    [Senate Hearing 113-273]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 113-273

                               ADVANCING REFORM:
                          MEDICARE PHYSICIANS PAYMENTS

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

                                    HEARING

                                   before the

                              COMMITTEE ON FINANCE
                              UNITED STATES SENATE

                        ONE HUNDRED THIRTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                  MAY 14, 2013

                                   __________

                             U.S. GOVERNMENT PRINTING OFFICE

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                Printed for the use of the Committee on Finance

                              COMMITTEE ON FINANCE

                         MAX BAUCUS, Montana, Chairman

    JOHN D. ROCKEFELLER IV, West         ORRIN G. HATCH, Utah
    Virginia                             CHUCK GRASSLEY, Iowa
    RON WYDEN, Oregon                    MIKE CRAPO, Idaho
    CHARLES E. SCHUMER, New York         PAT ROBERTS, Kansas
    DEBBIE STABENOW, Michigan            MICHAEL B. ENZI, Wyoming
    MARIA CANTWELL, Washington           JOHN CORNYN, Texas
    BILL NELSON, Florida                 JOHN THUNE, South Dakota
    ROBERT MENENDEZ, New Jersey          RICHARD BURR, North Carolina
    THOMAS R. CARPER, Delaware           JOHNNY ISAKSON, Georgia
    BENJAMIN L. CARDIN, Maryland         ROB PORTMAN, Ohio
    SHERROD BROWN, Ohio                  PATRICK J. TOOMEY, Pennsylvania
    MICHAEL F. BENNET, Colorado
    ROBERT P. CASEY, Jr., Pennsylvania

                          Amber Cottle, Staff Director

                   Chris Campbell, Republican Staff Director

                                      (ii)

                                C O N T E N T S

                                   __________

                               OPENING STATEMENTS

                                                                       Page
    Baucus, Hon. Max, a U.S. Senator from Montana, chairman,
      Committee on Finance...........................................     1
    Hatch, Hon. Orrin G., a U.S. Senator from Utah...................     3

                                   WITNESSES

    Miller, Mark E., Ph.D., Executive Director, Medicare Payment
      Advisory Commission (MedPAC), Washington, DC...................     4
    Steinwald, A. Bruce, MBA, president, Bruce Steinwald Consulting,
      Washington, DC.................................................     6
    Patel, Kavita K., M.D., M.S., fellow and managing director, the
      Engelberg Center for Health Care Reform, the Brookings
      Institution, Washington, DC....................................     7

                   ALPHABETICAL LISTING AND APPENDIX MATERIAL

    Baucus, Hon. Max:
        Opening statement............................................     1
        Prepared statement...........................................    21
    Hatch, Hon. Orrin G.:
        Opening statement............................................     3
        Prepared statement...........................................    23
    Miller, Mark E., Ph.D.:
        Testimony....................................................     4
        Prepared statement with attachments..........................    25
    Patel, Kavita K., M.D., M.S.:
        Testimony....................................................     7
        Prepared statement...........................................    64
    Steinwald, A. Bruce, MBA:
        Testimony....................................................     6
        Prepared statement...........................................    79

                                 Communications

    AARP et al.......................................................    89
    Genesis HealthCare, LLC..........................................    94
    Mayo Clinic......................................................    99
    Medicare Rights Center and Center for Medicare Advocacy, Inc.....   106

                                     (iii)

                               ADVANCING REFORM:
                          MEDICARE PHYSICIANS PAYMENTS

                                  ----------

                             TUESDAY, MAY 14, 2013

                                           U.S. Senate,
                                          Committee on Finance,
                                                        Washington, DC.
        The hearing was convened, pursuant to notice, at 10 a.m.,
    in room SD-215, Dirksen Senate Office Building, Hon. Max Baucus
    (chairman of the committee) presiding.
        Present: Senators Cantwell, Cardin, Hatch, Crapo, and
    Isakson.
        Also present: Democratic Staff: Mac Campbell, General
    Counsel; David Schwartz, Chief Health Counsel; Karen Fisher,
    Professional Staff Member; and Peter Sokolove, Robert Wood
    Johnson Fellow. Republican Staff: Chris Campbell, Staff
    Director; Jay Khosla, Chief Health Counsel Policy Director; and
    Dan Todd, Health Policy Advisor.

