[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
EXAMINING BARRIERS TO EXPANDING INNOVATIVE, VALUE-BASED CARE IN
MEDICARE
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 13, 2018
__________
Serial No. 115-166
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
36-533 WASHINGTON : 2019
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, prepared statement...................................... 73
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, preparedst atement........................ 97
Witnesses
Nishant Anand, Chief Medical Officer, Adventist Health System.... 4
Prepared statement........................................... 7
Mary Grealy, President, Healthcare Leadership Council............ 20
Prepared statement........................................... 22
Timothy Peck, CEO, Call9......................................... 25
Prepared statement........................................... 28
Michael Weinstein, President, Digestive Health Physicians
Association.................................................... 37
Prepared statement........................................... 39
Morgan Reed, President, The App Association...................... 47
Prepared statement........................................... 49
Michael Robertson, Chief Medical Officer, Covenant Health
Partners....................................................... 64
Prepared statement........................................... 66
Submitted Material
Statement of various medical organizations....................... 99
Statement of the Breaking Down Barriers to Payment and Delivery
System Reform Alliance......................................... 101
Statement of Advocate Aurora Health.............................. 103
Statement of AdvaMed............................................. 110
Statement of the College of Healthcare Information Management
Executives..................................................... 117
Statement of the Cancer Treatment Centers of America............. 123
Statement of the National Association of Chain Drugs Stores...... 130
Statement of Medtronic........................................... 133
Statement of the American Society for Gastrointestinal Endoscopy. 137
EXAMINING BARRIERS TO EXPANDING INNOVATIVE, VALUE-BASED CARE IN
MEDICARE
----------
THURSDAY, SEPTEMBER 13, 2018
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 1:15 p.m., in
room 2322 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,
Mullin, Hudson, Collins, Carter, Green, Matsui, Castor, Lujan,
Schrader, and Kennedy.
Staff present: Daniel Butler, Staff Assistant; Karen
Christian, General Counsel; Jay Gulshen, Legislative Associate,
Health; Brighton Haslett, Counsel, Oversight & Investigations;
James Paluskiewicz, Professional Staff, Health; Brannon Rains,
Staff Assistant; Jennifer Sherman, Press Secretary; Tiffany
Guarascio, Minority Deputy Staff Director and Chief Health
Advisor; Una Lee, Minority Senior Health Counsel; Samantha
Satchell, Minority Policy Analyst; and C.J. Young, Minority
Press Secretary.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess. We will go ahead and call the subcommittee to
order, and thank you for your indulgence. We were waiting a few
minutes because there was another hearing starting downstairs
and some of our members may be joining us in progress.
But, for now, the hearing will come to order. I'll
recognize myself 5 minutes for an opening statement.
And today, we are convening to discuss a topic that is of
significant importance to the healthcare industry at large, and
this is the ever-evolving transition to value-based care as
well as new ways of assuming risk and the role technology can
play in these efforts. Over the course of the last few years,
our healthcare system has begun a shift toward rewarding
physicians for the quality of care rather than the quantity,
and building off these efforts, providers, doctors, health
systems, and payers are willing to explore new value-based
arrangements and open the door to providing new benefits for
their beneficiaries. I am certain that many members of this
subcommittee have taken meetings in their districts on this
topic, especially in the past couple of years as the shift to
value-based care has accelerated.
Notably, Congress passed the Medicare Access and CHIP
Reauthorization Act of 2015 in the 114th Congress. For
situational awareness, this is the 115th Congress, so that was
2 years ago. This was a critical step in the right direction as
we helped begin to shift Medicare towards being a more value-
based payment system. We have had other hearings about the
Medicare Access and CHIP Reauthorization Act including the
Merit-Based Incentive Payments Systems, conducting general
oversight on the implementation of this crucial law.
A lot of the work that this subcommittee conducts is to
oversee the influence in the healthcare industry as moving into
coordination with the 21st century. The Medicare Access and
CHIP Reauthorization Act provided a platform for this effort to
do so, and this afternoon we are going to hear from a number of
people on the front lines who are working to deliver better
outcomes at lower costs. This hearing will provide us with a
significant amount of information as we move forward in
assessing value-based payments, where it holds the most
promise, where there may be barriers that Congress might
consider examining in the future to ensure its success. I think
it goes without saying everything we can do to lower the burden
on physicians, freeze them up to deliver more in-patient care
and that is the general direction that I think it's good for us
to go.
Value-based care models have been effective and have gained
support throughout the country as they have proven to improve
the quality of care and lower costs. This allows for positive
outcomes for patients, physicians and insurers, as well as the
overall healthcare system. As we have heard from witnesses at
other hearings on this topic, taking these models on as a
physician or healthcare system can be a difficult but still a
rewarding task.
Promoting innovation and quality are essential to
modernizing American healthcare and enabling our world-class
physicians to focus on providing coordinated quality care to
their patients.
Value-based models have evolved over time since their
inception in the early 1990s, beginning with the efforts among
private payers and state Medicaid programs to reward
improvements in care with financial incentives. Models have
grown broader and incentives more innovative as we have seen
accountable care organizations and bundled payment programs,
which address both quality and cost, take off across the
country.
These newer and more advanced models have allowed for
physicians and other professionals to voluntarily come together
to provide more coordinated care for patients and rewarding
physicians with bonuses for hitting certain quality measures
and based payments on expected costs for specific episodes of
care. These models are the future of healthcare and it is
important that Congress hear from the industry about how the
implementation of such models works on the ground, or to the
extent it's not working it's important that we hear that as
well.
Today, we have the chance to hear from witnesses about the
models and ways that they are working to improve the quality of
care or reducing cost. I suspect we will hear about the
critical role that the laws we have worked on, including the
Medicare Access and CHIP Reauthorization Act--the role that
they have played in expanding innovation, but that barriers to
implementing potentially beneficial models still exist.
So I certainly look forward to hearing the thoughts of our
expert panel of witnesses about the challenges and achievements
in the world of value-based care. So I want to anticipate by
thanking our witnesses for their willingness to testify today.
We appreciate being able to have this important conversation
and learn from your expertise.
Seeing that the ranking member of the subcommittee is not
here, the chairman of the full committee is not here, and the
ranking member of the full committee is not here, perhaps it
would be prudent to proceed with witness statements and then we
will allow those individuals--as they arrive from their other
hearing we will interrupt and allow them to deliver their
opening statements.
And I do want to remind members that all members' opening
statements will be made a part of the record.
So thanks to your witnesses for being here today and taking
time to testify before the subcommittee. Each witness will have
the opportunity to give an opening statement followed then by
questions from members.
Today, we are going to hear from Dr. Nishant Anand, the
Chief Medical Officer for Adventist Health System; Ms. Mary
Grealy, the President, Healthcare Leadership Council; Dr.
Timothy Peck, CEO of Call9; Dr. Michael Weinstein, President,
Digestive Health Physicians Association; Mr. Morgan Reed,
President of the App Association; and Michael Robertson, Chief
Medical Officer for Covenant Health Partners.
Again, we appreciate all of you being here today. Dr.
Anand, you are now recognized for 5 minutes for the purpose of
an opening statement, please.
[The prepared statement of Mr. Burgess follows:]
Prepared statement of Hon. Michael C. Burgess
Good afternoon. Today, we convene to discuss a topic that
is of the utmost importance to the healthcare industry at
large, the everevolving transition to value-based care as wells
as new ways of assuming risk and the role technology can play
in these efforts. Over the course of the last few years, our
healthcare system has begun to shift towards rewarding
physicians for the quality of care provided, rather than
quantity. Building off these efforts, providers, health systems
and payors are willing to explore new value-based arrangements
that open the door to providing new benefits for beneficiaries.
I am sure many of the members of this Subcommittee have taken
numerous meetings regarding this topic, especially in the past
several years as the shift to value-based care has accelerated.
Notably, Congress passed the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA) in the 114th Congress. This
was a critical step in the right direction as we helped begin
to shift Medicare toward being a more value-based payment
system. We have held various other hearings about MACRA,
including the Merit-Based Incentive Payments System, as we
conduct oversight on the implementation of this crucial law.
Much of the work that this Subcommittee conducts is to
oversee and influence the healthcare industry in moving care
coordination into the 21st Century. MACRA provided the platform
for this effort to do so, and today we will hear from people on
the front lines who are working to deliver better outcomes and
lower costs. This hearing will provide us with a wealth of
information as we move forward in assessing the value-based
payments space, where it holds the most promise, and where
there may be barriers that Congress might consider examining in
the future to ensure its success.
Value-based care models have been largely effective and
have gained support throughout the country as they have proven
to improve quality of care and lower costs--boasting positive
outcomes for patients, physicians, insurers, and the overall
healthcare system. As we have heard from witnesses at other
hearings on this topic, taking these models on as a physician
or healthcare system can be a difficult, yet rewarding task.
As a physician and as a Congressman, I believe it is
important for physicians and health systems to take on risk
when it can lead to rewarding outcomes, both for them and for
their patients. Promoting innovation and quality are essential
to modernizing American healthcare and enabling our world-class
physicians to focus on providing coordinated, quality care to
their patients.
Value-based models have evolved over time since their
inception in the early 1990s, beginning with the efforts among
private payers and state Medicaid programs to reward
improvements in care with financial incentives. Models have
grown broader and incentives more innovative as we have seen
accountable care organizations and bundled payment programs,
which address both quality and cost, take off across the
country.
These newer, more advanced models have allowed for
physicians and other healthcare professionals to voluntarily
come together to provide more coordinated care for patients,
rewarded physicians with bonuses or reductions in payments for
hitting certain quality measures, and based payments on
expected costs for specific episodes of care. These models are
the future of healthcare, and it is important that Congress
hear from the industry about how the implementation of such
models works on the ground.
Today, we have the chance to hear from witnesses about
models that they are working on and how there are or could be
effective ways of improving quality of care or reducing cost. I
suspect that we will hear about the critical role that laws we
worked on, including MACRA, have played in expanding
innovation, but that barriers to implementing potentially
beneficial models still exist.
I look forward to hearing the thoughts of our expert panel
of witnesses about their challenges and achievements in the
world of value-based healthcare. Thank you to our witnesses for
their willingness to testify today. We appreciate being able to
have this important conversation and to learn from your
expertise.
STATEMENTS OF DR. NISHANT ANAND, CHIEF MEDICAL OFFICER,
ADVENTIST HEALTH SYSTEM; MARY GREALY, PRESIDENT, HEALTHCARE
LEADERSHIP COUNCIL; DR. TIMOTHY PECK, CEO, CALL9; DR. MICHAEL
WEINSTEIN, PRESIDENT, DIGESTIVE HEALTH PHYSICIANS ASSOCIATION;
MORGAN REED, PRESIDENT, THE APP ASSOCIATION; DR. MICHAEL
ROBERTSON, CHIEF MEDICAL OFFICER, COVENANT HEALTH PARTNERS
STATEMENT OF DR. NISHANT ANAND
Dr. Anand. Good afternoon, Chairman Burgess and members of
the subcommittee. I am Dr. Nishant Anand and I serve at
Adventist Health System as a Chief Medical Officer for
Population Health Services and the Chief Transformation
Officer.
We have 46 hospitals located in nine states serving 4
million people each year. This includes Florida Hospital
Orlando, which is the largest single site Medicare provider and
the second largest Medicaid provider in the nation.
We have accountable care organization arrangements in
Kansas, North Carolina, and Florida. We serve more than 400,000
patients in our ACOs and we partner with several thousand
physicians, two-thirds of which are independent physicians.
Additionally, we will participate in the BPCI advanced
model and are successfully participating in the CJR program.
Today, I speak to you as a board-certified emergency medicine
physician and a healthcare professional who has led value
transformations at Memorial Hermann Health System in Texas and
at Banner Health Network, which was a pioneer ACO, in Arizona.
In value-based care delivery, I know firsthand the benefits
this brings to patients and the barriers that block providers
from realizing its full potential.
We can improve the health and wellbeing of our patients but
we need policy changes. As healthcare providers, there are many
innovations that we would like to undertake that will improve
the health and wellbeing of Medicare and Medicaid
beneficiaries.
First, we desire to build high value networks that enable
healthcare providers to ensure high quality care and reduce
variation in care. Second, we can expand shared technology
services across that network. Third, we can develop common
operational work flows to navigate patients across that complex
network. Fourth, we can implement clinical pathways across the
continuum of care--pathways that reward the triple aim rather
than fragmented care.
