[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
                        
                               ___________
                               
                               
                        U.S. GOVERNMENT PUBLISHING OFFICE
20-640 PDF                       WASHINGTON : 2016                        
_______________________________________________________________________________________
For sale by the Superintendent of Documents, U.S. Government Publishing Office, 
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center,
U.S. Government Publishing Office. Phone 202ï¿½09512ï¿½091800, or 866ï¿½09512ï¿½091800 (toll-free). 
E-mail, [email protected].  




                    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.]
    [Material submitted for inclusion in the record follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    

                                 [all]