       OPENING STATEMENT OF HON. MAX BAUCUS, A U.S. SENATOR FROM
                MONTANA, CHAIRMAN, COMMITTEE ON FINANCE

        The Chairman. The committee will come to order.
        The best-selling business author Tom Peters once said, ``If
    a window of opportunity appears, do not pull down the shade.''
    We should keep those words in mind today as we examine the
    method Medicare uses to determine physician payments, the
    Sustainable Growth Rate, otherwise known as the SGR.
        For the past 10 years, this flawed formula has dictated
    drastic reductions in Medicare payment rates. Next year,
    physicians will face a 25-percent cut under the SGR. This deep
    cut would mean many seniors would lose access to their doctor.
        Each year, Congress has intervened to prevent these cuts.
    But we need to get beyond this annual ``doc fix'' ritual. The
    year-in, year-out uncertainty is not fair to physicians. It is
    not fair to seniors.
        Since 2003, Congress has made 15 short-term fixes to the
    SGR at a cost of nearly $150 billion. In 2010 alone, we passed
    6 short-term fixes. It is time to break this cycle.
        Ninety-seven percent of Medicare beneficiaries see a
    physician at least once a year, and most beneficiaries with
    chronic conditions see their doctor at least monthly. We need
    to ensure that seniors can continue to see their doctors. We
    must permanently repeal this broken formula, and we need to do
    it this year.
        The most recent 10-year score for repealing the SGR is $138
    billion. While this is a large amount, it is more than $100
    billion less than the last year's score. This is a window of
    opportunity. We need to seize it.
        But we should not simply repeal the SGR. We must also
    change the underlying fee-for-service system that Medicare uses
    to pay physicians. Fee-for-service promotes volume over value.
    Physicians are rewarded for doing more tests and more
    procedures, even when unnecessary. It does not encourage
    physicians to coordinate patient care to save money and improve
    health outcomes.
        Last year this committee held three roundtable sessions on
    improving the system to reward physicians for providing high-
    quality, high-value care. We heard from former CMS
    Administrators, private plans, and physician groups.
        This year we held two hearings in which we heard from CMS
    leaders about their efforts to develop new payment models. We
    heard that there is a better way of doing business. The
    Innovation Center told us there are promising payment systems
    that would hold physicians accountable for providing high-
    quality, efficient care.
        These models include Accountable Care Organizations,
    payment bundles, medical homes, and there are certainly others.
    They incentivize physicians to coordinate patients' care. They
    focus on reducing emergency visits and hospitalizations. They
    have the potential to control spending for Medicare and
    beneficiaries alike. More important, they mean better care for
    patients.
        Physicians are eager to move to better systems. Jean
    Branscum from the Montana Medical Association recently wrote me
    about the uncertainty created by the current SGR policy. She
    said that ``Montana physicians want new payment models that
    improve health care and lower costs.'' She added, ``There's no
    time to waste.'' The continual uncertainty is driving
    physicians to limit the number of Medicare patients they see.
        Unfortunately, the new models the Innovation Center is
    developing are not ready to replace the fee-for-service system.
    CMS and the Innovation Center need to quickly finish new models
    so that Medicare rewards value instead of volume. In the
    meantime, we must improve the current system.
        We want to hear from doctors and other providers who see
    patients every day. They can help us identify ways to improve
    care and reduce unnecessary costs. We need the doctors on the
    front lines to step up with ideas.
        Last Friday, Senator Hatch and I sent a letter to health
    care providers. We asked for their advice on improving the
    current fee-for-service system. First, we need to make sure
    each service is valued appropriately. Second, we want ways to
    reduce unnecessary services, because Congress originally
    enacted the SGR to control spending, but it has not worked. The
    replacement clearly must do a better job of controlling costs.
    And finally, we need advice on how to help physicians
    transition to alternative payment models.
        Our letter asks for specific suggestions. I emphasize the
    word ``specific.'' Not abstractions, but ``specifics.'' We need
    concrete policies that can be implemented now to replace the
    SGR.
        I look to our panelists to help us identify them. We have
    an opportunity to repeal the SGR once and for all this year.
    Believe me, this committee would very much like to do that. We
    have been going around this merry-go-round too many times. I
    encourage us not to draw a shade on this window of opportunity.
        [The prepared statement of Chairman Baucus appears in the
    appendix.]
        The Chairman. Senator Hatch?

               OPENING STATEMENT OF HON. ORRIN G. HATCH,
                        A U.S. SENATOR FROM UTAH

        Senator Hatch. Well, thank you, Mr. Chairman. I appreciate
    you holding today's hearing on this important issue, Medicare
    physician payments.
        Last year this committee held a productive series of
    roundtable discussions with key stakeholders on this very
    topic, which helped to set the stage for us to move forward
    with reform. The chairman and I agree that we must find a
    better way to pay physicians in Medicare. The SGR system--as we
    all know--is fundamentally flawed and must be repealed. We are
    committed to working together to try to do just that.
        As it stands, unless Congress intervenes, Medicare
    physician payments will be reduced by 25 percent in 2014 due to
    the SGR formula. And, with such large cuts, physicians will
    quickly be unable to offer care to millions of seniors on
    Medicare. Our seniors deserve better than to have government
    inaction threaten the availability of their care.
        Due to the recent slowdown in overall health expenditures,
    the current cost of permanently repealing the SGR is down
    sharply from a previous Congressional Budget Office estimate of
    $245 billion to now less than $150 billion. However, we know
    from previous years that the CBO score has a tendency to
    fluctuate.
        I believe we currently have a good window of opportunity
    before us. But we need to act very soon. We must provide a
    stable foundation for paying our physicians, now and in the
    future. If we fail to act, we will run the risk of causing a
    physician shortage in the Medicare program that will have a
    broad impact for beneficiaries.
        This past Friday, the chairman and I sent a letter to
    members of the health care provider community appealing to them
    for their input on how to improve the current system and how we
    can help physicians transition to new payment models. This
    builds on the discussions we started last year.
        As we await responses from the provider community, we have
    the privilege today to hear from our panel of expert witnesses
    and get their thoughts on the matter. This issue is well-
    covered terrain. We know this is not an easy task, but
    physicians and patients deserve better.
        We must find a more stable foundation to pay physicians
    treating Medicare patients. I believe if we identify the
    appropriate policy solutions, we can finally find a path to
    repeal the SGR, and that is my goal. I think it is the goal of
    the chairman as well. We work together on these matters. I want
    to personally compliment the chairman for his concerns in this
    area and for the work that he has done.
        Thank you for convening today's hearing, and I look forward
    to what the witnesses have to say. Now, I have to apologize
    because I am in the middle of that immigration markup, and
    there is not much I can do but be there, since a number of the
    amendments are mine. You will have to forgive me. But I am very
    interested in your testimony, very interested in what you have
    to say.
        I hope we can come up with the solutions to this problem,
    and I will do everything in my power to support the chairman in
    his desire to do so. Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator. I know you are very
    concerned about the SGR and very much want to find a
    replacement just as much as the rest of us. Thank you very much
    for your help. I appreciate it very much.
        [The prepared statement of Senator Hatch appears in the
    appendix.]
        The Chairman. Now I would like to welcome our panel. Our
    first witness is Mark Miller, Executive Director of the
    Medicare Payment Advisory Commission, otherwise known as
    MedPAC. Thank you, Dr. Miller, for being here. This committee
    relies on MedPAC very frequently and appreciates your work.
        In addition, we have Bruce Steinwald, president of Bruce
    Steinwald Consulting and a former Director of Health Care of
    the Government Accountability Office. GAO is also very
    important to this committee.
        And finally, Dr. Kavita Patel is a fellow and managing
    director at the Engelberg Center for Health Care Reform at the
    Brookings Institution.
        Did I pronounce your name correctly?
        Dr. Patel. Yes.
        The Chairman. Good. Thank you, everyone. Your statements
    will be included automatically. You will have 5 minutes each,
    so let her rip.
        We will start with you, Dr. Miller.