These four focus areas will help us achieve higher quality
and more cost effective healthcare. However, barriers impede
progress.
These barriers are Stark Law, misaligned value-based model
initiatives, and operational challenges.
Number one, Stark Law modernization--I am not an attorney
and cannot speak to the complexity of the law. But as a
physician, I experience the challenges of the Stark Law each
and every day.
I believe that it causes barriers to doing the right thing
for our patients. The Stark Law was developed in a
reimbursement world that paid providers based on the volume of
services.
In today's world, where ACO providers coordinate care in a
highly effective manner, these regulations serve more as a
barrier than a protection for our patients.
While HHS issues waivers for APMs, the problem is these
waivers are not permanent. Number two, encourage providers to
move to value. We are concerned that policies contained in CMS'
proposed ACO rule would discourage providers from participating
in value-based care.
The existing financial benchmark to specialty and lower
cost markets make it financially prohibitive to transition to a
two-sided risk model and will deter providers from
participating in the program. If the benchmarks do not provide
room for improvement, allowing providers to transition towards
value-based care delivery over time, providers will not
participate.
Benchmarks must also be accurately risk adjusted. Lastly,
the proposal to limit shared savings payments from 50 percent
to 25 percent of the savings will create an unsustainable
business model.
Number three, real-life operational challenges--to truly
partner with private practice physicians, we want to share
technology services such as clinical decisions support tools,
telemedicine platforms, and referral solutions. I know these
tools will help us make better decisions for patient care that
will ultimately lead to better outcomes and lower costs.
However, we need clarity that we can share these tools with our
physicians to use with all patients. We need quick
implementation of the 21st Century Cures Act.
As providers are investing in high value networks, we
painstakingly work to ensure that our partnerships are with the
best providers. As a result, we need to refer our patients more
intentionally, making sure that they see the best clinicians,
which is sometimes at odds with the current Medicare conditions
of participation.
In summary, I ask you to consider a deeper dive into value-
based reforms that will accelerate our journey. We are ready to
go faster but need additional help with payment reform,
focusing on holistic care as well as regulatory reform.
We need to help ACOs achieve critical mass in order to hit
the tipping point where value-based care is what we deliver.
This will allow us to achieve the coordination abilities as a
community that will better serve our Medicare and Medicaid
beneficiaries.
I thank you for your time and interest and look forward to
your questions.
[The prepared statement of Dr. Anand follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Dr. Anand.
Ms. Grealy, you're recognized for 5 minutes, please.
STATEMENT OF MARY GREALY
Ms. Grealy. Good afternoon, Chairman Burgess and members of
the subcommittee, and thank you for the opportunity to testify
today on what I believe to be one of the most important topics
in American healthcare.
As our healthcare system evolves from a long-standing fee-
for-serve orientation to a patient-centered value-based
approach to care, I am proud that the members of my
organization, the Healthcare Leadership Council, are not only
supportive of this transformation but have led it.
Our members are innovative systems such as Adventist health
plans, drug and device manufacturers, distributors, academic
health centers, health information technology firms, and all
are driving change within and across virtually every healthcare
sector.
We appreciate your effort today to shine a light on some of
the barriers that are preventing an optimal transformation and
transition to value-based care that will result in better
outcomes for patients and improve sustainability for the
Medicare program.
Today, I would like to focus on several areas that warrant
significant attention of this committee. I will begin by saying
a word about the legal barriers that are keeping healthcare
innovators from accelerating toward value-based care.
Let me be clear. We believe it is essential to keep
consumer and program protections in place while, at the same
time, working in both the legislative and regulatory spheres to
create an open unobstructed pathway for these value-focused
activities that benefit both patients and the system as a
whole.
The Stark Physician Self-Referral Law and the Anti-Kickback
Statute were created to prevent overutilization and
inappropriate influence in a fee-for-service environment in
which healthcare sectors and entities operated in their own
individual silos.
Today, however, in order to make the transformation to
value-based care we need greater integration of services,
improved coordination of care with cross-sector collaborations,
and payment that is linked to outcomes rather than volume.
Adopting these new delivery and payment models becomes
difficult when faced with outdated fraud and abuse laws and
potential penalties of considerable severity. For example, it
is desired for healthcare providers to achieve optimal health
outcomes through coordinated care, meeting high quality and
performance metrics, and saving money through the avoidance of
unnecessary hospital admissions and office visits.
And yet, there are obstacles to incentivizing this level of
performance. If a hospital wishes to provide performance-based
compensation, it can run afoul of the current fraud and abuse
framework. In fact, in terms of maintaining good patient
health, the legal status quo does not even allow physicians to
provide patients with a blood pressure cuff or a scale to
monitor their healthy weight at home.
To achieve meaningful progress toward a value-based
healthcare system, it is also necessary to address how to
foster further success in alternative payment models such as
accountable care organizations. We know that better care
coordination results in better outcomes for patients, which is
the goal of accountable care organizations. But we must address
the flaws in the current ACO structure.
Medicare beneficiaries today do not choose to enroll in a
particular ACO. Rather, they are assigned to one based on the
physician they choose to see. So the accountable care
organization is charged with the responsibility of managing the
patient's care even though the patient is likely unaware they
are even under that umbrella.
Medicare beneficiaries may also not be aware of the
benefits of this approach. Patients should be proactively
informed of the benefits of coordinating care among providers.
They should also be encouraged to remain in ACOs and other care
delivery models that focus on coordination, information flow,
and value. Doing so will enable these models to better achieve
quality outcomes while controlling costs, and also to optimize
the effectiveness of ACOs more progress needs to be made in
data sharing and data interoperability so that entities have
real-time knowledge of work flows, care coordination, and
progress toward quality measures.
Mr. Chairman, I also need to mention the importance of
technology and the movement toward value-based care.
Specifically, the expanded use of telemedicine is essential to
more efficient utilization of healthcare resources, expanding
the reach of healthcare providers.
So we urge Congress and the administration to address
Medicare's restrictions on reimbursement for telemedicine
services and there's also considerable value to be found in
making digital health applications more accessible for
beneficiaries.
And, finally, as we talk about coordinated care, we must
focus on how we can gain the greatest patient and population
health benefits from our healthcare workforce.
All healthcare professionals must be empowered and rewarded
to perform to the full extent of their professional license and
to be valued members of healthcare teams.
Thank you again for the opportunity to testify and I look
forward to your questions.
[The prepared statement of Ms. Grealy follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Ms. Grealy. Thank you for
participating with us today.
Next, we'll hear from Dr. Timothy Peck. You're recognized
for 5 minutes, please.
STATEMENT OF DR. TIMOTHY PECK
Dr. Peck. Thank you, Chairman Burgess, and please extend my
gratitude to Ranking Member Green and members of the
subcommittee for the honor to speak to you today.
I am here to share how I've seen firsthand how the lack of
value-based care in Medicare fee-for-service system has led to
wasted dollars on patient care.
My name is Timothy Peck. I am an emergency physician and I
am also an entrepreneur. I went to residency and did my chief
here at Harvard Medical School and Beth Israel Deaconess and
stayed on as faculty there.
I left my career in early 2015 to be an entrepreneur and
solve a problem--a problem that, in the emergency department, I
lived every day. Nineteen percent of the patients who arrive in
an ambulance to the emergency department come from SNFs--from
skilled nursing facilities. One out of five patients I saw
every day from an ambulance came from a SNF.
Nursing home patients and patients over 65 in general don't
receive great care in the emergency department. Hospitals are
not a great place to get well for those over 65. Our own data
on patients in nursing homes shows that 43 percent of patients
in SNFs have dementia and almost all become delirious from
moving them from a familiar place to the bright lights of the
emergency department.
In emergency departments we order every test under the
rainbow. We put them in the hallway. They get renal failure and
bed sores. We then admit them to the hospital that exposes them
to infections and they often experience post-hospital syndrome
condition in which most patients leave the hospital worse off
than when they came in.
Although I knew this about emergency departments and
hospitals because I worked there, I didn't know anything about
nursing homes. I went to medical school. I went to residency,
and I had never once stepped foot into a nursing home. I needed
to understand these patients better and why they were coming to
me, and so I went and lived in a nursing home for 3 months
myself.
CMS says two-thirds of the transfers are avoidable and 45
percent of the hospitalizations to the hospitals are avoidable
for an estimated cost of about $20 billion per year. I needed
to understand why this was happening. Right now, as of this
moment, the only way to get paid for this care is to go by what
the fee-for-service system says, and that is to put those
patients in an endless loop of expensive care in which they're
treated in the nursing home at a cost, they're put in an
ambulance at a cost, and admitted to the hospital at a cost, to
go right back into the SNF again.
I needed to break this loop and, based on my research from
living in the nursing home, I created a model in which we embed
a first responder in the nursing home 24/7 who connects to an
emergency physician by telehealth, who is home, remote, 24/7
whenever there's any type of acute change in condition of that
patient. The emergency physician who's home directs the care of
that patient and decreases hospitalizations by upwards of 50
percent, saving $8 million per 200-bed nursing home.
In our first nursing home we've served, Central Island
Healthcare in New York, according to CMS' own nursing home
compare website, the percentage of Medicare residents who are
rehospitalized after admission to Central Island is 11.1
percent. The national average is 22.4 percent. Because of their
success on this measure, Central Island received the highest
possible quality score under the new SNF value-based payment
program. One of our most recent SNFs, Terence Cardinal Cooke in
Manhattan, has been able to lower its rehospitalization to
single digits after full activation of the Call9 model.
There are 15,600 nursing homes in the U.S. and there are
billions of dollars and millions of lives to improve. I,
myself, had no way of getting paid for the fee-for-service--
from the fee-for-service system for this type of program, and
so we treated 3,500 Medicare patients, losing money on every
single one, to be able to give you the data on--that I just
quoted.
It's not just us. I know a lot of health systems,
providers, and entrepreneurs who have amazing ideas. But they
are in no way incentivized to execute them.
The only existing option for testing models is CMMI. When
CMMI is able to succeed, it brings innovation to our patients,
which they need. However, in the startups world we had a saying
that in order to learn you need to be flexible and fail fast,
fail smartly, fail safely, but also fail inexpensively. When
CMMI doesn't work, it's far from inexpensive.
The other way we can bring innovations to the Medicare
program is by lifting 1834(m) of the Social Security Act. The
issue is that the fee-for-service schedule does not create
value and lifting 1834(m) would not protect us from those fees.
Changing fee-for-service is the way that we need to move
forward.
Representatives Griffith, Lujan, Smith, Black, and Crowley
have already championed a new approach, the RUSH Act of 2018.
What this does is allows Medicare to avoid the $20 billion
being spent on unnecessary hospitalizations and a novel
approach in which providers can have value-based contracting
instead of following the fee-for-service schedule. RUSH Act is
the tip of the spear creating value-based contracting by
supporting a program that has shown to increase quality and
decrease costs.
The bill is set up in a way that when savings happen,
providers, nursing homes, and Medicare share in the potential
savings. It's also set up in a way that providers get kicked
out of the program if they don't save money or increase
quality, which is how value-based care should be set up.
You can be the change agent. You can be the reason why we
saved Medicare program, not only for the $20 billion being
spent on nursing home patients, the billions being spent on
unnecessary services every year.
The faster this happens, the less lives are lost and the
more money that is saved.
Thank you to the committee and Congressmen Griffith and
Lujan for introducing the RUSH Act. It's the first step to
bringing value to Medicare.
[The prepared statement of Dr. Peck follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Dr. Peck.
Dr. Weinstein, you're recognized for 5 minutes, please.
STATEMENT OF DR. MICHAEL WEINSTEIN
Dr. Weinstein. Chairman Burgess and members of the
subcommittee, thank you for inviting me to testify regarding
the importance of removing barriers to value-based care in
Medicare.
I am Dr. Michael Weinstein, a practicing gastroenterologist
and President of Capital Digestive Care, an independent
physician practice. I am also President of the Digestive Health
Physicians Association, which represents 78 GI practices across
the country.
Independent physician practices provide high quality,
accessible care in the community at much lower cost than
identical services in the hospital setting, yet value-based
arrangements are generally not available to us. Physician
practices are facing increasing challenges competing with mega-
hospital systems that are favored by antiquated Medicare law
and regulations.
