing in people. Team-based care
is not inexpensive--nurse care managers, extra medical
assistance, making sure the physician or the provider is
surrounded by the best people to take care of their population,
not just the patient that is in front of them that day.
The next area is, like I mentioned, an EMR is only as good
as you can draw the data out of. So, our largest area of
investment in the EMR is not really the EMR anymore. It is
digital platforms to draw the data out, to analyze it, to
hopefully someday get access to claims data, which we need, to
be able to look at a risk population and predict what is going
to happen to a patient before it happens to them.
And the third area of investment is that digital platform
that is patient-facing. Our patients want access to their
record. It is not our medical record; it is their medical
record. It is creating environments for them to interact with
us in virtual care, like we launched this year, where they
don't have to come into the office.
Those have been the three categories of investments that we
personally made to make sure we are successful not only with
MACRA, but with value down the line.
Mr. Carter. Right. Thank you.
Dr. Parekh, I wanted to ask you, in your testimony you had
mentioned that MedPAC had made the recommendation that MIPS
should be replaced with a voluntary value program that might be
phased in over time. And I just wanted to ask you--and in full
disclosure, I agree with you; I don't agree with MedPAC. I
think that would be the wrong route for us to go. I think we
are headed in the right direction with this. We ought to figure
out a way, I think, if not to incentivize, then to require
physicians to do this. And I don't like that. I don't like the
heavy-handed government, particularly in healthcare. But, at
the same time, I am convinced we are moving in the right
direction.
I just wanted to ask you, what are some of the challenges
to developing outcome measures in the practice of medicine?
Dr. Parekh. It is just hard. It is hard to do. You have to
have a clean measurement. You don't want all these other
comorbidities that are ``messing up your outcomes''. So, let's
take cataract surgery, for example. If I have a patient who has
got severe blinding macular degeneration at baseline, and then,
they have developed a cataract on top of that, as bad as it
originally was, now it is worse. So, I take their cataract out
and I get them maybe to 2400, which is the big ``E'', legal
blindness still. They are ecstatic, but my measure might look
bad because, ``Oh, Dr. Parekh, this patient, you operated on
them and they are legally blind.'' So, things like that, those
subtleties, the devil is in the details.
Mr. Carter. Right.
Dr. Parekh. Those subtleties make all the difference. So,
coming up with those kind of clean outcomes is very hard to do.
Mr. Carter. Right.
Dr. Parekh. And so, there are certain surgeries that lend
themselves to that, but others that don't.
Mr. Carter. I am out of time. But I want to thank all of
you for your efforts in moving this forward, because I do
believe it is we are headed in the right direction with this.
And I yield back.
Mr. Guthrie. Thank you. The gentleman yields back.
Seeing there are no further members wishing to ask
questions, I would like to thank you all for being here today.
As somebody mentioned earlier, you are missing a lot of
patients today to be here to inform us, but it is important
that you do.
And I would like to submit the following documents for the
record: American Academy of Dermatology Association, letters
from the American Academy of Family Physicians, the American
College of Physicians, Connected Health, American Society of
Clinical Oncology, Infectious Disease Society of America, and
Medical Group Management Association.
Mr. Green. No objection, Mr. Chairman.
Mr. Guthrie. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Guthrie. Pursuant to committee rules, I remind members
that they have 10 business days to submit additional questions
for the record, and I ask that witnesses submit their response
within 10 business days of receipt of the questions.
Mr. Green. Without objection. Mr. Chairman, I would just
like to recognize a family from my district, the Garcia family.
We spend a whole lot of time in these committee meetings. But I
thank them for coming here.
Mr. Guthrie. Welcome. Welcome to Washington. Thanks for
being here.
So, without objection, the subcommittee is adjourned.
[Whereupon, at 12:13 p.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
Prepared statement of Hon. Frank Pallone, Jr.
We're meeting today to discuss one of the great bipartisan
success stories of this Committee, the Medicare Access and CHIP
Reauthorization Act of 2015, or MACRA. MACRA built upon the
successes of the Affordable Care Act to improve the quality and
efficiency of the Medicare program, and of our health care
system more broadly.
The ACA took major steps towards improving the quality of
our health care system by creating new models of health care
delivery within the Medicare program. These new payment and
delivery models focused on transforming clinical care and
shifting from a volume- to a valuebased care model, such as
Accountable Care Organizations (ACOs) and Patient Centered
Medical Homes (PCMHs).
With MACRA, we are entering the next phase of delivery
system reform. MACRA builds on reform efforts by offering
opportunities and financial incentives for physicians to
transition to new payment models known as Advanced Alternative
Payment Models, or AAPMs. AAPMs must meet a number of criteria,
and requires clinicians to accept some financial risk for the
quality and cost outcomes of their patients. Physicians can
join existing and successful models that qualify as AAPMs, such
as ACOs and the Comprehensive Primary Care Plus (CPC+) model,
which we will hear about today. They can also develop their own
models, known as Physician-Focused Payment Models.
MACRA also created the Merit-Based Incentive Payment
System, or MIPS. This is an alternative path for clinicians to
make the shift away from a volume-based system to a valuebased
system. It focuses on quality, value, and accountability.
Our witnesses practice in a variety of settings across the
country and represent diverse expertise and training. They each
have a unique perspective to share with us regarding the
implementation of MACRA. I know that some of our witnesses have
concerns about how MIPS has been implemented by CMS, in
particular the decision by the agency to exclude 58 percent of
providers from MIPS requirements through the low-volume
adjustment. I share these concerns and want to learn more about
how CMS's decisions may impact successful MACRA implementation
going forward.
I want to thank you all for your commitment to delivery
system reform-it is only through the sustained commitment of
the leading physician organizations and clinicians such as
yourselves that we can hope to bend the cost curve and create a
system that truly rewards high value care. I hope that after
hearing from our panelists today, we will all have a better
understanding of the opportunities and challenges faced by
physicians in the MIPS program.
Thank you, I yield back the remainder of my time.
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