        STATEMENT OF MARK E. MILLER, Ph.D., EXECUTIVE DIRECTOR,
     MEDICARE PAYMENT ADVISORY COMMISSION (MedPAC), WASHINGTON, DC

        Dr. Miller. Chairman Baucus, Ranking Member Hatch, and
    distinguished committee members, I am Mark Miller, the
    Executive Director of the Medicare Payment Advisory Commission.
    I would like to thank you for inviting us to testify.
        Before I get to the SGR, I think it is important to say
    that the Commission believes that Medicare's payment and
    delivery systems need to change. They need to move away from
    volume-driven systems to systems that focus on quality,
    coordination, and accountability.
        The goal of any SGR reform should not be to protect a
    fragmented fee-for-service payment system. Regarding the SGR
    and looking back at history, physicians controlled both the
    price paid by Medicare through their charges as well as the
    services that were provided to beneficiaries. This naturally
    led to escalating physician payments, and it also led to large
    payment inequities between services and, ultimately, between
    specialties.
        In the early 1990s, a fee schedule was put in place in part
    to correct those payment inequities, and also policies like the
    SGR were put in place to control volume. The Commission has
    recommended in the past and again more recently to repeal the
    SGR. The Commission believes the policy is flawed. It does not
    create incentives for physicians to cooperate and to avoid
    unnecessary volume.
        It is unfair to any physician who practices judiciously. It
    rewards physicians who are able to generate volume.
    Additionally, it has perpetuated the inequity between payments
    for procedural services on the one hand and cognitive and
    primary care services on the other.
        The Congress has chosen to override the legislative
    reductions for years. That, coupled with continued service
    volume growth, has led to an annual process of trying to avoid
    large fee reductions at the end of the year. This problem
    creates barriers to move forward in a more thoughtful way. It
    creates anxiety in the provider community, and it creates
    administrative anomalies for CMS and the providers of care.
        Furthermore, while the Commission's annual beneficiary
    survey continues to show strong access for Medicare
    beneficiaries, the Commission is concerned that that picture
    could change--particularly for primary care--if steps are not
    taken to repeal the SGR. And the time to repeal it is now.
        As you have noted yourself, the cost of the repeal has been
    revised downward from $300 billion to about $140 billion. But
    history is cautionary here. This is because service volume has
    slowed down, but trends in service volume are volatile, and, if
    they reaccelerate, the cost of repealing the SGR would go up
    again.
        With respect to the SGR, MedPAC has recommended the
    following. First, repeal the SGR and replace it with a set of
    legislative updates for the next 10 years. Now let me add
    quickly here, that MedPAC would continue to do its job and
    report annually to the Congress on the impact of those changes
    and would recommend changes if access were to be threatened
    under those new updates.
        Second, rebalance the fee schedule, again, to bring more
    equity between primary care services and procedural services.
    The Commission believes that to move towards a reformed
    delivery system, we need primary care physicians and other
    professionals to provide primary care. The fee schedule sends
    clear signals dissuading medical students from pursuing primary
    care as a career.
        Rebalancing the fee schedule has two steps. The first is a
    new approach to collecting data in order to reevaluate the
    relative values under the fee schedule and to specifically
    identify overpriced services. The second step, bluntly, is to
    reduce the payment rates for procedural services relative to
    primary care.
        You should note that this last point also reduces the
    overall cost of repeal. I should also note with both of those,
    the legislated updates and even with the reduction for
    procedural services, there would be a 72-percent increase in
    physician spending over the next 10 years. So this is not a
    reduction in spending.
        The Commission also recommends that there be incentives,
    and includes incentives for physicians to move away from fee-
    for-service and to either organize or join risk-based
    Accountable Care Organizations. As I have noted, fee-for-
    service focuses on generating volume. But, perhaps even more
    importantly, fee-for-service contributes to a lack of
    coordination and to a lack of accountability. It is the hope of
    the Commission that risk-based Accountable Care Organizations
    could be a platform for accountability and also a better
    platform for measuring quality.
        In closing, I would also like to remind the committee that,
    through our ongoing work, the Commission has provided the
    Congress with a list of Medicare savings that could be used to
    offset the cost of the SGR if the Congress were to choose to do
    that. With that, I will stop and look forward to your
    questions. Thank you.
        [The prepared statement of Dr. Miller appears in the
    appendix.]
        The Chairman. Thank you, Doctor.
        Mr. Steinwald?

        STATEMENT OF A. BRUCE STEINWALD, MBA, PRESIDENT, BRUCE
                  STEINWALD CONSULTING, WASHINGTON, DC

        Mr. Steinwald. Mr. Chairman, members of the committee,
    thank you for having me here today. As you pointed out, Mr.
    Chairman, it has been a tough 11 years of dealing with the SGR
    and the Medicare fee schedule. But, the circumstances might be
    right to do away with the SGR and to reform the fee schedule. I
    say this in part because of the widespread acceptance of the
    need to replace volume incentives with value incentives in the
    fee schedule.
        For decades, there has been a reluctance to accept cost as
    a legitimate concern in coverage and payment policy. And now
    the policy world seems to recognize that open-ended fee-for-
    service reimbursement is a major impediment to achieving value
    objectives. I also perceive--I could be wrong about this--a
    shift in the nature of the involvement of the medical
    profession in reforming Medicare physician payment. For years,
    the stance of the profession seemed to be, repeal SGR and then
    we will talk about reform. Now it seems to me that the medical
    profession recognizes that reform needs to be a part of the
    same conversation.
        Third, we have a growing capability in this country to make
    data-driven decisions on coverage and payment in Medicare. As a
    society, we have made a huge investment in improving the
    empirical base of the decisions we make in health care
    delivery. Medicare coverage and payment policy may need to be
    adjusted to take full advantage of this growing capability.
        Fourth, activity on the reform front: there has never been
    a shortage of reform proposals, but this appears to be an
    especially fertile period of experimentation in the health care
    delivery system, with much of it, but not all, financed through
    Federal research dollars. The SGR ``doc fix'' problem has
    become so prominent that it is included in Simpson-Bowles and
    all major budget reform proposals. So, if the Congress is able
    to achieve a grand bargain, it would certainly include the SGR
    fix.
        And finally, as you mentioned, there is the lower CBO
    score. The cost of repealing SGR appears to be on sale at least
    for a period of time. It is hard to say how long it will be, as
    Mark pointed out. But the lower score makes repeal more
    attractive, or at least less unattractive, from a Federal
    budget perspective.
        So what would a post-SGR world look like? Let me say three
    things about that. The movement toward a growing global payment
    system should be encouraged, but needs to be developed
    naturally for both beneficiaries and physicians. We have
    several integrated delivery systems that exist in all parts of
    the U.S., serving urban, suburban, and rural populations. At
    the same time, we have Accountable Care Organizations and other
    hybrid forms of healthcare delivery and financing growing.
        A reformed delivery and financing system that focuses on
    population, health, and value in service delivery should be
    attractive to both beneficiaries and providers alike. Second,
    the Medicare fee schedule, along with Medicare coverage policy,
    should be fine-tuned to reward value and discourage unnecessary
    utilization.
        With the blunt instrument of SGR out of the way, Medicare
    could have greater opportunity to use its extensive data to
    make distinctions between high-value and low-value care. Some
    of these opportunities can be accomplished under current law,
    and some will require new legislation.
        And finally, policymakers should never underestimate the
    power of fee-for-service incentives to generate more volume and
    more spending. Because spending increases in health care have
    been at low levels for the past few years, it is tempting to
    conclude that the pressure is off to limit spending. But I
    remind you that this was the situation that occurred during the
    1990s when the SGR was created, and it would be unfortunate if
    SGR were eliminated during a similar low-spending period only
    to have physician spending ramp up again in the absence of
    effective controls.
        So, in conclusion, I believe that the post-SGR world should
    be one of decreasing reliance on fee-for-service payment, but
    with effective controls in place that reward value and not
    volume in the Medicare fee schedule. The fee schedule is likely
    to be with us for some time. It can and should be improved.
    Those improvements in the fee schedule and the controls that I
    mentioned may encourage some physicians to seek alternative
    delivery settings, thereby providing a boost to the reform
    movement.
        That concludes my statement. I look forward to your
    questions.
        [The prepared statement of Mr. Steinwald appears in the
    appendix.]
        The Chairman. Thank you, Mr. Steinwald.
        Dr. Patel, you are next.