Hospitals recently embarked on a buying spree of physician
practices. The number of physicians employed by hospitals
increased 50 percent from 2012 to 2015. This has impacted
costs, as hospitals seek to recoup their investments by
capturing highly profitable ancillary services. These are the
same designated health services that are regulated by Stark
self-referral law. Despite some reforms, significant
disparities for high-volume services persist. For example,
Medicare pays nearly twice as much for colonoscopies in the
hospital outpatient department as in an ASC. There is no
clinical reason that nearly half of the 2.7 million
colonoscopies continue to be performed in the more expensive
setting.
Policy makers should be doing more to encourage robust
competitive market that allows independent practices to compete
and deliver value-based care. Targeted policy changes will
improve patient care and lower costs. Congress and CMS must
improve the system the develop, evaluate, and approve
alternative payment models.
A couple of years ago, CMS projected that 10 to 20 percent
of physicians would be enrolled in an APM. Today, that number
is just 5 percent.
PTAC was created to facilitate and recommend physician-
developed APMs. It has examined 26 APM submissions with five
recommended for implementation and six for limited scale
testing. But CMS has yet to implement a single APM recommended
by PTAC. Moreover, many stakeholders have refrained from
submitting proposals because they cannot test them first.
The Medicare statute permits HHS to waive the Stark and
other fraud and abuse laws on a case by case basis only for
approved APMs. It does not allow testing. For example, PTAC
recommended for pilot testing Project Sonar, an APM designed to
promote coordinated care for patients with chronic inflammatory
bowel disease. But that testing could not occur under the
statute without explicit approval of CMS. This means that both
clinicians and policy makers lack data to determine if the APM
worked or if modifications should be considered.
Also, access to affordable utilization data is needed to
model and develop innovative payment arrangements. CMS charges
$4,500 for one year of data from the HOPD and ASC setting,
making multiple years of trend data cost prohibitive for many.
Deidentified utilization information should be available to the
public, researchers, and stakeholders for free on a public
website.
The ACA created waivers from the Stark and fraud and abuse
laws for ACOs. This creates an uneven playing field for
independent practices that would like to participate in value-
based arrangements but cannot. We do not advocate amending the
Stark self-referral laws in the context of fee for service. But
we do think the law needs to be modernized to encourage
participation in APMs.
Explicit prohibitions on remuneration for value or volume
make no sense under at-risk arrangements that limit Medicare
cost exposure. Practices must be able to incentivize
appropriate physician behavior for adherence to recognize
treatment pathways. How can Medicare promote value-based care
if physicians are explicitly prohibited for paying for value?
Finally, patients need better and more accessible
information about their treatment options. For example, under
the law, screen colonoscopy is covered regardless of where it
is provided and the patient has no co-pay and patients have no
idea that there is a substantial hospital versus ASC cost
differential.
Similarly, patients should be able to access uniform
quality and patient outcome metrics across sites of service for
identical procedures.
Solutions are available and achievable. DHPA has joined 24
other physicians organizations in endorsing the Medicare Care
Coordination Improvement Act. That bill would provide the
secretary the identical authority to waive statutory
impediments for physician-focused APMs as provided to ACOs.
It would also repeal the volume and value prohibitions for
physicians participating in APMs and permits testing of
formerly submitted models while they are under review by CMS.
Enacting such improvements would dramatically increase
physician participation in value-based care.
We look forward to working with the committee on these
ideas to strengthen the Medicare program, improve patient care,
and conserve resources.
Thank you.
[The prepared statement of Dr. Weinstein follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Dr. Weinstein.
Mr. Green, we went ahead with opening statements from the
witnesses, and if it's all right with you, we'll conclude our
last two and then I will recognize you for an opening
statement, if that's agreeable to you.
Mr. Green. Mr. Chairman, I will just submit my opening
statement for you and I apologize for being late.
Mr. Burgess. That's not a problem. I know that there's a
lot going on today.
Mr. Reed, you're recognized for 5 minutes for an opening
statement, please.
STATEMENT OF MORGAN REED
Mr. Reed. Thank you, Mr. Chairman.
My name is Morgan Reed and I am the President of the App
Association and Executive Director of the Connected Health
Initiative--a coalition of doctors, research universities,
patient advocacy groups, and leading mobile health tech
companies.
Our organization focuses on clarifying outdated health
regulations and encouraging the move to value-based care
through the use of digital health tools to improve the lives of
patients and their doctors.
Demographics are set to overwhelm the Medicare system with,
roughly, 70 million Americans enrolled by 2030. Yet, physicians
and their teams are already reporting being overworked and
burned out. Moreover, patients report a high level of
frustration with the healthcare system. It simply takes too
long and costs too much. And yet, this is the same world where
every person can pay their mortgage, monitor their package
delivery, review their child's homework, all while sitting in
the waiting room of that very doctor.
What's going on that we can't better engage with patients
using the tools every single one of you has in the palm of your
hand right now or strapped to your wrist? Why is it that CMS
reimburses nearly a trillion dollars a year, yet can't use
those technologies to cover telemedicine in a meaningful way?
Why doesn't the system help doctors use tools that lower
administrative burden, allow doctors to treat a patient and not
the keyboard?
Well, since I don't want to leave this committee in a state
of depression--a condition, by the way, that has been proven to
be treatable using digital patient engagement tools--I want to
lay out what we see as the key questions to be asked and the
pathway forward for our sector.
First--the first question we should always ask in this case
is does the policy decision drive value for patients. Medicare
beneficiaries--wait a minute, let's call them what they really
are--people, who live in their districts, or better yet, how
about--let's we call them constituents--have a simple goal.
They want to be healthy and they want to be independent,
and for those with chronic conditions like type 2 diabetes they
want treatment to help them stay as healthy as possible for as
long as possible. For them, remote monitoring technologies are
lifesaving tools.
One of our member companies, Podimetrics, is one such
remote monitoring company. They make a foot mat that detects
diabetic foot ulcers up to 5 weeks before they become
clinically present. This tech is not only more efficient than
other methods but it also cuts down on hospital bills and
ultimately saves limbs. Doctors like it because they stay
engaged with the patient. But reimbursement under Medicare
remains a question mark.
Second question--does the policy decision drive value for
care givers? We are all familiar with the horror stories from
physicians on EHR adoption and the epic burnout we see as a
result. Patients rightfully complain that physicians seem
disengaged when they're typing away at a keyboard. Meanwhile,
doctors find they must subvert the system by typing asterisks
or other characters in a field they don't use. This not only
creates extra work for them but ultimately will prevent entered
data from being used predictably as part of machine learning or
augmented intelligence systems.
And finally, does it drive value for taxpayers? Taxpayer
value comes from a system that incentivizes the right things at
the right time.
When it comes to preventative health, this begins with
expansion of the CBO scoring window. I want to thank all of you
who supported the Preventative Health Savings Act--H.R. 2953--
which would expand this window to 10 years. That's a good
start. But preventative medicine can do much more.
For example, my friend, Congressman Harper, knows full well
that the University of Mississippi Medical Centers' telehealth
program would save the state $189 million in Medicaid if just
20 percent of Mississippi's diabetic population were enrolled.
Just think of the taxpayer savings for the country if CMS
supported what UMMC is doing today. And here are a few actions
that Congress and the administration can take to hit the mark.
First, Congress should pass the Connect for Health Act--H.R.
2556--to clarify that Medicare covers tech-driven tools that
enhance efficiency and clinical efficacy including the removal
of the outdated restrictions under 1834(m).
Second, for practices that still use the fee-for-service
model, CMS should adopt billing codes that cover activities
that use patient-generated health data and remote patient
monitoring. CMS has done good work in unbundling CPT Code 9091
and the proposed new code CBCI(1) and CMS should continue to
look at the ways that the Digital Medicine Payment Advisory
Group can develop future codes that support new technology.
Third, Congress should file down regulations like the Anti-
Kickback Statute in the Stark Law to allow providers to get
technology into the hands of patients. And finally, Congress
should support the use of unlicensed spectrum, sometimes known
as TV White Spaces technology to help cover rural populations
so they can have high-speed internet in places traditional
carriers don't cover cost effectively.
I want to remind everyone here that we all are or will be
part of the system, either as patient or caregiver. The least
we can ask is for the system that treats us and the care teams
that see us as real people, not just boxes on the spreadsheet.
Thank you very much.
[The prepared statement of Mr. Reed follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Mr. Reed.
And Dr. Robertson, you're recognized for 5 minutes, please.
STATEMENT OF DR. MICHAEL ROBERTSON
Dr. Robertson. Chairman Burgess, Ranking Member Green, and
members of the subcommittee, thank you for the opportunity to
testify on behalf of the National Association of ACOs.
NAACOS is the largest association of accountable care
organizations representing more than 6 million beneficiaries
through more than 360 ACOs. I share my perspective as a
practicing internal medicine physician since 1986 and currently
as Chief Medical Officer of Covenant Health Partners and
Covenant ACO in Lubbock, Texas.
Covenant Health Partners formed in 2007 and we have had a
clinically-integrated network for 11 years now. Through our
network we have instituted robust health information
technology, contracts for hospital services, and quality
metrics for measures like hospital-acquired infections.
We then branched out to commercial contracts and in 2014
made the quantum leap to a 3-year Track 1 Medicare Shared
Savings Program agreement. If we had not already had a
clinically integrated network in place where we had already
done much of the work to get ready for MSSP participation, it
is unlikely we'd have made the decision to participate in the
MSSP.
It is also important for us that we didn't have to be
concerned about taking downside risk since we were in a share
savings only model. We learned that moving to value-based care
is a massive undertaking that requires changing the behaviour
of multiple providers.
We've had to change physician behavior, hospital behavior,
skilled nursing facility behavior, home health agency behavior,
and the list goes on. In looking at our MSSP financial data we
came to understand that much of our cost was coming from post-
acute care, namely, skilled nursing facilities whose costs are
180 percent higher and home health agencies whose costs were
250 percent higher than national normative data.
We had to work closely with those providers to see costs go
down and that took time and effort. By developing and working
with providers in our preferred post-acute care network, we
eventually got to a place where we have seen quarter by quarter
decreases in costs in these areas.
Participation in the MSSP has allowed us to reinvest in
technology and infrastructure to manage our patient population.
In our first year of participation in the MSSP, we saved
Medicare $5 million and our share of that was $2.5 million
through the gains sharing arrangement.
We used the bulk of those funds to reinvest in our IT
infrastructure and developed a physician dashboard for quality
data such as adhering to evidence-based practices for chronic
disease management and preventative care like pneumococcal
vaccines and colonoscopy for our patients are displayed.
We also invested in an analyst to review and manage our
financial and quality data. One challenge we've had there is
that financial data for Medicare is only available on a
quarterly basis and then we receive that data some 4 to 6 weeks
after that.
So any change in our process can be delayed. We also hired
care coordinators and invested in software to manage care. We
now receive real-time alerts through our care coordination
system when our patients arrive at the emergency department
that allow us to push a care plan for the patient to the
emergency room physician so that he or she isn't working blind
and can assist us in providing high-quality cost efficient
care.
All of these things take time and money. Pushing too
quickly to achieve results and take on risk without giving
ample time for providers to develop the necessary
infrastructure will mean providers will not participate.
In year one of our Track 3 agreement, we ended up with a
small profit. But based on early actuarial work, at one point
we thought we would have to repay CMS $1 million to $4 million
because that financial reconciliation for the MSSP was is
delayed by about 8 months after the contract ends. Had my
physician board of directors been told they would even have to
pay back $1 million, there's no way that we would have
continued participation in the MSSP.
From a provider perspective, it doesn't make sense to
assume financial risk to take care of Medicare patients as this
entails accepting responsibility for costs the physicians
cannot control such as the increasing costs of pharmaceuticals
like chemotherapy.
I think CMS has had some very positive changes in the new
proposed rule. The expansion of the 3-day SNF waiver and the
increased stability in the rule are both great improvements.
I do have significant concerns about the speed at which the
agency is asking people to move to risk though as well as the
proposal to cut shared savings from 50 percent to 25 percent.
Two years is not enough time to take on risk. It took us 11
years and we are still hard at it, and the reduced shared
savings amount is going to keep providers out of this program
because it doesn't allow them to retain enough savings to
reinvest in the IT infrastructure and care coordination that is
needed to make these programs work.
Furthermore, the limitation of the risk score adjustment
between positive 3 percent and minus 3 percent over an entire
5-year contractual period will also be harmful as it will
penalize physicians financially for taking care of patients who
are sicker.
I commend this committee on its work to examine ways to
increase the use of value-based models and arrangements in the
Medicare program.
Thank you for the opportunity to testify.
