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

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

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

                                     HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 APRIL 19, 2016

                                   __________

                               Serial No. 114-137

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

          Printed for the use of the Committee on Energy and Commerce

                            energycommerce.house.gov

                                   ___________

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                        COMMITTEE ON ENERGY AND COMMERCE

                              FRED UPTON, Michigan
                                     Chairman

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

                             Subcommittee on Health

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

                                      (ii)

                                 C O N T E N T S

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

                                   Witnesses

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

                               Submitted Material

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

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

                                  ----------

                            TUESDAY, APRIL 19, 2016

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

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

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

                   Prepared statement of Hon. Joseph R. Pitts

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

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

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

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

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

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

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

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

                 Prepared statement of Hon. Frank Pallone, Jr.

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

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

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

                       STATEMENT OF ROBERT MCLEAN

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

        Mr. Pitts. The Chair thanks the gentleman. Thank you for
    your testimony.
        We're still having trouble with the mics. So Dr. Wergin,
    make sure you pull that close to you and make sure the mic is
    on.
        The Chair now recognizes Dr. Wergin, 5 minutes for an
    opening statement.

                       STATEMENT OF ROBERT WERGIN

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

        Mr. Pitts. The Chair thanks the gentleman.
        Now recognizes Dr. McAneny, 5 minutes for her opening
    statement.

                    STATEMENT OF BARBARA L. MCANENY

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

        Mr. Pitts. The Chair thanks the gentlelady and now
    recognizes Dr. Bailet, 5 minutes for his opening statement.

                      STATEMENT OF JEFFREY BAILET

        Dr. Bailet. Chairman Pitts, Ranking Member Green, and
    distinguished members of the Energy and Commerce Subcommittee
    on Health, thank you for the opportunity to testify on behalf
    of Aurora Health Care, the largest private employer and the
    largest integrated healthcare delivery system in the State of
    Wisconsin.
        I am Dr. Jeffery Bailet, co-president of Aurora Health Care
    Medical Group and one of the largest multispecialty medical
    groups in the Nation.
        As an otolaryngologist head and neck surgeon and medical
    group co-president, I am responsible for co-leading 2,600
    physicians and advanced practice clinicians who provide care to
    1.3 million unique patients.
        Aurora's diverse delivery system includes several rural
    community hospitals, urban hospitals, a psychiatric hospital as
    well as Aurora St. Luke's Medical Center, the State of
    Wisconsin's largest hospital.
        Thank you for extending this opportunity to speak on behalf
    of MACRA. I am pleased to be a leader of this transition not
    only as a medical group physician leader but also as co-chair
    of the physician-focused Payment-Model Technical Advisory
    Committee, or PTAC.
        I applaud Congress, particularly this committee, for
    incorporating the PTAC in MACRA as an advisory panel to
    consider physicians and other stakeholders' proposals for new
    models of high value care.
        I am also fortunate to serve as chair-elect of the American
    Medical Group Association representing medical groups and
    health systems including some of the Nation's largest most
    prestigious integrated delivery systems.
        I am pleased when standing in front of the physicians I
    support or speaking with physicians across the country that
    there's no longer debate about the need to transition to value-
    based care delivery.
        Shifting the culture of the healthcare community to the
    importance of value is a huge accomplishment and our patients
    across the country will benefit. It is equally important,
    however, that regulators appreciate the need to proceed
    cautiously during this transition.
        Many physicians are in various stages of readiness for a
    value-based payment system. There is and will continue to be a
    significant learning curve as providers begin to take on
    financial risk.
        When implementing the regulations for MACRA's payment
    systems, CMS should recognize that the healthcare system will
    need time to adapt and learn how to function in this new
    payment environment. Providing an incremental approach that
    includes flexibility and rational exposure for financial risk
    will be vital in ensuring a successful transition to value-
    based payment.
        Congressional oversight of this process is needed and
    welcomed. Physicians, whether they are in small group
    practices, larger multispecialty medical groups or high-
    performing integrated delivery systems must make significant
    investments to succeed in a risk-based environment.
        For example, Aurora launched a predictive analytic pilot
    focusing on preventing hospital admissions and readmissions.
    Using a predictive analytic tool, Aurora was able to stratify a
    population of heart failure patients who had an 80 percent or
    higher likelihood of needing to be hospitalized as a result of
    their disease.
        We then redesigned our care approach using health coaches,
    frequent proactive outreach and engaged patients to take active
    ownership of their treatment and health status. This effort
    helped Aurora reduce our congestive heart failure-related
    admissions by 60 percent.
        To help solo and small group practices participate, Aurora
    is developing clinically integrated networks across our
    geographic area. For example, we helped found About Health, a
    clinically integrated network that enhances clinical quality,
    increases efficiency and improves customer experiences,
    providing access to care for about 94 percent of Wisconsin's
    population.
        About Health is an example of how partnerships in Wisconsin
    between integrated delivery systems and small group practices
    can create a culture of learning and fostering of best
    practices to improve quality of care and reduce costs. This
    effort also helps small groups and solo practices that wish to
    maintain their independence the ability to do so.
        It is vital that CMS continues to engage the stakeholder
    community. The healthcare provider community is eager to share
    its insights with CMS and to date CMS is making a sincere
    effort to engage.
        I encourage CMS to build upon these efforts as value-based
    parameters are being clearly defined. MACRA represents a
    realistic opportunity for healthcare providers to improve the
    quality of care while reducing healthcare spending.
        High-quality patient outcomes is paramount and the
    continuous improvement initiatives and redesigned
    infrastructure we have implemented at Aurora can serve as a
    guide to other providers.
        Also, Aurora seeks out better, more effective ways to
    deliver care from our colleagues around the country. Moving
    forward, Aurora is prepared to fully participate in the
    development of new risk-based payment models that have the
    potential to improve patient care and bend the cost curve.
        Thank you.
        [The prepared statement of Dr. Bailet follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

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