       STATEMENT OF DR. KAVITA K. PATEL, M.D., M.S., FELLOW AND
    MANAGING DIRECTOR, THE ENGELBERG CENTER FOR HEALTH CARE REFORM,
               THE BROOKINGS INSTITUTION, WASHINGTON, DC

        Dr. Patel. Chairman Baucus and members of the committee,
    thank you for this opportunity to highlight ways to advance
    physician payment reform in Medicare. My name is Kavita Patel,
    and I am honored to present some solutions from our work at the
    Engelberg Center for Health Care Reform at the Brookings
    Institution and our related Merkin Initiative on Clinical
    Leadership, as well as work that has been done on the National
    Commission on Physician Payment Reform, and, perhaps most
    importantly, from my experience as a practicing primary care
    physician.
        Eliminating the SGR has been widely discussed, as you
    mentioned, sir. I applaud the committee's leadership and their
    recent call for proposals from the physician community. The SGR
    must be eliminated, but we need a transition pathway, since, as
    many others have mentioned, our current fee-for-service system
    is the one we must transition from to some of these novel
    methods of payment that we have been discussing for a long
    time. Short-term strategies that will result in better care-
    coordination between primary care physicians and specialists
    are the ultimate answer. But the question remains, how to get
    there.
        In our work at Brookings as well as a number of other
    places, we have conducted surveys, spent a lot of time with
    physicians in practice, and also looked at the economic
    incentives as well as the underpinnings of finance. One thing
    that has been clear in my work as a physician, as well as with
    numbers of health professionals whom we have spoken with, is
    that there are currently many initiatives that physicians
    participate in to promote higher value and quality.
        Just to name a few, there are meaningful use measures, the
    use of electronic health records, the Physician Quality
    Reporting System, value-based modifiers, and electronic
    prescribing, a number of which came from the work in this
    committee. All of these efforts combined, however, are simply
    not enough when you look at the aggregate amount of either
    bonuses or financial penalties that might be assigned to this.
        One straightforward mechanism in the short term to help
    physicians transition in the fee-for-service setting, would be
    to think about how to harmonize all of these programs,
    understand when the data is being submitted, and how physicians
    can use a larger payment from these pieces together to benefit
    in more of a care coordination payment manner in which they
    could work together and fulfill the requirements for each of
    the individual programs, but together form a better way of
    working between different silos which we currently do not have.
        Let me offer an illustrative example based on our work at
    Brookings as well as my own experience. In the case of
    meaningful use as well as PQRS, there are a number of ways
    physicians can submit measures, electronically as well as
    through participation in a registry. The payments for PQRS
    average about $1,000 for each provider per year. Imagine if
    that $1,000 combined with the upwards of $44,000 in incentives
    for electronic health records, could be used by a cardiologist
    in conjunction with a primary care physician to take better
    care of a population of patients like mine who have diabetes,
    heart failure, irregular heart rhythms, and a number of other
    problems for which the individual measures may not actually
    accurately capture the care provided to that patient.
        This is one manner in which current programs in our fee-
    for-service system can be harmonized and actually benefit us to
    help physicians see a way to take on the clinical risks and the
    financial risks to move to longer-term payment models. Another
    step that would help in the short-term setting would also be to
    do what CMS has been doing in terms of looking through the
    evaluation and management coding to better understand the value
    of these services. Another example has been the recent work by
    Medicare to actually evaluate, at a higher payment rate, care
    coordination when patients are discharged from a hospital.
    These are important steps that certainly can be accelerated and
    highlighted by the important work of this committee.
        And then, in summary, some of the tools that are necessary
    to take current programs into a longer-term setting must be
    observed. We have already heard a little bit about analytic
    methods to help physicians understand how they are using and
    utilizing care, but what is missing right now is timely data.
        We hear that over and over again in our work with
    physicians, that they are hungry for actionable data that can
    change the point-of-service care. When I submit my measures for
    meaningful use or for my value-based modifier payments, those
    measures are not acted upon financially for another 2 years.
    Often this data lag really causes us to miss a window of
    opportunity to have meaningful action in the patient setting.
        Additional tools that CMS, as well as others, and
    particularly the professional societies, are well-capable of
    providing can be offered to help physicians understand how to
    move from current payment to future payment. This includes
    taking more financial risk--this is not something I was taught
    in medical school, but I am eager to learn--as well as taking
    on more clinical risk, which I think we have heard a lot about
    in the forms of Accountable Care Organizations.
        So, in summary, I do hope that this committee will consider
    that there is a pathway, starting now, from the repeal of the
    SGR to longer-term payment reforms. I thank you for this time
    and look forward to your questions.
        [The prepared statement of Dr. Patel appears in the
    appendix.]
        The Chairman. Thank you, everybody. Dr. Miller, you said
    something interesting: that even with these recommended
    changes, physician reimbursement will be about 72 percent
    higher than it is today. That is, I think, over 10 years, or
    maybe that is in the 10th year. Could you expand on that,
    please?
        Dr. Miller. Yes. What I was referring to is that the
    Commission's proposal is to set the physician fee schedules,
    fee schedule payments, through the 10-year window and eliminate
    the SGR as a mechanism for setting those. At the same time, in
    order to get some greater equity in the fee schedule, we would
    actually pull down the conversion factor or the payment rate
    for procedural services relative to primary care services.
        As you might imagine, the specialty societies would be
    upset with that kind of proposal. But what I was trying to
    point out is, because more patients will be coming into the
    system and because service volume continues to increase,
    aggregate payments to physicians would continue to increase
    over that 10-year period.
        So, when you look at even reducing the fee that you pay for
    procedural service, you should not assume that net payments go
    down, because still more services are being provided.
        The Chairman. Right, and I do not quite understand that,
    because you said that services are down a bit now and that
    explains a different estimate for----
        Dr. Miller. The score.
        The Chairman. The score is down. That is right.
        Dr. Miller. I did say that. The service volume has slowed
    down, but there is not zero growth in service volume.
        The Chairman. All right. Why will service volume increase,
    do you think, under this new regime?
        Dr. Miller. The trends in volume have always gone up. They
    have slowed down, but the baseline assumptions in all of our
    experiences are that service volume will continue to grow over
    time. Some of it will be driven by technology. Some of it will
    be driven by the clinical needs of the patients. But under a
    fee-for-service system, some of it will be driven by the
    incentives of the fee-for-service system.
        The Chairman. How do you address the concern that the
    specialists have, that their income, relative to primary care,
    might not be what they expect or hope it to be? Dr. Patel
    mentioned something interesting about learning to accept or
    deal with financial risks. It seems to me that there might be
    an opening there somehow for specialty physicians to realize
    that, hey, they have to be a part of the solution here, but in
    a way too that eases their concern over their income.
        Dr. Miller. I will try to do that, but you know I generally
    do not come to you with really popular ideas, Senator.
        The Chairman. No, but you are very perceptive.
        Dr. Miller. Well, thanks for that. There are two things