[The prepared statement of Dr. Robertson follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. And thank you, Dr. Robertson, and thanks to
all of our witnesses for spending time with us this afternoon.
Mr. Green, I will once again offer to recognize you for an
opening statement. If not, we'll go directly to questions.
Mr. Green. I think we'll go directly, and I ask unanimous
consent to place my statement into the record.
Mr. Burgess. And without objection, so ordered, and----
[The prepared statement of Mr. Green follows:]
Prepared statement of Hon. Gene Green
Good afternoon and thank you all for being here today.
Today's hearing is titled, ``Examining Barriers to
Expanding Innovative, Value-Based Care in Medicare.''
I want to thank the Chairman for having this hearing and I
thank all of our witnesses for joining us today.
Today's hearing focuses on the current transition in the
Medicare Program away from fee-for-service and towards a value-
based payment system that is centered on the patient.
One of the main ways the Affordable Care Act sought to
reduce healthcare costs is by encouraging doctors, hospitals
and other healthcare providers to form networks that coordinate
patient care and become eligible for bonuses when they deliver
that care more efficiently.
ACA took a carrot-and-stick approach by encouraging the
formation of accountable care organizations, or ACOs, in
Medicare.
Today, there are 472 ACOs operating in the United States,
caring for 9 million beneficiaries.
In 2015, our committee passed the Medicare Access and CHIP
Reauthorization Act (MACRA), which expanded on the ACA to
further encourage the use of value-based compensation by
encouraging providers to create incentives to participate in
new care delivery models that increase quality and reduce
costs.
Starting next year, Medicare providers must participate in
either the Merit-Based Incentive Payment System (MIPS) or an
Advanced Alternative Payment Model. Both options are value-
based systems. This has led providers in recent years to adopt
new care delivery systems.
Studies have shown that value-based care systems lower
costs to the overall health system while improving patient
outcomes, a win-win that everyone should support.
ACOs saved Medicare an estimated $1.1 billion in 2017, with
a net savings of $314 million after bonuses were paid out. This
is a significant improvement over previous years and a clear
sign that ACOs are succeeding as intended.
Additionally, the experience with the Shared Savings
Program has shown that ACOs do better over time, both in terms
of performance on quality measures and at generating savings,
as they gain experience with care transformation.
Studies have shown that ACOs have reduced readmissions from
skilled nursing facilities, generated fewer emergency
department visits and hospitalizations, and had less Medicare
spending overall relative to comparison groups.
I am concerned with the proposed rule the Centers for
Medicare & Medicaid Services (CMS) issued on August 17 that
would shorten the onramp for new ACOs to take on downside
financial risk from 6 to only 2 years.
I am also concerned that the proposed rule cuts shared
savings in half for certain ACOs from 50 percent to 25 percent.
I am looking forward to hearing from our witnesses who have
managed or have experience with ACOs on their views on the
proposed rule and whether this proposal may be harmful to
current and new entrants.
I know some stakeholders are interested in making changes
to the Stark Act and AntiKickback statute. I agree that
Congress should be open to revisiting current laws if these
regulations are bona fide barriers to value-based care.
However, the Stark Act and Anti-Kickback statute were put
in place to protect patients and taxpayers from potential
abuses, including subjecting patients to unnecessary testing
and referring patients to lower quality services.
According to the Government Accountability Office last
year, improper payments in Medicare accounted for $51.9
billion. The Stark Act and Anti-Kickback statute continue to
serve important roles in protecting taxpayers from waste,
fraud, and abuse.
Any effort to reexamine these laws must place the
importance of protecting patients and taxpayers from excessive
costs and abuse at the top of the priority list.
Thank you again, Mr. Chairman, for holding this hearing,
and I yield the remainder of my time.
Mr. Green. I will share it with all of you all. You can
read it on the way home.
[Laughter.]
Mr. Burgess. The chair would remind all members that all
members' opening statements will be made part of the record,
filed following Mr. Green's missive.
So I will recognize myself 5 minutes for questions and, Dr.
Weinstein, thank you for being here. You represent I guess what
we would describe as independent physicians. Is that a fair
assessment?
Dr. Weinstein. Yes, independent gastroenterologists--about
1,900 across the country.
Mr. Burgess. So you raised the issue of independent
physicians--the difficulty they might have in accessing the
alternative payment model and being able to participate in
that.
Could you just kind of go over what are the major obstacles
for the independent physician to be able to participate in an
alternative payment model?
Dr. Weinstein. Yes, certainly. Thank you.
Independent physicians, particularly sub-specialty
physicians take care of chronic disease. We don't do primary
care. We are used when a patient needs a particular service or
has a particular disease.
So in a standard ACO type APM, we are technicians, in
general. But an independent practice like ours takes care of a
lot of patients with chronic inflammatory bowel disease,
chronic liver disease. These are very high cost, high beta,
high variable cost patients that generally are managed--even
their primary care is managed by gastroenterologists.
In developing an alternative payment model for inflammatory
bowel disease, we grouped. Our association got together and
used actuaries, did the data analytics using our own data to
determine what a model to take care of patients over a long
period of time would be.
Project Sonar was that APM. It was actually the first APM
presented to PTAC when PTAC started. It received a tentative
approval for testing and then got stuck. It does use technology
to engage patients in their own care so that we could do
outreach and try and identify patients before they show up in
the emergency room, before they show up in the hospital.
So the difficulties in developing that APM, obviously,
there was a cost burden in getting the actuarial data. There
was an inability to test to model because of the Stark
prohibitions and then not knowing how to modify it, obviously,
it makes it difficult.
So we are sort of shut out of APMs as gastroenterologists
because we don't have any alternative payment models that we
can participate as independent physicians.
But we are very willing to invest in the technology to do
that.
Mr. Burgess. Sure. If we can overcome some of those
obstacles and those obstacles would be what you just
delineated. I may get back to you in a written question form
about PTAC because I've got a particular sensitivity to that.
PTAC was a creation of, basically, this subcommittee a couple
Congresses ago and, conceptually, PTAC was there so that
physicians would be back in charge of quality metrics as
opposed to leaving that all up to the agency.
So it is very important to me the PTAC work and I am
discouraged to hear that you're having trouble. So I may follow
up with you on that because I do feel that it's such an
important concept.
But Dr. Anand, let me just ask you, in moving to downside
risk models to allow a system like Adventist to integrate
independent physicians into your networks, is that a
possibility?
Dr. Anand. Great question, Mr. Chairman.
From a philosophical perspective, two-thirds of our
clinically integrated networks are independent physicians, and
so we have always approached with the philosophy that we want
to have the best clinicians to be part of our networks.
Sometimes it's the best employed physician. Sometimes it's
the best independent. But we hold ourselves to high standards.
We want physicians who are going to be focused on quality at
the best experience at an efficient cost.
So with that, as we transition into the post-MACRA world
and being part of an advanced APM becomes more important to our
independent physicians, we've seen that as a great way for us
who are in a Medicare shared savings model to align with our
physicians who are going to be either subject to a penalty or a
possibility of a bonus in the MIPS program or, alternatively,
who are interested in taking more holistic care in moving
towards an advanced APM model.
So MACRA is one of the big opportunities that's going to
allow us to partner with their physicians. Too, taking downside
risk allows us to coordinate care more across the continuum
with the waivers that are present, with the ability to bring in
more components of the delivery system.
We talked a lot about post-acute. We talked about our
specialists. Bringing all those providers together in the--and
some are going to be independent, some will be academic, some
will be employed--that's going to allow us to coordinate care
more holistically.
It's also going to allow us to share tools and technologies
to achieve that coordination--sometimes apps, sometimes EMR-
integrated tools that are going to be part of it. There's an
upside potential that could also be--if the ACO is successful
that's also going to be an attractive component for the
physicians as well. So there's several components. In my mind,
I think the MACRA component, especially as we transition into
the later years of the MACRA model into the advanced APM model
I think there's going to be a lot of synergies with independent
physicians.
Mr. Burgess. And I just want to address for you, since you
brought up the interoperability title of 21st Century Cures,
the oversight of the implementation of 21st Century Cures has
been front and center in front of this subcommittee because the
scientific aspects, the FDA NIH aspects. There was actually a
mental health title.
So we've had separate hearings on both of those and the
third, of course, was the interoperability title, which I
thought deserved its own oversight or its own subcommittee
implementation hearing. Because of the delay from the rule
coming from the office of the national coordinator I was
actually talked into postponing that last June.
In retrospect, perhaps we should have pushed again with the
hearing. But and, obviously, we are up against some other
things in the calendar which you may have heard about in the
papers.
But at some point this year, I intend to have that
interoperability title implementation hearing that you said
would be critical for you.
Mr. Green, I recognize you 5 minutes for your questions,
please.
Mr. Green. Thank you, Mr. Chairman, and I thank you for
your effort to make the system work.
Dr. Weinstein, about 2 weeks ago I was invited to speak to
the gastroenterologists in Houston, Texas, and I was surprised
after I got up and talked about MACRA and how we are trying to
stay attuned to it as members of Congress, watching what the
agency does.
At the end of it, which is not usual, I didn't have any
questions at all. So I wasn't sure that the physicians were
aware of what's going on.
Have you seen that? And that's not just one specialty. That
was just one I happened to speak to a while back.
Dr. Weinstein. I think the largest physician groups around
the country have their ears to the ground as to what's
happening with MACRA and MIPS. In a gastroenterology practice
it's unfortunate that there really isn't a way for us to
participate in APMs and we are looking at having to implement
MIPS, which is a very expensive way to gather data and a very
inefficient way to gather data and yet it has never been proven
to help patient care.
So I think smaller groups are unaware of what's happening.
I am not sure----
Mr. Green. Although in the Houston area we should have a
whole lot of gastroenterologists.
Dr. Weinstein. There's some very large groups in Houston. I
am familiar with a couple of them.
Mr. Green. OK.
Dr. Robertson, welcome to our committee. The chair is from
north Texas. I am from Houston, and, obviously, we speak the
same language, coming from Lubbock.
Can you speak for a little more on your organization's
initial decision to transition in the ACO model and why this
model was the best fit for your organization?
I think you answered some of that. You were already on that
road that you thought the ACO would work.
Dr. Robertson. We were on the road because we had already
gone into Track 1 in 2014. We were making a decision as to
whether we wanted to participate another 3 years in Track 1 or
move to a different model when a law called MACRA became on our
horizon, and like many things in life, timing is everything.
This was fortuitous timing. We looked and the more we began
to discover about MACRA, the more we knew we wanted to be
qualifying providers under an advanced APM as opposed to being
thrown in the briar patch of MIPS. The positive and negative
variations in reimbursement under the MIPS systems is going to
be very disruptive for physician practices, especially small
physician practices.
Our ACO has a large employee medical group in it that's
owned by Covenant Health. But 50 percent of our organization is
composed of independent physicians, which are just one- or two-
person groups.
The amount of money that has to be put into that to make
those folks work under a MIPS system is horribly expensive and
together, collectively, we thought that we could do better if
we were in a risk-bearing program. We'd already had some
experience under Track 1.
We saw what we could do from a quality perspective and we
had been decreasing the amount of spend. The difference is,
though, the way they calculate your financial benchmarks under
Track 3. Totally different than Track 1, and we really didn't
have a good understanding of that when we entered into Track 3.
So that's made that a little bit problematic for us.
Mr. Green. Going from what you were, what type of
infrastructure changes and provider education and training did
your organization undertake to implement the ACO model? Was
it--from where you went to what you're doing now?
Dr. Robertson. We started in 2007 and initially just took
commercial contracts. But we started then developing a way of
showing physicians their individual performance. Every
physician believes that they are the world's greatest physician
and they provide absolutely good quality care.
The problem is our system is so broken that it encourages
just transactional care. You're there for 15 minutes and then
good luck to you, or you get to the hospital dismissal
driveway--good luck to you.
Doing this requires you to think differently. You own that
patient 365 days a year, 24 hours a day, and you have to have
access to some data to help you understand where the spend is
occurring and then you have to invest not only in IT systems to
show physicians how they're performing but you have to hire a
lot of people to help patients do things that you need for them
to do.
You can't imagine that a patient is going to be able to
take everything you tell them in a 15-minute visit. Our care
coordinators can move out into the community with them, help
them stay on track, help them set goals for self-care, and
provide them some other opportunities to find medications that
we sometimes prescribe that we have no idea are so expensive
and get them access to the medications they need at a better
price.
Mr. Green. Well, I've been on the committee since 1997 and
it's, like, I got so tired of hearing about how bad the SGR was
and that's why this committee wants to stay on top of it
because the last thing we want to do is recreate the problems
physicians had under the SGR, and that's why I appreciate the
whole panel to be here.
By the way, my son-in-law is a gastroenterologist and my
daughter is in infectious disease so and they do think they can
cure everything.
[Laughter.]
Mr. Burgess. They probably can.
Mr. Green. And I am glad they can.
Mr. Burgess. The gentleman yields back. The chair thanks
the gentleman.
The chair recognizes the gentleman from Kentucky, Mr.
Guthrie, the vice chairman of the subcommittee, 5 minutes for
your questions, please.
Mr. Guthrie. Thank you very much, and the first question is
for Mr. Reed, and I think I wrote it down. I was trying to
write as you were saying it but I am not that quick.
But you talked about making changes and you said in your
testimony make changes in the Stark and anti-kickback laws in
order to get the technology in the hands of patients. I think
that's pretty accurate what you said.
How does the anti-kickback statute prevent providers from
giving patients the tools that may help them, and if we update
the statutes how do we effectively protect against fraud and
abuse?
Mr. Reed. Well, I think that's at the core of the question
and I was very pleased to hear several other folks of this
panel talk about the fact that the way that, especially in the
ACO space, it works is, as I understand it, if a physician
group wants to provide technology into the hands of a patient
for remote patient monitoring or other patient engagement that
might have--part of it would be a referral that it kicks into a
consideration under the anti-kickback.
The problem with that is that the very tool that I might
put into the hands of a patient, a tablet like this one or
anything like that, that I am going to use to gather data on
the patient, I am going to want to necessitate a referral if
one of the things that shows up from the evidence that I am
collecting on that patient says, hey, they need to see a
gastroenterologist.
And so the moment that I do that I am in trouble with the
law. As far as where the fraud lies, the reality is the fact of
remote patient monitoring and digital services it's a whole lot
easier to monitor exactly what the use of that device is doing,
what it's entailing, how long it's used for.
In fact, the very data that we need to show effectiveness
is also going to be very useful to demonstrating that it's not
being used fraudulently.
So we think that removing that barrier for good
recommendations to good gastroenterologists or infectious
disease specialists like Mr. Green's daughter are the kind of
tools that we need to make available, and the idea that a
patient is now limited because I can't give them the tech that
they need, that's just crazy.
Mr. Guthrie. I don't disagree with you.
So, Dr. Peck, how are healthcare apps and telehealth
services changing the Nation's healthcare access? Sort of
mentioned here, and how do we encourage telehealth, from our
perspective?
Dr. Peck. Thank you.
In terms of the apps question and technology, I do agree
that there is the component that whenever I suggest to have an
app in the hands of a patient, when they start to use it if it
does generate the idea that they now need to see another
physician that can cause a lot of problems in terms of self-
referral.
So but moving into telemedicine, there's a lot of talk of
1834 and of Social Security Act, and lifting that. I would like
to make the point that lifting that in 1834(m) seems to be a
plug into the hole that fee-for-service Medicare beneficiary
program has created for itself.
Because smaller companies, startups, innovations even of
larger companies and of healthcare systems don't have a way
necessarily to value-based contract with Medicare directly,
they have no way to get paid for innovative programs that are
outside the fee-for-service schedule.
If you have something that's innovative, new, better,
cheaper, faster, and brings higher quality, well, that's
perfect for value-based care.
So why can't we have a provider contract with Medicare?
CMMI is one of the ways to do that. But, again, this is a long,
arduous, expensive, and not very flexible process.
The RUSH Act, which I talked about, was introduced and the
RUSH Act works for nursing homes but I want to broaden that
out. I think what's important about the RUSH Act, when you take
a look at it, is that has this value-based arrangement idea
with Medicare.
It allows the providers, the doctors, the nursing homes who
are housing the patients, and Medicare to all share in any
savings that are generated.
And then there's down side risk as well.
Mr. Guthrie. I've only got about 30 seconds. To anybody on
the panel, so we are talking with Medicare here and how
difficult it is to innovate and change things.
Are you seeing it when you're dealing with private health
insurance and others?
Dr. Peck. I am talking about Medicare.
Mr. Guthrie. I know you are, but do you see it in your
private world it's quicker to adapt and you're seeing these
changes?
Dr. Peck. Yes.
Mr. Guthrie. So that we would lose these changes if we just
went to pure Medicare for everybody?
Mr. Reed. Absolutely. There are problems on the innovation
side, and here's one of the problems.
As we noted earlier, it's a trillion dollars. So anyone,
any venture capitalist, when our members are looking at raising
money, the VC is going to ask, well, what's the total
addressable market, and when you have to describe that one-
third of your total addressable market is Medicare and
Medicaid, the next question is so how do we get paid out of
that system.
So when you look at 1834(m) as a plug that prevents--and I
am going to do something unheard of--I am going to say
something nice about a government agency--CMS has actually done
some good things lately to try to break free of where 1834(m)
has been preventing forward progress.
But to your direct question, even though in the private
sector there are ways around Medicare and Medicaid
reimbursement, there's a trillion dollars of addressable market
there that any wise venture capitalist is going to say how do
we get to it, and with barrier like 1834(m) it's staving off
our ability to move into that space.
So yes, it harms our ability on the Medicare and Medicaid
side, and yes, it harms our ability to grow our businesses to
cover more people.
Mr. Guthrie. Thanks. I am out of time. I yield back.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
The chair recognizes the gentleman from New Mexico, Mr.
Lujan, 5 minutes for your questions, please.
Mr. Lujan. Mr. Chairman, thank you so very much for this
important hearing and I want to thank our ranking member, Mr.
Green, as well.
I would also like to acknowledge Chairman Walden and
Ranking Member Pallone for looking at how telehealth services
can be used to improve access to quality care, to save patients
and Medicare time, energy, and money.
Dr. Peck, you point out in your testimony that if skilled
nursing facilities across the country are to implement
telehealth services to scale then something needs to change
within the billing system.
The skilled nursing facility value-based purchasing program
authorized by the Protecting Access to Medicare Act is shifting
Medicare's reimbursement for skilled nursing facilities to a
value-based system.
SNFs are now evaluated on a hospital readmission measure
that provides incentive payments to encourage SNFs to keep
patients healthy.
Dr. Peck, how does Call9 and models like Call9 affect
nursing homes' performance under this new reimbursement system?
Dr. Peck. Thank you for that question.
The new reimbursement system and models like Call9 that
decrease hospitalizations--unnecessary and avoidable
hospitalizations--increases the payments to nursing homes and
rewarding them for that good behavior.
And I would mention in my testimony that one of our first
nursing homes just finally got their value-based score and they
are receiving a large bonus from that.
What that program doesn't do is incentivize the providers--
the physician groups who are delivering that care. That program
does give the bonus to the nursing home itself but not to the
providers, the doctors.
So it's a good program and I think it will help a lot and
incentivize a lot of nursing homes to reduce hospitalizations
but leaving out the physician groups.
Mr. Lujan. I appreciate that very much, especially in light
of your testimony and the testimony of others that found that
19 percent of transfers to the emergency department are from
skilled nursing facilities--one in five.
You mentioned in your testimony that Call9 model uses
additional clinical staff to complement the nursing home staff.
Can you elaborate on how the Call9 staff work with nursing
homes to treat patients?
Dr. Peck. Certainly. So our particular model we place first
responders. These, by training, are EMTs, paramedics. They can
be nurses with emergency experience--CD techs.
What unites them all is that they understand emergencies
and acute care. I think this is a key point. A broader point is
that what we do is we bring the emergency department to the
nursing home in this way with the physician who is remote in
this onsite.
Nurses in nursing homes are great at chronic care. That's
what they do, and if the nursing homes had faculties and staff
that could take care of emergencies, we wouldn't have 19
percent of the patients going to emergency department coming
from nursing homes.
So what we do is put the emergency care in there to
supplement but not--and complement, excuse me, but not
supplement what they do--not replace what they do.
Mr. Lujan. Many members of the subcommittee worked on
recent provisions to expand telehealth reimbursement for
telestroke, end-stage renal disease, accountable care
organizations, and Medicare Advantage plans.
Dr. Peck, how does the RUSH Act build on this successful
legislation?
Dr. Peck. Right. So all of those legislations help address
the CBO issue of the CBO scoring telehealth usually as an
additive program. The reason for this is they count it as a
duplicative measure.
Telestroke--I will key in on that one--end-stage renal
disease, we can key on that as well. It's very hard to make
more strokes. It's very hard to make more sessions of dialysis
every week for a patient.
So it controls itself in terms of the volume that's there
and that lends itself perfectly to value-based arrangements and
value-based contracting.
Our model is working with emergencies. It's very hard to
rack up new emergencies and make more emergencies out of thin
air. So when you have that kind of cap on a certain condition I
think that's a nice place to start to focus on to start to chip
away at bringing value into Medicare.
Mr. Lujan. And the requirements under the RUSH Act speak to
additional workforce. What qualifications will these people
have and is there a way to train existing staff to accomplish
the same goal or is there value to bringing in a new person?
Dr. Peck. Yes, I think there are ways to have existing
staff become more trained in emergencies, have more skills for
emergency medicine, be more comfortable in CPR type settings.
However, I do believe it's important to have additional
staff if you're going to retain patients in a nursing home and
more patients who are sick. Having the existing staff there and
not augmenting with another person I think will take away from
the care of the rest of the patients who don't have
emergencies.
Mr. Lujan. I appreciate that. Thank you, Mr. Chairman.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
The chair recognizes the gentleman from Ohio, Mr. Latta, 5
minutes for your questions, please.
Mr. Latta. Thanks, Mr. Chair, and to our panel today,
thanks very much for being here on this very important topic.
If I could start, Dr. Anand, with you. Do medical
professionals or health practice of health practices face
barriers, regulatory or otherwise, to adopt new technologies?
Dr. Anand. Yes, great question. So I think we've alluded to
several comments on the barriers that we face. One is related
to being able to financially support the costs that go into
implementing new technologies and tools.
With our independent physicians, when I was in Texas the
average practice size was about one and a half for the
independent physicians. Some places are a little bit larger.
But independent physicians don't have the capital in order
to be able to make those purchases. When you're in an ACO
construct and you apply the Stark waiver and the Stark
exemptions, you can now, as a system, come together and allow
them to access those tools and technologies and apply it across
their patients.
The challenge we find is those tools and technologies, and
it's a question that we've struggled with, is can you apply
those tools and technologies only for Medicare beneficiaries or
apply them broader, more widely, across all of the patients or
the provider panel that the patients see.
And that's been a big struggle for us. We'd love to see the
Stark waiver expanded and, in an ACO structure, provided at the
provider level because as clinicians we can't sort out who's in
which program and when a member is in another program.
We can use this tool and technology that's going to change
care for this patient but we can't use it in that other patient
situation.
So those are some of the challenges that we face. I think
if we could, in the ACO construct, we are coordinating care
basically--provide these tools and technologies and allow them
to use those tools and technologies for all of their patients I
think we'd be in a much better situation.
Mr. Latta. Let me ask you this--just follow up on that.
You're talking about the independent practitioners out there.
Would that also--these barriers be disproportionately affecting
small and rural providers because--who could benefit quite a
bit from telemedicine?
Dr. Anand. We do. In our health system we have several
markets that are in rural markets. We have one in Asheville,
North Carolina--a campus that's there. We also have one in
Manchester, Kentucky, and in those settings what we are finding
is it's becoming harder and harder to have specialists and
particular services provided in those markets.
Now, in our system, we have a great skill set and great
number of specialists in our Orlando market and we would love
to be able to provide that cognitive expertise to those folks
in Manchester, Kentucky, as an example.
The reimbursement models we struggle with we'd love to be
able to support the providers that are providing primary care
services with the specialists that we have.
And so we struggle again with the Stark rules that go with
it. But rural services, at least in my opinion, are going to
continue to be harder to come by, especially with specialty
services, and when we have these large centers that can provide
those services if we could figure out a way through the Stark
exemption and payment models to transpose that cognitive skill
to those markets our beneficiaries will be able to get much
better care.
Mr. Latta. Well, if you look at what we could do in
Congress, what would you like to see us do specifically?
Dr. Anand. I think if we could do two things--one is allow
us in certain, especially rural markets and critical access and
hospitals that don't have access to larger partnerships--allow
us to provide those tools and technologies through a Stark
exemption.