    that I would say. The first thing to focus on--and I tried to
    make this clear in my 5 minutes, but it is a lot to try to get
    in in 5 minutes--is that compensation is very distorted in the
    payment system now. So for example, you have certain
    specialties. Given the services that they provide, they are
    reimbursed 2 and 3 times, both in aggregate and at an hourly
    basis, what a primary care physician gets reimbursed.
        So, I think the first point, in the Commission's view, is
    that there is an equity issue and that the specialists need to
    recognize that, given the greater circumstances that we are in,
    one being the desire to eliminate the SGR, because specialists
    do not like that either. Now, to your point of, could there be
    something to offer them? I think the Commission's view is, if
    you put pressure on fee-for-service, restraining fees,
    adjusting fees to get this greater equity, that is going to be
    an environment that specialists might want to move away from
    and, perhaps, to an Accountable Care Organization where they
    have the opportunity, if volume is controlled, to share in some
    of those savings.
        The Chairman. To anyone who wants to respond to this, the
    question is, how quickly and thoroughly can we move to this new
    regime, whatever it is? I am reminded of two rules I think are
    pretty important. The first is: do it now. And the second is:
    do it right the first time. But make sure we do it right. And
    do it right tends to mean you have to think it through and not
    be hasty. So how do we move as quickly as possible, yet lower
    the probability of significant mistakes either by pushing CMS
    or through legislative changes to move to this new regime?
        Dr. Patel mentioned some interim transition measures like
    coordinating all of the current measures to be undertaken,
    which makes some sense. Just generally, I know it is a broad
    question, but how do we move--what is the general approach we
    need to take here, whether it is accountable care, bundling,
    whatever it is that we move to?
        Mr. Steinwald. Well, I think the good news is that it is
    already happening. Partially with Federal support, but not
    entirely. When people say there are parts of the population
    that could never be served by these alternative delivery
    systems, I look around the country, and I see that there is no
    part of the country that is not served, at least, by some of
    these integrated delivery systems. Whether they are rural areas
    served by Intermountain Healthcare or intensely urban areas
    like Denver Health serves, these organizations exist and can
    serve all kinds of populations.
        The Chairman. But what do we do to speed it up in those
    other parts of the country?
        Mr. Steinwald. Well, I think one of the things Mark eluded
    to is, you want both beneficiaries and providers to be
    attracted to these changes. But part of the attraction is to
    not feel wedded to the system that they currently are familiar
    with. Therefore, that system needs to be modified so that in
    leaving that system, there has to be something to go to. And I
    agree that it has to be done organically, because we do not
    want to repeat the errors of the 1980s in the managed care
    movement. Attractive to go to, attractive to leave, I think is
    the combination.
        The Chairman. Thank you very much.
        Senator Cardin?
        Senator Cardin. Thank you, Mr. Chairman. Let me thank all
    of our witnesses. Dr. Miller, I want to go back to the 72-
    percent projected increase if you were to do the updates over
    the next 10 years. How much of that is related to volume?
        Dr. Miller. I am going to say a third or a fourth of it.
        Senator Cardin. So you are projecting a slower growth rate
    in volume over the next decade than in the past decade?
        Dr. Miller. Just to be clear, I am not. But in the CBO
    base, yes.
        Senator Cardin. Because I am looking at the volume growth
    on physician services. It looks like it was around 35 percent
    over the last decade, at least for major procedures, evaluation
    and management, if I am looking at the chart from MedPAC
    correctly.
        Dr. Miller. From our testimony?
        Senator Cardin. Yes, Figure 2 is what I am looking at.
        Dr. Miller. I think I know the chart. Keep going.
        Senator Cardin. Procedures such as testing and imaging are
    going up at a much higher growth rate on volume comparatively.
        Dr. Miller. Right.
        Senator Cardin. I guess my question to you is, are you
    suggesting that you are going to lock in the adjustments over
    the next 10 years, trying to give a fairer reimbursement to
    primary care, versus the higher-cost specialties? Will you
    still be relying on the RUC? * Are you still going to be using
    the process in which you accept a significant amount of the
    information from the RUC, or not?
    ---------------------------------------------------------------------------
        * The Relative Value Scale Update Committee.
    ---------------------------------------------------------------------------
        Dr. Miller. All right. There are a couple pieces to this.
    The RUC would still be in place, and we would envision that CMS
    would continue to accept information from the RUC. But also,
    MedPAC made a set of recommendations on the HHS and the
    Secretary side of that calculus in order to bring more
    information and parity between CMS and the RUC--and the
    Secretary could use that information--and an advisory board
    that we suggested get constructed there, to drive the RUC's
    process in a more organized way so that they are not completely
    taking all advice that the RUC provides.
        Senator Cardin. It seems to me that what you are doing is
    dividing accountability and responsibility here with, perhaps,
    no one being ultimately held accountable. Would it not be
    better just to bring it all within CMS?
        Dr. Miller. The only thing I would say about that is that I
    do think you want input from the medical community. I just do
    not----
        Senator Cardin. Absolutely. I do not disagree with that,
    but who is responsible for the final rate setting?
        Dr. Miller. CMS.
        Senator Cardin. So, if they take a certain amount of
    information from the outside, they are basically using that to
    justify their decisions? And then that is not a very open
    process as to how those numbers are worked out. Then you are
    suggesting you are not satisfied with balance between primary
    and higher-cost specialties.
        I am not sure that what you are suggesting gives us an
    accountable system. Whom do we hold accountable?
        Dr. Miller. Well, I think what I am trying to do is get
    greater parity between CMS and the RUC so that CMS is not
    completely dependent on the advice that comes from the RUC and
    drives the RUC's activities.
        We believe these services are overpriced. As part of our
    proposal, we have a data collection process where the Secretary
    would say, I believe these are overpriced and I direct you, the
    RUC, to go back and give me different values. And, if you do
    not, then I am going to use this information to reset.
        So the two things are to get greater parity between CMS and
    the RUC, and then, through that process, we believe there will
    be greater parity in the payment system between the
    proceduralist and primary care.
        Senator Cardin. I understand that. Let me get to one more
    question for the panel.
        Dr. Miller. I am sorry.
        Senator Cardin. No. That was a good answer.
        One more question for the panel, and that is, we all agree
    we have to get rid of the SGR system, and, absolutely, the
    dollar offset today is much more friendly than it was 2 years
    ago. So the opportunity is now, as the chairman has said. And
    we should do it.
        We do not agree as to what we should replace it with. We
    have been looking at this now for a decade, and yet it is
    somewhat disappointing we are not further along as to how we
    can replace it with a payment system that rewards quality
    rather than quantity, that really manages the individual rather
    than rewards multiple visits from different specialists.
        Why are we not further along on this? How much longer is
    this going to take? Any one of you?
        Dr. Patel. It has taken a long time because I do think it
    has been difficult to actually say, let us change the system.
    And then, to assign some sort of responsibility is ultimately
    difficult, I think. As we all have responsibility to our
    patients, we have had a challenge in trying to say, well,
    change payment and then hold providers accountable in a certain
    way. I actually think some of the shorter-term steps that I
    discussed have been a huge milestone in helping us get there. I
    do believe that, with a decade of discussion, we are ready to