Number two is if we could figure out a payment model where
we could reward those services and cover some of the
infrastructure costs that go with it I think that would allow
us to be able to provide that service on a larger scale and,
again, it would allow better access for beneficiaries and the
patients that live in those smaller rural areas.
Mr. Latta. Mr. Reed, with my last minute I have, I am a
firm believer that data has the power to spur change and data
allows us to recognize important trends and patterns that, in
turn, influences decision making and ultimately finds
solutions.
How could Congress reduce these barriers to sharing health
and patient data without compromising that patient privacy?
Mr. Reed. Well, it's a great question and, of course, it's
always good to remember that the P in HIPAA stands for
portability, and I think that's at the core of where we stand.
We would urge Congress to do everything in your power to
address what Dr. Burgess said earlier and that is let's see
ONC's report on info blocking, because ultimately, as we are
moving into this space where data has to be available and
interoperable, we know that the only way to get a patient the
solution that they need is to find out what's wrong with them,
and the more data that all of these gentlemen here at this
table, and Mary, can have, the better chance we have of
correctly identifying the disease and, more importantly,
getting you the right treatment at the right time.
So, first of all, we need to do better on interoperability.
Second, we need to continue to push forward on finding the
right terms and glossaries so that the notes fields, which are
a key aspect of how a doctor communicates your story, not just
your test results, becomes part of a record that can be used by
every single person at this table. And so it starts with ONC.
Let's see what they have to say.
Mr. Latta. Thank you very much.
Mr. Chairman, my time is expired and I yield back.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
The chair now is pleased to recognize the gentleman from
Virginia, Mr. Griffith, 5 minutes for your questions, please.
Mr. Griffith. Thank you very much, Mr. Chairman.
First, before I do that, I have a letter that has been sent
in support of the RUSH Act, which Dr. Peck was so kind to make
nice comments about earlier that Mr. Lujan and I of this
committee have signed onto along with a number of others,
including Adrian Smith. But I have a letter, without objection,
if we could submit that for the record.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Griffith. We'll get that down to you. All right, I
appreciate that.
And, Dr. Peck, again, thank you for your kind comments on
the bill and I know we've got a lot more to do, and this just
gets us started and you made some comments in that regard as
well.
You also mentioned in your testimony that Call9 treats 80
percent of the patients you see in the nursing home versus
transferring them to the emergency department.
How do you interact with the other 20 percent of patients
that are still transferred to the emergency department?
Dr. Peck. It's a great question. That's where we get to
save a lot of lives that otherwise wouldn't be saved. That's
why I left my job as a traditional emergency physician. Someone
took my job as an emergency physician after I left, right.
But these patients who we can't get to in their moment of
emergency in these nursing homes they otherwise would be
pulseless. They otherwise would be having very severe problems.
But with our program and other programs in nursing homes we
can get to them at that point, and the average--when you put
all the numbers together after you call 911 it takes about 64
minutes including the wait to see an emergency physician. If
you're pulseless, across the country that can be 36 minutes. So
yes, being with people at the moment of emergency saves lives.
Mr. Griffith. And that's very good. But I guess I am trying
to figure out, OK, what happens once they go off to the
emergency room? You have decided that you all can't take care
of it and you're getting 80 percent of them right there in the
nursing home--they never have to make that trip and, as you
describe in your opening statement, with the bright lights that
are confusing and the long wait and the ride in the back of a
van. It's an ambulance. But when you're sick and not feeling
well, it's just the back of a van.
Dr. Peck. Yes. Yes.
Mr. Griffith. So how are you able to continue to interact
with that 20 percent that's at the hospital?
Dr. Peck. Right, and we talk a lot about interoperability
and pushing data over, and writing--even being able to write
notes in the same language that an emergency department needs
to see and streamlining the data transfer is where there's a
lot of opportunity to help those patients. Yes.
Mr. Griffith. All right.
And in your testimony, you stated that Call9 currently
operates in 10 nursing homes in New York--and this was in your
written testimony--but has not spread to more rural areas.
Yet, how would Medicare's reimbursement of technology-
enabled care delivery models allow for these models to reach
more rural areas?
Dr. Peck. Yes. So right now, we are dependent on the
Medicare Advantage and commercial payers to be able to make
this happen. So we have to go to areas where those MA
penetrations is as high as possible, which is usually urban
areas as well as larger nursing homes where there's more MA
patients.
So we can't possibly go to smaller nursing homes or
Medicare-heavy nursing homes right now. We would lose the
company.
Mr. Griffith. Now, you said Medicare heavy. What about
Medicaid-heavy nursing homes?
Dr. Peck. Right, so long-term care Medicaid patients are
usually dual eligible for the most part because they're over 65
for the most part, or disabled for the most part. So Part B is
where these payments are coming from, not from the Medicaid
program.
Mr. Griffith. OK. I appreciate that.
Representing a fairly rural not affluent district, this is
one of the reasons that I am pushing for these ideas because my
constituents deserve to get just as good care as those folks in
the urban areas or in the wealthier areas.
Let's see if I have time to get one more in.
Dr. Peck, one issue policy makers have faced in advancing
telehealth legislation is the lack of data, and I know
everybody's talked about data, but the lack of that data on the
effects of telehealth on actual Medicare beneficiaries, this is
a hard barrier to overcome because without reimbursement for
providing these services to Medicare beneficiaries there are
few who are going to be able to take the financial loss to
build enough meaningful data.
How can Congress continue to support entrepreneurs in
generating these meaningful data points?
Dr. Peck. Yes, it's vehicles to be able to get these models
through after they're proven, the PTAC being one of those. We
have held back our PTAC application at this point until we
understand more about what the program intends to do.
We also see this opportunity--the RUSH Act as the tip of
the spear to be able to have Congress directly allow Medicare
to contract with startups and entrepreneurs and innovative
programs.
We need those on that side to be able for me, as an
entrepreneur, to go to the venture community and raise money.
They're not going to give it to me unless there's a way to make
return on that investment.
Mr. Griffith. Right. Well, I appreciate it and appreciate
all of you all being here. This is an important subject and I
look forward to working with all of you as we move forward.
I yield back.
Dr. Peck. Thank you.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
The chair recognizes the gentlelady from California, Ms.
Matsui, 5 minutes for questions, please.
Ms. Matsui. Thank you, Mr. Chairman. I want to thank the
witnesses for joining us today. I am pleased that we are
hosting this hearing to discuss how we transition toward
rewarding value over volume in our healthcare system.
Thanks to the Affordable Care Act, the MACRA providers
today have more opportunities than ever before to redesign how
they deliver care to their patients.
Moving to value-based care is important. But we can't lose
sight of the importance of the Stark Law in protecting the
Medicare program from waste, fraud, and abuse.
Although a shift to value-based care may require re-
examination of certain policies, the self-referral laws
continue to serve an important purpose.
It is important to differentiate between changes to Start
Law that would lead to more value-based payment models and
coordinated care and changes that would gut the intention of
Stark and allow the pay for play at the expense of patients.
Several of you note that the secretary has authority to
waive the Stark Law for innovative value-based arrangements.
Mr. Reed, your testimony notes that you believe that HHS
has clear authority to provide exceptions to the Stark Law. Can
you expand on what steps you believe the secretary can take to
modernize Stark to encourage high quality value-based care?
Mr. Reed. Well, I think you have heard from the
multiplicity of the witness perspectives here that essentially
the secretary needs to look at the Stark and any kickback from
the perspective of what is your ultimate goal.
You said the ultimate goal is to make sure that we don't
have waste, fraud, and abuse. I would posit the primary goal of
Medicare is to make sure that people over the age of 65 have
the kind of care that helps them stay healthy and be
independent.
And so when I look at it from the perspective of what is
the capability of the secretary to waive, you used some key
words, which was innovative technologies that can help improve
the outcome.
And so I think that with each request for an exception I
think it falls under that waiver authority. But I also would
note that we have to be very careful with waiver authorities to
something that Dr. Peck said earlier, which is when it only
happens every year enough to renew, it makes it quite difficult
when you sit down with a venture capitalist and your new board
to say our entire business model is dependent on our hope that
a waiver will continue to the next year.
Ms. Matsui. Yes.
Mr. Reed. And while we are not only bidden to the VC
community, we have limited resources. It changes where you
focus your time and energy if you have that possibility hanging
over your head.
So I would like the waiver to be exercised on those
innovative technologies but in a manner in which allows us to
really build and grow them and not just worrying about----
Ms. Matsui. OK.
Mr. Reed [continuing]. Where there might be an overuse.
Ms. Matsui. OK. Now, I want to get into telehealth, because
over the years a group of us on Energy and Commerce have worked
together to advance the adoption and use of Telemedicine.
As CMS implements MACRA, we want to make sure that the new
health technologies are integrated into new models of care from
the start.
And, Mr. Reed, in MACRA Congress intended for telehealth
and remote monitoring to be rewarded within the MIPS clinical
practice improvement activities.
Can you comment on CMS' recent efforts to support and
expand the use of these services?
Mr. Reed. Absolutely. We are very pleased that the MIPS
program included IA activities. Especially, we think it's very
important that they allowed for small practices to see their
number--to get an appropriate reward for engaging with their
patients when it comes to using telemedicine and remote patient
monitoring products.
I think what's really important though is for the parts
that you're mentioning, which are critical, and are worthy of
note, we don't think we should forget the fact that the APMs--
that there was no mention of remote patient monitoring as part
of the APMs----
Ms. Matsui. Right.
Mr. Reed [continuing]. And I think it's important to note
that, from our perspective, we appreciate what you have been
doing both as a cosponsor of Connect for Health and as a
cosponsor for the evidence-based Telehealth Expansion Act.
So we appreciate the work you have done in this space and
we think that that all needs to be continued.
Ms. Matsui. OK. Now, as CMS continues implementing MACRA,
in what ways should Congress be thinking of program oversight
with regards to promoting the use of telehealth and remote
monitoring services?
Mr. Reed. Evidence. That's the real crux of this issue. We
always take the perspective that every physician--and the whole
system has three real questions: does it work, will I be in
trouble for using it, and then, finally, does it make economic
sense.
And so that first question of evidence becomes critical.
You have heard multiple people here talk about CMMI. I think
it's ironic that CMMI--we met with CMMI the other day. Love
them, great people over there. But they told us, hey, we are
going to move really fast and get this study out in 10 years.
[Laughter.]
Ms. Matsui. OK.
Mr. Reed. Just recently all of you know that 10 years ago
there were no smart phones.
Ms. Matsui. That's right.
Mr. Reed. That's when that started. So and we are looking
at the evidence that we need to bring to the fore. We cannot
wait for CMMI and a 10-year study that hopefully shows how it
all works.
We are going to have to use other sectors.
Ms. Matsui. OK.
Well, thank you, and I've run out of time so I yield back.
Mr. Guthrie [presiding]. Thank you, and I appreciate the
gentlelady for yielding back and the chair now recognizes Mr.
Bilirakis from Florida for 5 minutes for questions.
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it
very much and I thank the panel for their testimony today.
Dr. Anand, thank you for being here and I have a couple
questions for you.
Adventist Health System has a sizeable, as you know,
presence in Florida. You stated that earlier, and throughout
the Tampa Bay area--and I represent parts of the Tampa Bay
area--I want to commend you also for making such tremendous
improvements to Florida Hospital North Pinellas, which is my
hometown hospital, and the community has really rallied around
the hospital. So thank you so very much. A wonderful place.
Dr. Anand, how many of your doctors are involved in and how
many independent physicians are part of your accountable care
organization?
Dr. Anand. Great question. When you look at the State of
Florida, we've set up one accountable care organization that
serves approximately 55,000 Medicare beneficiaries.
When you add our ACOs and our clinically integrated
networks in the State of Florida, we have approximately 3,900
physicians of which two-thirds are independent physicians.
We partner with them in the Tampa market, for example. The
numbers may vary a little bit but that statistic, about two-
thirds, holds pretty true.
Mr. Bilirakis. OK. You have set up again and operate a
number of ACOs. Is that correct? And where exactly in Florida?
Is that at the Orlando area or is that in several hospitals in
the Tampa Bay area?
Dr. Anand. Good question.
So what we've done, in order to help improve the care in
Florida we've actually set up one statewide Medicare shared
savings program--one ACO--that encompasses the whole area.
It's in the Tampa market, goes into the Orlando market,
brings together providers from the Daytona, Volusia, Flagler,
Highlands, Hardee County. In the future, we'll actually be part
of it as well.