    do it now over a short time period.
        Senator Cardin. I would just make one last point, Mr.
    Chairman, if I might. It seems to me that if we fix SGR--which
    I am for--and we do not substitute a proposal that deals with
    the underlying problem, we are going to have a hard time later
    substituting in the payment structure, it seems to me,
    politically, if we put off doing it all at one time.
        Dr. Miller. The thing I would say is, I think two major
    stumbling blocks--not the only two, and I think Dr. Patel's
    points stand here--are (1), the price was huge before. And the
    Congress just had to grapple with that, and it was difficult.
    The second is, there is not the organizational structure out
    there that you can point to and say, if this organizational
    structure existed, you could take accountability for it.
        Our hope in pushing the providers towards risk-based
    Accountable Care Organizations is that that structure begins to
    exist, and--I know I am out of time--it is starting to. There
    are 250 of them now. Four percent of the population is in them.
    They are starting to arise. I am not saying they are the
    answer, but something is starting to rise out there.
        Senator Cardin. Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator.
        I might say, I do not totally agree with you, Dr. Miller.
    That is because it is just too big a slug of money. And the
    second thing is, there is no organization. But I do feel we are
    starting to make some headway here, and I really appreciate
    that. Because for years and years and years, I have told
    physician groups, come up with a solution. Come up with a
    solution. You do not like it, well, come up with an
    alternative. They never have.
        But now we are getting to the point where various groups
    are starting to realize that maybe we have to, and now is the
    time. And second, I might say, as far as I am concerned, I am
    going to encourage this movement while we have the opportunity,
    very strongly. Maybe with some carrots, and maybe with some
    sticks.
        Now is the time. I appreciate the movement that groups are
    undertaking, addressing your point. But I think now we have the
    responsibility to keep pushing even further. Addressing your
    other point, if we do not do it now, we are never going to do
    it. Thank you very much.
        Senator Crapo? I apologize that I have to leave, but
    Senator Cantwell will take over the hearing.
        Senator Crapo. Thank you, Mr. Chairman.
        Dr. Patel, in your testimony, one of the recommendations
    that you make is that higher payment for facility-based
    services that can be performed in a lower cost setting should
    be eliminated. Could you elaborate on that a little bit?
        Dr. Patel. Yes. Thank you, Senator, for pointing out one of
    our recommendations on physician payment overhaul. In truth,
    right now there has been, because of the formulas assigned for
    calculation of facility-based payments, a differential such
    that, for example, if a physician had performed an ultrasound
    of the heart in an outpatient stand-alone community-based
    office, they would receive a certain dollar amount,
    approximately $159 for that. In a hospital-based facility, for
    the exact same physician, the exact same service, no additional
    personnel, no trainees, residents, students, or fellows
    involved, same exact service, same patient, they can receive
    about 3 times that amount as a payment. That is just one
    example of some of the site service differential payments which
    we think are an opportunity for savings in the Medicare system.
        Senator Crapo. Do you think that this differential in
    payment that you have described is one of the driving factors
    behind what we are seeing now with so many hospitals purchasing
    physician practices?
        Dr. Patel. It is one of the main driving factors. And it is
    an area of concern that we have as, not just physicians, but in
    looking at financing of the Medicare system. We think it is
    sending the wrong message for the care for our patients. Now,
    that does not hold for training institutions and places that
    have additional factors, but that is not the case that we are
    discussing.
        Senator Crapo. Thank you. Mr. Steinwald, in your testimony,
    you indicate--as I think almost everyone has indicated--that
    policies need to be developed to encourage providers to elevate
    value as the chief objective in determining what services are
    performed. Could you just tell me what two or three of those
    policies you think are the most promising that we should be
    focusing on?
        Mr. Steinwald. Right. I will start by repeating what I said
    a moment ago, which is, never underestimate the power of fee-
    for-service incentives to generate volumes. So, you are dealing
    with that underlying incentive. And while we are still using
    the fee schedule and still paying fee-for-service, we need to
    find countermeasures--if you want to call them that--to make
    sure that we are rewarding value instead of volume.
        So, such things as have been done in the private sector,
    like prior authorization for payment for expensive imaging
    technologies, using physician profiling, which Medicare has
    done, just to provide feedback, but perhaps you can put some
    teeth in them to make sure that the physicians who are
    overusing services are not rewarded for doing that. As long as
    we are going to rely somewhat on fee-for-service to pay for
    services to Medicare beneficiaries, we are going to have to
    deal with the volume incentive.
        I also think that we ought to coordinate payment policy
    with a coverage policy. There are two ways of dealing with a
    low-value service. One is to pay less for it. Another is to not
    cover it if there is a more high-value service that is a
    substitute. So that is another thing I think that needs to be
    considered: coverage policy in addition to payment.
        Senator Crapo. Thank you very much.
        And, Dr. Miller, you just mentioned the fact that you think
    one of the concerns or causes of our inability to get there in
    terms of finding the right alternatives has been the lack of
    the organizational structure that is necessary to help us
    transition to a new and more successful payment system. Could
    you describe the organizational structure that you are talking
    about there a little more specifically?
        Dr. Miller. Well, I think what the Commission is mostly
    focused on at the moment is the Accountable Care Organizations
    that were created by law, and also being run out of the
    Innovation Center, the Pioneer Accountable Care Organizations.
    I think the line of thinking is that--related to what Dr. Patel
    said--you can sort of lay out lots of different incentives for
    physicians to try to follow and rationalize, and I think she is
    right: currently there is an array of them.
        They probably have some effect, but they are also
    relatively confusing. Or, alternatively, say doctors could
    organize as a set of providers, accept some degree of risk, and
    then, as a group of physicians, decide what clinical evidence
    and pathways they are going to pursue. But the key thing is to
    come together as a group of providers, organize, and then
    accept, on a population basis, a risk-based payment, and then
    the Federal Government should, obviously, have some kind of
    quality measures to be sure that care is being provided. But
    those can be much more aggregated and
    population-based. So I think that is the line of thinking, and
    there is at least something of a structure there that is
    starting to emerge.
        I also want to say one thing quickly on the site-neutral
    point that you asked Dr. Patel. We also have a recommendation
    on that from a year or so ago, and we have some upcoming
    research on some other ideas along those lines that will come
    out in June, if you are interested in that.
        Senator Crapo. Thank you. I am interested. I look forward
    to that.
        Dr. Miller. Yes. Sorry to change topics there.
        Senator Crapo. No trouble.
        Senator Cantwell [presiding]. Thank you. Dr. Miller--well,
    actually for any of the panelists. I appreciate everyone's
    testimony this morning and certainly the focus on the ACO
    model, which is something big in the Pacific Northwest and has
    yielded some great efficiencies as they have tried to move
    towards that. And certainly we would like to leapfrog towards
    that as soon as possible.
        But we did write into the Affordable Care Act a value-based
    payment modifier that CMS is putting out preliminary rules on
    now that would be implemented fully by 2017 as a process for
    getting off of fee-for-service and focusing on outcome-based
    results. I did not see much of that in anybody's testimony.
        So I am just wondering what people are thinking about that,
    or, as I said, we would certainly like to leapfrog into ACOs,
    but getting off of fee-for-service and focusing on better
    outcomes and rewarding people for better outcomes at lower,
    oftentimes, at lower rates, we think is where we need to be
    going in the short term.
        Dr. Miller. Right. And I think what I would say is that we
    understand--I think the Commission's view is that they
    understand the concept, the notion of trying to reward a
    provider for efficiency, for high-quality, low-resource use. I
    think some of the concern about that particular modifier is how
    accurately it can be put together for an individual provider.
        I am not really deep on this, but my sense is that in the
    first wave of implementation that went out on it, CMS was
    saying, for groups of physicians, that there was some concern
    about the stability of measurement. And one of the things about
    an organizational structure of some size is, you get a lot more
    stability when you look at quality and efficiency that way. So,
    one of the concerns with the modifiers is how stable it can be
    for any given provider.
        Dr. Patel. And I will just add that, for the beginning of
    the program, you have to have at least 100 eligible health
    professionals. So, to Dr. Miller's point, you need not only the
    size but, in terms of the measurement for 2015, they will be
    using performance year 2013. So we are still seeing this lag in
    getting physicians' information about what they could be doing
    at any real point in time. But we think it is an important step
    in the right direction to get you closer to taking on more of
    the risks.
        Senator Cantwell. Well, this was a part of the debate. I
    know because, obviously, it was my language, and this is a
    philosophy from the Northwest. I mean, sure we would like to
    get paid more. Sure they would, but we gave up on that a long
    time ago because we are more efficient and we have better
    outcomes.
        So now all we want is the rest of the Nation to move
    towards that same level of efficiency so we are not penalized,
    so that physicians do not go practice medicine somewhere else
    just so they can get paid more when we actually have better
    outcomes. So we knew that the individual physician--I mean,
    that was part of the debate among committee members too. They
    knew if you isolated it down to that level, it would be
    somewhat problematic.
        And we get that there may be regions or parts of the
    country that may be, you know, more uniquely challenged to face
    this. But we are talking about billions of dollars of savings
    here if you move off of fee-for-service. And, as I said, we
    would leapfrog right to ACOs because we are ready to go there,
    but I do not know that everybody else is. So we definitely
    believe that the index should be put in place. So, we will
    certainly be working with everyone to be more vocal about it,
    because we do think it is an important interim step.
        Dr. Miller, on the kind of efficiencies that you think we
    can get out of ACOs, do you think there is enough savings there
    to then take those savings and focus on graduate medical
    education so that we can prioritize the volume that we need for
    primary care physicians?
        Dr. Miller. I have not thought about the issue in that way,
    and I would be very hard-pressed to tell you what kinds of
    savings to expect out of it. What I can say is that the
    Commission put together a proposal. It is a few years back now.
    I am forgetting exactly when we put it out, but the notion on
    graduate medical education was to stop having this kind of
    blind focus on slots which are producing more of the same when
    all of us at the same time are saying, don't we need a
    differently organized delivery system?
        We had a set of recommendations that would use those
    resources differently and direct them to graduate programs that
    are more focused on systems, focused on primary care, focused
    on rural types of care, so that we would get better
    accountability out of the graduate medical education dollars
    that we are spending. Like I said, it has been a few years now.
    I am not quite on top of that. But I had not thought about it
    in the context of the ACO.
        Senator Cantwell. Given the demand that we are going to
    face, do we need to dramatically increase the number of GME
    slots for primary care?
        Dr. Miller. Our point has been 2-fold. One, be sure that
    the graduate medical education dollars that are being spent now
    are directed towards accountability and producing more of the
    types of professionals who operate in a system-based care. If
    you are going to add slots at that point, then think about
    which way you want those slots to go and what you want them to
    be devoted to.
        Our basic concern is that just adding slots gets you more
    of the same in the current system.
        Senator Cantwell. Thank you.
        Senator Isakson?
        Senator Isakson. Thank you, Madam Chairman. Dr. Patel, when
    you were answering Senator Crapo's question, it prompted me to
    follow up with a question to you. I represent a State that has
    10.5 million people. Five and a half million live in the
    metropolitan Atlanta area. The other 5 million live in the
    largest geographic expanse east of the Mississippi River in one
    State. So they are a long way from medical facilities.
        In fact, we have lost two rural hospitals in the last year
    in Georgia. It seems like many of the directives and
    regulations and rules drive people to more expensive care, like
    the imaging example on the heart that you gave as an example.
        As we try to clean up the SGR and make some reforms, should
    we look at Stark laws, antitrust laws, the Affordable Care Act,
    in many cases, which directs people to a more expensive
    reimbursement for a service than they might otherwise get?
        Dr. Patel. Thank you, Senator. I do think the issue of how
    we can make sure that patients who do not have access to or do
    not live within urban areas have ready access to high-value
    providers is a huge one. I think that--not being an attorney,
    in full disclosure, I will tell you--not looking at Stark laws
    or antitrust laws would be a mistake if what we are trying to
    do is also help providers, as I mentioned, take on more of that
    risk that we did not really go to medical school to do. But we
    understand we need to, to get away from our fee-for-service
    system.
        So I do think that there are aspects of the Affordable Care
    Act that actually strengthen the ability to go to high-value
    providers. What I think all three of us have tried to reiterate
    is that what we need to do now is deal with the underlying
    formulas and mechanisms for which we still pay in Medicare to
    really drive that forward.
        Senator Isakson. When you were commenting on reimbursement
    based on quality of care, in that discussion, you made
    reference to a care coordinator between primary care and
    specialties. Was that begging a reimbursement for that
    coordination, when you made that statement?
        Dr. Patel. Yes, Senator. Thank you for picking up on that.
    It is not asking for an additional reimbursement. I am arguing
    that we can take proportions of what we are already paying for
    now and move that to reimbursement that actually allows primary
    care doctors and specialists to talk to each other more
    effectively.
        Senator Isakson. And get a better outcome because of it.
        Dr. Patel. Correct. Thank you. Yes.
        Senator Isakson. Dr. Miller--this really is probably for
    any of you who want to answer, but I would particularly like to
    hear Dr. Miller's answer. We talk about a better-educated--I
    think I am a better patient and have better health when I am
    educated as to what is wrong with me and what I need to do to
    correct it, or how I need to interact as a patient with the
    medical system.
        As we have studied Medicare for years, and I have looked at
    it, I have been a big advocate of raising the visibility of
    durable power of attorneys, living wills, end-of-life
    directives, advance directives, things of that nature, both for
    the quality of care for the patient as well as the common sense
    it makes for a patient, when of sound mind and body, to say
    what their wishes would be if they were not of sound mind or
    body or if they were in an irreversible cessation of brain
    waves or something like that. Is there a way we could reimburse
    for counseling sought by the Medicare beneficiary on that? Is
    there some way we could improve that education in America today
    for the benefit of both the patient as well as the system?
        Dr. Miller. The only thing I can offer you on that is that
    we have a line of research going now on something called shared