And so what we are hoping to do is starting to bring
together an improvement model where we can actually improve the
care and wellbeing of all the patients in Florida.
Mr. Bilirakis. Very good. Very good.
What makes your ACO unique when compared to other ACOs and
how has your ACO been successful? How has it been successful in
reducing costs and increasing outcomes?
Dr. Anand. Great question.
Mr. Bilirakis. Increasing outcomes--that's the bottom
line--the quality of care. But go ahead, please, sir.
Dr. Anand. Great question.
So let me tackle the first question--what makes our ACO
different.
Mr. Bilirakis. Yes.
Dr. Anand. So from a organizational perspective, we
fundamentally believe in holistic care. We believe that medical
care is a small portion of the overall health and wellbeing of
our patients and beneficiaries.
And so we focus on things that affect their social
determinants of health--their mental wellbeing, their spiritual
wellbeing, some of their financial issues that we have.
And so we really take a holistic picture and approach to
improving the health and wellbeing of those patients. The
literature has confirmed over and over that when you apply that
holistic approach you're going to get better health outcomes.
If you come and treat the emergency medicine physician as
well--if you treat the patient in the emergency department and
then they go off and they don't have the services that they
need, they will be back in the emergency department over and
over again.
And so that's been one of the fundamental approaches from
the beginning is that we want to make sure we incorporate all
of those elements into----
Mr. Bilirakis. Cost reduction is a factor as well.
Dr. Anand. Correct. From a cost reduction perspective, we
focused on where the variation lies in care and there is
tremendous variation as you go from region to region as well as
provider to provider.
And what we do is we help provide the tools, the
technology, the data, the analytics that empowers physicians to
have the information that they need to provide the best level
of care.
We are looking at pathways related to issues such as back
pain where we can actually provide interventions and treatments
that are going to make a lasting improvement such as physical
therapy, rather than just going straight to surgical therapy,
which may not improve outcomes initially.
Mr. Bilirakis. I like that.
Can you talk about some of the challenges you face in
structuring your particular ACO when dealing with the Stark
Law?
Dr. Anand. Yes. That's a great question.
So we had several challenges with the Stark Law. I think
we've covered a lot. But just to summarize, if it was permanent
I think that would be a big help.
Two, there's a lot of questions about the applicability of
the Stark waivers for all patients. Some of our providers have
10 Medicare beneficiaries. Some of them have Medicaid
beneficiaries.
Some of them have a hundred or 1,500 Medicare beneficiaries
and what we would like to do is actually see the Stark waivers
apply down at the provider level so that the provider doesn't
have to realize that this patient is a Medicare beneficiary
that's in an ACO program. This Medicare beneficiary is not--
this other one may be, but we are not quite sure right now.
It's too hard to operationalize from a physician
perspective and so we'd like the Stark Law to apply to provider
level. If we can do that, we can coordinate care effectively
because we have the pathways. We know what the clinical
pathways are and we can share it with the physicians and allow
them to provide the best care.
The tools and technologies that we've talked about we have
those available and we'd love to be able to share them with the
physicians. But we still have confusion on if they can share it
with just--and use them just on their Medicare beneficiaries or
if they can use it on all patients.
And so we love the direction that the committee is headed.
We'd like to see an expansion in those particular instances.
Mr. Bilirakis. Very good.
Thank you very much, Mr. Chairman. I yield back.
Mr. Guthrie. The gentleman yields back.
The Chair now recognizes Mr. Long from Missouri for 5
minutes for questions.
Mr. Long. Thank you, Mr. Chairman.
And Mr. Reed, in your testimony you talk about the value
telehealth can have for taxpayers. You state that evidence from
practitioners contradicts the often overstated fears that
telehealth could lead to a bonanza of over utilization.
Instead, telehealth could substitute for otherwise more
expensive healthcare services. Could you talk about what the
evidence has shown so far on the cost savings that telehealth
could produce?
Mr. Reed. Absolutely, and I know it's a rival state but the
also great State of Mississippi has done some amazing work with
telemedicine and remote patient monitoring, particularly in the
area of type 2 diabetes care.
What you see out of the University of Mississippi Medical
center is an effort to directly engage with patients,
particularly in the Delta, who have no care or no facility or
an originating site within 2 hours.
It was crushing the state economically. But by putting a
tablet in the hands of folks at home with the necessary high-
speed connection that exists in those areas what changed was
the nurse practitioner could notice, hmm, your blood glucose is
kind of high--let's get on the phone. Oh, it was a family
reunion? OK, stay off the pecan pie for the next week--let's
get that down.
And so what you saw is you didn't see an over utilization.
What you saw was a stoppage of the kind of danger symptoms that
went on. So instead of that person ending up on the pathway to
blindness, on the pathway to losing a leg, you saw them
engaging with a nurse, maybe with a little nagging, to say hey,
back off that--don't have that second piece--let's get you in
for a test.
So when you think of it in very simple terms, you're
right--maybe telemedicine means that they go have a face to
face visit.
But if that face to face visit is a conversation about how
they stay healthy, that's a whole lot cheaper than a face to
face visit that results in an amputation or blindness or a
treatment that they'll never recover from.
So I am OK with telemedicine leading to a lot of physician
engagement because it's the kind of engagement that keeps
people on the front side of the wave and not the back.
Mr. Long. So that's where the savings comes in then?
Mr. Reed. Absolutely.
Mr. Long. So how long would it take these cost savings to
materialize?
Mr. Reed. Well, here's what's amazing. In states like
Mississippi and in other places, they've seen 100 percent
reduction in readmissions in certain types of type 2 diabetic
problems and they've had those results in a matter of 2 to 3
years.
So a lot of it is what kind of nurses you have--we've had a
lot of discussion about skilled nursing--what kind of nurses
you have and what elements you have to engage.
But we are not talking about a decade to see an
improvement. We are talking about a short matter of years,
depending on the condition and where those people are in terms
of their education.
Mr. Long. OK. When you're talking about that they're using
telehealth and monitoring their type 2 diabetes--their glucose
monitor, I guess, or whatever--so these people are pricking
their finger at home and then relaying to the nurse or
practitioner, doctor----
Mr. Reed. Yes.
Mr. Long. Over the iPad? Is that correct?
Mr. Reed. That's correct, and here's the part that's really
good. It isn't just that that result goes. It's not passive.
They put that result in. They get information and feedback on
how they're doing.
The most dangerous thing, and I know every physician here
knows, is a passive patient. A patient who's engaged in their
care, they're on top of it. When they see that number on that
iPad, they say to themselves, well, how does that look. Oh, it
doesn't look good--what did I do. And then the nurse calls up
and says hey, I didn't like what you're seeing, and here's the
really good part. What if they're doing a great job? What if
that is a great number?
Mr. Long. More pecan pie.
Mr. Reed. That's right. But more importantly, then that
pecan pie--what's even better is the next step. The next step
is the nurse calls up and says, you're doing a great job, and
that creates an active engaged patient. That's where your
savings come from. That's what eliminates people. We are
talking about numbers here but we are also talking about lives
and quality of life. So it's important that we deal with the
numbers but let's never forget about the people that are
involved here.
Thank you.
Mr. Long. How do we ensure the long-term savings from
telehealth are factored in beyond a 10-year window?
Mr. Reed. Well, I think that's something we've all been
talking about here on the move that you and I believe your
cosponsor on the Preventative Health Savings Act to try to move
that ONC window.
I think that realistically, given the speed of technology--
like I said, there were no smartphones 10 years ago and then
now none of you would ever be 3 feet away from your smart
phone.
So think what you have to look at is let's extend the 10-
year window but then let's also be cognizant of the fact that
we are probably going to see some major shifts in the way that
people are engaged in their daily lives with technology.
There's this concept that tech is just about kids. That's
not true. Any of you have grandkids? I bet you you FaceTime
with your grandkids on your mobile device.
If you think about where adults over the age of 65 are with
technology it's a myth that people over 65 can't tech because
they can tech just fine.
Mr. Long. And these new watches that Apple rolled out
yesterday with the telehealth applications on there.
Mr. Reed. Correct.
Mr. Long. Pretty amazing stuff of what they--I can't
remember the CEO's name. Is it Cook now? Or whatever, but
rolled out yesterday.
Mr. Reed. I will be happy to come by and show you one on
September 22nd, I think.
Mr. Long. OK. Very good. Thank you, Mr. Chairman. I yield
back.
Mr. Burgess [presiding]. Chair thanks the gentleman. The
gentleman yields back.
The chair recognizes the gentleman from Georgia, Mr.
Carter, 5 minutes for your questions, please.
Mr. Carter. Thank you, Mr. Chairman, and thank all of you
for being here. This is certainly a very important hearing.
I want to start with you, Dr. Weinstein.
Full disclosure--before I became a member of Congress I was
an independent retail pharmacist so I appreciate independent
healthcare practices.
When I talk to my colleagues about the problems that we are
having hanging on to independent retail pharmacies they think I
am only talking about independent retail pharmacies. But I am
not. I am talking about independent healthcare practices.
That, to me, is a real big problem here and one of the
things I wanted to ask you to begin with is I am really
troubled to hear that your practice is having trouble with
participating in some of these cost-saving arrangements with
Medicare because of the outdated CMS policies.
And I just wanted to ask you what do you think are some of
the advantages that perhaps the big hospital systems have over
you, being an independent practice? Can you think right off of
some?
Dr. Weinstein. Well, hospital systems are really just
people. So, the big hospital systems--I guess you might say
that for the really complex tertiary care--complicated surgical
infectious--somebody with a multi-system disease needing multi
specialists, obviously--hospital systems are important.
But many of the diseases that we take care of are really
isolated to gastroenterology or maybe gastroenterology and
surgery. So one or two specialties, and the idea is to be able
to get to those people, engage those patients before they need
major hospitalization.
Mr. Carter. Right. Right.
Dr. Weinstein. That's where the savings is, and engaging
those patients. The Project Sonar that I mentioned before,
which was tentatively approved by PTAC but then didn't move
forward, is a technology engagement with patients to determine
how they're doing on a basis where they might ignore symptoms
from time to time and engage them before they get to a
hospital.
So there is certainly need for hospital systems for the
very acutely sick. But the majority of patients, hopefully, can
avoid hospitals.
Mr. Carter. Absolutely. Well, thank you and good luck. I am
pulling for you. Trust me.
Dr. Weinstein. Thank you.
Mr. Carter. Mr. Reed, I want to go to you because I'm very
interested in this. I've had a company in my office that--and
help me to articulate this because I suspect you know about it
better than I do.
But they're coming to Georgia now and they are involved--
they have an app that they've created because in Georgia right
now it takes 3 weeks on average to get an appointment with a
primary care physician and in some areas, particularly in the
area that I represent--south Georgia, a very rural area--it may
take even longer to get that.
Well, they've come out with an app that can take advantage
of cancelled--cancellations or changes in a schedule and you
can use that app but they're telling me that the only way they
can bill for it outside of the private pay--the only way they
can bill for it for the Medicare patients is if they do it by
flat fee and they want to do it on a per usage basis. Again, I
am sure you understand that much better than me. But the rules
are so antiquated that they can't do it.
Mr. Reed. That's correct. I had my staff, prior to this
hearing, poll through my written testimony and come up with a
glossary of 44 different acronyms that I used--just from my
testimony--and I am pretty sure that everybody here has the
same number--but that really represents the status that your
company in the great State of Georgia is dealing with.
The problem that they face is they also get completely
differing answers. For example, on the one you're talking
about, when you look to share that information on an
application like that on how you bill, you have got to deal
with a couple of different systems, not only from an
interoperability perspective but also how do you do the data
sharing.
Right now, they can do a flat fee that somebody pays but if
you try to do a per physician basis pay, there's no mechanism
by which it processes through the Medicare or Medicaid system.
So they're really stuck out there in the fee-for-service or
private payer model and it makes no sense because, as you say,
when somebody drops off of an appointment that they can't get
to, especially in areas like yours with a healthcare
professional shortage area, this is the exact time that you
want somebody to say hey, I need that patient, and as I said at
the beginning, this demographic problem is only going to get
worse, not better.
So when it comes to the model, we really don't see MACRA
and--and I am sorry, we don't see CMS really providing pathways
for those kind of innovative products at all.
Mr. Carter. OK. OK. Well, I see I am out of time. Thank
you, and I yield back.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
The chair recognizes the gentleman from Indiana, Dr.
Bucshon, 5 minutes for questions, please.
Mr. Bucshon. Thank you, Mr. Chairman.
Dr. Weinstein, can you talk about the challenges in
developing and testing an APM like Project Sonar and also do
you think that the current volume and value prohibitions in the
Stark Law make it difficult to test APMs?
Dr. Weinstein. I do. Thank you for the question.
The problem with APMs in developing care pathways and
determining how you're going to share the care of a patient,
potentially, with other physicians outside of the convener,
whether--if the convener is an independent physician, if the
convener is even a hospital system--if you're going to
interrelate with other physicians then you can't test that to
see whether the technology communication is correct, whether
the in-patient engagement is correct. You can't share the data
because you will buck up against certain Stark regulations.
So it would be great to be able to test an APM all the
outcomes, the technology that's needed, in a way before you get
to a PTAC decision once the application is submitted and the
current regulations don't allow you to test.
So, hopefully, I answered----
Mr. Bucshon. You did. It's pretty clear there are Stark and
anti-kickback problems that are making it difficult. The
Medicare Coordination Improvement Act, which I've introduced
with my Democrat colleague, Dr. Ruiz, would allow practices
legitimately developing and implementing an APM to essentially
be exempt through waivers from these provisions.
Do you think this would encourage more practices to develop
APMs?
Dr. Weinstein. I do. I think when we've polled, at least in
the Digestive Health Physicians Association, I think these very
large groups are very interested in modeling opportunities to
take care of patients under lower cost/better outcome care.
They've built the infrastructure to be able to do that.
They're willing to take risk to do that. So I think more people
would be willing to look into other diseases, not just
inflammatory bowel disease but chronic liver disease and such,
and thank you for submitting that bill.
Mr. Bucshon. You're welcome.
I yield back, Mr. Chairman.
Mr. Burgess. The chair thanks the gentleman.
The chair recognizes the gentleman from Illinois, Mr.
Shimkus, 5 minutes for questions, please.
Mr. Shimkus. Thank you, Mr. Chairman.
I apologize for not being here. I've learned everything
about forestry services, wildfires, prescribed burns, and the
health effects of wildfires in the air. So that's where I've
been the last 2 hours.
We wanted to get up here to make sure we set the records
for some public policy. So some of the questions that I had
have already been answered through the question and answer
period. But I want to state that promoting greater value within
our healthcare system is a worthy goal and I strongly support
efforts to promote value-based models within our Medicare
program and throughout our healthcare system. But current
progress has been slow.
As elected officials, we need to find ways to increase the
value opportunities in the Medicare program to address issues
of program solvency and improve the patient experience, both
for beneficiaries and, just as important, their loved ones.
Reforms that empower all healthcare entities to engage in
value-based reforms can lead to meaningful value for all,
unleashing private sector innovations within the program at a
time when our benefits to care and programmatic spending are
sorely needed.
As this committee considers opportunities to promote value-
based models, I recommend we consider two things. One is to
explore opportunities to support all stakeholders--patient,
payers, manufacturers, vendors, and providers--to enter in and
benefit from participating in value arrangements; ensure that
any reforms that are in this area are implemented in ways that
ensure patient care and program spending are protected.
Medicare beneficiaries and taxpayers should benefit from
our efforts, not be hurt by them. Hence, your discussion and
debate, which I missed a lot of, on the anti-kickback statutes,
the Stark Laws, and the like.
Also, you also talked about, obviously, the patient care
and the protection of the taxpayers, spending.
So, Mr. Chairman and Ranking Member Green, although he's
not here--we see the Honorable Congresswoman Matsui in his
place--I firmly believe that legislative approaches in this
area should empower all Medicare entities to drive value
throughout the program, ensure that beneficiary care and
program spending are protected, and promote opportunities for
beneficiaries to directly benefit from these reforms.
That's why I've asked my staff to begin developing
legislation that creates avenues for all stakeholders--
patients, providers, payers, manufacturers, and others to enter
into and succeed in value-based healthcare models throughout
the Medicare program, not just within the constraints of CMMI.
I hope to work with you, Mr. Chairman and Ranking Member
Green, and my colleagues on both sides of the aisle in
developing an advocacy of such an approach.
Mr. Chairman, I would like to enter into the record a
letter in support of the legislative efforts by the Breaking
Down Barriers to Payment and Delivery System Reform Alliance
and a letter from Advocate Aurora Health containing comments
filed with CMS in response to its request for information
regarding physician self-referral.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Shimkus. And with that----
Mr. Griffith. Would the gentleman yield?
Mr. Shimkus. I will yield.
Mr. Griffith. Mr. Reed has talked about how we didn't have
smart phones 10 years ago and the beauty of this is is that
while our nursing homes might not be able to use telemedicine,
you can go back and watch all the testimony later via your
smart phone.
Mr. Shimkus. And you don't think I've done that?
Mr. Griffith. I don't think you have done it yet. I think
you will do it on the way home.
Mr. Shimkus. You bet. Thank you, and I yield back my time.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
I believe that all the members of the subcommittee have
been recognized for questions and we'll now recognize Mr. Ruiz
of California, who's not on the subcommittee but has presented
himself here, and you're recognized 5 minutes for questions,
please.
Mr. Ruiz. Great. Thanks for letting me sit in here and
listen to this wonderful presentation and also participate in
this very important conversation.
I was pleased to partner with my colleague and fellow
physician, Congressman Bucshon, to introduce H.R. 4206, the
Medicare Care Coordination Improvement Act, which would
modernize Stark Laws to make it easier for physician practices
to successfully develop alternative payment models, or APMs,
incentivized in MACRA, and it will also incentivize us to fully
reach a value-based payment model that the ACA encourages.
I believe that Stark Law is important but it needs to be
tweaked because currently physician practices are hampered from
fully and successfully participating in APMs.
So the Stark Law was created to help curb some of the
quantity-based payment models that we have developed in the
past and oftentimes this Stark Law prevents physicians from
referring to other physicians that they know in a medical home
model-based in order to achieve a value-based payment model,
which we want to move toward.
So we need to update and we need to tweak it so that we can
encourage a value-based payment model and alternative payment
model.
So this bill will give CMS the authority to give a narrow
exception to Stark just for the time that the APM is being
developed, which is the same waiver authority that was given to
ACOs in the ACA.
So, Dr. Weinstein, thank you for being here today and for
your testimony in support of this legislation. In your
testimony, you referenced the slow pace at which independent
physicians have been developing alternative payment models.
I am also concerned that in order for MACRA to succeed, we
need to break down barriers encourage more innovation and care
delivery models to be put forward.
Can you give us a specific example of how, if we are able
to pass this narrow exemption, an independent gastroenterology
group like yours could improve patient care for your patients?
Dr. Weinstein. Again, thank you for the question and thank
you for submitting the bill.
As a specific example, we want to be able to reward
physician behavior for following better care pathways and as
opposed to just performing individual services.
So if I am going to work with a surgeon and I want to work
with a particular surgeon in an APM for dealing with
inflammatory bowel disease, then I want to reward that surgeon
for following the care pathways to lower the cost of care.
If I am doing that then--if I am rewarding him for value,
for better outcomes, well, that actually flies in the face of
some of the language of the original Stark Laws.
And I said it in my testimony--we are not in favor of
removing Stark prohibitions on fee-for-service standard, self-
referral, and things like that. That has nothing to do with
modernizing the Stark rule for an alternative payment model, a
model where groups of independent physicians are sharing risk
in managing a better outcome for a patient and in doing that in
a way that does not violate the Stark Laws.
Mr. Ruiz. Thank you. I yield back.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
Seeing that there are no further members to ask questions,
Mr. Reed, I do want to just point out you have graciously
mentioned several times today the Public Health Savings Act--
the bill that I introduced with Diane DeGette some time ago--
actually, several Congresses ago--and I had actually hoped to
have a hearing on that before we concluded this year, it's on
the list just like the data blocking bill from the Office of
National Coordinator.
But it is an extremely important concept to be able to look
for preventative healthcare at a wider window than the 10-year
typical budgetary window that the Congressional Budget Office
allows.
So I thank you for bringing that up and I am going to use
that as additional gas in the tank to see if we can't get that
hearing structured.
Mr. Reed. No, we'd love to help you gain more cosponsors.
Thank you.
Mr. Burgess. Thank you.
Well, seeing that there are no other members wishing to ask
questions, I do again want to thank our witnesses.
I do want to submit the following documents for the record
from Advo Med, from the College of information--I am sorry,
from the College of Healthcare Information Management
Executives, Cancer Treatment Centers of America, National
Association of Chain Drugs Stores, Medtronic, the American
Society for Gastrointestinal Endoscopy, and Jeff Lemieux and
Joel White article in ``Health Affairs.``
[The information appears at the conclusion of the hearing.]
Mr. Burgess. Pursuant to committee rules, I remind members
they have 10 business days to submit additional questions for
the record and I ask the witnesses to submit their responses
within 10 business days upon receipt of those questions.
And without objection, the subcommittee is adjourned.
[Whereupon, at 3:16 p.m., the committee was adjourned.]
[Material submitted for inclusion in the record follows:]
Prepared statement of Hon. Frank Pallone, Jr.
Today's discussion is important to help Congress understand
the different ways we might expand innovative, value-based care
in our Medicare program.
The Affordable Care Act (ACA) took major steps towards
improving the quality of our healthcare system by creating new
models of delivery within the Medicare program. These new
models were intended to transform clinical care and shift from
a volume- to a value-based care model, such as Accountable Care
Organizations (ACOs) and Patient Centered Medical Homes
(PCMHs).
With the passage and implementation of the Medicare Access
and CHIP Reauthorization Act (MACRA), we entered the next phase
of healthcare delivery system reform. MACRA built on the ACA's
efforts by offering opportunities and financial incentives for
providers to transition to new payment models known as Advanced
Alternative Payment Models, or A-A-P-Ms. AAPMs require
providers to accept some financial risk for the quality and
cost outcomes of their patients.
MACRA also created the Merit-Based Incentive Payment
System, or MIPS, an alternative path for clinicians to make the
shift away from a volume-based system to a value-based system
that focuses on quality, value, and accountability. Together
these new programs were designed to influence doctors to make
change and the law gives them great flexibility in choosing the
right model for the right provider.
Unfortunately, I have been disappointed thus far with the
Trump Administration's progress on building on these successes
and their lack of actions to move the Medicare program to a
value-based system.
Most notably they have rejected the goals made under the
previous administration, to make 50 percent of all Medicare
payments to hospitals and doctors through value-based models by
the end of 2018.
They have not taken meaningful action to expand the number
of Alternative Payment Models available to Medicare providers.
They have failed to test or implement any physician-focused
payment models and have cancelled or scaled back a number of
bundled payment models.
Meanwhile, CMS has taken steps to undermine MACRA's MIPS
program, by exempting 60 percent of Medicare physicians from
its requirements. While I understand that there are challenges
with MIPS, I don't think the answer is to just exempt providers
from its requirements. Nor do I think that is what Congress
envisioned. By exempting these doctors entirely, the
Administration is choosing not to engage small providers-a lost
opportunity to say the least.
I am also concerned that the Administration's proposed
regulation on ACOs will dampen enthusiasm for engaging in these
models. The evidence is unequivocal that ACOs have both
improved the quality of care for Medicare beneficiaries, and
saved the Medicare program money.
As our two witnesses with experience with the ACO program
will testify today, the kind of cultural change required to
implement an integrated, patient-centered, system like an ACO
takes time and investment in people and in systems. While I
support efforts to get more ACOs to embrace financial risk, the
proposed rule could potentially cut the program off at its
knees by requiring ACOs to take on risk within two years, and
by lowering the shared savings rate.
Let me conclude by addressing the issues of Stark and the
AntiKickback Statute. I know some stakeholders view these laws
as a barrier to value-based payment reform. I would be
interested in hearing about specific instances in which Stark
and the AntiKickback Statute have posed barriers to value-based
payment arrangements. But I also want to stress the continuing
importance of these laws, which are intended to ensure that
doctors do what is best for patients, not what is best for
their bottom line. There is empirical evidence that these laws
operate to prevent overutilization in Medicare. This is bad for
both patients and taxpayers. So, we must proceed with great
caution in making changes to these laws.
I also want to underscore-eliminating or reducing the
effectiveness of the Stark and Anti-kickback laws is not a
delivery system reform agenda. On its own, deregulation does
not move us to value. That will require transformative
leadership at HHS, and an industry-wide commitment to align
financial incentives with healthcare quality and performance,
with the patient always at the center.
I look forward to discussing these and other issues with
the panel today. I yield back.
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