    decision-making, where information is brought to bear for the
    patient when they are facing particular decisions, and then
    that helps them go into the room with a physician, or whatever
    other health professional, and be more educated about their
    choices and what are the consequences of their choices. We are
    just now coming up to looking at it in the end-of-life
    environment. So I do not have much to offer you here, but that
    is kind of a path that we are looking at this year, a decision-
    making path.
        Senator Isakson. Is there any other comment from the panel?
        Dr. Patel. I would just say, as a physician, I know that
    one of the areas in which all clinical providers have agreed is
    that we need to do a better job with understanding how to
    counsel and also receive information from patients about their
    preferences. There have been a number of attempts to do this in
    the Medicare program, and they have often been vilified and
    made out to be or misconstrued as something other than just
    sharing information.
        So, Senator, I think it would be a welcome attribute to
    clinical service if we provided for a very direct way to engage
    with patients on these issues.
        Senator Isakson. Yes, and if it is beneficiary- or patient-
    directed, I think that makes an awful lot of difference in the
    politics. Mr. Steinwald?
        Mr. Steinwald. I agree with what she said. The evidence, I
    believe, shows especially when people have multiple chronic
    illnesses and are at end-of-life, once they are informed and
    are making the decisions themselves or their family's directed
    decision-makers are making them, they tend to choose less care
    and fewer resources and are more likely to sign up for hospice
    care as well.
        Senator Isakson. Thank you, Madam Chairman.
        Senator Cantwell. Thank you very much, and I am sure that
    my colleagues would love to see any recommendations that you
    are making in this area, moving forward or as soon as possible.
    Not seeing any of my other colleagues here, I am going to
    adjourn the hearing, but thank you so much for your testimony
    this morning. This is a critically important part of our
    delivery system reform, and becoming more efficient and using
    those dollars to drive better quality at lower costs is going
    to be critical to the entire country.
        So we look forward to receiving more input from all of you.
    We are adjourned.
        [Whereupon, at 11 a.m., the hearing was concluded.]

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